Patient classification

Most PACUs have some type of patient classification system (PCS) either formal or informal. The most accurate PCSs are those that base the patient classification on length of stay in the PACU and intensity of the care required. The PCS can be used to justify budget for staffing and supplies as well as space requirements and charges for the PACU stay. For example, a patient with a classification of 1 has a lower charge than a patient with a classification of 3.

Developing a PCS for the PACU is difficult. Many variables must be considered and addressed when developing a PCS. Length of stay and anesthesia patient classification are starting points for PCS, but length of stay of each patient may vary significantly, and the acuity of a patient can change within a short period of time. Moreover, patient populations can range from pediatric to geriatric and can include minor to extensive surgical procedures, depending on the makeup and mission of the institution.

The advantages of a PCS include a more accurate assessment of the nursing time and energy needed for each patient, which helps a manager to estimate staffing requirements on the basis of the next day’s schedule. Other advantages can include knowledge of the highest workload time periods each day, allowing the manager to flex staff accordingly. This allows PACU nurses the knowledge that the type of workload in the PACU, with its peaks and valleys, is acknowledged and management is responsive to their unique staffing needs.

Visitors

The merits and benefits of visitation in the PACU are well documented. Patient visitation lowers anxiety and decreases stress for both the patient and the family. The result is an increase in patient and family satisfaction and increased adherence to the recovery plan.^1,2 In the past, PACU visitation was restricted for reasons such as the lack of privacy, the acuity of the patients, and the fast turnover that is common to the PACU. Visitation may have been allowed only if staffing and the physical structure of the unit permitted. In many institutions a change in culture surrounding PACU visitation has shown that the positive outcomes from visitation have outweighed the real and perceived drawbacks. A main catalyst behind the change has been the lack of available postoperative beds, thus extending the stay in the PACU for many patients. Some patients may have a prolonged stay in the PACU while they await critical care, telemetry, or surgical beds in the nursing unit. As the frequency of morning admissions increases, the incidence rate of extended PACU stays also increases because of lack of postoperative bed availability.^1,3

Part of the challenge with a change in the organizational culture to allow visitation in the PACU is that nursing care historically has concentrated on the care of the patient only. However, many family members also need nursing interventions, such as explanations of the PACU care provided to their loved ones, and require time and effort on the part of the nurses. However, PACU visitation can provide an excellent opportunity to start postoperative education with families.

Visitation times vary greatly, with some PACUs that still do not allow visitation and others that have adopted policies originally designed for other critical care units. Some PACUs may include a 5-minute visit each hour or a 20-minute visit every 4 hours, whereas other institutions have open visitation that is restricted only during the timeframe when a critical event is occurring in the PACU. Other criteria may include a limited number of family members at one time, the patient’s desire for visitors, the unit needs, and the patient’s condition. Privacy of other patients in the PACU must always be a consideration and priority.

Situations in which visitation should be encouraged include the following:

As facilities renovate or build new surgical suites, the design of the perianesthesia area should accommodate patients and families. In addition, patient privacy and visitation must be considered. The PACU needs to allow for the comfort and privacy of the patient population who may need an extended PACU stay, including the ability to allow for family members to have extended visits in the PACU setting.

Patient records

The postanesthesia care record is essential for every patient admitted to the PACU. Many institutions have evolved to total electronic documentation or a hybrid of computerized and paper documentation. Whether traditional paper documentation or electronic format is used, the record should be an accurate account of the patient’s postanesthesia stay and the care that was provided. Anecdotal notes should detail admission observations. The assessment, planning, and implementation phases of the nursing process should be documented, and an evaluation of the patient’s response to the care should be provided. A discharge summary should also be included.

The trend in many institutions is toward a fully electronic medical record, which allows multiple users in remote locations to have access to the medical record at the same time. The fully computerized record for the surgical patient begins in the preoperative evaluation phase and follows the patient through the PACU period to the ambulatory surgery unit or an inpatient unit. One of the important advantages of a computerized medical record includes immediate access by other health care practitioners involved in the patient’s care. It can also be a time saver for nurses, because data entry is often accomplished with drop-down menus much like a checklist as well as documentation prompts for critical areas that must be completed before the record is closed, thus ensuring all required documentation has been completed. Disadvantages include the cost of installation and education and the time necessary to orient the staff to the system, as well as staff resistance to change from paper to computer charting.

Discharge of the patient from the PACU

Written criteria for discharge of the patient from PACU must be available. At a minimum the criteria should include:

The criteria for discharge of a patient from the PACU vary by the unit, location of transfer, anesthetic technique, and physiologic status. Ultimately the physician is in charge of the patient’s discharge from the PACU. Predetermined criteria can be applied if the criteria have been approved by the physician staff members.

The use of a numeric scoring system for assessment of the patient’s recovery from anesthesia is common. Many institutions have incorporated the postanesthesia recovery score as part of the discharge criteria. Box 3-2 shows an example of two discharge scoring systems. The Aldrete Scoring System was introduced by Aldrete and Kroulik in 1970 and was later modified by Dr. Aldrete to reflect oxygen saturation instead of color. Clinical assessment must also be used in the determination of a patient’s readiness for discharge from the PACU. This scoring system does not include detailed observations such as urinary output, bleeding or other drainage, changing requirements for hemodynamic support, temperature trends, or patient’s pain management needs. All these criteria should be considered in the determination of readiness for discharge. The unit policy and the established PACU discharge criteria determine the appropriate postanesthesia recovery score and physical condition for discharge from the PACU. The patient must have a preestablished score to be discharged from the PACU. Scores or conditions lower than the preestablished level necessitate evaluation by the anesthesia provider or surgeon and can result in an extension of the PACU stay or possible disposition to a special care or critical care unit.

Because patient conditions vary with surgical procedure, anesthesia used, use of analgesics, and patient response, no specific time requirements for the PACU stay can be stated. Professional judgment is needed to determine when the patient is ready for discharge from the PACU. A complete accurate report is required from the PACU nurse to the nurse who will be responsible for the care of the patient. Hand-off communication has been identified as an area in which patient safety can be compromised if not performed accurately.

When ambulatory surgical patients are discharged to home, other criteria should be assessed. These criteria may include the following: pain control to an acceptable level for the patient, control of nausea, ambulation in a manner consistent with the procedure and previous ability, and a responsible adult present to accompany the patient home. Some Phase II PACUs require the patient to void or tolerate oral fluids before discharge to home. The Post Anesthetic Discharge Scoring System is often used for assessing the readiness of the patient to be discharged home or to an extended observation area.⁴

Phase II patients should receive a follow-up visit by the anesthesia provider and be released as appropriate, or as in phase I where the nursing staff of the Phase II PACU are appropriately educated, a discharge by criteria policy that defines discharge parameters and allows the nurse to discharge the patient may be in effect. Discharge criteria should be developed to meet appropriate standards, but should be individualized to each PACU.

Home care instructions should be taught to the patient and responsible adult, both of whom should verbalize an understanding of the instructions. Written instructions should be given to the patient to take home. Information on what to do if a problem or question arises should be addressed, and emergency and routine telephone numbers must be included in the instructions.

Standards of care

Every profession has the responsibility to identify and define its practice to protect consumers by ensuring the delivery of quality service.¹ The American Society of PeriAnesthesia Nurses (ASPAN) Perianesthesia Nursing Standards and Practice Recommendations provides a basic framework for nurses who practice in all phases of the perianesthesia care specialty.¹ These standards have been devised to stand alone or be used in conjunction with other health care standards and are monitored, reviewed, revised, and updated regularly. A copy of these standards can be obtained from the ASPAN National Office, 90 Frontage Road, Cherry Hill, NJ 08034-1424, or ordered via the ASPAN website at www.aspan.org.

All preanesthesia, postanesthesia, and ambulatory surgical nurses should be familiar with their professional organization’s standards of practice, and a copy of these standards should be available in each unit. The PACU may develop its own standards specific to the hospital, using the ASPAN standards as a reference, or adopt the ASPAN standards for use. If the PACU adopts the ASPAN standards, they must be adopted in their entirety or a policy must be added to note any exceptions. Any written standards must be attainable reflections of the actual practice.

Nurses must possess a minimum level of knowledge and ability. Standards are objective and are the same for all staff members, which means that an inexperienced nurse in the PACU is held to the same standard of practice as an experienced nurse. Standards are commonly used today in legal proceedings to measure the care a patient received. The ASPAN standards have been used in court proceedings, and many medical malpractice attorneys have the latest copy of the ASPAN Perianesthesia Nursing Standards and Practice Recommendations in their libraries.

Quality management and performance improvement

A multidisciplinary team to address quality management process improvement in the PACU is essential to basic operations. The quality management team’s composition should encompass management and staff level personnel. Members should at a minimum include the medical director, nurse manager, staff from both areas, and surgeons. Others to consider as either permanent or as ad hoc team members are: pharmacy, central distribution, the operating room manager and staff members, radiology, and respiratory therapy staff members. This quality team’s mission should focus on current practices and processes that require improvement, as well as review and critique any events. They should also have the goal of discovering how and where systems might have failed and what changes or improvements can be initiated to prevent future occurrences. The goal of this team is to improve processes thereby improving outcomes. Process improvement programs differ from the quality management programs of the past in that the emphasis on inspection has changed to an emphasis on continuous improvement. When excellent patient care is put first, departmental boundaries fade. The common, seamless focus becomes providing the patient with the best possible care.

The Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention initiated the Surgical Care Improvement Project. This project is a multiple-year national campaign and partnership of leading public and private healthcare organizations aimed at reducing surgical complications. PACU staff members have a major role in partnering with both the surgeon and anesthesia providers to ensure that many of these measures are addressed appropriately.⁵ Every nurse is responsible for quality management and performance improvement. The result is an effective program that has a positive effect on the process and outcome of care where patient care problems can be prevented, or where basic operating procedures or systems can be changed and improved.

Monitoring and evaluation are still important elements of the quality management process. The trend is no longer one of just data collection, but of using the collected data to improve systems and processes. These system improvements may affect only the PACU area or may be far reaching into the institution. Examples of performance improvement activities might include reduction in the time the pharmacy takes to respond to PACU needs, improvement in the system to decrease the length of time patients remain in the PACU waiting for beds, a change in staffing patterns in the PACU or ambulatory care areas to meet patient care needs, or a patient education program written for all outpatients discharged with a venous access device to ensure that all patients receive the same quality education.

Nurse manager

Each institution identifies the qualifications needed for a nurse manager position. It generally includes a baccalaureate degree in nursing and preferably a master’s degree in nursing or another health-related field, with an emphasis on administration and business. The nurse manager for a PACU should have a minimum of 5 years of strong medical-surgical and perianesthesia background, or critical care experience. It is also preferable that the nurse manager have previous managerial experience. Another prerequisite of the position should be national certification, either as a certified postanesthesia nurse (CPAN) or a certified ambulatory perianesthesia nurse (CAPA), or the requirement to obtain it within a specified timeframe. Active involvement in professional organizations such as ASPAN should be an expectation of any perianesthesia manager. This membership assists the manager with networking and keeping abreast of the latest professional developments within the specialty.

The nurse manager of the PACU is responsible for planning, organizing, implementing, and evaluating the activities of both the nursing staff and the patient care functions. In addition, the manager is responsible for staff scheduling, assignments, performance evaluation, counseling, hiring, firing, educational program coordination (including the development and implementation of a unit-specific orientation program), and the unit budget formulation and monitoring. The nurse manager is also responsible for developing and implementing standards of care and the unit’s quality improvement program; for evaluating and monitoring their effectiveness; as well as for the professional growth of the assigned staff.

The perianesthesia nurse manager should be skilled in time management, decision making, organization, financial management, communication, interpersonal relations, and conflict resolution. In addition, the manager should have the ability to negotiate and collaborate with other departments and health care team members. The nurse manager should also project a positive nursing image and with the clinical nurse specialist should have clinical expertise related to the PACU.

Clinical nurse specialist

The clinical nurse specialist (CNS) in the PACU can be identified by a number of titles, including advanced practice nurse, nurse practitioner, clinical leader, resource nurse, nurse educator, and nurse consultant. For the purpose of this discussion, the nurse in this role is referred to as the CNS.

Qualifications of the CNS include strong leadership skills, clinical expertise in the perianesthesia setting, excellent communication skills, the ability to share knowledge and ensure understanding, the ability to work in a collaborative manner with all members of the health care team, the capability to incorporate nursing research into practice, and the ability to multitask. The CNS usually is a master’s-prepared nurse or may be doctorally prepared (e.g., doctorate of nursing practice [DNP]). The nurse in this role should possess advanced clinical expertise in perianesthesia nursing. The CNS should also have CPAN or CAPA certification. Each institution develops role requirements for the CNS. Examples of activities that may involve the CNS are included in Box 3-3.

The CNS works closely with the nurse manager to achieve the mission and goals of the PACU. In addition, the CNS is involved in ensuring the clinical competencies of each perianesthesia nurse and provides in-service training and education to the staff on health care regulatory requirements and standards.

The CNS role should be part of the PACU’s quality team and plays an important part in the development of an effective monitoring and evaluation programs. This nurse is instrumental in implementing corrective action to rectify deficiencies and improve patient outcomes. The CNS can be invaluable in assisting staff members to develop and implement evidence-based practice (EBP) projects. EBP activities should be ongoing in the PACU. EBP can serve to strengthen the identity of perianesthesia nursing as a specialty and give the staff nurse direct input into their practice, which results in greater staff buy-in to changes resulting from the data.

The CNS is also the resource person for clinical problem solving and dissemination of information of an advanced nature. In addition, the CNS can ensure that standards of practice are implemented consistently throughout the organization. As a liaison, the CNS can work closely with units outside the PACU that are involved in patient recovery. These areas include labor and delivery, endoscopy, and special procedure units. The CNS can also be instrumental in collaborating with free-standing ambulatory surgery centers if the hospital is so affiliated.

The role of the CNS is an important one, but because of cost constraints it is a position that is not always budgeted for in the PACU setting. Through skill and expertise, the CNS can offer support and encouragement to staff members, thereby promoting satisfaction and teamwork in the PACU and improved patient outcomes. These factors ultimately lead to continued individual and professional growth among team members.

Staff nurses

The selection of quality nursing personnel for the PACU is of the utmost importance. The nurse manager, in conjunction with the institution’s human resource department and the CNS, should establish qualifications for PACU nursing personnel. These qualifications along with requirements such as shift rotation, weekend, and call expectations should be written and used in all employment proceedings. This practice tends to preclude, or at least minimize, subsequent problems such as job dissatisfaction, unsatisfactory work performance, and staff turnover; it also helps to ensure a smoothly functioning PACU.

The following qualifications should be considered in establishing selection criteria. The nurse who considers employment in the PACU must have an interest in perianesthesia nursing. The nurse needs a solid foundation in the care required for preanesthesia and postanesthesia patients¹ and should be committed to providing high-quality, individualized patient care. The candidate should also demonstrate exceptional communications skills and communicate in a positive manner with all members of the health care team. The nurse should have the ability to form good working relationships and be a positive team player. The perianesthesia nurse should be capable of making intelligent independent decisions and initiating appropriate action as necessary, and willing to accept the responsibility that accompanies working in a critical care unit. In addition, the nurse must have excellent patient teaching skills, the ability to coordinate care being rendered by a variety of health care team members, and the ability to function effectively in a crisis situation. The ability to be flexible is of the utmost importance for nurses working in the PACU.

The nurse who seeks employment in the PACU should also express an interest in and have the ability to learn the scientific principles and theory underlying patient care and the technologic aspects of perianesthesia nursing. The person should be in good health, dependable, and motivated and should express an intention to stay at least 1 year in the PACU after completing the unit orientation. The orientation and training of a perianesthesia nurse requires significant time, energy, and money. Temporary assignment to the PACU is not worthwhile, except as a student learning experience.

The cross-training of nurses to the PACU may be a feasible solution in hospitals or facilities where staffing is a concern. The nurse who is cross-trained to the PACU should fulfill the required competencies of competent support staff as outlined in the ASPAN Perianesthesia Nursing Standards and Practice Recommendations.¹

Ideally the PACU nurse should have at least 1 year of general medical-surgical nursing. Critical care experience may be an advantage. The perianesthesia nurse must also be able to adapt to changes in the health care setting. Continuous restructuring and reengineering of hospital practices has led to turmoil in some institutions. Nurses must be able to accept and adapt to the constantly changing environment of the future.

Membership in professional organizations as well as national certification by one of the professional nursing associations (Table 3-1) shows commitment to professional excellence and should be considered positively in the selection of perianesthesia nurses. If everything else is equal, ideally, candidates for PACU positions who have attained a CPAN or CAPA credential should be given preference in hiring. Commitments to other professional nursing organizations should also help the candidate to be considered for a PACU position.

Table 3-1 Certification by Professional Nursing Associations

CPAN, Certified Post Anesthesia Nurse; CAPA, Certified Ambulatory Perianesthesia Nurse; CEN, Certified Emergency Nurse; CCRN, Critical Care Registered Nurse; CNOR, a certification of competency in the field of perioperative nursing.

Certification in basic cardiac life support (BCLS) and advanced cardiac life support (ACLS) is required of all nurses who work in the PACU.¹ For units with a high volume of pediatric patients, certification in pediatric advanced life support (PALS) is also required. Application of BCLS in the PACU or ambulatory surgical unit helps to sustain a patient’s condition in a crisis until ACLS techniques can be instituted. ACLS includes training in dysrhythmia recognition, intravenous infusion, blood gas interpretation, defibrillation, intubation, and emergency drug administration. If the perianesthesia nurse responds quickly and efficiently during crisis situations, the patient’s chance of survival increases.

Perianesthesia nurses take pride in their competence to deliver safe patient care. Opportunities to broaden and expand the perianesthesia nurse’s knowledge base should be fostered. The knowledge necessary for direct patient care is provided by working with staff members individually to ensure the vital training, support, and guidance that eventually enables the nurse to function efficiently and competently. This process allows for consistent teaching and evaluation on an individual level.

The ultimate goal of the PACU nurse is delivery of quality patient care. To accomplish this goal, continuous professional nursing judgment is necessary; therefore only professional registered nurses should be assigned patient care.

Ancillary personnel

Minimal numbers of ancillary personnel should be assigned to the unit to support the registered nurses. Licensed practical nurses (LPNs) or licensed vocational nurses (LVNs) assigned to the PACU are restricted in their roles. A registered nurse must be the primary nursing care provider in the PACU, thereby limiting the role of the practical nurse in the PACU setting to one that does not allow functioning at their fullest capacity. This situation often causes dissatisfaction for the LPN/LVN and is not a cost effective use of limited budget dollars. Some PACUs have effectively used the LPN/LVN as a transport nurse to deliver appropriate patients safely to the unit after discharge. The PACU may employ unlicensed assistive personnel (UAP). When working with UAPs, the registered nurse (RN) is responsible for knowing the policies and procedures as set forth by the individual institution. UAPs can be a valuable asset to the PACU, but the RN should remain cognizant of the fact that nursing assessment, diagnosis, outcome identification, planning, implementation and evaluation cannot be delegated to UAPs. UAPs can assist the nurse by performing tasks that the perianesthesia RN supervises and determine the appropriate use of UAP providing direct patient care in accordance with state regulations.¹ Ultimately, the RN is responsible and accountable for the safe delivery of nursing care.

A skilled secretary clerk is a definite asset to the PACU. A person who is adept at handling and redirecting the numerous phone calls to the PACU and is proficient in clerical duties makes the job of the perianesthesia nurse much easier. A proficient secretary can assist the unit by acting as the liaison to family members. Frequent updates on the status of the patient help to reassure family members that the recovery is progressing as planned. The secretary clerk should possess excellent communication skills because this person communicates to a wide spectrum of individuals—from patient and family members to physicians and other health care workers. Often the first contact the family has with the PACU, either by phone or in person, is with the secretary clerk. As a result, this person must possess exceptional customer service skills. An individual who gives the impression that the patient is the most important contact of the day is certainly the individual wanted on the front line.

Retaining nursing staff in the PACU

As demand continues to outweigh supply, the existing nursing shortage only worsens over time. Regrettably, perianesthesia nursing is not immune to this shortage. Many nurses have found the perianesthesia specialty to be where they want to focus their careers. This group of experienced, dedicated staff members is an exceptional bonus to institutions lucky enough to have them. Unfortunately, many of these nurses are from the baby boomer generation and are looking to retire in the near future. At the same time, fewer nurses are graduating and demand for nurses is growing. Simultaneously, many colleges and universities have seen the recent number of nursing applicants increase, only to be turned away because of the lack of qualified nursing educators.⁶

In order to recruit and retain the dedicated and talented nurses needed in the perianesthesia setting, institutions must look at factors that influence job satisfaction and retainability. Recruitment into nursing and into specific hospitals is a widely discussed topic. After nurses are recruited into the perianesthesia setting, retention of these experienced staff members becomes a major challenge. Although salary is a factor, studies show that it is not the top reason for dissatisfaction and turnover.⁷ Items such as a workplace environment free from ongoing conflict, where staff has autonomy and where their ideas and opinions are valued, play a big role in job satisfaction. Other issues such as inflexible working hours and mandatory overtime are also major causes of dissatisfaction. Some research has defined that the nurse manager leadership behaviors and relations with staff members had the most influence on retention of hospital staff nurses (Box 3-4).

Retention of qualified nurses is fast becoming a priority for nursing administration. In exit interviews, nurses cite an unhealthy work environment as the reason they leave the workplace. The treatment of nurses toward each other continues to be challenge. Some reasons given for nurses who leave the workplace include lack of support, mentoring, and clear direction.⁸ Nurses are not exempt from conflict in the workplace. As trite as it may seem, women are generally expected to work harmoniously together in a sisterlike fashion. This belief could not be farther from the truth. When issues of conflict arise, some individuals may find it difficult to confront the situation and establish a resolution. As a result, an ongoing underlying current of tension may exist on the unit. Box 3-5 identifies some strategies that the nurse manager may use to build a supportive workplace.

Creation of an environment conducive to staff growth and development is the manager’s responsibility. A survey conducted by the American Academy of Nursing in 1982 identified variables in nursing that attracted and retained quality nurses. These variables include nursing autonomy and personal and job satisfaction, and nursing practice that resulted in excellence. As a result of this survey, the Magnet Recognition Program was established for recognizing health care organizations that provide nursing excellence.⁹ Facilities that strive for recognition as a Magnet facility have identified that the nurses employed at the facility provide quality patient care. Nurses who believe they have the support and resources needed to provide quality patient care are more likely to be satisfied in the workplace.

Nurse managers need to be cognizant of the workplace environment. When strife is evident in the unit, the issues need to be identified and addressed immediately to avoid a deluge of conflict, which can soon translate to discord among the staff.

Other factors linked to job satisfaction and retention have been flexible work schedules, appropriate pay scales, and shared governance. Flexible schedules and a shared governance philosophy are created and overseen by the manager.

Shared governance

Many units use a participative type of management. It is a well-documented fact that nurses want to be treated as professionals and desire autonomy and participation. A concept used by many hospitals to meet these needs is shared governance. In this form of management, the PACU nurse assumes more authority and responsibility and shares management skills and duties with peers. The overall structure is that of self management, with staff involvement in the decision-making processes that affect their nursing practice.

Committees that address the needs of the unit, the employees, and the patients are established. Usually a nursing practice committee is in charge of any decisions about policies and procedures or practice issues; a quality management committee is in charge of quality management and performance improvement activities for the unit; and an educational committee is responsible for meeting the educational needs of the unit. Other unit-specific committees that have been used are equipment and supply, budget and finance, communications, and statistics.

The nurse manager becomes a facilitator and a resource person for the staff. Most nurse managers retain responsibilities such as employee evaluations, interviews, and liaison with administration or physicians. The challenge for the nurse manager within this system of management is to maintain a vision and to impart that vision to the staff. In addition, the nurse manager must learn how to relinquish control and to support the decisions of the staff and the staff members must accept ownership and accountability of their practice and unit.

Self-scheduling

Managers need to reassess age-old beliefs that nurses must work set shifts. The 7:00 AM to 3:30 PM shift is a thing of the past. A creative manager works with the nursing staff to accommodate individual work schedules whenever possible. The mother who needs to put her children on the school bus before work may prefer to work 8:00 AM to 4:30 PM instead of the traditional 7:00 AM to 3:30 PM. For mothers or fathers who work the evening shift, a 5:00 PM to 1:00 AM shift may be a better fit to accommodate childcare issues. Implementation of a 10- or 12-hour shift or a split shift may assist in covering the gaps. Supporting creative scheduling solutions, which are key to staff retention and employee satisfaction, can become a juggling act for the manager who must also provide for safe patient care and stay within the staffing budget.

One option for scheduling of staff is a system that is completely coordinated by the staff nurses that also recognizes professional nurses as capable of making crucial decisions about their practices. The schedule is developed and implemented by nurses and other staff in the unit. The nurses are given preestablished requirements that must be filled. They can be as creative and flexible as they want in developing the staffing schedule. Advantages include decreased amount of time spent by the nurse manager on scheduling, increased team building by the staff, increased job satisfaction, increased staff autonomy, and decreased staff turnover. The manager must have final review and approval of the schedule to ensure that an overall fairness exists and all the preestablished requirements are met.

Basic staff orientation program

The orientation program for the PACU should be designed to specifically meet the needs of the nurse who works in the PACU. The program should include formal lectures and discussions and informal demonstrations and supervised practice. The orientation program should be structured to include objectives, content, resources, and the method used to evaluate the orientee’s progress. The orientee should be provided with materials that clearly delineate the structure of the orientation program. The expectations the orientee faces should be absolutely clear to everyone.

Each nurse who undergoes orientation to the PACU should have an individually assigned preceptor. The preceptor works closely with the CNS and orientee to ensure that individual needs are met and deficiencies are addressed promptly. In addition, anesthesia providers, surgeons, the CNS, and other nurses in the PACU should be involved in the orientation program. Fostering of seasoned nurses to prepare and present short lectures or skill demonstrations not only recognizes the nurse for individual expertise but also displays the manager’s confidence in the individual’s ability to provide quality patient care. Lectures and presentations should be geared toward the specific needs of the orientee.

Experienced staff members should support and encourage new staff members. Nurses who are made to feel a part of a team are certainly more likely to stay, whereas nurses who are unhappy leave. Orientation of a new staff nurse is costly and time consuming; therefore implementation of all possible measures to limit staff turnover is essential. Working to create a stable cohesive staff helps with staff morale. This process begins at orientation.

Objectives should be clearly stated, and methods for evaluation of the achievement of the objectives should be clearly outlined. A notebook of the objectives, resources, evaluation forms, pertinent PACU policies and procedures, and other valuable resources should be given to each orientee. The notebook should be carefully reviewed with each orientee. A clear understanding of objectives and expectations in the beginning avoids problems in the long term.

Competency-based orientation focuses on acquiring the knowledge necessary to perform the job and additionally encompasses applying that knowledge to real-life situations. Competency-based orientation is effective because it allows an expert clinician to transfer knowledge and skills to the novice learner. The learner then becomes responsible for the progress and the preceptor facilitates and guides the learner.

Content of the orientation program

The length of the orientation program should be tailored to meet the individual needs and previous experience of the orientee. Consideration should be given to the expectations placed on the orientee. Will they be expected to perform in a “call” situation at the conclusion of the orientation period, or will an experienced perianesthesia nurse be working with them for an indefinite period? The orientation period should be customized and adjusted as needed based on the orientee’s ability to grasp, understand, and process the information and situations encountered. During the orientation time, the orientee should work full time. An experienced perianesthesia nurse will require a much shorter orientation phase than an inexperienced PACU nurse. Suggested topics and content of the PACU orientation program are presented in Box 3-6. Additional material, as appropriate to the practice setting, should also be included.

During the orientation period, careful and constant communication must be maintained between the nurse manager, the orientee, the preceptor, and the CNS. Evaluation by the nurse manager and preceptor should be ongoing, and the orientee should receive a formal written evaluation at the end of the orientation. The orientee should clearly understand the expectations as set forth by the perianesthesia nurse manager, and the orientee and preceptor should discuss progress daily. If issues arise, the manager or the CNS may need to step in and clearly review progress and expectations with the orientee. In some cases, an orientee might clearly not fit into the perianesthesia environment. In these circumstances, the best solution is to assist the orientee in gaining the required prerequisite skills or explore employment opportunities in another area rather than allowing the orientee to flounder in an environment in which success is not possible.

Development of expertise

Expertise in nursing involves the overlapping of the following three basic components of nursing: knowledge, skill, and experience. Mastering any one or two of these components never equates with expertise. The expert nurse uses a complex linkage of knowledge, experience, skill, clue identification, gut feelings, logic, and intuition in problem-solving and the nursing process. As the nurse gains knowledge and experience through formal and informal programs, nursing intuition begins to develop. Intuition may be thought of as identification of a deviation from the expected or the feeling that “something just doesn’t seem right.” Over time, with experience and practice, the nurse becomes proficient. The accumulation of knowledge, along with the chance to practice the skills acquired, leads to competence.¹⁰

When the nurse finishes the formal PACU orientation program, the nurse should work continuously on improving background theory and skills. This improvement can be accomplished with active participation in on-the-job training, nursing in-service programs presented on the unit, outside reading, membership in ASPAN and other state and local professional nursing organizations, and attendance at both in-house and outside-sponsored seminars and educational offerings. Constant review of basic knowledge and procedures is essential. Keeping abreast of new scientific information and innovations is necessary to ensure quality care.

After the orientee has worked in the perianesthesia environment for at least 1 year and believes that sufficient knowledge and experience have been gained, certification as a CPAN or CAPA should be considered. Certification is one method of demonstrating to patients and families that the quality of services they receive is enhanced because the nurses caring for them have attained a CPAN or CAPA credential.

An investment made to stimulate the professional development of the nursing staff is directly reflected in the level of nursing care provided to the patient. Inclusion of funds in budgeting to send nurses to important educational and information-sharing meetings for the unit is essential. In addition, the individual nurse should be willing to finance some of the costs associated with advancement of their professional growth and practice.

Competency assessment

When the orientation period has ended, the assurance that staff members remain competent is essential. Integration of a competency checklist with the annual performance evaluation is one method to ensure competency. Assessment of competency on an annual basis provides a number of benefits. Staff members are forced to review procedures and equipment that might not be routinely used.

Assessment of competency can be divided into two aspects. The first aspect of staff competence assessment relates to policies and procedures and could include facility standards and national standards as set forth by organizations such as ASPAN. Some competencies that managers may want to address include:

A complete list of Recommended Competencies for the Perianesthesia Nurse can be found in the ASPAN Perianesthesia Nursing Standards and Practice Recommendations.¹

The second aspect of assessing staff competence relates to equipment. Evaluation of staff members is essential to ensure that their skills and knowledge in the operation of and caring for equipment used in the practice setting is proficient. Specific equipment competencies include:

Managers should develop processes to assess the previously named activities. For assessment of equipment competence, employees must be able to appropriately demonstrate proper use of the specific piece of equipment. Unit-specific tests can be developed to assess competence of policies and procedures.

In an effort to streamline processes, assessment of competence of the new orientee and of senior staff members should follow the same path. Competency assessment methods differ. The new orientee may be required to demonstrate the step-by-step process of defibrillation and to verbalize the rationale for each step. In contrast, the seasoned nurse may be required to just demonstrate the process.

Incorporation of competency assessments into monthly staff meetings may also be helpful. One method is the assignment of a staff member to present a short in-service on a specific piece of equipment or a specific policy to the staff members. Competence can then be assessed with a follow-up posttest or return demonstration from the staff members. Documentation can be a checklist that outlines the step-by-step return demonstration or the posttest that is filed electronically or in employee personnel files to document competence in the specific skill.

Quality management and improvement activities may uncover a specific deficiency. In this instance, development of a program to educate staff on the proper skills needed is important. After completion of the education, the nurse manager can follow up with a competency assessment of the problem-prone activity.

Perianesthesia nursing is unique in that the nurse has only a small amount of time to assess the patient, identify a plan of care, implement the plan, and then evaluate the effectiveness of the plan before care is turned over to someone else, be it another nursing professional, a family member, or the patient. The skill and expertise needed to provide quality care in the fast-paced environment takes time to obtain. Nurses who are motivated to learn, like a fast-paced environment, and work well in teams enjoy the challenges of the PACU work environment.