University Nursing: Legal and Professional Issues and ACORN Standards

This report delves into the legal and professional nursing issues, specifically examining the Australian College of Perioperative Nurses Standards (ACORN) and their significance in ensuring patient safety within a surgical setting. It analyzes a case study involving a 58-year-old patient undergoing anterior spinal fusion, where a Raytec sponge was mistakenly left in the patient's body due to failures in instrument accountability and communication. The report discusses the ACORN standards, emphasizing the importance of instrument handling, counting techniques, and communication between healthcare professionals. It evaluates the alignment of workplace settings with ACORN standards, critically assesses the evidence base, and offers recommendations for effective nursing practices to prevent medical negligence and enhance patient outcomes. The analysis highlights the need for proper training, adherence to standardized procedures, and clear communication to minimize risks and ensure compliance with the ACORN guidelines.

Running head: LEGAL PROFESSIONAL NURSING ISSUES
Legal Professional nursing issues
Name of the student
University name
Author’s note

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Table of Contents
Introduction................................................................................................................................2
Potential safety issue in actual clinical setting...........................................................................2
Discussion of the issue in relation to the ACORN standards for perioperative nursing............3
Alignment of the current workplace settings with ACORN standards......................................4
Critically evaluating the strength of the evidence base and the ACORN standards..................5
Recommendations for effective nursing practices.....................................................................6
Conclusion..................................................................................................................................7
References..................................................................................................................................8

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Introduction
The current assignment focuses upon the legal and professional standards of nursing.
The standards of nursing which had been taken into consideration over here is the Australian
College of Perioperative Nurses Standards (ACORN). The standards have been
implemented to ensure optimal patient safety in a surgical setup. The aim for the
implementation of the standard is to remove all items used during surgery and procedures
from the proximity of the patient unless intentionally retained. The principle guidelines of the
ACORN standards are aimed at retrieval of all items used during surgery. The instruments
used should be accounted for and properly documented. The ACORN standards are
underpinned by description of various roles such as circulating nurse, recovery nurse,
instrument nurse and anaesthetic nurse.
The minimum number of nurses required depends upon the complexity of the process
and the requirements of the patient. Some of the basic objectives of the ACORN standards
are – safety of the staff and patient, asepsis and clinical care, management and staffing,
prevention of infection. In the current assignment, the relevance of the ACORN standard
within a preoperative nursing scenario has been discussed. The practices adopted within an
actual scenario have been evaluated in accordance with the ACORN standards.
Potential safety issue in actual clinical setting
The implementation of the ACORN standards helps in ensuring that the patient safety
is maintained during the conduct of the surgical process and an instrument in not retained in
the body cavity of the patient by mistake. It could be done by following step wise checks
which ensures that the instruments are safely removed before a body cavity is closed.
For understanding the importance of the ACORN standards in an actual clinical set up
it is necessary to reflect upon an actual scenario. Here, the patient who was a 58 year old man
was admitted to the hospital for ANTERIOR SPINAL FUSION. The case was started at 10
am and finished at 5 pm. The count was performed by the same scrub and count nurse.
However, during the conduct of the operative procedures the nurses failed to comply with the
accountability standards of instrument handling. It was later found during one of the post –
operative diagnosis stage that a Raytec sponge was placed on top of lung during the surgical
process. The position of the Raytec was detected through post-operative X-ray.

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It could be related to the statement number 5 of the ACORN standards, which states
that all the absorbent accountable items used during the surgery should be handled in manner,
which will reduce the risk of the items being retained inside the body cavity of the patient
(Gore and Osborne 2017, p.56). On further analysis, it was found that the nurse failed to
notify the doctor that the count has not been finished. Additionally, the hospital staffs lacked
effective training and guidance upon the use of the ACORN standards for ensuring that
accountability is maintained for the handling and management of instruments within a
preoperative care unit. As per the standard statement 3 of the ACRORN policy and
guidelines, safe counting techniques need to be followed by the nurse. In the current scenario
by not providing the doctor the required information there was a clear breach of ACORN
standard 8. Under the safe counting techniques, the nurse was required to keep an account of
the actual instruments and items used during the surgical process (Lynn and Brownie 2015,
p.112). This could further help in reducing the chances of error within a perioperative care
environment.
Discussion of the issue in relation to the ACORN standards for perioperative nursing
The issue discussed with regards to an actual medical scenario can be further
evaluated based upon the ACORN standards. The ACORN standards can be divided into a
number of sub standards from standard statement 1 through 9. The relevance of the standards
with regards to the current healthcare scenario could be discussed over here. The standard
statement 1 contains policies and guidelines surrounding the management of items during
surgery. As commented by Hains et al. (2016), failure to comply with the standard can
result in incidence of medical negligence. The second statement states the nurses attending to
the care concerns of the patient within the perioperative environment needs to bear the
responsibility for the management of the surgical instruments (Irelandand Osborne 2016,
p.54). As per the directive when there is one instrument and one circulating nurse one
approved perioperative documentation (APD) should be used. However, if there is more than
one circulating nurse, separate APD should be used by each circulating nurse. This helps in
compliance checking and monitoring in critical care. The proximity of the surgical sites
makes it difficult to ensure the separation of the accountable items by the two teams (Duff et
al. 2016, p.24). One of the most important criteria is the safe counting technique, which is
complied in order to ensure that the surgical equipments and instruments are not retained
inside the body of the patient. In this respect, the nurses need to ensure that the items remain

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intact in their inner packaging so that they are not separated before counting (Hains et al.
2016, p.550). Additionally, it is the duty of the instrument nurse to ensure that the
contaminated surgical items are duly separated from the patient as contact with the
contaminated articles can initiate secondary infection within the patients. As per the standards
4, when a body cavity is entered during the surgical process an additional count needs to be
performed (Duff et al. 2016, p.24).
In the current scenario 200 raytec and 100 surgical sponges were used. During the 1st
count one raytec was left on top of the lungs. Due to the presence of a large number of
accountable items, the nurse failed to finish the count before closing the wound. Here, the
nurse also failed to finish the count before the removal of the endotracheal tube (ETT) or
extubation. Therefore, the patient had to be re-extubated and the wound site opened to take
the raytec out. Therefore, effective counting procedures techniques along with lack of
communication resulted in the situation of medical negligence (Ireland and Osborne 2016,
p.54). As per the standard 6, standardised trays were required to be maintained. The tray list
would further help in maintaining a safe count of the instruments. According to statement 7
of the of the ACORN framework, the nursing professional needs to conduct a progressive
count before removing the instruments from the actual clinical setup. Under this the scrub
nurse needs to ensure that the instrument bags are retained in the surgical room until the final
count is completed (Jensen and Shipp 2015, p.10). However as argued by Gore and Osborne
(2017), it is difficult to keep track of the small articles and items such as surgical sponges and
swabs which can also be a cause of secondary inflammatory reactions.
Alignment of the current workplace settings with ACORN standards
Therefore, compliance with the ACORN standards can help in ensuring the safety
standards are maintained within a clinical setup. Thus, reflecting upon the current case study
it could be said that there was violation on the part of the scrub nurse to follow the standard 8
statement mentioned in the ACORN. In this case, there was an error on the part of the scrub
nurse to follow the process effectively. The raytec left to the development of further
secondary infection in the patient. As per the sub-directive of the statement 8 of the ACORN
standards, extreme emergency situations may prevent normal counting and documenting
process form being followed (acorn.org 2018). However, there was a violation on the part of
the scrub and count nurse, where the nurse had used the item for local dressing and later on
forgot to remove it. On further diagnosis, it was found that there was also a lack of clear

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instructions to the nurse regarding the methodology to be followed on the operation table.
Hence, it was required that a clear working policy be implemented within the perioperative
care. Additionally, providing sufficient training over the ACORN standards can also help in
complying with the safe policy and measures (Guglielmi et al. 2015, p.360). As per the
standard 4 of the ACORN guidelines, once a surgical gauge or something of that order enters
the body cavity of the patient during the surgical process, effective care should be taken to
remove them duly. This is because retaining of such surgical instruments can elicit defence
reaction in the immunocompressed patient (White and Spruce 2015, p.52).
The ACORN standards were developed in order to safeguard the professional
interests of the perioperative nurses (Oriel and Itani 2016, p.640). They provide a minimum
standard of care for the perioperative nurses. Some of the objectives which had been
promoted though the implementation of the standards are infection prevention and adherence
to the 2016-2017 ACORN standards. As commented by Matikainen (2017), the
implementation of the guideline can help in controlling or reducing the risk of exposure to
infectious agents. Therefore, the policies and procedures are developed aligned to the
recommendations set by the Australian Commission on safety and quality. The figures and
stats have mentioned that 11% of the healthcare cost in Australia generate due to medical
negligence (aihw.gov 2018). Hence, implementation of the ACORN standards would ensure
that the additional healthcare costs could be diverted towards the development of an effective
and better integrated healthcare structure. As commented by Jensen and Shipp (2015), the
ACORN staffing systems and procedures varies from hospitals to hospitals. Therefore, the
education and skill sets possessed by the nurses play a critical role in ensuring the quality of
care. In this respect, the current healthcare set up also failed to employ implement effective
training programs for educating the nurses regarding the different aspects of perioperative
care and management.
Critically evaluating the strength of the evidence base and the ACORN standards
Therefore, for the management of the current issue within preoperative environment
evidence based practices needs to be developed. Some of the evidence based practices which
could be implemented over here are use of protective gloves which can further control the
rate of infection within the perioperaitve environment. The ACORN standards of care were
divided into two sub themes, which are the maintenance of standards of care, the
enhancement of the care standards. As mentioned by Battie (2016), it was required to set up

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a resource body that will support the registered nurses and advice them on the minimum
standards which needs to be followed. The second objective was to develop the effective
policies and guidelines based upon the real and actual scenario (Ross et al. 2017, p.90). The
development of a resource team was an instrumental step forward as it would help the nurses
in following the necessary standards of perioperative care.
Additionally, the development of guidelines based upon the current scenario can help
the scrub and the count nurses understand the loopholes in their services. However as
supported by Osborne (2017), awareness and sufficient support from the healthcare
committee is required for the implementation of the evidence based practices.
The ACORN standards could be further discussed with reference to the case scenario.
Here, the standards 4 and 8 were violated where the nurse failed to follow the surety
protocols with the patient and left the raytec over the lungs, which led to the development of
secondary infection. The standard 4 states, that before stitching the body part of the patient
after surgery, care needs to be taken that the surgical items and equipments have been duly
removed.
Recommendations for effective nursing practices
In order to ensure that effective nursing standards are maintained within the
perioperative care a number of additional quality control checks and measures needs to be
implemented. For example implementation of evidence based practices within the nursing
care, which would help in reducing the chances of accidents. Additionally, knowledge of the
ACORN standards would also help in preventing legal breaches. It has been seen that on an
average 5% hospitals in Australia fail to follow the legal and professional nursing standards
resulting in legal implications on the part of the hospices (Jensen and Shipp 2015, p.10). The
legal violations results in monetary implications which results in unnecessary cost cutting.
Additionally, reflecting upon the actual clinical scenario we have found that the
hospital nurses lacked knowledge regarding the ACORN standards. Therefore, the lack of
knowledge affected the quality of the care services delivered by the registered nurses. Hence,
implementing the effective policies and guidelines as a part of the care regimen of the
hospital can help in controlling the rate of negligence. Some of these could be made available
to the nurses in the form of handouts and maintained in the form of directives in the

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operational wards. This would help in ensuring that the nurses do not miss out on the
important steps and procedures to be followed.
Training and exposure to practical in-house sessions also forms a compulsory part of
the care scenario. As commented by Duff et al. (2016), the statetement 8 of the ACORN
standards further instructs that in case a normal count cannot be followed, post-operative x-
ray of the surgical site needs to be conducted. As commented by Gao et al. (2017), the
provision of training can improve the quality of care and support services. The training could
be given as a compulsory part of the care plan. Additionally, based upon the training the
employees could be awarded with special incentives, which could motivate them further in
improving the standards of care.
Conclusion
The current assignment focuses on the concept of legal and professional issues in
nursing. Here, a case study had been taken for reflection where the patient had to undergo
immediate surgery. Due to the lack of sufficient knowledge in the per-operative nurses
regarding the ACORN standards the infection prevention standards were not taken care of
effectively. Therefore, educating the healthcare staff regarding the ACORN standards along
with conducting internal checks and random assessment can help in maintaining the quality
of care. Additionally, implementation of the evidence based practices further helps in
maintaining the standards of care. Some of these are implementation of a resource team
which can help the nurses in understanding the requirements of the emergency care process.
In the current study the ACORN standards have been discussed with regards to a
perioperarive care. Therefore, revision of the policies and the guidelines of the hospital can
help in the implementation of acute care. Additionally, designing of effective care plans and
strategies based upon immediate situations can further help in improving the quality of care.
For the implementation of the ACORN standards more importance needs to be given upon
the legal and professional guidelines. The legal and professional guidelines ensure that the
policies are implemented in place. Therefore, building of effective legal framework forms the
backbone of an effective perioperative care.

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References
acorn.org 2018, acorn.org , Available at : https://www.acorn.org.au/standards/ [Accessed on
13 Mar. 2018]
aihw.gov 2018, aihw.gov , Available at : https://www.aihw.gov.au/reports-statistics
[Accessed on 12 Mar. 2018]
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Wright, A.J. and Groah, L.K 2015, ‘New Strategies to Assert the Value of the Perioperative
Nurse’, AORN journal, vol. 101, no.3, pp.359-369.

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