A nursing association takes issue with the American College of Surgeons' guidelines for clinician attire.
By Alexandra Wilson Pecci
A dress code for surgical teams intended to "support professionalism on behalf of patients," has been met with questions from a nursing group, which says the code lacks rigor.
The guidelines on operating room attire issued by the American College of Surgeons this month notes the symbolism of the skullcap to the surgical professional, and says that the skullcap "can be worn when close to the totality of hair is covered by it and only a limited amount of hair on the nape of the neck or a modest sideburn remains uncovered."
The iconic, wing-tipped nursing cap is a symbol of the nursing profession, but that doesn't mean it has any place in the operating room, says Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, Director of Evidence-Based Perioperative Practice for the Association of periOperative Registered Nurses (AORN).
"It's all about patient safety," she says. "It's not about our symbolism. It's not about how we look."
Basing guidelines on symbolism and hard-to-define notions such as modesty is problematic, AORN says.
"How does one enforce something like that? What is a modest sideburn?" Spruce asks. "It's very open to interpretation, and we need to be very clear."
That's why AORN last week issued a detailed response to the ACS's statement on attire, and the skullcap is only one of the elements that it takes issue with.
"Of particular concern to AORN and its membership of 40,000 perioperative registered nurses, is the introductory statement: 'The ACS guidelines for appropriate attire are based on professionalism, common sense, decorum, and the available evidence,'" AORN's response states.
It continues, "Regulatory agencies, accrediting bodies, and patients expect health care organizations to follow guidelines that are evidence-based rather than recommendations based on professionalism, common sense, or decorum."
Spruce notes that when it comes to patient safety regarding attire, regulatory agencies such as The Joint Commission and the Centers for Medicare & Medicaid Services don't cite decorum as an influencing factor.
"What they expect, she says, is that people are going to follow… evidence-based guidelines."
Although ACS says that "Soiled scrubs and/or hats should be changed as soon as feasible and certainly prior to speaking with family members after a surgical procedure," AORN notes that OSHA already requires that "attire that has been penetrated by blood, body fluids, or other infectious materials be removed immediately or as soon as possible and be replaced with clean attire."
"We need to follow the law, which is OSHA," Spruce says.
Another Set of Guidelines
The AORN response goes point-by-point through the ACS's guidelines, noting which are evidence-supported (the guidelines against dangling masks); which are not (changing scrubs and hats between cases); and those on which AORN has no opinion (wearing "clean appropriate professional attire [not scrubs] to be worn during all patient encounters outside of the OR.").
AORN notes that it already has its own guidelines for surgical attire that Spruce says should apply to all members of the surgical team. In addition, the "AORN guideline development process meets the rigorous requirements of, and [is]accepted by, the AHRQ National Guidelines Clearinghouse," the AORN response says.
This raises the question about whether the same type of development process was followed for the new ACS guidelines.
"It doesn't appear that they did a systematic review of the evidence because there wasn't any evidence cited," Spruce says that she was not aware of a public comment period before the ACS guideline was approved. "We didn't have any idea that it was coming out."
"We have to be a team, and everybody has to be practicing the same way," she says.