Using the ACORN Standards: An exploration of claims, concerns Using the ACORN Standards: An exploration of claims, concerns and issues and issues

An interactive action research workshop was offered during the ACORN & ASIORNA Conference which was held in Adelaide in 2018. The purpose of the workshop was to explore the research evidence supporting ACORN’s Standards for Perioperative Nursing in Australia , to identify gaps in the evidence related to standards and to explore challenges associated with the implementation of standards in clinical practice. The workshop also provided perioperative nurses with the opportunity to discuss their research interests and ask questions about undertaking research-focused degrees. Workshop participants provided an eclectic and credible range of issues related to the development and implementation of standards, underpinned by their concern for patient safety. In addition, the workshop outcomes have since provided the basis for the Research Committee to develop a research priorities survey to be distributed to the membership in the next 12 months.


Abstract
An interactive action research workshop was offered during the ACORN & ASIORNA Conference which was held in Adelaide in 2018. The purpose of the workshop was to explore the research evidence supporting ACORN's Standards for Perioperative Nursing in Australia, to identify gaps in the evidence related to standards and to explore challenges associated with the implementation of standards in clinical practice. The workshop also provided perioperative nurses with the opportunity to discuss their research interests and ask questions about undertaking research-focused degrees. Workshop participants provided an eclectic and credible range of issues related to the development and implementation of standards, underpinned by their concern for patient safety. In addition, the workshop outcomes have since provided the basis for the Research Committee to develop a research priorities survey to be distributed to the membership in the next 12 months.

Background
In 2017, the Australian College of Perioperative Nurses (ACORN, the College) established a Research subcommittee (RSC) to support and encourage research relating to perioperative nursing, to promote evidence-based practice and improve knowledge and learning. The primary function of the RSC is to guide and coordinate all aspects of research activity for the College. Its terms of reference are to: • identify and support world class, established and emerging researchers to undertake rigorous research in perioperative nursing The workshop used an action research approach that was informed by critical social theory and applied a claims, concerns and issues (CCI) framework 1 to explore the questions posed. Action research is a participatory method used to investigate and solve issues. It allows participants to engage collaboratively to solve practice-based issues and uses interactive and creative techniques to explore and gather data regarding the issues under discussion 2 .
The CCI framework allows the questions to be explored by examining three concepts 1 : 1. Claims: these are any assertions that a stakeholder may make that are favourable.
2. Concerns: these are any assertions that are unfavourable. The purpose is to highlight potential barriers: personal, systematic or organisational, real or perceived.
3. Issues: these are reasonable questions raised through better understanding of claims and concerns and are drawn from the latter by using 'what' and 'how' questions.
After gathering the data from participants, the results were summarised under each component of the framework and presented to participants. Framing participants' comments in relation to claims, concerns and issues allowed them to reflect on the results. It enabled claims to be acknowledged, and concerns and issues to be shared, discussed and potentially addressed 1 .
Presenting the workshop findings to the wider perioperative community in this article also adds to the participatory and collaborative nature of the action research methodology.
The workshop was conducted over one hour with 15 participants and three facilitators, the latter were members of the RSC. Three sets of questions were posed. 3. What are some of the issues associated with using the Standards in practice? How can these issues be overcome?
Participants were asked to respond to each question in turn by making both favourable and unfavourable assertions and raising any questions they had. Responses were written on three different coloured sticky notes, used to separately denote the claims, concerns and issues, and posted onto wall charts (Figure 1). At the end of each question the notes were examined by the facilitators, themes were identified and the information shared with the participants. Time for discussion was allocated Outcomes 1. Are the Standards evidencebased? How do we know?
The answers to this question (see Table 1) provided predominantly favourable assertions (claims) that the Standards are evidencedbased, fully referenced and undergo a rigorous review process. Unfavourable assertions (concerns) and questions (issues) related to recency of the literature included, differences in interpretation of state directives that often override the Standards and the availability of the Standards in clinical settings.

Claims Concerns Issues
• evidence-based (8 participants) • rigorous process (2) • referenced (2) • use systematic reviews • recency of literature (2) • interpreted differently (2) • state directives are used in some states • PPE consistency (presumed language and recommendations) • not accessible to all • legality of standards • are they reviewed often enough?
PPE -personal protective equipment The answers to question two (see Table 2) indicated mostly unfavourable assertions and questions that related to what might be missing. These included different interpretations of the Standards; unclear links to the national standards; the generalised nature of the Standards relative to answering specific clinical questions (e.g., use of cloth hats); discrepancies between theory and actual clinical practice; the lack of coverage relative to unregistered staff; time delays in synthesising evidence into practice e.g. preventing hypothermia, and the lack of a guidance tool to assist in tailoring the Standards for use, relative to specific health care facilities (HCF).
3. What are some of the issues associated with using the Standards in practice? How can these issues be overcome?
Question three highlighted questions or issues (see Table 3). Again, access to the Standards was a concern that was identified, with the clash with state directives also noted. Failure to use the Standards was highlighted and various reasons for this were proffered. They included lack of management and education support, lack of consequence for their non-use, inconsistencies with other professional standards (e.g. Sterilising Research and Advisory Council of Australia) and poor knowledge of their existence by novices.
Suggestions were given to address these issues including various educational activities and initiatives, being proactive to increase awareness of the Standards and engaging in mentorship.
There were two final questions posed to the workshop participants, particularly those who were beginner researchers. The first sought their ideas about aspects of perioperative practice worthwhile researching.

Claims Concerns Issues
• not sure • yes, but the Standards can conflict with state directives; sometimes definitions used in standards are too broad.
• interpreted differently (3) • sometimes too general to answer specific questions (2) e.g. cloth hats • the ACORN standards should show a link to national standards • do not cover unregistered staff • credentialing • guidance tool to develop to be HCF specific • mismatch between theoretical practice and observed clinical practice -the theory-practice gap • time delays to synthesising evidence into practice (2) e.g. preventing hypothermia • mandate plume policy • cover most things but always room for change The support needed to undertake research, including research-based higher degrees elicited several responses, as follows: • How do you embark on a PhD?
• How do you choose a good supervisor?
• Does ACORN provide research advice?
• How do you go ahead with research and how do you break through barriers in conducting research?
• How can we have a clear pathway for supporting publications and getting them recognised?
• Wanting support with masters' degree research subject -what is available?

Claims Concerns Issues
• audit tool required to standardise compliance • able to be implemented as considered 'gold' standard • change takes so long (could be overcome by policy review and education) • different state laws • local culture, nurse won't use EBP, other team members won't use standards • access to the Standards • policies and procedures direct link to AORN (could be overcome by mentors, increasing importance of the Standards to individuals) • staff not reading or referring to the Standards • variance in facility policy in not aligning to the Standards i.e. not following them, no consequence • managers and educators are weak -if you get in their face they may wake up • facility access • management of poor application of standards (could be overcome by interactive training or tools) • novice nurses are not familiar with standards (could be overcome by competency packages) • difference between ACORN standards and others e.g. CSSU • not everyone passionate about standards (could be overcome by posters • directly support facilities (to use the Standards) • relevance e.g. size of facility

Conclusions
The research workshop provided the opportunity to further the work of the RSC and explore perioperative nurses' views about evidence for practice and implementing standards. Using a critical social theory framework, underpinned by participatory methodology, the workshop allowed the identification of perceived gaps in the use of standards and potential areas for further research. The workshop was also the means to communicate with ACORN members who are interested in exploring the evidence more successfully, becoming early researchers or exploring further study, and to establish contacts now and for future. This will allow the opportunity to support emerging researchers, develop a community of perioperative researchers and build research capacity in the perioperative speciality. It has also provided the basis for the RSC to develop a research priorities survey to be distributed to the membership via an email link.