NR 513 Week 5 Scholarly Writing Exercise Example

Two Nurses on Call: Why Small Hospitals Should Stop Counting a Distant House Supervisor as the Second Nurse in Phase I Recovery

Student Name

College of Nursing, Chamberlain University

NR 513: Professional Role Enhancement

Instructor Name

Month Day, Year

Two Nurses on Call: Why Small Hospitals Should Stop Counting a Distant House Supervisor as the Second Nurse in Phase I Recovery

The Claim

Small hospitals that recover emergency surgical patients at night should put a second perianesthesia-competent registered nurse on call for every night, rather than naming a house supervisor elsewhere in the building as the second nurse. That is my claim, and the rest of this paper argues for it. I make it as a postanesthesia care unit (PACU) nurse who has taken night call at a community hospital for twelve years; the observations about night call below are my own, and every other idea is credited where it is used. The argument runs in four steps: the risk in Phase I is real and documented, the specialty's standard already addresses it, the best objection is about money and workforce, and a modest proposal meets the standard at a cost a small hospital can see and plan for. I do not claim more certainty than the evidence allows.

The Problem Is Real

The first hours after anesthesia are dangerous in specific, predictable ways. Kellner et al. (2018) reviewed 43 malpractice claims in which the damaging event occurred in a PACU and counted respiratory injury as the largest single category, 32.6% of claims, with nerve and airway injuries next. Among the deaths in that series, 56.3% involved a diagnosis that was delayed or missed. The authors concluded that close monitoring by the responsible clinicians is what allows these complications to be caught in time; that conclusion is theirs. My inference from it is narrower: a nurse who is alone when an airway problem develops is less able to diagnose it and act at the same time.

What the Standard Says

Phase I is the period of care immediately after anesthesia, while the patient is still emerging and cannot yet be trusted to protect his or her own airway; I use the term in that ordinary clinical sense. The practice recommendation of the American Society of PeriAnesthesia Nurses (ASPAN) on staffing calls for a pair of registered nurses wherever a Phase I patient is being cared for, at least one of them trained for that phase, with the partner positioned to respond immediately to a spoken request for help, on call nights included (American Society of PeriAnesthesia Nurses, 2025). It also expects the nurse caring for the patient to be able to see and reach the stretcher at every moment. It also cites a Canadian court decision, Laidlaw v. Lions Gate Hospital, as calling the Phase I PACU the most important room in the hospital because it poses the greatest potential dangers to the patient. I quote that phrase because the court's wording, not mine, is the point: the risk was recognized in law long before the current standard was written.

The standard does not say that a house supervisor cannot be the second nurse. It says where the second nurse must be. A house supervisor covering the whole hospital from another floor is, by the terms of her job, not in the unit.

The Strongest Objection

The strongest objection is about workforce and money, and ASPAN states it in the same document. Its staffing recommendation lists the aging workforce, difficulty recruiting, the nursing labor shortage and retention among the pressures on perianesthesia staffing (American Society of PeriAnesthesia Nurses, 2025). A small hospital may recover only a few patients a week after midnight. A second call nurse is paid for every night on the call schedule, most of which end without a single case, and asking a small group of nurses to take more call may drive some of them to leave, which would make staffing worse.

I think this objection is correct about cost and wrong about the alternative. The house supervisor arrangement does not save the cost of a second nurse; it moves the cost to the patient on the nights when the second nurse is needed and is not there.

What the Wider Evidence Adds

There is no trial comparing one nurse with two in a PACU at night, and I am not aware of one that could ethically be run. The nearest evidence comes from general hospital wards. In a study of 422,730 surgical patients in nine European countries, Aiken et al. (2014) linked each added patient per nurse to a rise of about seven percent in the likelihood of dying within thirty days after surgery. Their setting differs from mine, and I do not claim the figure transfers. I use it for a more limited point: the number of nurses available to watch a patient is associated with whether deterioration is caught, which is the concern behind the ASPAN standard.

A Workable Proposal

The proposal is modest. Each night, a second PACU nurse is on call along with the first, and both come in for any Phase I recovery. Where that is not possible, an intensive care nurse competent in airway management comes to the PACU and stays until the patient leaves Phase I, and handover from the operating room waits until both nurses are standing in the unit. Call pay for the second nurse is the cost; set it next to the price of one airway event, which falls on a patient, a family and a nurse who was alone.

My claim is not that every night will go badly with one nurse. Most nights go well. It is that a hospital that accepts emergency surgery at night has accepted the Phase I care that follows it, and the standard for that care does not change because the clock does.

What This Argument Does Not Settle

Two questions remain open, and I leave them open deliberately. The first is who pays: whether call pay for a second nurse comes from the perioperative budget, the nursing budget or a reduction in the number of elective cases scheduled late in the day, which would reduce the number of emergencies that spill into the night. That is a decision for hospital leaders, and my argument only establishes that the cost exists and should be counted. The second is whether a hospital that cannot staff two nurses at night should stop accepting some emergency cases after midnight and transfer them instead. That question involves surgeons, emergency physicians and the communities these hospitals serve, and it is larger than a nursing standard. I raise it because it is the honest consequence of taking the standard seriously.

References

Aiken, L. H., Sloane, D. M., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R., Diomidous, M., Kinnunen, J., Kózka, M., Lesaffre, E., McHugh, M. D., Moreno-Casbas, M. T., Rafferty, A. M., Schwendimann, R., Scott, P. A., Tishelman, C., van Achterberg, T., & Sermeus, W. (2014). Nurse staffing and education and hospital mortality in nine European countries: A retrospective observational study. The Lancet, 383(9931), 1824-1830. https://doi.org/10.1016/S0140-6736(13)62631-8

American Society of PeriAnesthesia Nurses. (2025). 2025-2026 perianesthesia nursing standards, practice recommendations and interpretive statements. https://www.aspan.org/Publications-Resources/ASPAN-Publications/ASPAN-Standards

Kellner, D. B., Urman, R. D., Greenberg, P., & Brovman, E. Y. (2018). Analysis of adverse outcomes in the post-anesthesia care unit based on anesthesia liability data. Journal of Clinical Anesthesia, 50, 48-56. https://doi.org/10.1016/j.jclinane.2018.06.038