A reflection on the development of the advanced scrub practitioner.
Previously, the ASP role was performed by a junior doctor. However, since the European Working Time Regulation (EWTR) (DH 1998) for doctors in training was implemented, there is now a necessity for other healthcare professionals to take ownership of this role. From August 2004, junior doctors in the NHS and throughout Europe will no longer be excluded from the provision of the EWTR (DH 2004). Their working hours will be limited by law, first to 58 hours per week, and by 2009 to 48 hours per week (DH 2004).
It was first recognised by the National Association of Theatre Nurses (NATN) in 1993 that this situation was not acceptable, and a structured plan was developed to define the role of the first assistant. The expanding role of surgical assistant was given clarification and justification by a Perioperative Care Collaborative position statement (PCC 2003). It was at this time that the first assistant title was changed to that of ASP. By using Gibbs' Framework for Reflection (1988) I will endeavour to explain my perception of the developing role of the ASP within the operating department, reflecting on my own experiences during my time as a student surgical scrub practitioner.
The change to ASP
My clinical supervisor is a consultant gynaecologist and his approach is to treat me as he would a registrar or junior doctor. I was surprised at how different the role was from that of a scrub nurse. I was quizzed by the consultant about my practice and was questioned in depth about the anatomy and physiology of the patient in question. For example: how to prepare the patient appropriately regarding the correct procedure for positioning; draping and preparation of the surgical site; when to apply the dressing; when to remove the drapes; and how to retract safely and cut sutures in the correct manner. He also required evidence from me to be able to substantiate my claims that I was competent to perform this new role.
My regular job in the operating theatre is as team leader for general, gynaecology, endoscopy and ear, nose and throat (ENT) surgery--therefore by definition taking overall control of the day-to-day running of the unit. In my role as assistant I was reminded on many occasions to remain focused on this change of responsibility. At times I found this quite difficult and was distracted by events happening around me which would normally be within my remit as team leader. I was reminded that while practising this role I was not responsible for the events of the day and I had to delegate this responsibility to one of my colleagues. This has sometimes been hard to grasp--to remain focused on the role of the ASP and not the dual role which has been in practice, in my opinion, for far too long.
I have given much thought to the complexities and legal implications of the role of the ASP. In my position as a healthcare professional I am very aware of the NMC Code of Professional Conduct (NMC 2004). It states that I must possess the knowledge and skills to practice safely and effectively without supervision and be aware of my limitations and seek advice as needed, and only accept situations where I am proved to be competent. The PCC (2003) position statement clearly states that the role of the ASP must only be undertaken by a competent practitioner who has undergone the appropriate training. It is my duty at all times to protect and support the health of patients and clients. I am personally accountable for my practice. To be accountable is to work confidently and with assurance in a professional, ethical and lawful way and through my contract I am accountable to my employer (Caufield 2005).
Beesley (1998) states that ASPs are expected to undertake the duties to the same safe and legal standards expected of a doctor. The current situation for doctors is that they have indemnity insurance from organisations such as the Medical Defence Union (Dearlove & Morris 1998) which means that litigation costs are borne by such organisations. Practitioners in the extended role of ASP must have their job description changed to include the new aspects of the developing role. Vicarious liability insurance is within the contract of employment for all staff. This means that the employer will incur any costs for damage and/or support and defend your practice if a claim for malpractice is brought upon you. That is unless it is proved that the practitioner is in breach of contract in some way or policies and procedures are flouted.
However, the practitioner must act within clearly set guidelines and protocols. If the best interests of the patient were judged not to have been met, then the practitioner may face a professional misconduct tribunal and possibly a civil court action.
The National Patient Safety Agency (NPSA) was created in July 2001, and a system for reporting any untoward incidents and service failures was implemented. Lessons must be learned from adverse patient incidents and patient safety and quality of care will remain of paramount importance (Dimond 2004). Many of my tasks depend on the personal preferences of the surgeon (as within this role I work more closely with him), some of which may be deemed to be 'unconventional'. Therefore I must show awareness and discuss with my manager any practice I consider disturbing. The ASP and all theatre personnel are obligated to practice beneficence and at the same time maintain the respect for the autonomy of the patient. Beneficence is defined as 'to prevent harm, to remove harm and to do and promote good' (Beauchamp & Childress 1994). Autonomy is defined as considering the wishes of the patient, and not usurping the patient's wishes simply because we think we know better (Ascensionhealth 2007). Advocacy is defined as 'pleading for another' (OUP 1992).
It is specified in the NMC Code of Professional Conduct (NMC 2004) that the registered practitioner take on the role of advocacy. The theme regarding advocacy through the role of the ASP begins at preoperative visiting. However, with time restraints, a real relationship with the patient is impossible to achieve, but with careful questioning some progress in this area can be made. By meeting the patient at all stages of their progression through theatre, a little of this process can be achieved. Brown (1995) states that the professional operating department practitioner must be orientated to the needs of the patient, as opposed to the solely technical needs of the surgery.
Preoperative patient visiting
As part of my new and developing role I made several preoperative visits to my patients with my clinical supervisor. These were part of my clinical supervisor's preoperative ward round and between us we discussed the procedure, pain management, anti-embolic therapy, postoperative nausea and vomiting, the importance of early mobilisation, physiotherapy and all aspects of aftercare with the patient. I was also at this time observing the consent procedure in great detail and the patient's understanding and perception of what and why they were signing the document. After the consultation with the surgeon I remained with the patient for a few minutes for any questions that the patient may ask of me. From this experience I have found that I have much more empathy with my patients (they are 'real' and not just another name on a list).
It comes as no surprise that one of the greatest fears for a patient is postoperative pain (Charlton 1997). What is pain? According to McCaffrey & Beebe (1994), pain is what the patient says it is. This problem can be discussed in depth at the preoperative visit and the options (of which there are several) for pain relief explored. The use of Patient Controlled Analgesia (PCA) has, over the years, proved invaluable. The main advantage of this technique is that the opioid administration is guaranteed and it is relatively simple and easy to apply (Commission on the Provision of Surgical Services 1990). This is probably the most used and well-known system for patients following major surgery, and the preoperative visit is the best time to educate the patient on how this system works, avoid confusion postoperatively, and get the most benefit from it. However, other options should also be explored, including the use of a non-steroidal analgesia, the well-recognised benefits of regular paracetamol and, if the patient so wished, alternatives like hypnotherapy could be considered. This aspect of the perioperative journey can be discussed at length along with other preoperative options and then reiterated at postoperative visits. At this time adjustments can be made to the prescription for analgesia to give the patient the most benefit from our expertise.
Postoperative nausea and vomiting (PONV)
Another major concern for the patient is PONV. No practitioner likes to see a patient suffering from nausea and vomiting when it can be avoided. Often the case that the patient may not reveal their anxieties to the anaesthetist but they will to a practitioner (I know this to be true through my experience as a theatre practitioner. However, I cannot find any reference to substantiate my claim to this statement). Prevention of PONV is preferable to the treatment. We as practitioners should ensure that anti-emetics are administered prophylactically. To discuss the consequences of anti-emetic prophylaxis with the patient reduces anxiety and the likelihood of postoperative emesis occurring (Nightingale 1994). I believe that as part of my role, following preoperative visiting, I should convey my findings and concerns to other members of the multidisciplinary team and so promote continuity of care.
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Once again it falls to the ASP to reassure the patient that we as a team can employ a number of options and techniques to relieve this distressing problem. It is also very time consuming for the hard-pressed recovery practitioner, and upsetting for the patient by adding to their already considerable discomfort. Patients who have had day surgery are usually eager to go home quickly, while any sickness or nausea will delay early discharge. There is not enough time to visit all my patients after surgery but I have tried to prioritise and visited postoperatively the patients whom I considered to be the most approachable and receptive to my attention.
Rothrock (1998) states that ASP personnel, must be involved preoperatively, intraoperatively and postoperatively. I believe that my postoperative visits were that my preoperative visits had been a valuable part of the patient's education and the information I had imparted helped to ease and reassure the patient for their forthcoming surgery. With most, but not all, of my postoperative visits a good relationship developed and patients seemed genuinely at ease and more confident about their situation. I was able to reassure them at each stage of the process. After my preoperative visit I asked the patient if they would like me to follow their progress through the department. Most of my patients seemed to find this a great reassurance. I then arranged to meet the patient in the anaesthetic room and whenever possible again in the recovery room. I tried to be the familiar friendly face to reassure the patient at this very vulnerable time. I have found the experience to be invaluable.
A study of surgical patients given preoperative visits was carried out in 1996 (Martin 1996). This study concluded that there was a significant reduction in anxiety levels, levels of postoperative pain, nausea and vomiting, leading to an earlier discharge from hospital. This provided evidence of the efficacy of preoperative visits and the recommendation that all surgical patients should receive such a visit from theatre practitioners prior to their operation.
In 1860, when Florence Nightingale established her training school for nurses, nursing was defined as either a womanly duty or a religious vocation. This opinion held fast for many years and still in some areas nurses and non-medical staff are regarded as 'hand maidens' to the surgical staff. This is unacceptable. Perioperative practitioners today have recognised the need for change within the professions and have made the change dramatically from vocation to profession. Within the theatre setting, with the development of the role of ASP, this situation has been compounded by the EWTR (DH 1998) which changes the working practices of junior doctors forever. Consequently I can only see the numbers of ASP trained theatre staff increasing. We cannot go on doing the job of assistant and team leader as a dual role. However, with a bit of foresight and planning the roles can be intertwined with team leader delegation. It is unacceptable to take on this role simply through experience and length of service. I believe that it will positively benefit all aspects of the healthcare profession if after qualifying as an ASP the candidate expanded his or her experience and continued to study for the next level of expertise and take on the extended role, and ultimately become a Surgical Care Practitioner (SCP).
The experience of this training course has provided me with a deeper insight and understanding of the expectations, clinical skills and knowledge I need to provide a more comprehensive service to my employer and, above all, to be able to offer to the patient the very best clinical experience and expertise that they deserve. We can now provide proof of this skill. A risk has been identified through using unauthorised staff members and this risk has now been minimised through the development of this training programme. We must constantly evaluate the process of education for our nurses and other operating department personnel with the result of producing practitioners who have the abilities, attitudes, skills and knowledge to react and care for the patient holistically and realistically.
Ascension Health 2007 Autonomy Available from: http://www.ascensionhealth.org/ethics/public/issues/autonomy.asp [Accessed 12 September 2007]
Beauchamp TL, Childress JF 1994 Principles of Biomedical Ethics Oxford, Oxford University Press
Beesley J 1998 The nurse as first assistant to the surgeon: implications of expanding practice within the operating department British Journal of Theatre Nursing 8 (1) 42-44
Brown A 1995 Trends in Operating Dept Nursing: The Role of Patient Advocate British Journal of Theatre Nursing 5 (2) 5-8
Caufield H 2005 Accountability [Vital Notes for Nurses Series] Oxford, Blackwell Publishing
Charlton E 1997 The management of postoperative pain Update in Anaesthesia Available from: http://www.nda.ox.ac.uk/wfsa/html/u07/u07_003.htm
Commission on the Provision of Surgical Services 1990 Report of a Working Party on Pain After Surgery London, Faculty of Anaesthetists; Royal College of Surgeons
Dearlove O, Morris L 1998 The nurse as first assistant British Journal of Theatre Nursing 8 (5) 37-41
Department of Health 1998 European Working Time Regulations Available from: www.dh.gov.uk/workingtime [Accessed 6 July 2007]
Department of Health 2004 Working Time Directive 2004-FAQs Available from: www.dh.gov.uk [Accessed 12 September 2007]
Dimond B 2004 Legal Aspects of Nursing (4 edn) London, Pearson Education
Martin D 1996 Pre-operative visits to reduce patient anxiety Nursing Standard 10 (23) 33-38
McCaffrey M, Beebe A 1994 Pain: Clinical Manual for Nursing Practice London, Times Mirror International Publishers Limited
National Association of Theatre Nurses 1993 The Role of the Nurse as First Assistant in the Operating Department Harrogate, NATN
Nightingale K 1994 Post Operative Nausea and Vomiting: Achieving Quality of Care Direct Publishing Solutions Ltd
Nursing and Midwifery Council 2004 Code of Professional Conduct London, NMC
Oxford University Press 1992 Concise Oxford Dictionary Oxford, OUP
Perioperative Care Collaborative 2003 The Role and Responsibilities of the Advanced Scrub Practitioner (position statement) Harrogate, PCC
Rothrock JC 1998 The RN First Assistant: An Expanded Perioperative Nursing Role (3rd edn) Philadelphia, Lippincott Williams & Wilkins
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RGN, ENB 997/998
Advanced Scrub Practitioner/Senior Sister, Nuffield Hospital Operating Theatres, Harrogate
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|Title Annotation:||IN THEIR OPINION|
|Publication:||Journal of Perioperative Practice|
|Date:||Oct 1, 2007|
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