The Surgical Care Practitioner role problems and possible solutions from nurses in the UK offered to RNFSA colleagues in New Zealand.
The British healthcare workforce has undergone significant change over the past two and a half decades. The effect of the European Working Time Directive (EWTD) which limits the number of hours worked each week by junior hospital doctors, combined with changes in medical training and the career goals of newly qualified doctors, have all significantly reduced the number of junior medical staff available to assist with operations and other tasks in the surgical department (Chalmers, Joshi, Bentley, & Boyle, 2010). This necessitated an increase in the contribution by non-medically qualified members of the team to the service component of surgical practice. Political drivers for this expansion came from the NHS Plan (DOH 2000), reinforced by the National Practitioner Programme drawn from the NHS Modernisation Agency (Younger, 2006). With support from professional associations, including the surgical Royal Colleges, it became recognised that it was permissible for nurses and registered allied health professionals (AHPs) to undertake advanced roles in surgery. Longstanding leaders in this area, the Royal College of Surgeons of England, issued the following statement in 2011:
"The College expects surgical assistance to be carried out by surgeons in training wherever possible. If this cannot be a doctor we expect the role to be filled by a trained nurse or registered allied health professional' (RCSEng 2011).
Surgical Care Practitioners are non-medical practitioners (nurses or allied health professionals) who, in the absence of junior hospital doctors, have extended the scope of their training to work as members of surgical teams. They perform surgical intervention and other elements of care under the supervision and direction of a consultant, although not independently (RCS Eng, 2013).
The significant point is that "they can perform surgical intervention ..." This differentiates the SCP from other non-medically qualified perioperative personnel within the UK (Table 1).
The first formally trained non-medically qualified surgical assistant within the UK outlined the development of her role, now known as a Surgical Care Practitioner (SCP), and explored problem areas which had become apparent (Holmes, 1994). At the outset, Holmes identified a lack of role definition, formalised training and career structure. She reported patient concerns over practitioners' recognition of limitations, particularly in emergency situations, the possibility of the role having a negative impact upon surgical training for junior doctors and the isolation of individual practitioners. Cost benefits and the role's appropriateness to nursing were unclear at this early stage.
Whilst a number of publications outlined the achievements of early surgical assistants (Biggins 2002; Martin 2002; Kingsnorth 2005; Newey et al 2006), the sustainability of SCP posts in the absence of succession planning, robust transferrable training programmes or support from professional associations was questionable. A number of professional organisations provided guidance, support and training and collaborated in formulating role-specific educational standards for SCP trainees as well as professional definitions, criteria and support networks (Table 2).
Due to a lack of formal educational opportunities in the UK, Suzanne Holmes underwent competency training in the United States of America, returning to the UK on completion. Favourable evaluation of the project laid the foundation for the development of a training programme within cardiac surgery (Beecham 1993, Royal College of Surgeons 1994). Collaboration by a number of professional groups, in part driven by the National Association of Assistants in Surgical Practice (NAASP), who merged with the Association of Perioperative Practice (AfPP) in 2012, led to the development of a national SCP curriculum framework in 2006; recently revised by the Royal College of Surgeons of England (RCSEng 2014). This details the specific role, responsibilities and boundaries of the SCP working in a wide range of specialties. It also outlines both the core and specialist knowledge and skills required by an SCP to perform the role in such a way as to ensure patient safety. Masters level study is now the norm with the RCSEng offering accreditation of SCP modules delivered by higher education institutes that meet their criteria. Educational standards continue to improve, with surgical workshops and support networks offered by AfPP.
Despite calls for urgent statuary regulation of nurses and AHPs who undertake non-medical surgical assistant roles in Britain, SCPs remain under the governance of their primary regulatory authorities --either the Nursing and Midwifery Council or, in the case of allied health professionals, the Health and Care Professions Council. The maintenance of high academic standards and good surgical skills is necessary in an increasingly litigious culture where legal commentators have taken the stance that non-medically qualified surgical assistants must meet the standards of the junior hospital doctors they are replacing (Dimond, 1994 & 2011). Quick (2013) however argues that surgical trainees should meet the standards of the SCP.
The introduction of a voluntary code of conduct for practitioners undertaking advanced perioperative work (AfPP 2013) provides an additional professional standard for those undertaking SCP roles to follow; thus improving standards of patient care and reducing the risk of harm.
Initial concern by surgeons (Newman 2004; Shannon 2005; Wraight 2005; Bruce, Bruce and Williams, 2006; Freudman 2006) that junior doctors' surgical training would be disrupted if they were expected to compete with SCPs for operative exposure have not been borne out. Although there is the potential for competition when both SCP trainees and junior hospital doctors need exposure to the same case mix, careful planning can avoid this. Hickey and Cooper (2009) and Jones et al (2012) suggest that a fully trained SCP supports surgeons in training, with Quick (2013) identifying that one way they do this is by recognising the presence of junior doctors at operating theatre sessions and stepping aside to maximize training opportunities. SCPs also make a positive contribution by teaching basic surgical skills in the clinical setting.
As more research studies have been published, they demonstrate the clear benefits of the inclusion of an SCP to the surgical team (Table 3). These include the recognition of limitations and the opportunity for career progression. Cost savings are apparent although more research is required in this area. Appropriateness to nursing has been demonstrated by Quick (2103) who identified that that the SCP drew upon her nursing experience whilst part of a surgical team.
Succession planning remains problematic in a climate of acute cost consciousness when the time and financial commitment involved in training practitioners is considerable. Currie and Grundie (2011) consider that that it takes time to develop the skills necessary to advancing practice and that there is a need for strategic planning. Raftery (2013) argues that failure to provide suitably trained and experienced replacements for nurse practitioners who take on advanced roles compromises patient care and that succession planning is key to patient safety.
Many of the issues raised by Holmes (1994) have been addressed but there is still considerable variation in the way in which practitioners are managed in the workplace. Some SCPs are employed by surgical teams and others by the operating theatre department. This usually reflects the source of initial funding but can lead to isolation, particularly in departments employing single practitioners. Whilst research has shown that interprofessional relationships improve following the inclusion of an SCP to the surgical team (Abraham 2011, Jones et al 2012, Quick 2013), the requirement to work to a medical model may isolate the SCP from other team members. Negativity from operating theatre staff is difficult to quantify, with only one recent publication on the subject (Sayers, 2010), therefore robust regional and national support mechanisms previously mentioned are needed.
In the UK, a reduced availability of medical staff generates problems with the provision of surgical assistance. This is the result of a combination of factors; the British healthcare system and the imposition of European Union laws. This article has explained how, over a 25 year period, this challenge has been faced and to a considerable extent, solved, offering advice for countries like New Zealand as they begin to implement a similar role. Difficulties remain for nurses and AHPs working as surgical assistants, not least the threat of isolation for some individuals. Associations within the UK exist not only to define professional standards in education and practice but also to provide a network of support for those undertaking the SCP role.
Abraham, J. (2011). Innovative perioperative role improves patient and organisational outcomes in minimally invasive surgery. Journal of Perioperative Practice, 21(5).
Association for Perioperative Practice. (2013, November). AfPP voluntary code of conduct for registered practitioners working in advancing perioperative roles. Retrieved April 2014, from Association for Perioperative Practice: www.afpp.org.uk
Beecham, L. (1993, November 13). Consultants give qualified approval for surgeon's assistant. British Medical Journal, 307, 1286.
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JULIE QUICK RGN, Non-Medical Prescribe (NMP), MSc (Professional Studies in Healthcare) SUSAN HALL, RGN, MSc (Clinical Sciences) & ADRIAN JONES RGN, ENB 176/998, Cert SCP
Julie Quick, RGN, Non-Medical Prescribe (NMP), MSc (Professional Studies in Healthcare) is a Surgical Care Practitioner at Walsall Healthcare Trust, Walsall, West Midlands, England and is the AfPP Advancing Surgical Roles Specialist Interest Group Co-lead.
Susan Hall, RGN, MSc (Clinical Sciences) is a Surgical Care Practitioner (retired from NHS practice 2013) and AfPP Advancing Surgical Roles Specialist Interest Group Co-lead.
Adrian Jones RGN, ENB 176/998, Cert SCP is an Orthopaedic Surgical Care Practitioner/Lecturer Nurse Practitioner, working in the Trauma and Orthopaedic Department, Norfolk and Norwich Hospital NHS University Foundation Trust and is an AfPP Trustee.
Table 1: Titles of non-surgical interventional perioperative roles in the UK Surgical First Assistant (Perioperative Care Collaborative 2012) Physicians Assistant (Department of Health 2005) Physicians Assistant (Anaesthetics) (Royal College of Anaesthetists 2008) Perioperative Specialist Practitioner (Department of Health 2007) Table 2: Associations involved in the development of the surgical care practitioner: Arthroplasty Care Practitioners Association Association of Cardiac Surgical Assistants Association for Perioperative Practice (AfPP) National Association of Assistants in Surgical Practice (NAASP), merged with AfPP in 2012 Royal College of Surgeons Table 3: Benefits of the inclusion of a surgical care practitioner to a surgical team (Abraham 2011 (^), Quick 2013 *) Provides a knowledgeable surgical assistant and competent operator * Improves the patient experience * (^) Maintains surgical provision * Supports surgical training * Opportunity for further role progression * (unpublished data) Streamlines patient discharge (^) Cost effective (^)
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|Author:||Quick, Julie; Hall, Susan; Jones, Adrian|
|Publication:||The Dissector: Journal of the Perioperative Nurses College of the New Zealand Nurses Organisation|
|Date:||Jun 1, 2014|
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