To scrub or not to scrub? That is the question.
Drivers for development of the role
The trust had introduced the role of ward practitioner following the publication of Working together - learning together: a framework for lifelong learning for the NHS (DH 2001). The benefit of this new role for patients was having access to a highly skilled and knowledgeable practitioner who focused upon delivering direct holistic patient care, with a particular emphasis on the aspects within Essence of care such as nutrition and continence. This provided ward practitioners with a clear role within the ward team and allowed the qualified nurses to concentrate on more complex aspects of care with the confidence that patients were receiving quality care from staff that were highly competent to deliver fundamental care. Following the first cohort a presentation was given at the trust's Professional Forum to explain the role. Other areas in the trust, including theatres and outpatients, became interested in the role. The education team then became involved with the development of the ATP role in response to the European Working Time Directive (DH 2003). With the subsequent reduction in junior doctors' working hours the trust developed registered staff into the role of advanced scrub practitioners. The trust then took this opportunity to challenge traditional ways of working and developed an ATP role to undertake the role of the scrub practitioner (NHS Modernisation Agency 2004).
It was anticipated that the role would enable greater flexibility within the theatre team through using a skill mix that may improve theatre utilisation (PCC 2007a). It was also hoped that it would aid retention of staff as highlighted by Huddleston and Scoins (2006), as the role would provide development opportunities for support staff in theatres who had previously had limited opportunities to extend their practice (PCC 2007b).
The assistant theatre practitioner role
The role of ATP involves undertaking additional roles to that of the traditional theatre support worker i.e. scrubbing under the direct supervision of a registered practitioner. The role involves delegation of tasks traditionally undertaken by registered practitioners to the ATPs (Hopkins et al 2008). The role initially created some anxiety amongst registered practitioners who perceived a reduction within their role remit, but anxiety reduced over time as staff became familiar with the role. It would appear that this may have been due to a lack of awareness of the role as stated in the Assistant Practitioner Foundation Degree Evaluation Project Final Report 2008 (NHS Northwest 2008 p44-51).
Although the ATP role was seen as providing a career framework for support staff, it was developed as a practical role on its own merit rather than one which would lead towards a registered qualification. Staff were informed about the role of the ATP via staff meetings. The information given covered how the role would develop and that the natural fears of registered practitioners being reduced in numbers were unfounded.
The ATP role did initially cause conflict with registered practitioners, but being included in how the role developed enabled staff to have a greater understanding (Tanner 2001). The registered practitioners were to be the mentors throughout the programme and were also informed that the new role was dependant on delegation from registered practitioners within the theatre teams. This aided staff to become more involved with the training programme. NVQ assessors were already trained to assess at that level, due to the operating department practitioners in the past training at NVQ Level 3.
The differences between the ATP role and a registered practitioner role using our hospital job descriptions are limited, but they are within the scope of professional practice of registered practitioners. The job description includes the person to whom they are responsible. The ATPs can only scrub for cases delegated to them by the registered practitioner within the theatre team (RCN 2011). Registered nurses and operating department practitioners have a duty of care and legal implications to the care of that patient, as does the ATP if they accept the task delegated (RCN 2011).
Assistant theatre practitioners are not currently regulated, and are not able to scrub for National Confidential Enquiry into Perioperative Deaths Classification 1 (NCEPOD 2004). ATPs have a responsibility to the patient and members of staff and remain accountable for their own actions according to their job description. There were not any policies or protocols written specifically for the role, although as patient and staff safety were paramount in developing the training programme, a risk assessment of the role and the programme was undertaken. This was in consultation with the lead theatre practitioner, patient safety team and human resource staff and was incorporated into our standard operating procedures and local policies (Chesterfield Royal Hospital NHS Foundation Trust 2004), following approval from the trust board and patient safety through clinical governance. To remain covered by an employer's vicarious liability our ATPs only work within their abilities and sphere of assessed competence (NMC 2008).
During their period of training, ATPs were employed at Band 2 on the Agenda for Change pay scale (RCN 2004) and rostered to work out of hours as a support worker. On completion of their training they were employed as an ATP on Band 4 of the pay scale (RCN 2004).
In order to become an ATP individuals were required to be experienced support workers and to have completed either the NVQ Level 2 in operating department practice or operating department support.
Assistant theatre practitioner training programme
Following a competitive selection process the first cohort of four candidates for ATPs were recruited to an 18 month programme in March 2004. This programme was not affiliated with a higher education facility but was developed in-house utilising NVQ Level 3 care award, as Chesterfield Royal Hospital NHS Foundation Trust was a centre for NVQ awards. This training programme was commenced at the trust prior to the development of the national NVQ Level 3 Health Perioperative Care Surgical Support award, which was introduced in April 2005. Therefore, in the absence of a national award for the role, the trust needed to develop its own programme of competencies. This included the NVQ Level 3 in care and an additional trust competency portfolio of foundations in surgical practice, which was based upon the surgical competency elements from the NVQ Level 3 Operating Department Practice award.
Candidates were required to attend a formal study day every other week over the 18 month programme which included lectures on a variety of key areas to provide them with the underpinning knowledge for the role (see examples in Box 1). Although the candidates were supernumerary they were rostered out of hours to work as support workers which sometimes caused difficulties in releasing individuals to attend study days.
The NVQ units were based around the role responsibilities, and candidates were supernumerary during the programme, which enabled them to have additional training in clinical practice, allowing evidence to be generated holistically. Assessment planning and regular reviews were important, as was the relationship between the assessor and trainee because it provided support throughout their training. Surgeons assisted with the training, signing off the log book of operations participated in and providing feedback on individuals' performance because they wanted to be involved with training to ensure that these roles enhanced the theatre lists and were productive. We have in the past always involved the surgeons with staff development that includes newly qualified nurses being trained for a role within theatres. However this is not always required for newly qualified operating department practitioners as they receive this training during their diploma and time spent as a student on both surgery and anaesthetics.
Initially candidates were allocated to a particular theatre speciality, enabling them to develop competence before moving on to develop skills in a different speciality. This enabled them to develop their confidence to be able to scrub for more complex cases.
In March 2006 a further four candidates were recruited with an additional two candidates recruited 12 months later. The training package for these individuals was changed to the NVQ Level 3 Health Perioperative Care Surgical Support award, to be consistent with the national award developed for these roles. This ensured a recognised standard of training for the role and provided assurance of quality of care. Eighteen units were selected from this award and individuals were still required to complete the programme within 18 months and attend a series of lectures. The initial candidates were given the opportunity, in 2006, to achieve the NVQ in Health Perioperative Care Support through, wherever possible, using accredited prior learning. This ensured that all the ATPs had completed the same nationally recognised award.
Due to the introduction of the new role and the previously mentioned anxiety of registered practitioners, there were initial difficulties in relation to registered practitioners understanding their responsibilities for the supervision of these staff and their accountability in relation to the delegation of tasks (Hopkins et al 2008). This is evident in the diverse experience of the initial candidates as highlighted by the differing accounts of two of the ATPs presented below.
Assistant theatre practitioner 1 experienced a sense of role conflict with differing staff expectations, which illustrates a lack of understanding about the purpose of the role and the problem of combining a training role with a 'work' role.
'At times I feel that we are used and abused, carrying out twice as much work as Band 5s and with higher expectations of us. We often work as a Band 2 theatre support worker at week-ends but do not agree with this as we end up combining both roles.' (ATP1).
Box 1 - Examples of lecture subjects Basic anatomy and physiology Infection control Aseptic technique Patient draping Surgical hand asepsis Gowning and gloving Consent Accountability and responsibility
This is in contrast to ATP 2 who felt that they were a valued member of the team, although they were still concerned that there was a lack of clarity about how their responsibilities differed from that of the registered practitioners.
'I feel part of the surgical team and feel very valued and not treated any differently to any of the qualified staff. I also feel that the role has really developed over the years; we are able to scrub for minor surgical procedures to major procedures, but I feel there should be a cut off in what procedures we are allowed to do.' (ATP 2).
The experience of ATP 2 is reflected by other department staff who recognise the role to be important, valuing the individuals as team members with skills that provide benefits to both patients and the theatre skill mix. Candidates were able to reduce some of the initial concerns of registered staff through the demonstration of their competence in practice, which appeared to have been facilitated by the previous credibility they had developed within the team as support workers. The ATPs scrub for extensive cases, with the exception of NCEPOD 1 (NCEPOD Classifications 2004) and emergency caesarean sections (NCEPOD Classifications 2004). However, some individuals require more time than others to develop the confidence to undertake complex cases and are allowed to 'opt out' of particular cases until they feel confident and are competent to undertake these safely. All are competency based and each ATP is required to keep a log of surgical procedures that they have scrubbed for during training and after completing the course, as do registered practitioners.
The ATP role has been in place at the trust for more than seven years and is a recognised role within the theatre team and has an ongoing programme of training. The success of the role has resulted in extension into other areas of the theatre complex. ATPs care for patients throughout their journey in theatres, with posts for example in patient reception, where individuals check and admit patients into theatres, releasing staff to return to the ward following handover of patient checks. In the post anaesthetic care unit they manage the patient's care and airway following surgery.
Although an ATP job description had been developed, initially there was an absence of a job description for the training role. This has since been introduced to help reduce some of the role confusion experienced by the candidates to registered practitioners.
The next cohort of candidates will be prepared using the new qualification and credit framework (Skills for Health 2011). This will be a new development for the trust, requiring a review of the current programme to ensure that we are able to deliver the role through the new framework and are still able to maintain and enhance the standards already achieved.
The original question posed was 'To scrub or not to scrub?' Our experience at Chesterfield Royal Hospital NHS Foundation Trust has been that we would support the contention that where assistant theatre practitioners complete a comprehensive training programme supported by the multidisciplinary team in practice, the role enhances the skill mix of the team and provides safe, quality care which enables effective utilisation of the theatre resource.
Success of the role depends upon having enthusiastic experienced candidates, a robust training programme which is supported by managers, and the engagement of a wide range of theatre staff to support individuals during their training and in their substantive role.
No competing interests declared
Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication July 2011.
Department of Health 2003 Protecting staff; delivering services: implementing the European Working Time Directive for doctors in training HSC 2003/001 London, DH
Department of Health 2001 Working together, learning together: a framework for lifelong learning for the NHS London, DH
Hopkins S, Hughes A, Vaughan P 2008 Nursing Standard Essential Guide - Health care assistants and assistant practitioners: Delegation and accountability Harrow, RCN Publishing Company Ltd Available from: www.rcn.org.uk/__data/assets/pdf_file/0004/198049/HCA_booklet.pdf [Accessed September 2011]
Huddleston M, Scoins H 2006 Assistant theatre practitioners: 'must have' or 'needs must' Journal of Perioperative Practice 16 (10) 482-6
National Confidential Enquiry into Perioperative Deaths 2004 The NCEPOD Classification of Intervention London, NCEPOD
National Health Service Modernisation Agency 2004 A career framework for the NHS London, DH
National Health Service Northwest 2008 Assistant practitioner foundation degree evaluation project final report Preston, University of Central Lancashire
Nursing and Midwifery Council 2008 Advice on delegation for registered nurses and midwives London, NMC
Perioperative Care Collaborative Position Statement 2007a Delegation: the support worker in the scrub role London, PCC
Perioperative Care Collaborative Position Statement 2007b Optimising the contribution of the perioperative support worker London, PCC
Royal College of Nursing 2004 Agenda for Change Paycard London, RCN
Royal College of Nursing 2011 Accountability and delegation: what you need to know London, RCN
Skills for Health 2010 Summary of attributes and definitions for career framework levels Bristol, Skills for Health
Skills for Health 2011 The Role of Assistant Practitioners in the NHS, factors affecting evolution and development of the role Bristol,
Skills for Health Tanner J 2001 Healthcare support workers and the scrubbed role Journal of Perioperative Practice 11(6) 262-8
Correspondence address: Jean Timmons, Chesterfield Royal Hospital, Calow, Chesterfield, S44 5BL.
About the authors
Clinical Teacher/Theatres (Retired), Chesterfield Royal Hospital NHS Foundation Trust
SRN, Cert Ed, MHSC
Learning Skills Sister, NVQ Centre Manager, Lead IV, Assessor, Clinical Teacher & Skills for Life Coordinator, Chesterfield Royal Hospital NHS Foundation Trust
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|Title Annotation:||CLINICAL FEATURE; role of assistant theatre practitioners|
|Author:||Timmons, Jean; Johnson, Susanne|
|Publication:||Journal of Perioperative Practice|
|Date:||Oct 1, 2011|
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