Perioperative roles
The role of the surgical care practitioner within the surgical team Julie Quick
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reviously known by a variety of titles, the surgical care practitioner (SCP) is a nurse or allied health professional who performs pre- and post-operative care and surgical intervention under the supervision of a consultant surgeon (Department of Health (DH), 2006). Despite differences in professional regulation and accountability, the SCP role was initially introduced to the UK in response to the success of the registered nurse first assistant role in the US. The addition of a nurse assistant to the surgical team was considered to expedite surgery and improve patient care (Holmes, 1995). Planned changes to health policy and the surgical workforce have continued to support the expansion of innovative perioperative roles by maximising the potential of nurses and allied health professionals for more than two decades (Calman, 1993; DH, 1999; DH, 2000a; DH, 2000b; DH, 2004; DH, 2007). Although the SCP role has been evident within healthcare since the 1980s, there continues to be strong debate over the use of innovative perioperative roles in healthcare today. Concerns over training (Kingsnorth, 2005), the loss of core allied health skills (McGee and Castledine, 2003) and the impact on surgical trainees (Freudmann, 2006) have been raised but rarely examined.
Literature review Legal and professional considerations Edwards (1995) found a fear of litigation by nurses performing surgical intervention in her early study. Since practitioners who undertake the SCP role are working outside the traditional boundaries of nursing and allied healthcare, practice must not fall below the standard of care that is expected, as laid down by case law (Bolam v Friern Hospital Management Committee (1957)). Dimond (2008) argued that the standard of care expected from advanced practitioners would be that of a junior doctor who continues to perform the tasks and skills associated with the SCP role. Therefore, SCPs must acquire the knowledge, skills and abilities necessary to perform the role to the standard expected of surgical colleagues. Concerns have been raised over the lack of formalised training (Edwards, 1995). More recently, others found that SCPs were suitably qualified and trained to safely assist with and perform surgery (Hickey and Cooper, 2009). SCPs also have a professional obligation to recognise and work within the limits of competence (Nursing and Midwifery Council (NMC), 2008; Health and Care Professions Council (HCPC), 2008). Newey et al (2006) found that the SCP was able to recognise situations during surgery when the consultant was needed for advice. These
British Journal of Nursing, 2013, Vol 22, No 13
Abstract
Changes to the surgical workforce and the continued development of health policy have perpetuated the requirement for innovative perioperative roles. The surgical care practitioner is a nurse or allied health professional who works within a surgical team and has advanced perioperative skills, including the ability to undertake surgical interventions. With only limited literature evaluating this role, any benefits of their inclusion to a surgical team are largely anecdotal. This article presents the findings of an autoethnographic inquiry that explored the experiences of surgical team members who worked with the nurse researcher in her role as surgical care practitioner. Surgeons identified the provision of a knowledgeable, competent assistant and operator who enhanced patient care, helped maintain surgical services and supported the training of junior doctors. The professional, ethical and legal obligations of advanced perioperative practice were upheld. Interprofessional collaboration was improved, as was service provision. This further enhanced the patient experience. The traditional viewpoint that nurses who undertake tasks previously associated with medicine should be working to the standard of a doctor is challenged but requires further examination. Key words: Surgical care practitioner ■ Interprofessional collaboration
■
Autoethnography
findings demonstrate that the SCP is aware of professional and legal issues that relate to innovative perioperative roles.
Patient perceptions Cheang et al (2009) and Moorthy et al (2006a) found that most of their patients would prefer to have their operation carried out by a doctor. In addition, some patients would rather wait longer to be operated on by a doctor than have their operation performed by a SCP (Cheang et al, 2009). Conversely, when a SCP is part of the surgical team patients’ views appear to change. Martin et al (2007) found that patients who had their operation carried out by a SCP were satisfied with the care they received. Their findings demonstrate that patient perceptions of the SCP role differ between those that have been cared for by a surgical team that includes a SCP and those who have been cared for by a surgical team without one. Julie Quick is Surgical Care Practitioner, Walsall Healthcare Trust Accepted for publication: May 2013
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Patient outcomes
Ethical considerations
Several authors found no adverse events occurred when a SCP assessed patients’ suitability for surgery, undertook operative procedures or assisted during low-risk major surgery (Alex et al, 2003; Newey et al, 2006; Hickey and Cooper, 2009; Abraham, 2011). However, one US study showed that when a nurse assistant was part of a surgical team operative, time decreased and monthly mean surgical site infection (SSI) rates improved. Yet, when junior doctors were used as assistants, both operative time and the incidence of SSIs increased (Pear and Williamson, 2009). These studies demonstrate that the addition of a SCP to the surgical team is not detrimental to patient care. Furthermore, and similarly to the thinking of Forty (1995) and Rockrock and Seifert (2009), the findings suggest that the standard of patient care improves when an experienced nurse assistant is part of the surgical team. The development of the SCP role has been gaining momentum over the past 30 years. However, the effect of this professional group on the delivery of surgical care has yet to be fully evaluated. The findings of the small number of published studies demonstrate that the SCP enhances patient care. Any additional benefits of the inclusion of a SCP to a surgical team remain anecdotal. With benefits to the surgical patient previously identified, this study aims to investigate additional benefits of the inclusion of a SCP to a surgical team.
Ethical approval was granted before the study started. Informed consent was gained from all participants before the study with the opportunity to withdraw at any time. Each interview was recorded and transcribed. All responses were anonymised. Individuals who may be recognisable within the narratives and who had not given their consent for inclusion in the study have been given pseudonyms.
Methodology
Findings
No previous study has attempted to explore the experiences of those that work with a SCP. Team feedback is important since modern perioperative teamwork increasingly relies on interprofessional collaboration (Quick, 2011a). Exploring the experiences of colleagues has previously been used in empirical nursing research studies to investigate critically the impact of other non-medically qualified practitioners (Griffin and Melby, 2006; Bradley and Nolan, 2007). A narrative autoethnographical approach enabled the nurse researcher to explore the experiences of members of the surgical team who work with a SCP, along with her own experiences of working as a SCP in general surgery.
The view of the surgeons interviewed was that the addition of a SCP to the surgical team resulted in a number of benefits to the patient, members of the surgical team, the practitioner and the employing organisation.
Population, sampling and access
Respondents had confidence that the SCP knew the surgeons’ preferences and how they liked to operate:
All members of the general surgical team at one NHS trust in the West Midlands who had worked with the researcher in her role as a SCP for at least 6 months were invited to take part in the study. This included five consultant surgeons and one associate specialist, each working in a variety of subspecialties within general surgery, including breast, vascular, bariatric and paediatrics.
Data collection Semi-structured interviews took place during May and June 2012. An interview schedule included the main research question and an aide mémoire that served as a reminder to explore additional advantages of the role (see Table 1). Following the principles of autoethnography, a number of narratives based on reflection of the researcher’s own experience and patient correspondence were used to add richness and depth to the data collected (Eriskon, 1986).
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Data management Data analysis was carried out manually by the researcher in line with autoethnographic theory (Ellis, 1999; 2004). Recurring words, phrases and concepts emerged that allowed a number of themes to be identified.
Credibility and reliability The inclusion of participants from different surgical specialties allowed the collection of multiple perspectives on the topic of interest. Credibility of the study was further strengthened by the use of narratives, adding another viewpoint to the study and allowing multiple-perspective triangulation. While narrative autoethnography allows the researcher to combine her own experiences with those of the participants, Miles and Huberman (1994) argue that this may damage the overall rigour of the study.To overcome this problem, insider involvement was acknowledged throughout the study and this article.
‘Provides a knowledgeable surgical assistant and competent operator.’ Participants identified that there were benefits to be gained from the SCP being a permanent member of the surgical team. ‘… you are a permanent member of the staff and you know each and every surgeon’s requirement and you … adapt yourself around their needs.’
‘… you … are here all the time, not like a registrar or SHO FY1 [senior house officer foundation year 1] doctor who keeps changing every 12 months, 4 months, and so on. So, since you are here all the time, you have learned the practice of different surgeons and the way they operate.’ Consequently, the surgeons recognised that the SCP had become a knowledgeable surgical assistant. ‘We’re delighted when we happen to be rostered with you on the list because we don’t have to explain anything to you. You always … know what we are about to do even if you haven’t seen the particular procedure maybe very often. You’ve obviously taken effort to find out what it entails
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Narrative 1 Mr Clarke called me. ‘Hi, Julie? I’m running a bit late; stuck downstairs in clinic. Could you start the list? I’ll only be another half hour. Start with the inguinal hernia. Ask Sister Wooton to help you. She’s helped me many times before. She won’t mind.’ ‘Okay,’ I said and he hung up. Although I knew that Sister Wooton had undertaken and passed an advanced scrub practitioner course, I was unsure if theatres would be adequately staffed for her to assist and, at the same time, not undertake the ‘dual role’. I went to find her. ‘Susan, Mr Clarke is running late in clinic, he’s asked me to start. Would you be able to assist me with the inguinal hernia? He’ll join us in half an hour.’ ‘Oh, yes that’s fine. I have Stacey and Anne with me so one can scrub and the other can circulate. He shouldn’t be too long.’ The list started. I started surgery with Sister Wooton assisting me. I was just opening external oblique when Mr Clarke arrived in theatre. ‘Ah, Julie, I’m here!’ He came over to the table. ‘It looks like everything is under control. Susan, are you happy to continue to assist Julie?’ he asked Sister Wooten. ‘Yes, I’m fine,’ she replied. ‘Good. Okay then I’ll just grab my sandwich in the coffee room. Call me when the next case is here.’
and clearly, when you come a lot, like routinely, we don’t have to explain everything.’ However, this was felt to be in contrast to some of the doctors on surgical rotation: ‘It’s lovely to have a person that’s so knowledgeable with you and that’s always punctual. Almost the total opposite of a junior doctor; they are unpunctual, they are not really knowledgeable, they haven’t usually tried to find out what the operation entails.’ Narrative 2 Dear Julie, I just wanted to say a big thank you for your work on my operation. You were brilliant—and extremely kind and patient before the operation. I was in really safe hands and am very grateful. All good wishes, Simon
Narrative 3 Dear Mrs Quick, Just a line to thank you for the procedure carried out on the 21st. All appears to be going well, and I am very much obliged to you for your competence and professional attitude. With kind regards, Jack Smith
‘... sometimes ... the registrars ... they are turning up in the theatre having no information about the patient. And then you ask them, “What was the angiogram?” they are just looking at you.’ Respondents also viewed the SCP as a careful, competent operator: ‘I think that we have shown, in the time you have been here and started the role to where you are now, that you can train someone that is competent in theatres to operate and to be a very sensible and very safe operator.’ Consequently, the participants were satisfied that the SCP could undertake operative procedures under distant supervision (Narrative 1 supports this finding). Participants also perceived that the SCP was involved in clinical decision-making and, if needed, would contact the surgeon for advice: ‘… over the years, you have built up so much experience so you can see the pre-op patients … and if there are any doubts, getting in touch with the consultant or registrar, saying that, “This is the wrong operation, can you come and see?”’ This suggests that the SCP is involved in making clinical judgements but is aware of her limitations.
Improves the patient experience The findings from this study demonstrate that the addition of a SCP to the surgical team enhanced the patient experience. Participants identified that the SCP had a positive influence on the patient experience: ‘it’s nice to have a familiar face for the patients, and if you have got somebody who has seen this operation, done this operation, worked with the consultant for 6 months, a year, and knows exactly what the routine is … it makes a huge difference to the patients; they feel that a team is looking after them …’ One participant felt that the SCP’s nursing background further enhanced the patient experience.
Narrative 4 Mr Roberts had undergone a hernia repair earlier that morning. I went to visit him postoperatively on the day case ward. ‘Mr Roberts? It’s Julie ...’ I said as I approached him ‘... the nurse who saw you earlier.’ Mr Roberts was blind. ‘I have just come to see how you are feeling.’ ‘I’m fine, thank you,’ he replied. I continued, ‘The operation went well. The hernia was quite big but it’s been repaired now.’ I explained that I would check his wound, which I reassured him was fine, and I asked him if he had any questions. I talked him through the discharge process, and reminded him to take his painkillers. He thanked me for my help and I started to say my goodbyes. However, as I got up to leave I noticed that the drink that had been placed on his bedside table was untouched. I asked him if he had known there was drink for him. ‘Yes, I’ll have it in a bit,’ he replied. However, there was also a drink of water on the table and this too was untouched. This was probably because the table had been placed out of arm’s reach for Mr Roberts, and as he was blind he had been unable to see it. I moved the table nearer and showed him where the cup was by placing his hand by the saucer. ‘Now if you need any help,’ I suggested, ‘press the buzzer that is in your other hand. Okay?’ ‘Yes, that’s fine, thank you, Julie.’
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‘It does benefit [sic] because you have all come from nurse training. So you have spent more time with the patients, speaking to them and alleviating their fears and apprehensions and … because you guys have more patience than the doctors.’ Narratives 2, 3 and 4 reinforce this finding. This suggests that nurses continue to use their nursing skills when undertaking expanded roles.
Supports surgical training Participants felt that the addition of a SCP to a surgical team supported the training and development of junior doctors. Surgeons identified that the SCP was able to teach the junior doctors basic surgical skills. ‘Even the junior doctors are usually delighted
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Perioperative roles Table 1. Interview schedule
Discussion
Main research question: What are the benefits of an SCP assisting during major surgery?
Despite concerns over the loss of professional identity by nurses who take on advanced roles (McGee and Castledine, 2003), a key finding from this study was that the SCP relied on her nursing expertise while part of the surgical team. Preexisting skills, such as good communication and professional attributes, including patience, reliability and trustworthiness, were identified by surgeons as an integral part of the role and were felt to improve the patient’s surgical experience. In a similar way to the findings of Martin et al (2007), this was also reflected within three of the narratives, which demonstrated patient satisfaction when the SCP undertook operative procedures. This suggests that nurses who undertake the SCP role maintain professional values and support the position of the Royal College of Nursing (RCN) and the DH that nurses should continue to rely on their nursing skills when undertaking advanced roles (Ball, 2005). While this study acknowledged that the SCP helped to maintain surgical services, the addition of a nurse to the surgical team offers benefits far greater than simply picking up the shortfall from surgical colleagues. In a similar way to the agenda of healthcare and workforce planning over the past three decades, the findings from this study identified that as a permanent member of the surgical team, the nurse made a difference to the experience of the surgical patient. As a knowledgeable team member, the addition of a SCP to the surgical team was seen by the surgeons to directly improve patient care by ensuring patient understanding and compliance. However, this was not the only way the SCP enhanced patient care. One additional finding suggested that including a nurse in the surgical team encouraged a cohesive approach that improved the patient’s experience. Although patients were not included in this study, surgeons acknowledged that they felt their care was the responsibility of an interprofessional surgical team that had developed close working relationships. Such relationships within the perioperative environment have already proven essential in improving patient safety and enhancing care (World Health Organization, 2008; National Health Service Institute for Innovation and Improvement, 2011). The addition of a SCP to the surgical team provides an additional opportunity for successful interprofessional relationships to develop. Unlike in early reports (Edwards, 1995; Kingsnorth, 2005), no concerns were identified over the training of the SCP in this study. This is likely to be due to the introduction of a
Aide-mémoire: What are the benefits of SCPs working alongside junior doctors? What are the benefits of the SCP undertaking surgery? What are the benefits for patients? Are there any disadvantages of the role? Any additional comments you would like to make?
to be with you because they feel that you teach them … they learn little things like suturing, knotting, that sort of thing.’ In addition, the SCP would step aside to provide an opportunity for surgical exposure for the surgical trainee: ‘I have seen that whenever there is a trainee you give the opportunity for the trainee and you put the trainee in the first place …’ Narrative 5 affirms this finding. This suggests that the SCP complements the training of junior doctors on surgical rotation.
Maintains service provision Surgeons raised concerns over the reduced number of junior doctors on surgical rotation: ‘… there are fewer juniors around, that’s for sure.’ Consequently, the surgical teams had implemented changes in practice to overcome this directive: ‘… we’ve made it quite clear that our priority is that the patients on the ward get seen and assessed every day, and if they don’t then clearly they are going to either come into problems or not progress towards being discharged.’ Therefore, the doctors’ priority was transferred from attending theatre lists to working on the wards. This was felt to impact on covering the theatre lists: ‘We’ve got a very serious problem to occupy the rota.’ Consequently, the surgeons in this study had become reliant on the SCP to fill this deficit: ‘So, you guys, when you step in, actually, we are so very dependent now upon this service.’ Since the doctors were busy on the wards, the respondents identified that the SCP could start the operating lists: ‘You nurse practitioners, you are available, so you can take on the first case, and as you are experienced, the consultants are also comfortable, and … that’s where your role is.’
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Narrative 5 It was a Wednesday afternoon and I was rostered to assist on the general day case list as usual. Dr Shoab, a senior house officer, also turned up to help on the same list. She had attended many of the day case lists before. While we were waiting for the list to start Dr Shoab approached me. ‘Julie, could I have a word with you please?’ ‘Yes, of course,’ I replied and motioned for us to move into the empty recovery bay. ‘I have to apologise to you.’ ‘Why?’ I asked, perplexed. ‘I have not been kind to you. I have been distant and curt.’ I was taken aback by her honesty but had not consciously noticed any rude behaviour directed to me by Dr Shoab. She did seem quiet during the lists but I presumed she wanted to concentrate on the case in hand. She continued. ‘I have not treated you well because I thought that you were here to take over my role, but having worked with you for a while now I realise that you are here to help. You have supported me when I have been left to finish the case and have also given me good advice.’
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Key points n Innovative perioperative roles have been evident within healthcare for more than three decades, yet any benefits of their inclusion in a surgical team remained largely anecdotal n Using an autoethnographical inquiry allowed the nurse researcher to explore the experiences of surgical team members with her own experiences of working as a surgical care practitioner in general surgery n Surgeons identified the surgical care practitioner as a knowledgeable, competent assistant and operator who enhanced patient care n While working as a surgical care practitioner, the nurse upheld the professional, ethical and legal obligations of advanced perioperative practice n The claim that nurses undertaking advanced roles should be working to the standard shown by a doctor is challenged by the findings of this study but requires further examination
national curriculum framework for nurses and allied health professionals who undertake the SCP role (DH, 2006). Although this framework was not directly evaluated, by identifying that SCPs have gained the necessary skills and knowledge required to meet the challenges of the role, the findings from this study suggest that the national curriculum, through its standardisation of education, has produced SCPs who are safe and competent operators. This supports the view that nurses and allied health professionals could be safely trained to fill the deficit resulting from the reduced availability of junior doctors on operating lists (Royal College of Surgeons of England, 1994; DH, 2006; DH, 2007). This study is the first to identify that while working as a SCP the nurse adhered to the professional, legal and ethical obligations of an advanced perioperative role. The surgeons who took part in this study acknowledged that not only had the SCP obtained the skills and knowledge to undertake the role but also recognised their limitations, seeking advice when necessary. This supports the work carried out by Newey et al (2006), which recognised that the SCP is working within the professional obligations of the role. Nurses working as SCPs also have a moral responsibility to clarify their non-medical role to patients (Quick, 2011b). Since the narratives identify that the SCP had explained her role to patients, this suggests that she is meeting the ethical obligations of the role and refutes the argument of Moorthy et al (2006b) that patients are being deceived by practitioners undertaking advanced perioperative roles. Dimond (2008) surmised that to fulfil their legal obligation, practitioners undertaking activities that in the past were the sole remit of doctors must meet the standards of care expected of a doctor: ‘The reasonable standard of care will be required of any professional carrying out an extended role. If that activity was formally carried out by a doctor, then a nurse undertaking that activity will be expected to provide the reasonable standard that a doctor would have provided.’ (Dimond, 2008; 574) Yet, the findings from this study show that the surgical ability of junior and middle grade doctors falls short of the
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surgeons’ expectations. This, therefore, challenges Dimond’s argument, instead suggesting that the doctor who attends surgical lists should be working to the reasonable standard of practice demonstrated by the SCP.
Study limitations Since autoethnography aims to explore the experiences of a particular group or setting, the findings from this small-scale study may not be transferable outside the context of this general surgical team. Additionally, the narratives are specific to the emic researcher, making the study difficult to replicate. A multi-site study undertaken by an etic researcher might produce a stronger confirmation of the findings.
Conclusion This systematic study is the first to collate the benefits of the inclusion of a SCP to a surgical team as perceived by surgical team members and therefore makes a significant contribution to the literature. A number of perceived benefits emerged for the patient, surgical team members and the organisation, providing reassurance for those who have had concerns over the SCP role in the past. In particular, the findings from this study suggest that the addition of a nurse to a surgical team enhances patient care, maintains surgical services and supports the training of junior doctors. Additional findings suggest that nurses who undertake innovative roles adhere to the professional, ethical and legal obligations of advanced perioperative practice. Interprofessional collaboration was improved, as was service provision. This further enhanced the patient experience. The proposal that doctors on surgical rotation should be working to the reasonable standard of care achieved by the SCP challenges the established perception of medical negligence for nurses and allied health professionals undertaking advanced roles, but BJN requires further examination. Conflict of interest: none Abraham J (2011) Innovative perioperative role improves patient and organisational outcomes in minimal invasive surgery. J Perioper Pract 21(5): 158-64 Alex J, Rao VP, Cale ARJ, Griffin S, Cowen M, Guvendik L (2003) Surgical nurse assistants in cardiac surgery: a UK trainee’s perspective. Eur J Cardiothoracic Surg 25(1): 111-5 Ball J (2005) Maxi Nurses: Nurses Working in Advanced and Extended Roles Promoting and Developing Patient-centred Care. RCN, London Bolam v Friern Hospital Management Committee [1957] 1 WLR 582 Bradley E, Nolan P (2007) Impact of nurse prescribing: a qualitative study. J Adv Nurs 59(2): 120-8 Calman KC (1993) Consultation on report working group on specialist medical training. Department of Health, London Cheang PP, Weller M, Hollis LJ (2009) What’s in a name – patient’s view of the involvement of ‘care practitioners’ in their operations. Surgery 7(6): 340-4 Department of Health (1999) Making a Difference: Strengthening the Contribution of Nurses, Midwives and Health Visitors to Health and Healthcare. DH, London Department of Health (2000a) A Health Service of All Talents: Developing the NHS Workforce. DH, London Department of Health (2000b) The NHS Plan: A Plan for Investment, a Plan for Reform. DH, London Department of Health (2004) Modernising Medical Careers: The Next Steps. DH, London Department of Health (2006) The Curriculum Framework for the Surgical Care Practitioner. DH, London Department of Health (2007) New Ways of Working for Everyone: A Best Practice Guide. DH, London Dimond B (2008) Legal Aspects of Nursing & Healthcare. 5th edn. Pearson Education Edwards K (1995) What are nurses’ views on expanding practice? Nurs Stand 9(41): 38-40 Ellis C (1999) Heartful autoethnography. Qualitative Health Research 9(5): 669-83 Ellis C (2004) The Ethnographic I: A Methodological Novel about Autoethnography.
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Perioperative roles Altamira Press, California Erickson K (1986) In: Miles MB, Huberman M (1994) Qualitative Data Analysis: An Expanded Sourcebook. 2nd edn. Sage Publishing, London Forty J (1995) A change for the better. In: Leifer D. Nursing Standard 9(18): 16-7 Freudmann M (2006) Surgical Care Practitioners are having a detrimental effect on surgical training. BMJ Careers; 9 Sept: 97 Griffin M, Melby V (2006) Developing an advanced nurse practitioner service in emergency care: attitudes of nurses and doctors. J Adv Nurs 56(3): 292-301 Health and Care Professions Council (2008) Standards of Performance, Conduct and Ethics. HCPC, London Hickey N, Cooper K (2009) Varicose vein surgery performed by a surgical care practitioner. Phlebology 24(1): 43-5 Holmes S (1995) A change for the better. In: Leifer D. Nursing Standard 9(18): 16-7 Kingsnorth AN (2005) Training SCPs to perform inguinal hernia surgery: results of the Plymouth Action On programme. Bulletin of the Royal College of Surgeons of England 87(4 Suppl): 242-3 http://tinyurl.com/nwz5n6l Martin S, Purkayastha S, Massey R et al (2007) The surgical care practitioner: a feasible alternative: results of a prospective 4-year audit at St Mary’s Hospital Trust, London. Ann R Coll Surg Engl 89(1) 30-5 McGee P, Castledine G (2003) Advanced Nursing Practice. 2nd edn. Blackwell Publishing, Oxford Miles MB, Huberman M (1994) Qualitative Data Analysis: An Expanded Sourcebook. 2nd edn. Sage Publishing, London Moorthy R, Grainger J, Scott A, Powles JW, Latis SG (2006a) Are patients happy with SCPs operating? Annals of the Royal College of Surgeons of England 88:
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101-3 http://tinyurl.com/ovhx8mq Moorthy R, Grainger J, Scott A, Powles JW, Latis SG (2006b) Surgical care practitioner – a confusing and misleading title. Annals of the Royal College of Surgeons of England 88: 98-100 http://tinyurl.com/oqem9na National Health Service Institute for Innovation and Improvement (2011) The Productive Operating Theatre: Building Teams for Safer Care. www.institute. nhs.uk/quality_and_value/productivity_series/the_productive_operating_ theatre.html (accessed 28 April 2011) Newey M, Clark M, Green T, Kershaw C, Pathak P (2006) Nurse-led management of carpel tunnel syndrome: an audit of outcomes and impact on waiting times. Ann R Coll Surg Engl 88(4): 399-401 Nursing and Midwifery Council (NMC) (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. NMC, London Pear SM, Williamson TH (2009) The RN first assistant: an expert resource for surgical site infection prevention. AORN J 89(6): 1093-7s Quick J (2011a) Modern perioperative teamwork: an opportunity for interprofessional learning. J Perioper Pract 21(11): 387-90 Quick J (2011b) The Surgical Care Practitioner: The Legal and Ethical Issues. Challenges & Change: Leading from the Front Line. AfPP2011 47th Congress and Exhibition. Bournemouth, 20 October. Harrogate: AfPP. Rothrock JC, Seifert PC (2009) Assisting in Surgery: Patient-centered Care. Competency & Credentialing Institute, Denver, CO Royal College of Surgeons of England (1994) Cardiac Surgeons’ Assistants: Guidelines for Heads of Departments. RCS (Eng), London World Health Organization (2008) WHO Surgical Safety Checklist and Implementation Manual. WHO, Geneva
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The role of the surgical care practitioner within the surgical team Julie Quick
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reviously known by a variety of titles, the surgical care practitioner (SCP) is a nurse or allied health professional who performs pre- and post-operative care and surgical intervention under the supervision of a consultant surgeon (Department of Health (DH), 2006). Despite differences in professional regulation and accountability, the SCP role was initially introduced to the UK in response to the success of the registered nurse first assistant role in the US. The addition of a nurse assistant to the surgical team was considered to expedite surgery and improve patient care (Holmes, 1995). Planned changes to health policy and the surgical workforce have continued to support the expansion of innovative perioperative roles by maximising the potential of nurses and allied health professionals for more than two decades (Calman, 1993; DH, 1999; DH, 2000a; DH, 2000b; DH, 2004; DH, 2007). Although the SCP role has been evident within healthcare since the 1980s, there continues to be strong debate over the use of innovative perioperative roles in healthcare today. Concerns over training (Kingsnorth, 2005), the loss of core allied health skills (McGee and Castledine, 2003) and the impact on surgical trainees (Freudmann, 2006) have been raised but rarely examined.
Literature review Legal and professional considerations Edwards (1995) found a fear of litigation by nurses performing surgical intervention in her early study. Since practitioners who undertake the SCP role are working outside the traditional boundaries of nursing and allied healthcare, practice must not fall below the standard of care that is expected, as laid down by case law (Bolam v Friern Hospital Management Committee (1957)). Dimond (2008) argued that the standard of care expected from advanced practitioners would be that of a junior doctor who continues to perform the tasks and skills associated with the SCP role. Therefore, SCPs must acquire the knowledge, skills and abilities necessary to perform the role to the standard expected of surgical colleagues. Concerns have been raised over the lack of formalised training (Edwards, 1995). More recently, others found that SCPs were suitably qualified and trained to safely assist with and perform surgery (Hickey and Cooper, 2009). SCPs also have a professional obligation to recognise and work within the limits of competence (Nursing and Midwifery Council (NMC), 2008; Health and Care Professions Council (HCPC), 2008). Newey et al (2006) found that the SCP was able to recognise situations during surgery when the consultant was needed for advice. These
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Abstract
Changes to the surgical workforce and the continued development of health policy have perpetuated the requirement for innovative perioperative roles. The surgical care practitioner is a nurse or allied health professional who works within a surgical team and has advanced perioperative skills, including the ability to undertake surgical interventions. With only limited literature evaluating this role, any benefits of their inclusion to a surgical team are largely anecdotal. This article presents the findings of an autoethnographic inquiry that explored the experiences of surgical team members who worked with the nurse researcher in her role as surgical care practitioner. Surgeons identified the provision of a knowledgeable, competent assistant and operator who enhanced patient care, helped maintain surgical services and supported the training of junior doctors. The professional, ethical and legal obligations of advanced perioperative practice were upheld. Interprofessional collaboration was improved, as was service provision. This further enhanced the patient experience. The traditional viewpoint that nurses who undertake tasks previously associated with medicine should be working to the standard of a doctor is challenged but requires further examination. Key words: Surgical care practitioner ■ Interprofessional collaboration
■
Autoethnography
findings demonstrate that the SCP is aware of professional and legal issues that relate to innovative perioperative roles.
Patient perceptions Cheang et al (2009) and Moorthy et al (2006a) found that most of their patients would prefer to have their operation carried out by a doctor. In addition, some patients would rather wait longer to be operated on by a doctor than have their operation performed by a SCP (Cheang et al, 2009). Conversely, when a SCP is part of the surgical team patients’ views appear to change. Martin et al (2007) found that patients who had their operation carried out by a SCP were satisfied with the care they received. Their findings demonstrate that patient perceptions of the SCP role differ between those that have been cared for by a surgical team that includes a SCP and those who have been cared for by a surgical team without one. Julie Quick is Surgical Care Practitioner, Walsall Healthcare Trust Accepted for publication: May 2013
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Patient outcomes
Ethical considerations
Several authors found no adverse events occurred when a SCP assessed patients’ suitability for surgery, undertook operative procedures or assisted during low-risk major surgery (Alex et al, 2003; Newey et al, 2006; Hickey and Cooper, 2009; Abraham, 2011). However, one US study showed that when a nurse assistant was part of a surgical team operative, time decreased and monthly mean surgical site infection (SSI) rates improved. Yet, when junior doctors were used as assistants, both operative time and the incidence of SSIs increased (Pear and Williamson, 2009). These studies demonstrate that the addition of a SCP to the surgical team is not detrimental to patient care. Furthermore, and similarly to the thinking of Forty (1995) and Rockrock and Seifert (2009), the findings suggest that the standard of patient care improves when an experienced nurse assistant is part of the surgical team. The development of the SCP role has been gaining momentum over the past 30 years. However, the effect of this professional group on the delivery of surgical care has yet to be fully evaluated. The findings of the small number of published studies demonstrate that the SCP enhances patient care. Any additional benefits of the inclusion of a SCP to a surgical team remain anecdotal. With benefits to the surgical patient previously identified, this study aims to investigate additional benefits of the inclusion of a SCP to a surgical team.
Ethical approval was granted before the study started. Informed consent was gained from all participants before the study with the opportunity to withdraw at any time. Each interview was recorded and transcribed. All responses were anonymised. Individuals who may be recognisable within the narratives and who had not given their consent for inclusion in the study have been given pseudonyms.
Methodology
Findings
No previous study has attempted to explore the experiences of those that work with a SCP. Team feedback is important since modern perioperative teamwork increasingly relies on interprofessional collaboration (Quick, 2011a). Exploring the experiences of colleagues has previously been used in empirical nursing research studies to investigate critically the impact of other non-medically qualified practitioners (Griffin and Melby, 2006; Bradley and Nolan, 2007). A narrative autoethnographical approach enabled the nurse researcher to explore the experiences of members of the surgical team who work with a SCP, along with her own experiences of working as a SCP in general surgery.
The view of the surgeons interviewed was that the addition of a SCP to the surgical team resulted in a number of benefits to the patient, members of the surgical team, the practitioner and the employing organisation.
Population, sampling and access
Respondents had confidence that the SCP knew the surgeons’ preferences and how they liked to operate:
All members of the general surgical team at one NHS trust in the West Midlands who had worked with the researcher in her role as a SCP for at least 6 months were invited to take part in the study. This included five consultant surgeons and one associate specialist, each working in a variety of subspecialties within general surgery, including breast, vascular, bariatric and paediatrics.
Data collection Semi-structured interviews took place during May and June 2012. An interview schedule included the main research question and an aide mémoire that served as a reminder to explore additional advantages of the role (see Table 1). Following the principles of autoethnography, a number of narratives based on reflection of the researcher’s own experience and patient correspondence were used to add richness and depth to the data collected (Eriskon, 1986).
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Data management Data analysis was carried out manually by the researcher in line with autoethnographic theory (Ellis, 1999; 2004). Recurring words, phrases and concepts emerged that allowed a number of themes to be identified.
Credibility and reliability The inclusion of participants from different surgical specialties allowed the collection of multiple perspectives on the topic of interest. Credibility of the study was further strengthened by the use of narratives, adding another viewpoint to the study and allowing multiple-perspective triangulation. While narrative autoethnography allows the researcher to combine her own experiences with those of the participants, Miles and Huberman (1994) argue that this may damage the overall rigour of the study.To overcome this problem, insider involvement was acknowledged throughout the study and this article.
‘Provides a knowledgeable surgical assistant and competent operator.’ Participants identified that there were benefits to be gained from the SCP being a permanent member of the surgical team. ‘… you are a permanent member of the staff and you know each and every surgeon’s requirement and you … adapt yourself around their needs.’
‘… you … are here all the time, not like a registrar or SHO FY1 [senior house officer foundation year 1] doctor who keeps changing every 12 months, 4 months, and so on. So, since you are here all the time, you have learned the practice of different surgeons and the way they operate.’ Consequently, the surgeons recognised that the SCP had become a knowledgeable surgical assistant. ‘We’re delighted when we happen to be rostered with you on the list because we don’t have to explain anything to you. You always … know what we are about to do even if you haven’t seen the particular procedure maybe very often. You’ve obviously taken effort to find out what it entails
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Narrative 1 Mr Clarke called me. ‘Hi, Julie? I’m running a bit late; stuck downstairs in clinic. Could you start the list? I’ll only be another half hour. Start with the inguinal hernia. Ask Sister Wooton to help you. She’s helped me many times before. She won’t mind.’ ‘Okay,’ I said and he hung up. Although I knew that Sister Wooton had undertaken and passed an advanced scrub practitioner course, I was unsure if theatres would be adequately staffed for her to assist and, at the same time, not undertake the ‘dual role’. I went to find her. ‘Susan, Mr Clarke is running late in clinic, he’s asked me to start. Would you be able to assist me with the inguinal hernia? He’ll join us in half an hour.’ ‘Oh, yes that’s fine. I have Stacey and Anne with me so one can scrub and the other can circulate. He shouldn’t be too long.’ The list started. I started surgery with Sister Wooton assisting me. I was just opening external oblique when Mr Clarke arrived in theatre. ‘Ah, Julie, I’m here!’ He came over to the table. ‘It looks like everything is under control. Susan, are you happy to continue to assist Julie?’ he asked Sister Wooten. ‘Yes, I’m fine,’ she replied. ‘Good. Okay then I’ll just grab my sandwich in the coffee room. Call me when the next case is here.’
and clearly, when you come a lot, like routinely, we don’t have to explain everything.’ However, this was felt to be in contrast to some of the doctors on surgical rotation: ‘It’s lovely to have a person that’s so knowledgeable with you and that’s always punctual. Almost the total opposite of a junior doctor; they are unpunctual, they are not really knowledgeable, they haven’t usually tried to find out what the operation entails.’ Narrative 2 Dear Julie, I just wanted to say a big thank you for your work on my operation. You were brilliant—and extremely kind and patient before the operation. I was in really safe hands and am very grateful. All good wishes, Simon
Narrative 3 Dear Mrs Quick, Just a line to thank you for the procedure carried out on the 21st. All appears to be going well, and I am very much obliged to you for your competence and professional attitude. With kind regards, Jack Smith
‘... sometimes ... the registrars ... they are turning up in the theatre having no information about the patient. And then you ask them, “What was the angiogram?” they are just looking at you.’ Respondents also viewed the SCP as a careful, competent operator: ‘I think that we have shown, in the time you have been here and started the role to where you are now, that you can train someone that is competent in theatres to operate and to be a very sensible and very safe operator.’ Consequently, the participants were satisfied that the SCP could undertake operative procedures under distant supervision (Narrative 1 supports this finding). Participants also perceived that the SCP was involved in clinical decision-making and, if needed, would contact the surgeon for advice: ‘… over the years, you have built up so much experience so you can see the pre-op patients … and if there are any doubts, getting in touch with the consultant or registrar, saying that, “This is the wrong operation, can you come and see?”’ This suggests that the SCP is involved in making clinical judgements but is aware of her limitations.
Improves the patient experience The findings from this study demonstrate that the addition of a SCP to the surgical team enhanced the patient experience. Participants identified that the SCP had a positive influence on the patient experience: ‘it’s nice to have a familiar face for the patients, and if you have got somebody who has seen this operation, done this operation, worked with the consultant for 6 months, a year, and knows exactly what the routine is … it makes a huge difference to the patients; they feel that a team is looking after them …’ One participant felt that the SCP’s nursing background further enhanced the patient experience.
Narrative 4 Mr Roberts had undergone a hernia repair earlier that morning. I went to visit him postoperatively on the day case ward. ‘Mr Roberts? It’s Julie ...’ I said as I approached him ‘... the nurse who saw you earlier.’ Mr Roberts was blind. ‘I have just come to see how you are feeling.’ ‘I’m fine, thank you,’ he replied. I continued, ‘The operation went well. The hernia was quite big but it’s been repaired now.’ I explained that I would check his wound, which I reassured him was fine, and I asked him if he had any questions. I talked him through the discharge process, and reminded him to take his painkillers. He thanked me for my help and I started to say my goodbyes. However, as I got up to leave I noticed that the drink that had been placed on his bedside table was untouched. I asked him if he had known there was drink for him. ‘Yes, I’ll have it in a bit,’ he replied. However, there was also a drink of water on the table and this too was untouched. This was probably because the table had been placed out of arm’s reach for Mr Roberts, and as he was blind he had been unable to see it. I moved the table nearer and showed him where the cup was by placing his hand by the saucer. ‘Now if you need any help,’ I suggested, ‘press the buzzer that is in your other hand. Okay?’ ‘Yes, that’s fine, thank you, Julie.’
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‘It does benefit [sic] because you have all come from nurse training. So you have spent more time with the patients, speaking to them and alleviating their fears and apprehensions and … because you guys have more patience than the doctors.’ Narratives 2, 3 and 4 reinforce this finding. This suggests that nurses continue to use their nursing skills when undertaking expanded roles.
Supports surgical training Participants felt that the addition of a SCP to a surgical team supported the training and development of junior doctors. Surgeons identified that the SCP was able to teach the junior doctors basic surgical skills. ‘Even the junior doctors are usually delighted
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Perioperative roles Table 1. Interview schedule
Discussion
Main research question: What are the benefits of an SCP assisting during major surgery?
Despite concerns over the loss of professional identity by nurses who take on advanced roles (McGee and Castledine, 2003), a key finding from this study was that the SCP relied on her nursing expertise while part of the surgical team. Preexisting skills, such as good communication and professional attributes, including patience, reliability and trustworthiness, were identified by surgeons as an integral part of the role and were felt to improve the patient’s surgical experience. In a similar way to the findings of Martin et al (2007), this was also reflected within three of the narratives, which demonstrated patient satisfaction when the SCP undertook operative procedures. This suggests that nurses who undertake the SCP role maintain professional values and support the position of the Royal College of Nursing (RCN) and the DH that nurses should continue to rely on their nursing skills when undertaking advanced roles (Ball, 2005). While this study acknowledged that the SCP helped to maintain surgical services, the addition of a nurse to the surgical team offers benefits far greater than simply picking up the shortfall from surgical colleagues. In a similar way to the agenda of healthcare and workforce planning over the past three decades, the findings from this study identified that as a permanent member of the surgical team, the nurse made a difference to the experience of the surgical patient. As a knowledgeable team member, the addition of a SCP to the surgical team was seen by the surgeons to directly improve patient care by ensuring patient understanding and compliance. However, this was not the only way the SCP enhanced patient care. One additional finding suggested that including a nurse in the surgical team encouraged a cohesive approach that improved the patient’s experience. Although patients were not included in this study, surgeons acknowledged that they felt their care was the responsibility of an interprofessional surgical team that had developed close working relationships. Such relationships within the perioperative environment have already proven essential in improving patient safety and enhancing care (World Health Organization, 2008; National Health Service Institute for Innovation and Improvement, 2011). The addition of a SCP to the surgical team provides an additional opportunity for successful interprofessional relationships to develop. Unlike in early reports (Edwards, 1995; Kingsnorth, 2005), no concerns were identified over the training of the SCP in this study. This is likely to be due to the introduction of a
Aide-mémoire: What are the benefits of SCPs working alongside junior doctors? What are the benefits of the SCP undertaking surgery? What are the benefits for patients? Are there any disadvantages of the role? Any additional comments you would like to make?
to be with you because they feel that you teach them … they learn little things like suturing, knotting, that sort of thing.’ In addition, the SCP would step aside to provide an opportunity for surgical exposure for the surgical trainee: ‘I have seen that whenever there is a trainee you give the opportunity for the trainee and you put the trainee in the first place …’ Narrative 5 affirms this finding. This suggests that the SCP complements the training of junior doctors on surgical rotation.
Maintains service provision Surgeons raised concerns over the reduced number of junior doctors on surgical rotation: ‘… there are fewer juniors around, that’s for sure.’ Consequently, the surgical teams had implemented changes in practice to overcome this directive: ‘… we’ve made it quite clear that our priority is that the patients on the ward get seen and assessed every day, and if they don’t then clearly they are going to either come into problems or not progress towards being discharged.’ Therefore, the doctors’ priority was transferred from attending theatre lists to working on the wards. This was felt to impact on covering the theatre lists: ‘We’ve got a very serious problem to occupy the rota.’ Consequently, the surgeons in this study had become reliant on the SCP to fill this deficit: ‘So, you guys, when you step in, actually, we are so very dependent now upon this service.’ Since the doctors were busy on the wards, the respondents identified that the SCP could start the operating lists: ‘You nurse practitioners, you are available, so you can take on the first case, and as you are experienced, the consultants are also comfortable, and … that’s where your role is.’
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Narrative 5 It was a Wednesday afternoon and I was rostered to assist on the general day case list as usual. Dr Shoab, a senior house officer, also turned up to help on the same list. She had attended many of the day case lists before. While we were waiting for the list to start Dr Shoab approached me. ‘Julie, could I have a word with you please?’ ‘Yes, of course,’ I replied and motioned for us to move into the empty recovery bay. ‘I have to apologise to you.’ ‘Why?’ I asked, perplexed. ‘I have not been kind to you. I have been distant and curt.’ I was taken aback by her honesty but had not consciously noticed any rude behaviour directed to me by Dr Shoab. She did seem quiet during the lists but I presumed she wanted to concentrate on the case in hand. She continued. ‘I have not treated you well because I thought that you were here to take over my role, but having worked with you for a while now I realise that you are here to help. You have supported me when I have been left to finish the case and have also given me good advice.’
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Key points n Innovative perioperative roles have been evident within healthcare for more than three decades, yet any benefits of their inclusion in a surgical team remained largely anecdotal n Using an autoethnographical inquiry allowed the nurse researcher to explore the experiences of surgical team members with her own experiences of working as a surgical care practitioner in general surgery n Surgeons identified the surgical care practitioner as a knowledgeable, competent assistant and operator who enhanced patient care n While working as a surgical care practitioner, the nurse upheld the professional, ethical and legal obligations of advanced perioperative practice n The claim that nurses undertaking advanced roles should be working to the standard shown by a doctor is challenged by the findings of this study but requires further examination
national curriculum framework for nurses and allied health professionals who undertake the SCP role (DH, 2006). Although this framework was not directly evaluated, by identifying that SCPs have gained the necessary skills and knowledge required to meet the challenges of the role, the findings from this study suggest that the national curriculum, through its standardisation of education, has produced SCPs who are safe and competent operators. This supports the view that nurses and allied health professionals could be safely trained to fill the deficit resulting from the reduced availability of junior doctors on operating lists (Royal College of Surgeons of England, 1994; DH, 2006; DH, 2007). This study is the first to identify that while working as a SCP the nurse adhered to the professional, legal and ethical obligations of an advanced perioperative role. The surgeons who took part in this study acknowledged that not only had the SCP obtained the skills and knowledge to undertake the role but also recognised their limitations, seeking advice when necessary. This supports the work carried out by Newey et al (2006), which recognised that the SCP is working within the professional obligations of the role. Nurses working as SCPs also have a moral responsibility to clarify their non-medical role to patients (Quick, 2011b). Since the narratives identify that the SCP had explained her role to patients, this suggests that she is meeting the ethical obligations of the role and refutes the argument of Moorthy et al (2006b) that patients are being deceived by practitioners undertaking advanced perioperative roles. Dimond (2008) surmised that to fulfil their legal obligation, practitioners undertaking activities that in the past were the sole remit of doctors must meet the standards of care expected of a doctor: ‘The reasonable standard of care will be required of any professional carrying out an extended role. If that activity was formally carried out by a doctor, then a nurse undertaking that activity will be expected to provide the reasonable standard that a doctor would have provided.’ (Dimond, 2008; 574) Yet, the findings from this study show that the surgical ability of junior and middle grade doctors falls short of the
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surgeons’ expectations. This, therefore, challenges Dimond’s argument, instead suggesting that the doctor who attends surgical lists should be working to the reasonable standard of practice demonstrated by the SCP.
Study limitations Since autoethnography aims to explore the experiences of a particular group or setting, the findings from this small-scale study may not be transferable outside the context of this general surgical team. Additionally, the narratives are specific to the emic researcher, making the study difficult to replicate. A multi-site study undertaken by an etic researcher might produce a stronger confirmation of the findings.
Conclusion This systematic study is the first to collate the benefits of the inclusion of a SCP to a surgical team as perceived by surgical team members and therefore makes a significant contribution to the literature. A number of perceived benefits emerged for the patient, surgical team members and the organisation, providing reassurance for those who have had concerns over the SCP role in the past. In particular, the findings from this study suggest that the addition of a nurse to a surgical team enhances patient care, maintains surgical services and supports the training of junior doctors. Additional findings suggest that nurses who undertake innovative roles adhere to the professional, ethical and legal obligations of advanced perioperative practice. Interprofessional collaboration was improved, as was service provision. This further enhanced the patient experience. The proposal that doctors on surgical rotation should be working to the reasonable standard of care achieved by the SCP challenges the established perception of medical negligence for nurses and allied health professionals undertaking advanced roles, but BJN requires further examination. Conflict of interest: none Abraham J (2011) Innovative perioperative role improves patient and organisational outcomes in minimal invasive surgery. J Perioper Pract 21(5): 158-64 Alex J, Rao VP, Cale ARJ, Griffin S, Cowen M, Guvendik L (2003) Surgical nurse assistants in cardiac surgery: a UK trainee’s perspective. Eur J Cardiothoracic Surg 25(1): 111-5 Ball J (2005) Maxi Nurses: Nurses Working in Advanced and Extended Roles Promoting and Developing Patient-centred Care. RCN, London Bolam v Friern Hospital Management Committee [1957] 1 WLR 582 Bradley E, Nolan P (2007) Impact of nurse prescribing: a qualitative study. J Adv Nurs 59(2): 120-8 Calman KC (1993) Consultation on report working group on specialist medical training. Department of Health, London Cheang PP, Weller M, Hollis LJ (2009) What’s in a name – patient’s view of the involvement of ‘care practitioners’ in their operations. Surgery 7(6): 340-4 Department of Health (1999) Making a Difference: Strengthening the Contribution of Nurses, Midwives and Health Visitors to Health and Healthcare. DH, London Department of Health (2000a) A Health Service of All Talents: Developing the NHS Workforce. DH, London Department of Health (2000b) The NHS Plan: A Plan for Investment, a Plan for Reform. DH, London Department of Health (2004) Modernising Medical Careers: The Next Steps. DH, London Department of Health (2006) The Curriculum Framework for the Surgical Care Practitioner. DH, London Department of Health (2007) New Ways of Working for Everyone: A Best Practice Guide. DH, London Dimond B (2008) Legal Aspects of Nursing & Healthcare. 5th edn. Pearson Education Edwards K (1995) What are nurses’ views on expanding practice? Nurs Stand 9(41): 38-40 Ellis C (1999) Heartful autoethnography. Qualitative Health Research 9(5): 669-83 Ellis C (2004) The Ethnographic I: A Methodological Novel about Autoethnography.
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Perioperative roles Altamira Press, California Erickson K (1986) In: Miles MB, Huberman M (1994) Qualitative Data Analysis: An Expanded Sourcebook. 2nd edn. Sage Publishing, London Forty J (1995) A change for the better. In: Leifer D. Nursing Standard 9(18): 16-7 Freudmann M (2006) Surgical Care Practitioners are having a detrimental effect on surgical training. BMJ Careers; 9 Sept: 97 Griffin M, Melby V (2006) Developing an advanced nurse practitioner service in emergency care: attitudes of nurses and doctors. J Adv Nurs 56(3): 292-301 Health and Care Professions Council (2008) Standards of Performance, Conduct and Ethics. HCPC, London Hickey N, Cooper K (2009) Varicose vein surgery performed by a surgical care practitioner. Phlebology 24(1): 43-5 Holmes S (1995) A change for the better. In: Leifer D. Nursing Standard 9(18): 16-7 Kingsnorth AN (2005) Training SCPs to perform inguinal hernia surgery: results of the Plymouth Action On programme. Bulletin of the Royal College of Surgeons of England 87(4 Suppl): 242-3 http://tinyurl.com/nwz5n6l Martin S, Purkayastha S, Massey R et al (2007) The surgical care practitioner: a feasible alternative: results of a prospective 4-year audit at St Mary’s Hospital Trust, London. Ann R Coll Surg Engl 89(1) 30-5 McGee P, Castledine G (2003) Advanced Nursing Practice. 2nd edn. Blackwell Publishing, Oxford Miles MB, Huberman M (1994) Qualitative Data Analysis: An Expanded Sourcebook. 2nd edn. Sage Publishing, London Moorthy R, Grainger J, Scott A, Powles JW, Latis SG (2006a) Are patients happy with SCPs operating? Annals of the Royal College of Surgeons of England 88:
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101-3 http://tinyurl.com/ovhx8mq Moorthy R, Grainger J, Scott A, Powles JW, Latis SG (2006b) Surgical care practitioner – a confusing and misleading title. Annals of the Royal College of Surgeons of England 88: 98-100 http://tinyurl.com/oqem9na National Health Service Institute for Innovation and Improvement (2011) The Productive Operating Theatre: Building Teams for Safer Care. www.institute. nhs.uk/quality_and_value/productivity_series/the_productive_operating_ theatre.html (accessed 28 April 2011) Newey M, Clark M, Green T, Kershaw C, Pathak P (2006) Nurse-led management of carpel tunnel syndrome: an audit of outcomes and impact on waiting times. Ann R Coll Surg Engl 88(4): 399-401 Nursing and Midwifery Council (NMC) (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. NMC, London Pear SM, Williamson TH (2009) The RN first assistant: an expert resource for surgical site infection prevention. AORN J 89(6): 1093-7s Quick J (2011a) Modern perioperative teamwork: an opportunity for interprofessional learning. J Perioper Pract 21(11): 387-90 Quick J (2011b) The Surgical Care Practitioner: The Legal and Ethical Issues. Challenges & Change: Leading from the Front Line. AfPP2011 47th Congress and Exhibition. Bournemouth, 20 October. Harrogate: AfPP. Rothrock JC, Seifert PC (2009) Assisting in Surgery: Patient-centered Care. Competency & Credentialing Institute, Denver, CO Royal College of Surgeons of England (1994) Cardiac Surgeons’ Assistants: Guidelines for Heads of Departments. RCS (Eng), London World Health Organization (2008) WHO Surgical Safety Checklist and Implementation Manual. WHO, Geneva
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