Expanding Non-Medical Roles

Introduction

In the recent past, there has been an observed development in the roles of non-medical practitioners who engage in various duties that were traditionally assigned to medical practitioners. According to Burkitt & Quick (2008), the developments of this role have made a significant contribution to patient care and have even become critical to the delivery of surgical care services. With the same regard, Kirk & Whitaker (2010) observes that such roles are delivered as part of the day to day surgical care that lies within the responsibilities of competitively trained practitioners with a variety of specialties. A typical example of such roles includes the Surgical First Assistant (SFA). The perioperative Care Collaborative (PCC, 2012) defined an SFA as a registered practitioner whose role is to provide dedicated, competent, and continuous assistance to the operating surgeon during the surgery processes of Preoperative, intraoperative, and postoperative care. This essay seeks to evaluate the role of SFA. Based on a case study, the essay will examine how the SFA, working as part of the surgical team, contributes to the care of surgery care throughout the three stages of surgical care, including preoperative, intraoperative, and postoperative care.

The Case Study

John (Not his real name) is a 45-year-old patient with colorectal cancer and has been lined up for protectomy. John lives with his Son, Ken, who has been his close relative since the death of his wife three years ago. John was brought to the hospital by Ken, who visits him at the hospital every eight hours. John was admitted to the surgical ward and was under the full care of surgical nurses up to when he was recommended for surgery. The following sections illustrate how I took part in John’s surgical process as a registered SFA.

Preoperative Care

John’s preoperative care involved preparing him for surgery. As argued by Nair & Holroyd (2011), a carefully delivered preoperative preparation for surgery increases the chances of obtaining a satisfactory patient outcome. Furthermore, The Perioperative Care Collaborative (PCC, 2012) asserted that patients have specific needs, and therefore effective preoperative care would ensure early identification of any imminent risks and the development of strategies to mitigate these risks. Thus, it is important to conduct preoperative consultation with the patient as it creates an opportunity for evaluating the patient’s overall health status and educating the patient on the treatment procedures lying ahead (Whalan, 2006). In my engagement with John in the preoperative care as a SFA, I performed three major tasks as a SFA, including skin prep, draping, and all the activities involved in the Five Steps to Safer Surgery (Baker et al., 2010).

The Five Steps to Safer Surgery

The PCC surgical safety checklist has been made mandatory by the NHS and the National Patient Safety Agency (PCC, 2012). Furthermore, the NMC Code (2015) identifies the need for pre and postoperative briefing, as well as the checklist. This led to the creation of the Five Steps to Safer Surgery. I implemented the Five Steps to Safer Surgery to reduce the risk of perioperative harm. As the SFA, part of my role was to guide the team of surgeons through the preoperative team brief, which is the first among the five steps. Immediately after assembling, I introduced each person to the team members, mentioning their names and tittles as recommended by (Beauchamp & Childless, 2009). Besides, I read out a list of concerns that were crucial for the team to be aware of. This included the fact that it was the first surgery experience for one of the surgeons who had attained the relevant qualifications to be part of the team. Based on the suggestions by Garden & Parks (2017), this was important, especially considering that there are certain procedures that the new surgeon could need help from the other senior surgeons. I also briefed the team on lunch breaks and time outs. One of the concerns about briefings is that it takes quite a long time (Oakley et al., 2004). However, our briefing session took about 7 minutes, which, according to Servant et al. (2002), is within an acceptable range.

After the briefing, in the anesthetic room, I assisted in signing in the patient. I confirmed the patient’s name as well as the number of safety checks, including the site of operation. According to Hall et al. (2014), the sign-in ensures that the right patient, having the right operation, and at the right site. Considering the safety issues related to protectomy, I carefully guided the team in checking the list to ensure that there were no chances of making even the simplest mistakes. Some of the items I led the team in checking were the confirmation of patient’s name, the surgery procedure for which he was booked, any anticipated blood loss, any airway issues, allergies, as well as the consent form. Besides, I checked the machines before finally allowing the lead surgeon to check the surgical site marking.

Once the patient was anesthetized, he was brought into the theatre. However, just before the incision, there was a time out. During the time out, the lead surgeon performed a verbal confirmation of patient details and other safety issues such as the surgical site infection bundle and whether thromboprophylaxis imaging was within site. As also confirmed by Farrel (2009), most of these details had been confirmed before, and therefore the time out was used as a final check. However, it was important to check whether the patient had received antibiotic prophylaxis (Quick & Hall, 2014).

I also guided the team in the sign-out step, whereby I confirmed whether all the equipment that was available at the start is intact (The Royal College of Surgeons of England, 2016). Therefore, I led the team in a confirmation procedure to ensure that all the swabs, instruments, and sharps. According to Abood (2005), this is a crucial procedure that all team members should participate in. So, I sought the attention of all the team members, including the anesthetists, all the surgeons.

After completing the sign of the checklist, the team gathers for the last time to receive a final briefing (debrief). As the SFA, I guided the team in identifying and reflecting on anything that we could have done to make the patient safer. Furthermore, we identified any hick-up in the procedure. It brought together the whole team at par with regards to ensuring patient safety (Burges, 2001).

The Intraoperative Phase

I also took part in various activities with the intraoperative phases of the surgical procedure, including camera holding, tissue retraction, wound closure, and hemostasis. During the surgery, the surgeons made a deep cut, and therefore he needed assistance to open the cut and take a look around. As the SFA, I stepped into assist in opening up the cut (retraction) for a better view. However, as strongly advised by Farrel (2009), retractors can only be placed in position by the surgeon. Therefore, my role at this point was to enhance the site exposure, thereby enabling efficient access to the target, and not to place the retracters. Besides, I assisted the surgeon in identifying and coordinating the right incision with the right retraction to have the best angle of view. Meanwhile, it is important to note that during the entire incision, I observed strict adherence to the surgeon’s instruction and supervision because according to Hamlin et al. (2009), the surgeon is responsible for ensuring that both superficial and deep tissue retraction is performed with strict adherence to patient safety procedures.

I was also largely involved in maintaining haemostasis to ensure that the surgeons had a clear operating field during the entire intraoperative phase. In doing so, I participated in the direct application of surgical diathermy with strict adherence to the surgeon’s instructions. Nonetheless, it is important to note that at this point, I did not participate in any activities under the surgeon’s remit, such as the direct application of electro surgical diathermy to the body tissue, cast bandaging, and haemostats application (Harmer, 2010). Ideally, haemostasis creates coagulation cascade, which is a sequence of interactions between proteins to cause vibrant depositions at the spot of injury, thereby causing wound closure (Makary et al., 2002).

Postoperative Phase

In the theatre, immediately after the surgery and sign out, I cleared away and sterilized all the surgical tools. Furthermore, I disposed of the entire waste, removed all the drapes used in covering the patient, and prepared all the samples taken from the patient for testing. However, a major role that I participated in was in the preparation and transfer of John. In doing so, I sutured the incisions and applied bandages and dressings on the surgical site. Part of preparing John for transfer also involved an evaluation of John’s condition through the monitoring of vital signs such as temperature and blood pressure. According to Burkitt & Quick (2008), the patient transfer can only be done once it has been determined that the patient is safe to move from the theatre to the recovery room. Hence, my role as the FAS was to determine John’s stability as he awakes from anaesthesia, then transfers him to the post-anaesthesia ward where he could be monitored by specialized nurses trained in anaesthesia.

Surgery patients require close monitoring of the incision to ensure that the sutures are holding, especially when they are immediately from anaesthesia (Abood, 2005). While John was still in the recovery room, I kept constant monitoring at him to ensure he could be put under antibiotics in case of complications arose. The close monitoring was especially important considering that the vulnerability of patient’s increases after surgical procedures, and therefore the SFA should keep a closer watch for signs of easily transmitted diseases.

The NMC (2015) has recognized an overlap in the roles of SFA with other practitioners and has acknowledged an expended scope of practice guidelines for safe operation with clear demarcations of practice limitations. In fact, some scholars have termed this phenomenon as ‘boundary expansion in nursing practice as a professional move to address the changing needs of healthcare (Nair & Holroyd, 2011). Thus, the operating theatre is one of the areas of practice where the nursing role has seen in the expansion of the roles of SFA. As mentioned before, the SFA may perform activities such as preoperative and postoperative patient assessment and handover, providing surgical exposure, tissue haemostasis and use of instruments.

Nair & Holroyd (2011) observe that before the introduction of SFA, senior scrub nurses stepped in to assist surgeons with these tasks whenever there was a paucity of staff to provide extra help. However, according to Burkitt & Quick (2008), the implementation of SFA roles has seen the acknowledgment of these staff and their role in contributing to patient care within the perioperative environment. During my practice, I was placed as a student nurse following my mentor (surgeon) for 100 hour of practice. Also there was another permanent SFA employed in by the hospital clinical nurse specialists in protectomy, responsible for the patients’ perioperative journey. Our roles were not only limited to protectomy procedures assisting in the theatre and suturing, but also in preoperative and postoperative patient education, multidisciplinary referrals, patient assessment, and discharge planning.

A good example of my role in the postoperative phase was to ensure service improvement by overseeing a reduction in surgical site infection rates. In fact, achieving a reduced rate of surgical site infection was the reason for the employment of a permanent SFA. Hence my role was to ensure that the case duration of procedure, complexity, and patient comorbidities did not cause an upsurge of surgical site infection rates. In this role, I engaged in a variety of evidence-based procedures for surgical site infection surveillance and mitigation. For instance, I performed a direct and daily observation of John’s surgical site starting from 24 hours post-operation. However, a major challenge I encountered with the direct and daily observation was extensive use of time and surgical resources for dressing. Indeed, this experience resonates with the assertions by Nair & Holroyd (2011), that whereas the direct method of surgical site surveillance is the most appropriate for monitoring surgical sites, it is rarely practiced due to its impracticality and excessive resource use. Therefore, as a remedy to the highly resource and time-consuming direct surveillance method of surgical site infection, I employed an indirect method of surgical site surveillance (Beauchamp & Childless, 2009), which included a review of John’s microbiology medical records and reports, as well as a review of other sources of information including operative reports, coded procedures and ordered antimicrobials. According to Beauchamp & Childless (2009), the indirect method of surgical site surveillance is less time consuming and can readily be performed by the SFA during surveillance ward rounds.

I continued with my role of surgical site infection surveillance for John, even at the post-discharge surveillance. This was aimed at enhancing John’s quality of life and reducing his postoperative length of hospital stay, considering that he would incur higher costs of treatment to stay in the hospital for certain services such as surgical site infection surveillance. In fact, literature by Beauchamp & Childless (2009) shows that in the past few decades, medical technology advances and changes in hospital bill payments have led to a shift in the delivery of surgical procedures from the acute care setting to ambulatory outpatient care. Furthermore, Garden & Parks (2017) observed that there had been a steady decline in the postoperative length of hospital stay, highlighting the importance of post-discharge surveillance in reducing surgical site infection rates. Nonetheless, I recommended periodical hospital visits for John to deliver postoperative surgical site infection surveillance using a patient questionnaire to reduce his postoperative length of hospital stay. While this approach was effective in reducing the cost of treatment, I encountered a variety of challenges that are worth noting. For instance, there is a paucity of reliable, standardized procedures for post-discharge surveillance of surgical site infection. In fact, literature by Garden & Parks (2017) shows that patient and surgeon questionnaires have poor specificity and sensitivity. Furthermore, I encountered a problem with outpatient surgical site infection surveillance because John could skip some appointments. Similar observations were made by Beauchamp & Childless (2009), who noted that ambulatory surveillance poses challenges because patients fail to adhere to routine postoperative care management appointments.

To conclude, this essay has explored the role of an SFA throughout the perioperative phases and how these roles help in enhancing safety and positive patient outcome. The essay has begun by identifying the role of the nurse in a preoperative setting, with a specific focus on the Five Steps to Safer Surgery. Here, the essay has highlighted a variety of checklists and patient information, such as that are considered before the surgical procedure begins. Besides, we have identified the role of SFA in ensuring patient safety by briefing and debriefing the surgical team before and after the surgery, respectively. Next, the essay has explored the role of nurses in the intraoperative phase. Here, the essay has demonstrated the role of SFA in opening up the cut (retraction) for a better view and helping in identifying and coordinating the right incision with the right retraction to have the best angle of view. Furthermore, the essay has explored the role of SFA in maintaining haemostasis to ensure that the surgeons had a clear operating field during the entire intraoperative phase. Lastly, the essay has explored the role of SFA in the postoperative phase, whereby roles such as clearing sterilizing all the surgical tools, waste disposal, and preparing the patient for transfer were explored. More importantly, the essay has explored the role of SFA in ensuring service improvement by overseeing a reduction in surgical site infection rates. Here, the essay has identified explored the possibility of ambulatory surgical site infection surveillance and its role in reducing the cost of treatment. However, further research is recommended on the standardization of ambulatory post-discharge surgical site infection surveillance to improve the quality of care.

References

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