Surgical care practitioner practice: one team's journey explored.
Subject: Surgery (Health aspects)
Surgery (Analysis)
Surgeons (Practice)
Medicine (Practice)
Medicine (Analysis)
Authors: Jones, Adrian
Arshad, Homa
Nolan, John
Pub Date: 01/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Jan, 2012 Source Volume: 22 Source Issue: 1
Topic: Event Code: 200 Management dynamics
Product: Product Code: 8000410 Surgical Procedures NAICS Code: 62 Health Care and Social Assistance
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 280303365
Full Text: Surgical practice in the UK changed in 1993, when Suzanne Holmes and her cardiac surgical colleagues introduced the surgical care practitioner role (SCP). Within a consultant led extended surgical team, SCPs work alongside a variety of healthcare practitioners to provide safe patient care, meet service demands and educate the future surgical workforce. This article reviews the history of this development over the last fifteen years in the context of a busy orthopaedic department and discusses some unforeseen consequences.

Operating theatre teams are nothing if not adaptable. In an emergency or during times of staff shortages, theatre practitioners have always turned their hands to holding a retractor, a leg or camera, without this actually being a 'legal' part of their role (Peysner 1996). Often this has led to misunderstanding, tension and at times the threat of censure (Hunt 1995) from within differing professional groups who make up the operating theatre team.

The reform of specialist surgical training: The New Deal (NHS Management Executive 1991), the Calman report (Calman 1993), and the implementation of the European Working Time Directive (DH 1998a), provided significant pressure on the consultant led surgical team's ability to deliver and maintain national surgical service. The use of operating theatre staff to fill in gaps was no longer sustainable (NATN 1994) and raised concerns.

In 1996 the orthopaedic department of the Norfolk & Norwich Hospital under Edwards & Keely's leadership (Edwards & Keeley 1998) took the first tentative steps to alleviate this foreseen pressure by employing two non-medical surgical assistants. A degree level academic course was provided to educate them to a standard of surgical competency expected of a junior surgical trainee. Their role was initially to provide directly supervised, safe and timely assistance to the operating surgeon (consultant or surgical registrar level), whilst adhering to the Bolam principle (Bolam v Friern Hospital Management Committee 1957) judged for professionals of equal standing.

There must be an equivalent standard of assessment for both doctors and trainee and qualified surgical care practitioner's (SCP) (DH 2006) who perform similar procedures. Three established perspectives guide this assessment:

* Assessment of knowledge and reasoning

* Performance

* Personal and professional awareness.

Such local, below the horizon developments had clearly become a concern to The Royal College of Surgeons of England, who have a duty to maintain national surgical standards. The RCSENG initiated a consultation (1999) of its own membership, non-medical surgical assistants and other professional associations. The purpose of the consultation was to:

* assess the present and future role of non-medically or dentally qualified personnel in the surgical team

* advise on the development of multi-disciplinary teams, with particular reference to defining career patterns, roles, training, assessment and supervision of those involved in surgical care, with a view to producing college guidelines

* consider whether this practice development was safe.

A positive outcome was achieved Mr Hugh Phillips, president of RCSENG in 2005, encouraged SCP roles within extended surgical team practice in the NHS, and extended them to all four national devolved health services.

A Department of Health led public consultation (DH 2005) led to a national role title and the publication of the Curriculum Framework for the Surgical Care Practitioner (DH 2006). It also established graduate level qualification and a two year education programme to enable core and surgical speciality knowledge and skills to be acquired in NHS clinical settings, in partnership with educational institutions.

A surgical care practitioner was finally defined as:

'A non-medical practitioner, working in clinical practice as a member of the extended surgical team, who performs surgical intervention, preoperative and post-operative care under the direction and supervision of a consultant surgeon.'

This definition has drawn upon the experience of the health departments of UK devolved governments, professional bodies and of SCP's newly formed association: The National Association of Assistants in Surgical Practice (NAASP 2003).

Consultation evidence exposed justifiable opposition from associations representing surgical trainees, as discussed by Freudmann and Aning (2005). The outspoken witch doctor blogger's most significant concern was that SCPs would undertake independent operating procedures and would further compromise future consultant surgeons' training.

Continuing surgical education changes (DH 2004) and government waiting list initiatives (DH 1998b, Armstrong 2003) have resulted in a reduction of overall training period with reduced working hours. Chambers et al (2010) calculated that a 56 hour week on full or partial shift to provide night duty cover, reduced total hours of surgical training from the pre-Calman figure of 25-30,000 hours, to 8,000 hours for current trainees. The figure fell as low as 6,000 hours when the 48-hour week became a reality in 2009, in order to provide safe, alert and supervised surgeons. Any further reduction in the numbers of surgical procedures available to trainees to qualify/complete their education - the Certificate of Completion of Specialist Training (RCSENG 2011) - was deemed totally unacceptable.

Under Jackie Younger's leadership, one of the aims of 2007 National Practitioner Programme: The New Ways of Working in Surgery project (Younger 2006) was to investigate whether the SCP could/should be trained to undertake independent minor procedure operating lists, as part of government's 18 week targets plan (DH 2011). Our department's SCPs were invited to participate, but on reflection we decided that the bundle of procedures under consideration for this project were those considered as key supervised procedures for our core surgical trainees (CT 1&2) to undertake within our department. Some surgical departments have developed SCP led services, notably Malcolm Clarke's carpal tunnel surgery service (Newey & Clarke 2008), Shirley Martin's minor ops/'see and treat lists' (Martin et al 2007).

These should be seen as exemplars in clinical settings that support this activity. Senior trainees' fears have not been justified (Dehn 2005), and support for the SCP role has been enhanced by surgical leaders (Kneebone & Darzi 2005), academics and associations (Bruce et al 2006).

Assistant practice development

From a confused period of consultation, clear parameters were defined for the SCP role. Or were they? A literature search reveals no clear definition of a first or second assistant role and function. May I suggest one?

'The assistant to the surgeon undertakes supervised manipulation of tissues and surgical instruments to enable safe surgical approach, surgical field exposure, operative procedure(s) and repair of anatomical structures, as ordered by the operating surgeon. Assistants are able to respond to emergency situations, responding to surgeon's lead. As part of ongoing training, elements of surgical procedure may be delegated to assistant(s), who then become co-operators.'

The SCP participates as cooperator (not surgeon) during an operative procedure and undertakes surgical interventions as delegated to them by the operating consultant or surgeon. A surgeon may be a non-consultant medically qualified member of the surgical team (e.g. a specialist registrar (SPR) or surgical trainee ST3-7) who has been delegated the role by a consultant surgeon (DH 2006). For the first time a non-medical team member is able legally to undertake full wound closures during hip arthroplasty surgery.

Delegation and supervision of these tasks has been developed through three distinct phases (NAASP 2003):

1. The Direct Phase. This occurs during initial SCP training. The consultant surgeon, ST3-6 surgical trainee, or qualified experienced SCP (mentor) is directly opposite or alongside the SCP.

2. The Indirect Phase. This occurs when the operating surgeon, having delegated the task, may step down from the surgical site, but remains either in the theatre itself or the operating theatre environment. Their location is identified: 'I will be next door in the trauma theatre', or they are contactable in person or on a mobile and are able to return to theatres without delay.

3.The Proximal Phase. This phase applies to qualified SCPs who have demonstrated that they are able to practice without direct or indirect supervision. The consultant or surgeon may leave the theatre, and the theatre environment and may proceed to a known location i.e. office or clinic, but remains contactable by phone at all times.

Our department's five SCPs support 22 surgical teams and routinely perform the following surgical interventions:

* Placement of hand held and self retaining retractors

* Use of power tools as directed by surgeon

* Soft tissue/bone dissection, debridement and haemostasis

* Preparation of auto/allograft used in revision surgery

* Preparation of anterior cruciate hamstring/bone patella femoral grafts

* Wound local anaesthetic infiltration and placement of peri-articular cannulae

* Placement of intraoperative drains

* Full wound closure for routine joint replacements and dressing application(s)

* In the absence of consultant: Teach, support and re-enforce junior surgical trainees' (Foundation years 1&2 - CT/ST 1&2) basic surgical skills

* Verification of final swab and instrument checks

* Safe transfer of patient from operating table to bed, post transfer/operation clinical check including: joint stability, circulation and neurological checks.

For the repair stages of surgery, a close working relationship has evolved with the patient's anaesthetist, as all medications are prescribed and their use is supervised by them.

Although this article has concentrated on the operative phases of the patient's journey, the SCP team has also developed independent perioperative roles. These include: pre and postoperative assessment clinics, telephone review clinics, audit/research and teaching responsibilities, the characteristics of which match the Skills for Health template for advanced practitioner roles, i.e. leadership, innovation, mastery and excellence (Skills for Health 2009).

SCP supervision and delegation

Every team needs a leader, and here I may lose some friends by suggesting that only the consultant surgeon has the clinical authority, responsibility and accountability for all surgical procedures performed on patients in his or her care. Sam Nashef as a cardiac consultant surgeon training SCPs (Nashef 1999) suggested that: '... what makes a surgeon is the competence to know when a surgical operation is indicated, its attendant risks and benefits, the optimal timing of intervention, the precise methods by which it is carried out, the likely complications and how to deal with them: Beyond this, who holds what instrument at what stage of the procedure becomes secondary'.

Taking this argument further I suggest that all surgical patient care is indeed a delegated cascade of function and performance. Decisions made as lead clinician directly affect delegated care provision through other care delivery professionals, who as individuals or in teams follow his or her prescription or instructions to affect patients' recovery of health, function or a timely death! None more so than who is to assist them during surgery!

An unforeseen practice development

In supporting the surgical activities of our department, one emerging consequence of an SCP practice is recognition of their emerging ability to support ST4-6 trainees as they make the transition from requiring direct/indirect consultant supervision, to proximal consultant supervision only i.e. independent operating.

A trainee's performance whilst operating is assessed by procedure based assessment and direct observation, which leads to a judgement of competency on the levels set by Intercollegiate Surgical Curriculum Programme: Orthopaedic curriculum (ISCP 2010a, b) as below:

For each procedure undertaken, in this case a primary total hip arthroplasty, defined competencies and definitions for assessment are indicated.

Competencies and definitions for section 5 - intraoperative technique:

1. Follows an agreed, logical sequence or protocol for the procedure

2. Consistently handles tissue well with minimal damage

3. Controls bleeding promptly by an appropriate method

4. Knots and sutures demonstrate a sound technique

5. Appropriate and safe use of instruments

6. Proceeds at appropriate pace with economy of movement

7. Anticipates and responds appropriately to variation

8. Deals calmly and effectively with untoward events/complications

9. Uses assistant(s) to the best advantage at all times

10. Communicates with scrub nurse clearly and professionally

11. Dislocates hip safely

12. Cuts femoral neck appropriately to match design of implant

13. Demonstrates familiarity and understanding of acetabular preparation including osteophyte trimming medially and at the rim

14. Broaches the femur properly and prepares the bony surface

15. Uses trials and checks component orientation properly

16. Fix acetabular components appropriately

17. Implants femoral components appropriately

18. Performs final reduction and checks for stability.

Each element of the observed intraoperative technique is assessed by the mentor as:

* N = Not observed or not appropriate

* U = Unsatisfactory

* S = Satisfactory

Once a trainee's performance has been observed by their consultant as achieving level 3-4 competency, an SCP may then be asked to 'look after' the trainee, providing direct supervision. The consultant remains available in the department, however towards the end of a six month attachment during consultant study/annual leave, cases may be left for the trainee to complete, with cover available from another consultant operating in the department.

Using the current ISCP (2010a,b) assessment definitions, a traffic light decision model based on Schon's (1983) reflective practitioner modelling, was developed to allow early intervention should a SCP 'feel - in action reflection' that a patient is at risk and that the trainee is not coping. The code is as follows:

* Green indicates positive behaviour. The trainee is doing what should be done.

The trainee follows a logical sequence or protocol for the procedure as normally undertaken by consultant. Minimal verbal reminders may be required.

* Amber indicates negative passive behaviour. The trainee is not doing what should be done.

Trainee appears to have forgotten the sequence, and surgery is disrupted.

1. A verbal warning/cue is given 'Would Mr N do that now?/Have you forgotten to do this?/Are you sure that looks/feels right?'

2. The trainee may realise that they have missed the intervention and may need reassurance 'How does this look to you?/Am I doing this right?'

3. If three such events occur the consultant is called.

* Red indicates negative behaviour. The trainee is doing what shouldn't be done.

An unsafe proposed action will be stopped by direct intervention.

1. Verbal warning: 'Stop - what are you about to do!' i.e. you are about to put a stay suture through a nerve.

2. Physical action: Instruments are removed from trainee and placed on the Mayo table. The error is pointed out to the trainee.

3. The consultant is called to theatre and the situation is discussed.

A 90 minute operating rule is enforced for trainees undertaking trauma list surgical cases, after which senior theatre staff may contact the on call consultant.

A surgical trainee's viewpoint

'Since the widespread implementation of the European Working Time Directive (EWTD) most surgical departments have experienced greater pressures. There are frequently fewer junior doctors working during normal working hours, with implications for training as well as service provision. The impact on surgical training has been variable, with some units struggling to provide high-quality training.

'There is concern amongst trainees regarding the use of surgical care practitioners and a further impact on training. However, here at the Norfolk and Norwich University Hospital SCPs can play an essential part in promoting opportunities for training to progress.

'There is little doubt that contemporary trainees are generally less capable than they used to be at the start of the specialty training programme. They need help if they are to make the most of their training time. In an ideal world we would be rolling out superb training for all. More realistically, as the Royal College of Surgeons' guidance makes clear, operative training really must be focused on the higher surgical trainee. Where time in the operating theatre is limited for the FYs and CTs they stand to gain more from supervised operating than from assisting. Much has been discussed about continuity of care on the wards and for patient care in general, but this is also applicable to the operating theatre environment. Here it is consistency as well as continuity which can be difficult. The SCP has a central role in maintaining the consultant's way of working in his absence. Repetition is a key mechanism of learning and if this can continue uninterrupted it is to the benefit of the trainee.

'A six-month attachment must include annual leave, study leave and periods while the consultant is away. This limited training time can be further truncated where shift working patterns are used (not applicable in our unit) and where trainees from several sources rotate in at different times of the year. This is the case at the Norfolk and Norwich Hospital, with registrars coming from East Anglia, London and the United States.

'My most recent attachment was with Mr John Nolan for a total of four months. It followed on from the scheduled end of an attachment from my London-based Percival Pott training programme. Supervised operating with the consultant forms an essential part of the surgical training experience. Then there comes a time where trainees can gain greater insight into their limitations but also confidence and competence from operating without the trainer directly present. Working with a SCP allows for all of this with a guaranteed, skilled assistant. It is not without stress and we would freely admit that both registrar and SCP feel the burden of responsibility far more whilst doing our own lists. This is perhaps as it should be and also an extremely valuable part of training to be a consultant.'

Conclusion

In 1993 Suzanne Holmes (Holmes 1994) was appointed as the UK's first non-medical cardiac surgical assistant (Beecham 1993). This confirmed Seifert and Rothrock's (1999) later observations on similar practice developments in the USA that: 'Teamwork can be achieved only when ... ALL PARTIES ... decide that working together in the interest of consistent, quality patient and family care will bring them to their fullest potential'.

Such teamwork is the interaction of the operating surgeon with other members of the surgical team, which affects his/her surgical performance and patient outcomes (Undre et al 2009). As all levels of surgical trainees continue to undertake their nomadic education, disruptive work patterns and frequent team changes affect the continuity of patient care.

Mr John Nolan, consultant surgeon and orthopaedic clinical director believes that the experienced SCPs provide a reassuring continuity in the theatre environment for both the consultant and the trainee. They bridge the gap between consultantsupervision and independent operating, enhancing the trainees' educational exposure and ensuring patient safety, as the chick prepares to fly the nest.

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Acknowledgement

To present and past SCP colleagues and students, thank you for your support, patience and understanding.

by Adrian Jones, Homa Arshad and John Nolan Correspondence address: Adrian Jones, Orthopaedic Surgical Care Practitioner/Lecturer Practitioner, Trauma and Orthopaedic Department, Norfolk and Norwich University Hospital NHS Foundation Trust Colney Lane, Norwich, NR47UY. Email: adrian.jones@nnuh.nhs.uk

About the authors

Adrian Jones RGN, ENB 176/998, Cert SCP

Orthopaedic Surgical Care Practitioner/Lecturer Nurse Practitioner, Trauma and Orthopaedic Department, Norfolk and Norwich University Hospital NHS Foundation Trust

Homa Arshad MB BChir, MA, MRCS

Specialist Registrar in Trauma Orthopaedics, Norfolk and Norwich University Hospital

John F Nolan MBBS, FRCS, FRCS (Orth)

Consultant Orthopaedic Surgeon, Norfolk and Norwich University Hospital NHS Trust

No competing interests declared
Global summary (based on the observed/relevant parts of this
procedure only)

Level 0  Insufficient evidence observed to support a
         judgment
Level 1  Unable to perform the entire procedure under
         supervision
Level 2  Able to perform the procedure under supervision
Level 3  Does not usually require supervision but may need
         help occasionally
Level 4  Competent to perform the procedure unsupervised
         (can deal with complications)
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