The advanced scrub practitioner role: a student's reflection.
Abstract: This article will reflect on my experiences in becoming an advanced scrub practitioner (ASP), using a reflective model to support the structure. Since Dewey's simple claim (1938, cited by Rolfe 2001) that 'we learn by doing and realising what came of what we did', many other authors have advocated and adapted this mantra (Rogers 1983 cited by Rolfe 2001, Gibbs 1988). A reflective model enables learning whilst utilising experiential knowledge from previous reflections (Rolfe 2001). Using Gibbs' reflective model this article reflects and evaluates the experience of becoming an ASP looking at both positive and negative issues, benefits to patients, colleagues and the organisation I work within. It examines issues of accountability and concludes by asking the question 'what next?'

KEYWORDS Advanced scrub practitioner / Reflective model / Gibbs / Student Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication September 2010.
Article Type: Report
Subject: Emergency medical personnel (Practice)
Author: Brame, Karen
Pub Date: 04/01/2011
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: April, 2011 Source Volume: 21 Source Issue: 4
Topic: Event Code: 200 Management dynamics
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 272168012
Full Text: My background is, of course, in theatre and for many years I have been at a senior level. Consequently, in describing the role of advanced scrub practitioner, especially to medical staff, it was clear that I thought that I performed this role already. I explained that I was not formally trained to carry out certain tasks, but that if I followed a course then I would become trained. The assumption was that the course would put me on a level with the surgical care practitioner currently in post.

This lack of clarity came primarily from the tradition of scrub practitioners taking on the role without formal training (Mardell 2004) and accepting it as part of their scrub role. Some even perform a dual role, which will be discussed later. On a personal level I have in the past cut sutures and applied dressings when junior doctors have been called away; equally I have assisted in draping patients when junior doctors have been delayed. I felt competent to perform both of these tasks (Turner & McLaughlin 2005) and did so in the belief that I was covered by vicarious liability as the department had no formal policy.

The issue came to ahead when a junior member of staff would not assist in draping a patient, stating that she had not been trained to perform this role as it was part of the assistant role (PCC 2007). It also transpired that the surgeon assumed that the scrub practitioner or one of the team would assist as, if he did not have an assistant, the list would need to be cancelled. I felt that staff were put under emotional pressure during these discussions (Mardell 2004). Following the incident senior management issued a directive that staff were not to undertake any activities that were part of the assistant's role. This created a situation which made the day to day running of the department difficult, and also left senior experienced staff feeling undervalued as they had previously carried out some of these duties (Turner & McLaughlin 2005). Tanner (2001) also suggests that these activities are routine theatre nurse practice.

The situation raised awareness amongst senior management that an urgent risk assessment and policy review were needed so that clear guidelines could be put in place. Staff were given an in house competency based training for prepping and draping from the surgical care practitioner and consultants. The need for formally trained assistants was also identified, which was the reason I began the course. I felt that the course would formalise my job and support the knowledge I already had. But in reality it turned out to be more challenging than that, and introduced me to areas that I had not visited before.

The first challenge for me was preoperative visiting. This was not something I had done before, but I couldn't identify what was making me so anxious, particularly since the literature supports preoperative visiting as being beneficial to both patients and staff. The benefits of preoperative visiting in reducing patients' stress and anxiety levels (Fyfe 1999) and allowing perioperative practitioners the opportunity to assess patients, to develop a plan of care, and to discuss expectations (Pittaway 2004) are well documented.

We currently meet our patients in the forward wait area before they are brought to the anaesthetic room. I have done this on many occasions. Our role is to explain the course of events, to enquire if they have any further questions or need to speak with the surgeon again, and to try to allay their anxieties. Now I was being required to meet and introduce myself as the advanced scrub practitioner, which had to be followed by an explanation of the title and role. I think I was expecting more questioning from patients regarding what my participation was going to be, but I found that many patients willingly accepted my role within their care. So long as they were safe and all went well (Heaton 2007) the title seemed of little consequence; I was a nurse. I did have concerns that patients may not agree to my participation, but to date this has not occurred.

This is a situation that still does not sit comfortably with me. I still feel that I perform better within the forward wait area. It's as if that department holds my knowledge and has the required answers; this is my comfort zone.

Beyond that, postoperative visiting is even more stressful to me. What if the patient's experience did not match their expectations? Did I give incorrect information? Can I give a full and proper explanation? Yet to date these visits, whilst few in number due to the nature of our surgical lists, have gone well; but it is not an area that I am comfortable with.

One of the problems with this is lack of planning. Currently a proportion of my assisting is ad hoc as there is no defined advanced scrub practitioner role. As mentioned before, my attendance on the ASP course came about mainly due to an incident. If a set plan with pre-booked sessions was in place this would help to alleviate my anxieties and allow me to plan my roles as either assistant or theatre practitioner. I do not have any issues with either role and understand that junior doctors also need to gain experience. Unlike Bernthal (1999) I do not see this in a negative context. The dynamics of healthcare delivery today, and the limitations imposed by the European Working Time Directive (DH 2007) have created the opportunity for scrub practitioners to expand their role (PCC 2007).

The ASP course had within it practical competencies or skill statements which, on face value, looked comfortable. I felt I knew about them, and had done most of them before. Yet as I worked through them it made me re-evaluate my knowledge, especially as regards positioning patients. I understand the principles of safe moving from trolley to table, the use of positioning aides, looking at and assessing the patient on the table in a general perspective i.e. with the patient fully on the operating table. However, we should be assessing how patients are positioned with regard to the effects of general anaesthesia on defence mechanisms and protective reflexes that normally prevent the stretching, twisting and compression of tendons (Hoshowsky 1998, Beckett 2010).

When tucking a patient's arms down by their side, ensure that the palms are facing inward and not upward as when on an arm board (Hoshowsky 1998) but also without putting pressure on the elbow. I was aware of compartment syndrome in lower limbs following fractures and surgery, but was not aware that many other areas can be affected by surgery, external pressure applied from dressings, plaster casts or bad positioning (Malik et al 2009). I learned that compartment syndrome has also been described in gynaecological, urological and abdominal surgery following the use of the Lloyd Davies position (Malik et al 2009). Also a revelation to me was the number of compartments in the hands and feet. A literature search on patient positioning and compartment syndrome released many articles on this subject. A lot of the information also supported my rationale for skill statement 2: positioning of patients.

Whilst positioning patients we are aware of nerve damage, yet pressure can also contribute to the formation of pressure sores, especially in vulnerable patient groups (Beckett 2010). Beckett (2010) suggests that surgical patients are not always considered to be at risk, which may mean that no extra measures are taken to pad vulnerable areas. She also highlights that intraoperatively acquired pressure sores may not be recognised, as in the immediate postoperative period skin changes may not be apparent. Hartley (2003) suggests that intraoperative pressure sore development may even be mistaken for a burn. Hartley looked at the literature on pressure relieving devices, especially table mattresses.

When undergoing a table mattress replacement scheme, we were advised by a tissue viability nurse to ensure the optimum for the patients, as we also only had a limited number of action gel pads in relation to the number of tables. Anecdotally these mattresses raised issues with the orthopaedic consultants as the movement within the mattress caused problems when doing joint replacements. This increase in knowledge was applied to positioning patients and was also disseminated to trainees.

Working through the practical skills and required competencies on the ASP course has given me the opportunity to gain more clinical time. A downfall to progressing up a career path, in my view, is the way it can take you away from clinical time. The ASP role will put me back into the clinical area with an enhanced sense of purpose.

Having been a scrub nurse for many of the cases that I am now assisting with, a recent comment brought into sharp focus the responsibilities of assisting. A consultant was heard to explain to a house officer some of the perils of retracting tissue. In particular he explained the need to be aware when retracting the liver not to cause a tear. This suddenly resonated with me and the issues around responsibility and accountability of roles. Here I could clearly identify how the Bolam test (1957) would be used if the person retracting were an advanced scrub practitioner.

If a court case were to emerge, the actions of the ASP would be considered alongside those of a medical practitioner who would normally perform that role. There is no leniency given because you are a nurse, as you have taken on this extended role. As Dimond (2005 p553) clearly states when discussing extended roles and competency: 'if that activity were 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'. This is further supported by the case of Wilsher vs Essex Health Authority 1986 which points out that there is no legal concept of team liability. You cannot hide within the team dynamics; you are responsible for your actions. The ruling also stated that, regardless of experience the person undertaking the work, the work should be performed to a standard expected of that position (Wood 2002). I interpret that to mean that training needs to be to a recognised standard and that the length of time doing the job is not relevant (Deighton 2007). That is certainly becoming clearer to me having undertaken the course.

The ASP course made me recognise my accountability and to whom I am accountable. The employer certainly must be aware of the extended role that you are undertaking. If this role is not within your contract vicarious liability will not apply (Bernthal 1999, Bazeley 2003) and if a legal case occurs, the nurse may well be disciplined by her employer as well as being sued. You have accountability to your professional body, as the code of conduct gives clear guidance (NMC 2008) on accountability and competence. You are also accountable to the patient and owe a duty of care to them (Bernthal 1999). Part of this responsibility I found came from speaking to patients preoperatively and explaining that I would be assisting the surgeon. I made it clear that I was a nurse who would help the surgeon and that he would be performing the actual surgery. As nurses we have always known from our code of professional conduct (NMC 2008) that we carry responsibility for our actions or inactions, that we must acknowledge our limitations, and that we must not for any reason feel inadequate when asking for help.

The source for a lot of information around accountability came from Dimonds' (2005) book Legal Aspects of Nursing. This is a good reference book for many aspects within nursing. Chapter 24 especially explores issues around professional practice and nurse specialists. I have come across some of the legal aspects before when undertaking a law module during my degree. There are also many and varied articles on the subject of extended roles and accountability.

Through my progression on the ASP course I had to face a personal conflict regarding catheterisation. Although I had done many female catheterisations I had not, up to this point in my long career, ever catheterised a male patient. Part of that was due to old-fashioned thinking when I trained that females did not undertake this; it was almost a traditional taboo (Milligan 1999). To put this into context, male nurses were few in number and did not work on female wards. Tasks were very segregated, and as time has progressed I had never revisited this issue or sought out training to do so. I always relied on other staff, usually doctors, to perform the task. Now one of the ASP competencies included male catheterisation, which caused me personally some anxiety, although I would state at this point it was not a gender issue. I had of course sought help from experienced specialist staff but I still worried about what could go wrong. I understood the principles of male catheterisation and the potential complications, but again my concerns were around training, competency and acknowledging the limitations of my experience.

A difficulty I found with this competency was acquiring the skill practice. Within the trust I knew of the urology specialist but had some difficulty making contact. The surgical care practitioner was helpful in this quest and, as a catheterisation course was not currently available, she identified an alternative source. The theory was supported by an educational package from the coursework; it was just the practical element to fulfil. I finally obtained this by attending a urology clinic in the treatment centre where catheterisations took place and I could perform the skill under supervision, having practiced on a simulator.

Another issue under accountability is practitioners performing a 'dual role'; there are many articles on this subject. Dual role in this context is acting as scrub practitioner and managing the instruments whilst also assisting the surgeon (Timpany & McAleavy 2010). An issue around dual role roles comes from the overlap of skills, for example prepping and draping. The PCC (2007) lists prepping and draping as enhanced skills for the advanced scrub practitioner role and states that, if an employer feels a dual role is needed, then it is up to the employer to provide a policy to cover this. On the other side, Tanner (2001) suggests that prepping and draping are part of the routine practice for theatre practitioners. She supports this with the argument that it would be unusual for theatre practitioners not to be taught the underlying principles of infection control relating to skin preparation and draping. Tanner points out that practitioners are taught these skills and can provide evidence to support their competency, but questions whether medical staff can do the same.

As Sutton (2003) suggests, nurses should only take on these tasks or dual roles if they feel confident and understand fully the ramifications of their actions. She supports this statement with legal cases from surgical incidents where in the judgements it was noted that damage resulted not from doing two jobs, but from doing neither effectively. Within the literature the dual role has become a recurring theme, as some minor operations did not have junior medical staff present (Turner & McLaughlin 2005) and the European Working Time Directive (DH 2007) has had an impact on doctors' working hours (Timpany & McAleavy 2010). To provide two staff to act as scrub and assistant for every case, regardless of size or complexity, could become a logistical headache (Sutton 2003). This issue created a major impasse within my department some time ago, as identified in the introduction. One result from this was the recognition by higher management of a limited dual role, and a policy was put in place following a risk assessment (Timpany & McAleavy 2003).

On a personal level I side with Tanner (2001) and feel that, with in house training and support, some dual roles can be undertaken. Our department allows staff to perform skin preparation and draping once their competency is signed. Also some minor procedures, such as those that may be performed in other areas, can be undertaken if the staff feel competent and confident to do so. The prevailing message here is to ensure that you fulfil your duty of care to your patients and meet the requirements of your professional body (Turner& McLaughlin 2005).

The discussion around dual roles with regard to skin preparation can be further supported by evidence-based practice. The evidence shows that preoperative visiting reduces patients' stress (Fyfe 1999, Pittaway 2004) and allows the practitioner to assess and plan the patient's care intraoperatively and aide wound healing (Fyfe 1999). Planning patient care can also reduce a patient's risk of developing pressure sores (Hartley 2003) nerve damage or compartment syndrome (Malik et al 2009).

With all that said, it would be reasonable to ask is there a need for a separate role such as advanced scrub practitioner. I am in agreement with Turner and McLaughlin (2005), who support a limited dual role, but also point out that roles within the scrub setting need to be clearly defined and separated. If the roles are totally separate this could potentially remove experienced staff from the staffing pool.

Bernthal (1999) suggested that practitioners acting as assistant should have well defined parameters which are mutually agreed and set out in their job description, as part of a national framework. The PCC (2007) identified that the advanced scrub practitioner role should have a training programme that will assist in setting the boundaries in which to practice, whether validated or in-house.

As healthcare changes practitioners must define their role to ensure that they can determine their own limitations (Sutton 2003). Practitioners must not allow themselves to be pressurised into taking on roles for which they do not have adequate training. They must always act as autonomous practitioners and in the best interests of their patients. Identifying this specific role can have organisational as well as departmental benefits, and could assist with retention of experienced staff by offering alternative career opportunities.. Equally it would benefit the organisation by providing a pool of consistent and available staff with expertise for the surgeon and the department to utilise. Lists would continue safely and effectively with a reduced risk of patient cancellation (Thatcher 2003).

In reflecting on the ASP course I recall wondering what format evidence would take and how it would be achieved. Obviously the practical elements would be mainly observational supported by knowledge shown in discussion or written format. Searching the literature, using Proquest, for supportive evidence for the rationales for some of the skill statements was difficult i.e. cutting sutures and handling of instruments. Picking keywords would sometimes draw a blank or alternatively give too many to look through. Whilst filtering the literature I did acquire further knowledge, especially regarding patient positioning, and I see this to have had one of the larger impacts on my practice. What I previously thought I knew would now be described as superficial. Most of the practical elements of this course have assisted in validating my previous occasions of assisting and I can move forward and participate in more assisting, as there will also be a greater need within the department. I know that currently there are no plans to identify an advanced scrub practitioners post and that I will have to combine it with my current role. I will become what Thatcher (2003) described as a theatre based assistant, which may be quite ad-hoc, but as schedulers become more aware of advanced scrub practitioners it could be planned.

Deighton's (2007) reflective article resonated with me regarding the times spent gaining my clinical hours and how difficult it can be to switch off from your leadership role. Although not necessarily distracted by events around me, I was often disturbed by messages or questions being asked. Also I would find myself suggesting to the scrub practitioner to send for the next patient, or asking for an instrument well in advance of need and not allowing them to anticipate. A good way to switch off was participating in joint replacement surgery, as I was required to wear a helmet and that made it difficult to carry out a conversation.

Gaining the required clinical hours became a concern as the course neared completion. Certainly seconding two staff from a small department instantly halved the opportunities. For future participants from this department this will require better planning.

This course had the option of e-learning or attendance. I found that attendance suited me better. Whilst not against technology, I found taking the information from a screen very one-dimensional. It became apparent that there should have been some interaction amongst students on line, but not being a social networker, this felt alien to me. I much prefer the greater dimension gained from face to face, the chats that occur during a break.

Participating in the course has created a personal inner dilemma. Whilst I like the challenge of day to day running of the suite, I do enjoy the skills of scrubbing and certainly would like to divide my time to encompass both. Deighton (2007) believes that, with planning, these roles can be intertwined. Since doing the course I agree that the ASP role should not just be taken on through length of service and experience. Anecdotally someone told me that length of time has no value if you have been doing badly all of this time, hence the need to have the evidence. Deighton (2007) also believes in the benefits of this role and the need to push to further to expand it to become a surgical care practitioner. This is not for me, although to gain skin closure as an additional skill would for me round things off. I am not against practitioners gaining further experience. As Bernthal (1999) stated 'if it enables patients to receive treatment more quickly and effectively it should be considered'. Turner and McLaughlin (2005) bring it all into focus when saying that, when undertaking the ASP role, practitioners must be sure that they are fulfilling their duty of care to patients, whilst still meeting the requirements of their professional body.

No competing interests declared

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Correspondence address: Karen Brame, c/o The Association for Perioperative Practice, Daisy Ayris House, 6 Grove Park Court, Harrogate, HG14DP. Email: karen.brame@nhs.net

About the author

Karen Brame RGN, DipHE, BSc (Hons) Theatre Co-ordinator
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