Since the NHS was formed in July 1948, it has undergone continual development to improve effectiveness and to modernise, including advancing non-medical roles to enhance patient care (Abraham, 2013). Contemporary guidance, including the NHS Constitution (Department of Health and Social Care (DHSC) (2015) and the NHS Long Term Plan (NHS England/NHS Improvement, 2019), has advocated increased collaboration with service users, while the DHSC (2022) and the Topol (2019) review provide useful frameworks for increased modernisation and digitalisation.
The report, Reshaping the Workforce to Deliver the Care Patients Need (Imison et al, 2016), acknowledged the need for improved provision of a dynamic, highly reactive workforce, signposting the increasing use of non-medical professionals in advanced roles to enhance NHS capacity while maintaining quality. Furthermore, the Royal College of Surgeons of England (RCSEng) (2016) predicted an increase in the use of assistive technologies in surgery, which would require additional advanced perioperative roles.
To explore perioperative advanced practice, the authors performed a literature review to investigate advanced roles and assistive technologies in the operating theatre. Databases such as the Allied and Complementary Medicine Database (AMED), Cochrane, CINAHL, ProQuest and Medline were used. Additionally, the search criteria advance*, technolog*, surg* and role* were applied, with truncation chosen for increased likeliness of relevant hits. No date range was set to allow for historical insight into the development of advanced roles and technologies to be reviewed. Only publications in the English language that had not been translated were accepted, although appropriate international literature in English was included, dependent on its appropriateness to perioperative advanced practice. Excluding translated papers was to reduce the chances of any mistranslation in an already complex topic, although it was decided that this exclusion criteria could be relaxed if there was a low number of results.
The USA is one of the most active areas of expansion for non-medical advanced clinical practitioner (ACP) roles (Pulcini et al, 2010), and non-medical ACP roles are also integrated and maturing in Australia (Hains et al, 2017), New Zealand (Duffield et al, 2009) and within Europe (Maier, 2015), which supports the inclusion of international literature in this review.
The UK perioperative environment offers opportunities for developing ACP roles. However, this development has been highly nuanced (Jones et al, 2012; Royal College of Surgeons of England (RCSEng) and Royal College of Surgeons of Edinburgh (RCSEdin) (2022). Within the past 30 years in the UK, ACP roles have evolved to develop autonomous practice, undertaking procedures and tasks historically performed by medical professionals (Abraham, 2013; Tingle et al, 2016). An example of these roles is the surgical care practitioner (SCP), which requires core and specialty knowledge, skills and attitudes to independently manage patients with a wide range of presentations across pre-, intra- and postoperative care (RCSEng and RCSEdin, 2022; RCSEng, 2023), with the SCP curriculum explicitly aligning to the Multi-Professional Framework for ACPs (Health Education England (HEE), 2017).
Evolution of non-medical perioperative roles
The origins of the SCP role date back to 1989, when a nurse from Oxford travelled to the USA for a 6-month period to observe and undertake training, similar to that of a physician assistant (Holmes, 1994). Following evaluation, this training exercise was approved by the RCSEng and the Department of Health (DH), and a cardiothoracic training programme was approved, trailblazing perioperative staff in advanced non-medical roles (Beecham, 1993). This novel role subsequently evolved into the SCP role, now governed by robust educational curricula and a clinical framework (RCSEng and RCSEdin, 2022).
Two key driving forces are said to have increased and expanded the SCP role: the European Working Times Directives (EWTDs) and increasing surgical waiting times (Abraham, 2013). The initial EWTD introduced in August 2004 limited junior doctors' weekly working hours to 58, while in 2009 this was reduced further to 48 hours with additional restrictions on rest periods between shifts (RCSEng, 2014). Combined with changes in medical training originating from recommendations by the Calman report (DH, 1993), surgical training was to become more condensed, with fewer working hours. Additionally, the number of doctors entering surgical training fell, with increasing numbers working less than full-time hours and with some leaving surgery altogether (General Medical Council (GMC), 2015; Harries 2016; RCSEng, 2016; Al-Himdani et al, 2016). The British Medical Association (BMA) predicted a total loss of 476 638 hours per week, equating to 9900 full-time doctors (McBride, 2004). In turn, this led to the continued re-definition of traditional roles and the development of autonomous non-medical roles, innovatively covering shortfalls (Martin et al, 2007; Britton, 2017).
The secondary driver to workforce evolution was the increase in NHS waiting times (NHS website, 2016). The total number of patients waiting over 18 weeks in 2014 was 51 388, compared with 92 739 patients in 2015 and 193 406 in 2016 (NHS England, 2017). Although, due to the COVID-19 pandemic, recent data are complex to interpret, this upward trend appears to be continuing (BMA, 2023).
To support the introduction of advanced roles within operating theatres, research has shown that SCPs facilitate productivity and service delivery (Kumar et al, 2013; Tingle et al, 2016; Fletcher and Russell, 2022; Krishnamoorthy and Britton, 2022). To further evidence this, SCPs are supported to improve care collaboration (NHS Constitution (DHSC, 2015), the NHS Long Term Plan (NHS England/NHS Improvement, 2019), often by facilitating effective use of assistive health technologies (Topol, 2019; DHSC, 2022).
Emergence of assistive technologies
In 1985, the first surgical robot, Puma 560, was used to perform neurobiopsies. Consequently, this technological advance improved surgical precision and led to great interest among surgical specialties in how it could be adopted and used within their field (Ashrafian et al, 2017). A now commonly used assistive technology is the DaVinci robotic system (Intuitive, 2023), which enables operators to have 3-dimensional vision with greater magnification, acuity and improved depth perception. Robotic systems also offer improved dexterity of movement in comparison with the human hand, while also eliminating any hand tremors (Ashrafian et al, 2017). There is a tentative link to reduced pathogen spread also. However, a specialist skillset of operating between ‘surgical zones’ and ‘manipulating zones’ is required, offering an opportunity for advanced practitioner development (Zemmar et al, 2020).
The scale of impact of robotic-assisted surgery (RAS) can be challenging to judge due to the rapid development of these systems (Government Office for Science, 2016). Between 2012 and 2018, RAS use increased within general surgery from 1.8% to 15.1% (Sheetz et al, 2020).
The influential report by Darzi (2007) found that surgeons considered the use of assistive technology in keyhole surgery more favourably than in open procedures, but noted the underuse of RAS in the UK, citing a potential distrust of assistive technology. By 2015, due to the changing evidence base surrounding RAS, this had resulted in fewer surgeries being performed robotically, offering opportunities for bespoke local implementation and development (Brooks, 2015). This also appeared to indicate an opportunity for innovative ACP roles within technology-assisted surgeries.
Zemmar et al (2020) highlighted the development of telesurgery, software development and 5G connectivity to the dynamic field of remotely operated surgical devices, with telesurgery becoming increasingly achievable. Telesurgery involves inviting experts from sub-specialty fields to offer remote support and advice, which the Future of Surgery report (RCSEng, 2018) advocated, stating that the centralisation of multiprofessional expertise was a positive development. Zemmar et al (2020) noted that, previously, telesurgery had been challenging due to occasional lags in connection speed, linking to the previously mentioned technological distrust (Darzi, 2007; Brooks, 2015).
Ashrafian et al (2017) noted that there is a stereotaxic element to RAS, requiring a ‘master-slave’ mechanism, where the surgeon operates remotely via a ‘master’ console and these movements are translated and conducted by the ‘slave’ patient cart. Due to this, ACP roles become pertinent, identifying the potential requirement for a novel digital skillset, which is supported by the RCSEng and RCSEdin (2022), alongside the advanced communication skills required for multi-zone operating (Zemmar et al, 2020). This RAS skillset is now reflected in the RCSEng and RCSEdin's SCP curriculum framework, supporting innovative and bespoke ACP roles (RCSEng and RCSEdin, 2022).
The Future of Surgery report (RCSEng, 2018) acknowledged the progressive requirement of future surgical training, including roles for SCPs, advanced nurse practitioners (ANPs), prescribing pharmacists and surgical first assistants (SFA), all recruited from non-medical professions. This holistic view of future surgery requires foresight and planning, invoking discussions of complex communication training, alongside other non-technical skill development when assistive technologies are implemented (Topol, 2019; Tørring et al 2019). Aligned to perioperative ACP development, both the Future of Surgery (RCSEng, 2018) and the Topol review (2019) noted that there has been an increase in the number of perioperative ACPs taking part in diagnostic interventions, autonomous procedures and collaboration within increasingly complex and technologically advanced surgeries.
Regarding non-technical skills, Schiff et al (2016) found the primary reasons for poor communication in technologically assisted surgery were excessive transient noise (78% of respondents) and challenging communication with a surgeon operating away from the bedside (64% of respondents). Furthermore, Schiff et al (2016) found that ineffective communication was responsible for an increase in estimated blood loss (average: 51 ml) and increased operating time (an extra 31 minutes) among patients undergoing robotic abdominal surgery, suggesting a requirement for effective communication and leadership, mapping the perioperative ACP skillset to the ACP multiprofessional framework (HEE, 2017).
The Multi-professional Framework for Advanced Clinical Practice (HEE, 2017) identified four pillars of advanced practice as:
- Clinical practice
- Research
- Education
- Leadership and management.
Effective leadership is required to ensure the safe and efficient use of the increasing number of assistive technologies being implemented (Topol, 2019), and increasing adoption of RAS (RCSEng and RCSEdin, 2022). Tsafrir et al (2020) discussed the benefits of novel innovations within technology-enhanced surgeries, again advocating for effective leadership. For example, Tsafrir et al (2020) supported the inclusion of personal wireless headsets, which help overcome the communication challenges identified by Schiff et al (2016). Tsafrir et al (2020) found that not only did wireless headsets reduce transient noise levels, but they also improved direct communication between team members, a benefit that links to the clinical practice and leadership pillars of advanced practice.
The ACP role requires critical analysis and appraisal of research, advising and implementing empirically robust initiatives (Britton, 2017). This aligns with the suggestion of a bespoke and robust local perioperative concept, as proposed by Brooks (2015).
Role and impact of advanced practice in a perioperative setting
ACPs working within operating theatres are usually regulated by the Nursing and Midwifery Council (NMC) or the Health and Care Professions Council (HCPC). The NMC Strategy 2020-2025 (NMC, 2020), discussed both ACP and assistive health technologies. In comparison, Hardy (2021) noted in a large-scale qualitative study that there is no clear consensus among the HCPC workforce as to the definition of ACP roles, which could negatively impact the development of HCPC-regulated autonomous perioperative advanced practitioners. This is an interesting conclusion from the research, showing a perceived lack of ACP definition among perioperative staff, even with the availability of the HEE (2017) multiprofessional framework.
Jayasuriya-Illesinghe et al (2016) identified interprofessional socialisation as a key factor to the effectiveness of teams in the operating theatre, alongside understanding the dynamics of professional interdependency. Jayasuriya-Illesinghe et al (2016) suggested that an understanding of professional power dynamics and hierarchy is a prerequisite to effective teamworking. Tørring et al (2019) described this as ‘relational co-ordination’, defining it as ‘communicating and relating for the purpose of task integration’ with a common goal. An effective practitioner will not only have technical skills but also non-technical skills, such as situational awareness, decision-making, communication, teamworking, task management and leadership (Tørring et al, 2019). This supports the dynamic training requirement suggested by the Future of Surgery report (RCSEng, 2018), alongside developing novel and effective communication strategies (Schiff et al, 2016; Tsafrir et al, 2020).
When reviewing the literature around interdisciplinary teamwork, position statements and discussion of the ACP role, some key discussion points emerge. The first is to define the scope of autonomy when considering ACP roles in operating theatres. Jayasuriya-Illesinghe et al (2016) advocated the understanding of professional power and hierarchy, identifying multiple layers of perioperative decision-making, and therefore multiple autonomy definitions. Tørring et al (2019) further highlighted the importance of interprofessional dynamics and the requirement to adapt interactions from day to day, highlighting that positive surgical outcomes cannot be managed solely through protocol or evidence-based decisions. Tørring et al (2019) also acknowledged the importance of individual team members' knowledge and experience.
It is useful to review the categories of surgery relating to perioperative ACP roles. These are classified as diagnostic interventions, small procedures, and collaborating in complex and technologically advanced surgeries (RCSEng, 2018). Autonomy for ACPs can be found in diagnostic interventions and small procedures; however, when collaborating in complex and technologically advanced surgeries, autonomy is challenging to define. von Vogelsang et al (2019) stressed that, because effective communication is vital and forms the foundation of the advanced practice pillars cited above, the ACP's underlying non-technical skills are key in these types of surgeries (HEE, 2017).
The advanced practice pillars provide a clear opportunity for ACPs to initiate research within their surgical specialties. This will inform autonomous decision-making appropriate to perioperative ACP roles, which manifests as clinical leadership at the appropriate level of interdisciplinary hierarchy (Brooks, 2015). Furthermore, identifying that multiple layers of autonomous decision-making occur within interprofessional teams is useful when collaborating in complex and technologically advanced surgeries (RCSEng, 2018). HEE (2017) aligned this to dealing with the complexity of clinical situations, raising concerns of risk, uncertainty or working with incomplete information, all part of advanced practice. Additionally, autonomy of reflection and identifying individual development needs is demonstrated within advanced clinical practice frameworks, while also aligning clearly with common professional philosophies (NMC, 2018; HCPC, 2023).
Conclusion and implications for practice
When considering the nuanced topic of the SCP role within perioperative practice and assistive health technologies, a dynamic approach to implementation and personalised skill development is essential (Ashrafian et al, 2017; RCSEng, 2018; von Vogelsang et al, 2019). Perioperative SCP skills can be classified as both technical and non-technical (Tørring et al, 2019; von Vogelsang et al, 2019). Communication, which is a vital ACP skill, is part of working collaboratively, and has been emphasised by HEE (2017). Tsafrir et al (2020) advocated using innovative approaches to communication within technologically assisted surgery.
The SCP role has developed to enable autonomy of both technical and non-technical skills. However, perioperative advanced practice may need further interpretation for this role to develop fully, especially as the technology continues to develop (Hardy, 2021). Anyone working at an advanced and autonomous level clinically must follow a national framework, the most robust of which appears to be that drawn up by HEE (2017), which sets out the four pillars of advanced practice. For SCPs, this is also reinforced by the curriculum framework (RCSEng and RCSEdin, 2022). Through adhering to these frameworks and building their experience, SCPs are working at a level of personalised and autonomous practice to benefit individual patients and the multidisciplinary team.
KEY POINTS
- Surgical care practitioners (SCPs) work in advanced roles within the operating theatre, performing autonomous surgical interventions
- The SCP operates within a complex network and hierarchy of interdisciplinary practice, leading to collaborative and patient-centred care
- Communication is paramount for the effective implementation and development of surgical initiatives involving assistive health technologies
- Further interpretation of advanced practice roles with translation to autonomous practice is required within technology-enhanced surgery
CPD reflective questions
- In your clinical practice, how and why do you engage with assistive health technologies?
- What areas of advanced practice do you currently undertake in your role and how can this be further enhanced?
- What might be the barriers and facilitators to adopting assistive health technologies?