A clinical nurse specialist (CNS) is an autonomous practitioner who works as part of a multidisciplinary team in both acute and community settings. A CNS requires advanced knowledge and skills, which include specialist expertise, the ability to integrate service improvement and evidence-based practice, and skills to effectively collaborate and communicate with all health professions (Mayo et al, 2017).
This article focuses on the role of a CNS in a surgical orthopaedic specialty. In addition to delivering nurse-led clinics, the CNS provides support and advice to patients both virtually and in person.
The role of a CNS role is ever expanding as healthcare demands grow but resources remain limited. Using a reflective case-study approach, the author explores the potential benefits of a CNS becoming competent as a surgical first assistant (SFA).
Background
The Perioperative Care Collaborative (PCC) (2018) defines an SFA as ‘registered practitioner providing continuous, competent and dedicated surgical assistance under direct supervision of the operating surgeon’. This description, however, does not define the type of registered practitioner that can undertake this role. SFAs provide dedicated assistance under the direct supervision of the operating surgeon throughout a procedure. The Royal College of Surgeons of England (RCS) (2021) has drawn up a list of the activities that come within the remit of SFAs (Box 1).
Box 1.Surgical first assistant activities
- Communication link between theatre, patient and ward
- Involvement in World Health Organization (2009) surgical safety checklist for all surgical interventions
- Male urethral catheterisation
- Assistance with patient positioning, including tissue viability assessment
- Skin preparation prior to surgery and draping
- Use and maintenance of specialist surgical equipment
- Handling of tissues and manipulating of organs under direct observation of surgeon
- Superficial and deep-tissue retraction
- Assistance with haemostasis, including indirect application of surgical diathermy
- Use of suction guided by the operating surgeon
- Camera and instrument manipulation under direction of surgeon during minimal access surgery
- Cutting of deep sutures and ligatures
- Assistance with wound closure: cutting of sutures and ligatures
- Application of dressings
- Assistance with the transfer of patients to postoperative anaesthetic care unit
Source: Royal College of Surgeons, 2021
Surgical assistance has historically been provided by qualified medical doctors. However, the change in doctors' hours and training regulations led to a lack of medically trained staff to resource surgical theatres. This led to the introduction of non-medically qualified surgical assistants (NMQSA), enabling more patients to be treated (Limb, 2016). It has been argued that the availability of SFAs enhances consultant teams, supports surgical training and improves patient care (RCS, 2016).
Surgical assistant roles performed by nurses is not new. Nursing support was required to assist surgeons during times of conflict, and it was in the 19th century, during Florence Nightingale's nursing career, that the first surgical nurse assistant role was conceived, and the registered nurse's role included preparing wounds for surgery and operations at that time (Rothrock, 1999). Such extended roles are arguably even more important in health care today, where demand for health care frequently outweighs the available resources.
According to the RCS (2011; 2016; 2021), NMQSAs must be suitably experienced and educated to deliver safe high-quality care. The Nursing and Midwifery Council (NMC) (2018) also mandates that nurses must participate in appropriate learning underpinned by evidence-based practice to gain the specialist skills needed to maintain patient safety. Failure to gain recognised accredited competencies not only puts patients at risk, but also the practitioner's registration.
An SFA has a duty of care to adhere to professional standards to maintain patient safety. Breaching professional standards puts patients at risk of harm as illustrated by major inquiries into poor care such as the Shipman inquiry (Smith, 2003) and the Francis report (2013). Breaches of care such as those reported following these inquires can also result in a fitness-to-practise case being bought against nurses by their professional body and their employer (Quick et al, 2015), as well as risking the violation of professional, legal and contractual obligations (Reid, 2014).
An SFA must be able to justify their actions and decisions when assisting a surgeon, and their actions must be in accordance with both civil and criminal law (Quick et al, 2015). Essential skills, anatomical knowledge and appropriate training are vital to the role, as highlighted by a case where an assistant's lack of knowledge of anatomy, along with poor operative technique, caused a patient to suffer harm (HealthTrust, Inc. v. Cantrell, 1997), resulting in significant financial compensation to the patient. Dimond (2015) has stressed the necessity for registered practitioners to have a good understanding of the legal implications.
Implementing a surgical first assistant role
The RCS (2021) national guidance framework recommends that healthcare providers implement extended surgical teams based on the needs of their service and patients. The college also recommends standardised SFA training, which includes competencies for extended roles (RCS, 2021). Quick at el (2015) recognised that a lack of practice guidelines and educational standards resulted in dissimilarity in job titles and responsibilities for nurses and allied health professionals performing surgical assistance. The standards within the RCS (2021) framework are designed to ensure the continued delivery of high-quality patient care, experience, safety and efficiency of hospital services by qualified professionals.
Clinical governance frameworks are paramount in the implementation of new roles such as that of the SFA. The RCS (2021) recommends a strategic approach to ensure successful implementation, which includes:
- Clinical governance approval
- Risk assessment
- The development of clear job descriptions and responsibilities supported by local policies
- Allocated supervision of surgical trainees
- Management
- Mentoring peer support
- Ongoing professional development.
Without comprehensive implementation planning, the SFA is exposed to vulnerability, and this could compromise patient safety. Practitioners working in extended roles, including SFAs, are only covered by vicarious liability within the NHS if they work within their competencies and are deemed to be following local and national policies and national guidelines. Halliwell (2012) has noted that private professional indemnity cover is mandatory for those working outside of the NHS.
Rationale for implementing a surgical first assistant role
The decline in the number of surgical trainees and an increase in service demand has had a significant impact on the need for non-medical assistants. A report from the RCS (2016) highlighted that effective extended surgical teams improve patient care and training quality, and foster efficient working. The report was based on the experiences of eight hospitals and concluded that the introduction of extended surgical teams was overwhelmingly positive, identifying no concerns regarding the greater use of non-medical practitioners.
The case study described in this article is based on a nurse's experience at the Royal National Orthopaedic Hospital (RNOH), a specialist trust based in Greater London. The demand for SFAs to assist with the busy theatre schedule was high and often unable to be met. The number of consultant surgeons outweighed that of surgical trainees within the specialty, and there were regular requests to other surgical teams for help in assisting with planned procedures. This was not ideal in the case of complex patients and when trainees did not have experience in the specialty. Furthermore, the shortfall in surgical assistants impacted on the training timetable for the surgical trainees, and it was important to factor in both the allocated study leave and annual leave of trainees.
In addition to the aims of improving continuity of care, enhancing the patient experience and increasing patient safety, there was a desire to reduce surgical waiting times, provide enhanced learning opportunities for surgical trainees and, as a result, reduce the burden of additional locum costs and remove the need to request other surgical trainees or junior doctors from other orthopaedic specialties to assist.
Gibbs' reflective model
The author used Gibbs' reflective cycle (1988) to examine and evaluate the experience of developing as an SFA, and to consider future implications for the organisation and for individual SFA experience/future development. Gibbs' model is divided into six stages and used to considered the experience:
- Description
- Feelings
- Evaluation
- Analysis
- Conclusion
- Action plan.
Description
In 2017, to address the need for more SFAs to support theatre activity in a safe and effective manner at the RNOH, I was formally approached by the clinical lead with a proposal that I should train to take on this extended role. The following year, I completed an SFA-validated university programme of study and, in 2019, I undertook the SFA extended scope of practice accredited programme. The extended programmes involved training on suturing superficial layers of the skin, administering local anaesthetic, securing wound drains and maintaining haemostasis, including the use of mono- and bipolar diathermy.
As part of both programmes I had to achieve nationally recognised competencies, as outlined in the Surgical First Assistant Competency Toolkit (Association for Perioperative Practice (AfPP), 2018). During my training I worked in theatres alongside the consultants and my mentor. They all played an important role in teaching, assessing my competence and supporting my learning requirements.
Feelings
As a permanent and respected member of the surgical team, I felt honoured to be asked to take on the SFA role, but also felt some apprehension. These concerns resulted in doubts about my ability—I felt unable to consider the larger picture, and the potential beneficial impact that taking on the role would have on service delivery and the patient experience. The reality felt daunting, and questions started to emerge, in particular relating to accountability and litigation within the new role, including:
- I haven't worked in theatres since I was a student nurse. How will I cope with a new field of practice?
- How will I manage my CNS service, as well as this new surgical role?’
- Will this new role deviate me from direct patient care and clinical duties as a nurse specialist?
I experienced a steep learning curve, but the support of my mentor, the consultants and the welcoming theatre staff helped me succeed, and I overcame my concerns. Weekly meetings with my mentor and consultants provided feedback on my development and competence, which enabled me to improve practice. I felt proud that I achieved competence through sheer dedication, determination and interest in developing a new role in line with the Surgical First Assistant Competency Toolkit (AfPP, 2018). I was particularly pleased that, rather than distracting me from direct patient care as I had feared, I felt that the two roles complemented each other and helped me provide enhanced care to my patients.
Evaluation
The PCC (2018) position statement is clear about the importance of an SFA developing sound underpinning knowledge and being able to demonstrate skills and competencies. I not only completed a SFA validated university programme of study that meets national standards (College of Operating Department Practitioners, https://cpoc.org.uk/guidelines-and-resources; AfPP, 2018), but also completed one of the first SFA extended scope of practice accredited programmes. All nurses and other registered health professionals who perform extended roles, such as that of an SFA, have a duty of care towards their patients, underpinned by the codes of practice of their professional bodies (AfPP, 2013; Health and Care Professions Council (HCPC), 2016; NMC, 2018). The professional codes acknowledge that some skills may not be part of their members' scope of extended practice. It is important that the SFA is aware which skills these are.
I think that my taking on an enhanced role as a CNS has benefited both patient care and service provision. Operating lists have seemed to run more smoothly as a direct result of my knowing the preferred theatre set-up, organisation and running of the list, as well as having an understanding of how the surgeon likes to operate. As a CNS, part of my role is to follow up patients 6 weeks postoperatively and provide a full explanation of the operation and the findings. Assisting in theatres enabled me to provide patients with more comprehensive information and I was better able to answer their questions. When you are not present during an operation, you are solely reliant on what is entered in the operation note to do this. Ad hoc verbal feedback from patients has supported the value they placed on this opportunity to ask the SFA questions.
During my training, I performed the role of an SFA in nine of the 50 (18%) operations in which I assisted, as there was a shortage of surgical trainee support. From my perspective, this benefited service provision because otherwise the operating lists would have been cancelled, impacting on the patients requiring surgery and the loss of income to the hospital. However, if I was not confident about a procedure or if the surgery was particularly complex, I felt confident in being able to decline. During our operating lists the unit consultants normally operate on the same day in parallel with each other, so advice or support from another consultant is always available, if needed, especially with some of the more complex cases because it potentially leads to two consultants operating together.
Things did not always go as smoothly as planned and there were times when I needed to overcome the prejudiced attitudes of some healthcare staff. One example was when a consultant refused to allow me to assist or observe in an operating room, giving the reason that the theatre environment was not my background. This made me feel intimidated and unwelcome. Hall et al (2016) highlighted three Cs as the most important qualities of a perfect assistant: calmness, confidence and courage. Although I respected the opinion of this consultant, without exposure to the appropriate environment, learning cannot take place.
Becoming an SFA has given me the confidence to speak up about any potential error that I considered could cause harm—my new skills and knowledge have served to reinforce the specialist experience I have already gained during my nursing career and recognition of my professional duty of care (NMC, 2018). In 2009, the World Health Organization (WHO) recommended the use of a surgical checklist as good practice for maintaining patient safety. Within my organisation, following the checklist is routine procedure, although on one occasion I did have to remind the surgeon to complete the ‘time out’ before commencing the operation, to ensure that safety was not compromised. Reid and Bromiley (2012) emphasised that speaking up in the face of a potential breach of patient safety is the responsibility of all theatre staff present.
As an SFA, regular exposure to the operating environment has enabled me to develop technical skills related to the handling of instrumentation, tissue and appropriate support of retraction. The Intercollegiate Surgical Curriculum Programme (2020) recognises that technical and non-technical skills are developed over time, and these become embedded and result in practice, enhancing patient care. According to Kvick (2014), taking on more technical skills is not less caring—it enables nurses and other practitioners to deliver more effective, personal and holistic care.
The SFA role complements my CNS role. Being involved in the operating procedure means that I can provide patients with a greater understanding of the complexity of their surgery in advance of the procedure and postoperatively in CNS-led outpatient clinics, enabling care to be more consistent. Kvick (2014) pointed out that continuity of care can be achieved by embracing the perioperative role required by an SFA—and this has certainly been the case in my experience.
Analysis
Although the experience of taking on an enhanced SFA role as a CNS is not new, such roles are still not common practice in the UK. This case study highlights the benefits of these complementary roles, while considering how best to overcome the challenges related to implementation. Regardless of their professional background, a good surgical assistant can increase patient safety. SFAs develop extensive knowledge of anatomy and operating procedure, which can help avoid preventable errors during an operative procedure.
Human factors are ever present in work environments and situational awareness must be maintained, with intraoperative intervention required if personal or patient safety is at risk. Situational awareness encompasses the cognitive skills of perception and attention to continuously monitor the task, detect any changes and anticipate situational development (Flin et al, 2016). A competent SFA can help prevent risks to the patient, which may occur if a surgeon is distracted or fixed on a particular task.
Hall et al (2016) stressed that the SFA should remain calm and professional during stressful operating situations. Surgical procedures can be complex—one commonly encountered complication is altered anatomy—and procedures may not always run as specified in manuals, especially in specialist centres in a tertiary hospital. These issues can increase stress levels and may explain the resistance by some surgeons to the implementation of new roles. Stressors include the theatre team not focusing on the operation, ie not paying attention to instructions or talking among themselves, distractions such as mobile phones, communication failures or even equipment problems, which can all affect surgical performance and decision-making, with the potential to lead to an increase in psychiatric morbidity (Wetzel et al, 2006; Hotton et al, 2019). Experienced CNSs who have well-developed skills in managing complex and stressful situations are well placed to perform this role.
Developing the role of a CNS to incorporate enhanced SFA skills also facilitates effective communication between the perioperative and surgical teams. The CNS plays a pivotal role in multidisciplinary team pre-operative planning meetings, which include ordering specialist instrumentation and allocation of assistants. These planning meetings ensure that surgical lists run smoothly, thereby avoiding complications. Inadequate pre-operative planning can affect patient outcomes, lead to cancellations and prevent the assistant having time to prepare for the list (Quick and Hall, 2014). CNSs have an opportunity to prepare for allocated lists, familiarise themselves with the patient, read notes and operation plans, and meet the patient in the presence of the consultant surgeon during the consent process.
Effective teamwork improves the quality of patient care and enhances patient and staff safety (Flin et al, 2016), while ineffective multidisciplinary planning and communication can lead to poor service delivery, with a consequent negative impact on patient care. Interdisciplinary safety briefings are part of the NHS England (2015) National Safety Standards for Invasive Procedures: the aim is to ensure that there is clear discussion and communication of the final surgical plan to minimise potential problems or risk factors. Flin et al (2016) highlighted the importance of input by all members of a team during the briefing meeting, irrespective of seniority, stating that this must be encouraged and accepted. The brief should include a discussion of whether excessive bleeding is expected, what actions are to take place, and whether the patient's blood has been cross-matched to prevent unnecessary harm. Furthermore, the RNOH is a specialist hospital and there is a need to manufacture bespoke prostheses for complex patients. During the brief, therefore, it is important to verify that the correct prosthesis for each patient is available—as well as the appropriate surgical kit—to avoid any errors as set out in the national safety standards. The CNS/SFA role includes coordinating and ordering of bespoke prostheses in a timely manner.
Although SFAs are responsible for their actions or inactions and should make the surgical team aware of their limitations and responsibilities, they must not be made to feel inadequate when asking for help (Brame, 2011). Consultant surgeons play a crucial part in the supervision and ongoing performance of the SFA and are responsible for ensuring that delegated tasks are suitable for the SFA.
According to the RCS (2014), good surgical practices should support an SFA under the supervision of a surgeon to enable the SFA to learn and develop through the activities required to perform their roles. Competence is achieved through continuous exposure to learning opportunities, effective supervision, assessment and feedback. An SFA should possess common sense, competence, commitment, compassion and good communication skills (Myint, 2018). Having the courage to speak out is important when there are concerns about a surgical procedure that may have a detrimental effect on patient outcome.
Research outlined within the RCS (2021) guidance framework found that patients are happy to be treated by a member of the extended surgical team. Permanent staff who know the surgeon's preferences can bring several benefits to the patient and the surgical team, eg consistency of care, extensive knowledge of surgical procedures, and competence in the operations to be performed (Quick, 2013). However, the RCS (2021) guidance suggests that the patient should be informed that a non-medical practitioner will be assisting with the operation as part of the extended surgical team, because a patient has the right to refuse. At the RNOH, the patient is introduced to the SFA on the morning of the surgery and provided with pre-operative patient information booklets explaining the extended CNS role, but in the author's experience no patient has ever refused consent.
The cosmetic appearance of a surgical scar can be very important to a patient, and an SFA with extended skills acting as first assistant to the surgeon can assist with suturing. An SFA is also able to monitor the timing of the operation and, more generally, aid smooth running of the operating list. SFAs are expected to assist with the closure of deep-tissue layers and superficial layers of the surgical wound. They may also extend their scope of practice to suturing of skin layers following completion of an accredited course (PCC, 2018).
Wound management is an essential competency for SFAs (Quick, 2013; Vowden and Vowden, 2017): it requires good anatomical knowledge, an understanding of the principles of wound healing, appropriate suturing skills and knowledge of wound dressing. Nurses are used to managing complex wounds and recognise the importance of a well-healed wound, understanding how to reduce the risk of dehiscence and infection. A CNS is therefore well placed to manage this important aspect of surgical care effectively (WHO, 2016).
Conclusion and action plan
Although most SFAs are still members of the perioperative team, the RCS (2021) guidance recognises and embraces other practitioners developing into this role. Regardless of professional background, an SFA with an appropriate level of education can make a significant positive contribution to patient care.
This case study has described a generally positive experience. As time passed, I learnt to become more confident and assertive. In future, I would certainly speak up and challenge my right to work as an SFA. Being a permanent member of staff within the team provides consistently high standards of service delivery and having the opportunity to regularly work with the same surgeons builds trust and effective working relationships.
The development and implementation of extended nursing roles, which challenge the traditional boundaries of care, are integral to the delivery of safe and efficient health care.
This case study has included a personal reflection of the experience based on assumptions about its impact. The next step is to formally evaluate the role at a local level within the RNOH, from both a patient's perspective and that of the surgical team. An audit is planned in the near future, which will also look at health outcomes and service delivery metrics, but this work has been delayed due to the COVID-19 pandemic.
Conclusion
This reflective case study has demonstrated the benefits of a CNS who has undertaken an accredited SFA course not only for the individual registered practitioner, but also for the surgical team, the patient and the wider NHS organisation. The SFA contributed to efficient service delivery, showing that this enhanced role optimises good quality care, which in the long term will maximise outcomes to ensure operative success and enhance patient satisfaction.
KEY POINTS
- The NHS faces persistent financial pressures, especially in view of the COVID-19 pandemic, yet surgical standards of care continue to rise, coupled with a downturn in the number of surgical trainees and junior doctors
- The health service must look at different ways of working to maintain consistency in care without compromising quality
- Developing enhanced roles, such as that of the surgical first assistant, for clinical nurse specialists can maintain high-quality care while offering career development benefits to the nurse specialist
CPD reflective questions
- What benefits are associated with a clinical nurse specialist undertaking a surgical first assistant (SFA) accredited course?
- What challenges might be encountered?
- What do you need to consider when taking on an enhanced practice role?
- What long-term gains does the role of SFA have for the nurse, the patient and area of practice?