NATN (1993) defines first assistants as registered Nurses who provide skilled assistance under the supervision of the surgeon but do not intervene surgically. Their standard of care must be of a very high order. Holding retractors, using suction, Handling tissues and organs, skin preparation, assisting with skin closure and haemostasis, cutting sutures and ligatures, prepping, draping and general assistance to the surgeon are examples of this role. Patient safety is paramount and to ensure this, the importance of undertaking training beforehand is emphasised. The role is not to be confused with that of a surgeon’s assistant where Nurses have more extensive involvement during surgeries NATN (1994)
Theatre Nurses began to function as first assistants during World War Two when there was a shortage of surgeons and their juniors. Recently this role has evolved as Nurses expand their practice as well as compensating for a similar shortage of Surgeons, resulting from a reduction of Doctors’ working hours NHSME (1991). By assuming this role, Nurses are acquiring greater responsibility and therefore greater legal accountability. Studies show that considering the amount of time Nurses are spending on these expanded role activities, the continuing expansion has created cost implications, which include training costs, and the costs of increased hours required to enable the Nurses to carry out these procedures.
As the years are going by, it has become clear that the roles of all healthcare workers have changed and are still changing. Reforms in healthcare delivery have arisen from the move to degree level education of the Nurses and the implementation of the New Deal (NHSME1991), which concerned Doctors’ working hours and delegating to Nurses activities previously undertaken by medical staff. Professional and legal developments such as the United Kingdom Central Council’s (UKCC) Code of Professional Conduct (1992), Scope of Professional Practice (1992) and Exercising Accountability (1989) have all acted as guidelines for the Nurse when developing practice and expanding their roles.
In 1989, the Government agreed that the number of hours worked by junior Doctors was unacceptable and it was necessary to reduce their workload. This initiative also had implications for Nurses to take on some of the activities or tasks which had been considered a part of the junior Doctors remit Higgins (1997). The author continues by saying that this extension and expansion of the Nurse’s role would also fulfil the key requirements of the New Deal. In the process, the training incentives would also enhance and expand the scope of nursing practice, and provide a more holistic approach to patient care. To ensure that these training programmes complied with the scope of professional practice requirements (UKCC 1992), each programme has three centre objectives to be achieved by the participant. By the completion of the course, each participant must be able to recognise the legal and the professional issues surrounding the practice, gain skills and experience required to perform the procedure and attained all the requisite knowledge underpinning the practice with improvement in communication between disciplines. DHSS (1997)
Theatre Nurses working as first assistants have many matters such as accountability, responsibility, autonomy and duty of care to the patient with which to contend. Hind (1997) declares that there are four issues to consider, which are professional, legal, contractual and self, as described below:
Professional: UKCC (1996) states that a registered Nurse must promote and safeguard the interests and well being of patients and clients, acknowledge any limitations in knowledge and competence and decline any duties unless able to perform them in a safe and skilled manner. Bernthal (1999) advocates this by saying that Nurses are totally accountable and Surgeons can only supervise and not take responsibility for any action of the Nurse acting as a first assistant. They must not help the surgeon out without adequate education.
Legal: Bernthal (1999) says that Nurses are accountable to the public through criminal law and to the patient through civil law. Theatre Nurses need to be aware of the possibilities of litigation as they extend their role. If a theatre Nurse does not feel competent in a role, they have a duty in civil law as well as in the guidelines set by UKCC to refuse to act, thereby ensuring patient safety. Lack of experience is never an excuse for incompetent care, once a duty of care is breached causing harm to the patient, the result is a charge of negligence. Therefore, major legal and professional implications exist.
Contractual: When a contract of employment is signed, employees are bound by its terms Hunter (1994). Employers can control not only what nurses do but also how they do it Lunn (1994) which creates a dilemma. Nurses have a responsibility, legally and professionally, to protect their patients by performing only in those areas in which they are competent but as employees, they also have a duty to carry out the orders of the employer. Therefore the employer must provide adequate training and support so that the staff can carry out any extended role competently that they require of them Bernthal (1999).
Self: Bernthal (1999) states that to be ‘self’ accountable, Nurses have a moral, as well as a legal and professional duty, to educate themselves in any deficient area of knowledge. If all professionals self regulated themselves perfectly, there would be no need for other legal and professional bodies to ensure patient safety Hind (1997)
A group of senior Nurses at the University Of Dundee in 1999 stated that a high percentage of scrub practitioners are undertaking first assistant activities. They also stated that there was a lack of funding to support this role and to recognise those who had successfully completed the formal first assistant training course. They also realised that for the initiative to progress, it was imperative that there was an actual record of the current scrub practitioners’ practice in Tayside, which resulted in a four-week long scrub practitioner audit in 1999. This audit involved each scrub practitioner filling a questionnaire for every case admitted to the theatre. However the result wasn’t as expected (Robinson and McIntosh 2002).
Robinson and McIntosh (2002) stated that the analysis, though, showed the first assistant activities were undertaken to some extent by the scrub practitioner, confirming the working party’s initial theory. The audit team also learnt that the degree of involvement of first assistant was far higher than originally thought, and that all the first assistant duties which scrub practitioners had accepted as a part of their normal practice were inclined to be undertaken more often. These include activities such as skin preparation, draping and cutting of sutures and ligatures. The personal opinion of the audit team was that, locally, medical staff had adapted their practice and accordingly were happy for scrub practitioners to perform the first assistant activities. The audit team also learnt that surgeons have helped in redefining the role of scrub practitioners. Despite increasing emphasis on professional accountability, it is evident that the scrub staff are routinely performing outside their ‘normal scope of practice’.
Tanner (2000) stated that first assistant’s activities constitute an extended role and it is necessary to explore whether the tasks undertaken are extended skills requiring additional training and separate contracts. There is a concern that if scrub Nurse or ODP takes on the first assistant role, they will encounter problems with professional accountability and liability and also require additional training. This however has been accepted, apparently unchallenged, by scrub and theatre Nurses. However it is time to address this and find out whether the activities currently recognised as a part of the first assistant’s role do or do not constitute extended practice (Tanner 2000). Timmons (2000) states that evidence on the above statement is based on the qualitative study exploring Theatre Nurse practice. The methodology of this study used observations of scrub Nurse practice and interviews with scrub and theatre nurses. As suggested by NATN (1993), some first assistant activities (e.g. assisting with skin closure and haemostasis, cutting sutures and ligatures, prepping, draping etc.) were actually all routine theatre Nurse practice.
Sutherland et al (2000) confirmed these findings in a later audit of theatre Nurse practice showing that in 951 surgical cases, 73% of the theatre Nurses undertook first assistant activities, and on asking why, 39% of them said the activities were a part of their normal practice, especially prepping and draping. EORNA (1997) supports this idea of first assistant tasks in the curriculum content for theatre course, e.g. preparation of the patient. This does not mean that the first assistant role is not an extended role, but rather the tasks currently described by NATN as being a part of first assistant role may be routine theatre practice.
Tanner (2000) states that the observations of theatre practice identified some activities which occurred infrequently, were limited to certain surgical specialities and appeared to require additional education or understanding, e.g. staff developing x-rays, setting up image intensifiers, shaping grafts, putting cement on prostheses, hammering, preparing ‘back slabs’, cementing and directing laparoscopic camera equipment. It does not mean that these tasks are skills of the first assistant but merely that these tasks seemed to be additional skills which may form part of the future developing role of the theatre practitioner.
NATN’s principles of safe practice in the perioperative environment (1998) goes on to say that surgical preparation requires knowledge of infection control and aseptic techniques and that staff at all grades should receive support in these techniques until proficient. One should assume that all qualified theatre practitioner possess a proficient aseptic technique and therefore they are able to undertake this task. Tanner (2000) stated that in fact, a majority of theatre nurses prep and drape patients, which make it superficial to label these activities as additional skills. It is much better to incorporate them into our existing developing role in response to a changing environment. The current role of theatre Nurses has evolved as a response to the changes brought by advances in surgery, world wars, staff shortage and even a personality dispute (Kneedler and Dodge 1987) (Groah 1990) (Fairchild 1993, 1996) (Adams 1990)
Bernthal (1999) called for the need to provide well-defined parameters defining the first assistant role. Tanner (2000) stated that the theatre is a complex environment with a large number of professional groups where the smooth running of operating sessions is dependent upon boundaries that are fluid and continually negotiated. Scrub Nurses will be familiar with situations where Surgeons have opened sutures for them, moved the theatre lights or transferred patient, all tasks considered to be the responsibility of nursing or circulating staff. Placing boundaries or limit may prevent such negotiated ‘swapping’ of roles. Boundaries which are inflexible and not responsive to changing situations may restrict the smooth running of the operating lists. If limitations are built around theatre practice, in the future theatre Nursing may become over-specialised and eventually untenable. Ultimately the boundaries set down by theatre Nurses may end up excluding theatre Nurses themselves.
It is time to consider whether scrub Nurses can adapt successfully to their expanded and extended roles. Wright (1995) stated that in the simplest terms, role extension refers to Nurses carrying out tasks not included in their normal training. Most of these tasks relate to acute medical-technical intervention usually carried out by Doctors such as setting up intravenous infusions. Such tasks are thought to require greater intelligence and skill. Role expansion, on the other hand, is based on an alternative set of values. The significance and intricacy of scrub Nurses’ core skills are recognised in a concept of ‘fundamental’ rather than ‘basic’ training.
UKCC (1992) states that the scrub Nurse undertaking either some or all the elements of the first assistant role, as defined by NATN (1993) should be competent enough to do the task as no work should be carried out unless the Nurse is certain in the requisite knowledge and skills. Section 9 guidelines of UKCC (1992) gives enormous scope for Nurses to expand their activities, provided that certain critical questions can be adequately answered: whether the patient care will get better, whether core Nursing is preserved and the essential values and practices associated with caring protected, whether the scrub Nurse is competent and able to judge as not all Nurses are aware of the limitations of their knowledge and skills. More importantly, whether any management support is present, as Nurses need to feel that any new work that they take is supported by the organisation in which they work. Also, a comprehensive strategy is needed to ensure that any role development is safe and based on sound knowledge and skills which can be made possible by education. UKCC (1992)
Thus, the aim of this initiative is to educate Nurses to undertake the role of first assistant, which is recognised nationally as an interface between the Doctor and the Nurses in the operating department. The education programme is divided into two sections dealing with clinical and academic issues. During this period, the first assistants critically analyse the care needs of patients for both elective and emergency surgery and scrub practitioner participates in care and preparation of patient for surgery and act as a first-assistant to the surgeon.
Beesley (1998) and Bernthal (1999) stated that numerous hospitals support their staff to undertake university based Theatre Nursing courses or in-house theatre course where e.g. prepping and draping are taught. It is also surprising for a hospital that has paid for its theatre staff to be taught prepping and draping not to undertake these activities as a part of their contract.
Beesley (1998) also describes a hypothetical situation where a patient prepped and draped by a theatre Nurse developed a post-operative wound infection. Beesley continues by suggesting that in this situation, the Nurse could be deemed negligent, as the Nurse had no formal training on the role of first assistant. However, it would be surprising for a qualified theatre Nurse not to have been taught the underlying principles of prepping, draping and infection control. Tanner (2000) also stated that a surgeon in a similar situation, although knowledgeable of asepsis would be unlikely to have covered ‘draping the patient’ as part of the FRCS exams.
NATN (1993) also states that it is essential that adequate education and training be offered to those Nurses who are likely to undertake the first assistant role. While this is also a wise advice to offer Nurses undertaking new roles, it is based on the assumption that the activities currently associated with the first assistant role are indeed new. Beesley (1998) also bring forward the NATN stance and advocate that ‘nurses must first seek the education and training they require to become competent in this role’.
Tanner (2000) states that as a result of this demand for education, the ENB N77 ‘The Nurse as the First Assistant’ was developed. Farrell (1999) describes the development and the delivery of this course at Manchester University and includes a table showing an example of the course content reading ‘core anatomy and physiology, skin prep and draping, wound healing, tissue viability, sutures, wound drainage and haemostasis’. This would appear indistinguishable from the contents of a routine theatre course (Tanner 2000).
In conclusion, theatre practitioners will continue to face challenges to their practice in a dynamic and changing healthcare system. The role of the first assistant has wide implications, legally and professionally, and all theatre practitioners must be aware of these. Nurses have a unique professional role and it is essential that this is developed and not eroded if Nurses take on the role of the first assistant. Wright (1995) states that expanding the role of a theatre Nurse is fraught with difficulties, but also full of possibilities.
Observation of theatre practitioner’s practice suggests that prepping, draping and retracting are routine theatre practice and not extended duties which require additional education and separate contracts. This should not be misinterpreted as suggesting that first assistant activities do not require additional education or separate contracts, but simply that some of the activities previously mentioned, which are identified as being first assistant activities, do not require this.
If boundaries to theatre Nursing practice are set which are incorrect or inflexible, theatre Nurses may find themselves excluded, not only from carrying out these routine tasks, but from any future tasks developed in response to a changing environment. Stretching the boundaries of care, may of course, increase the employment opportunities for theatre Nurses in an increasingly competitive and cost-conscious healthcare market. More importantly, it seems that the patient has a chance of a better deal. Formal approaches to role expansion can replace the previous ad hoc methods providing safer practice and legitimising what many theatre staff already do anyway. There is no need to fear the creation of a ‘mini-doctor’ if we are clear about our values, practices and methods of development. Indeed, the potential is there to create many varied ‘mega-nurse’ roles that can be turned into a genuine clinical career structure, based not on managerial hierarchy, but on expanding knowledge and skills in-patient care (Wright 1995).