Nurses in surgery — opportunity or threat? A personal view
W. J. G. MURRAY
Consultant Surgeon, Perth Royal Infirmary
Keywords: nurse-led developments, nursing
Surgeons are at risk of becoming an endangered species. Recent events have placed us in
the spotlight as never before. The expectations of patients and their relatives have never
been greater, often raised to unrealistic levels by a section of the media whose motives
appear to go beyond pure altruism. The Bristol debacle has accelerated this process. In
addition, surgeons currently have to grapple with a host of related issues including
increased accountability, increased specialization and hospital accreditation. Litigation
is rife. Is it any wonder that some surgeons perceive another potential threat waiting in
the wings; that of the increasing role of nurses in surgery? For some surgeons this is the
last straw. They have seen interventional radiology and pharmacotherapy erode huge areas
of traditional surgical practice. Who would deny, however, that these
advances have not been to the benefit of patients? Other surgeons see the role of nurses
in surgery as a golden opportunity to improve multidisciplinary teamwork whilst at the
same time freeing us to perform other duties. They point out that now is the time for
innovation and flexibility and that anything less will lead to the inevitable accusations
of reactionism and vested interest. In addition to the views of surgeons there are others
to be considered, namely those of patients, nurses themselves and managers. One thing that
is certain is that the medical profession must be in the forefront of shaping any such
change. Despite what we are sometimes led to believe we remain the principal custodian of
clinical care for patients and must demonstrate leadership in training, supervision and
assessment of nurses extending their role into areas of surgery. I believe that the
momentum for such change is already irreversible, fuelled both by economic factors and a
desire by nurses themselves to find an alternative to their traditional role. While nurses
have inevitably found themselves playing a secondary role to the medical profession in
areas of clinical care, their contribution to the overall well-being of patients has been
immense.
As a more structured degree-based education for nurses has emerged there are many outside the nursing profession, as well as within, who claim that this has led to a diminution in the ‘hands-on’ skills that are the cornerstone of patient support. They believe that this, along with a failure on the part of successive governments Ito address properly issues relating to pay and conditions has led to poor morale amongst nurses and difficulties in recruiting and retaining staff.
As the traditional role of the nurse has decreased so new roles have been sought, and sometimes found. However, this process has been going on for much longer than is generally recognized. I remember visiting an intensive care unit in Australia over 20 years ago and seeing nursing staff routinely intubating and extubating patients, adjusting ventilatory parameters, interpreting ECGs and administering drugs accordingly. In the United Kingdom, similar practices have been slower to develop but have been part of a much wider change in areas of hospital specialist nursing skills such as coronary care, nutrition, diabetes, stoma care, pain relief and oncology. In the operating theatre we have seen specialization towards anaesthesia, recovery skills and the traditional role of scrub-nurse. What a pity that some in the nursing profession seem to trivialise the role of the scrub-nurse when every surgeon knows what a vital member of the team such a person is. It is my belief that this recognition should lead to the development of a progression of practical nursing skills in theatre, as is already happening in many centres. Such skills include skin suturing/stapling and minor surgical procedures. There is some irony in the fact that such nurses may receive better training in these techniques than many of their surgical colleagues received during their training. However, this may be less of an indictment of how we have trained our surgeons over the years, and more recognition of the vulnerability of nurse-led developments to medico-legal problems and consequent adverse reporting in the media (as has already happened on several occasions). Some surgeons are opposed to nurses performing minor surgical procedures on the grounds that this will deny surgical trainees similar opportunities. I do not subscribe to this view. The training of surgeons is now more structured and supervised than ever before with such developments as the Basic Surgical Skills courses at the College leading the way. Whilst it is true that there is no real substitute for the handling and suturing of living tissues the days of being sent off unsupervised as a newly qualified junior doctor to perform a minor operation list have, I hope, gone. There is a right way and a wrong way to perform even the simplest procedure and proper supervised training, whether nurse or doctor, is mandatory nowadays. I believe the College has a major role to play in the training of nurses in surgery to ensure the highest standards. Such a role might become self-limiting in time as the dissemination of such skills occurs but not if, as I believe, such courses become the ‘gold-standard’ with associated Certification of Completion. Whilst individual surgeons and hospital trusts must have a vital role to play the College is uniquely placed to maintain and monitor standards.
Let us turn to the nurse’s perspective, of such developments. The United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) has no objection to nurses developing the extent of their professional practice but asks that ‘nurses concerned are competent for the purpose, and mindful of the personal professional accountability they bear for their actions’. Such statements hint at the underlying minefield of potential medico-legal issues. For instance, the common law of negligence requires that, at all times, a reasonable standard of care be attained. Thus, a nurse performing a surgical procedure will be judged according to the standard of a reasonably competent surgeon. If a patient suffered harm a successful defence claim for compensation would depend on expert evidence being available to satisfy the Court that, at all times, a reasonable standard of care was attained. The fact that it is no defence to say the operator was inexperienced, but doing their best, applies to an operating nurse, just as it does to an operating surgeon. Vicarious liability is little reassurance in such cases.
Equally, surgeons must be aware of the medico-legal consequences of delegation. The following quote is from the General Medical Council publication on Professional Conduct and Discipline: Fitness to Practice
The Council recognises and welcomes the growing contribution made to health care by nurses and other persons who have been trained to perform specialist functions, and it has no desire either to restrain the delegation to such persons of treatment or procedures falling within the proper scope of their skills or to hamper the training of medical and other health students. But a doctor who delegates treatment or other procedures must be satisfied that the person to whom they are delegating is competent to carry them out. It is also important that the doctor should retain ultimate responsibility management of these because only the doctor has received the necessary training to undertake this responsibility.This last sentence is a vital one and underpins what many of us believe to be of fundamental importance. The consultant in charge of the case must remain in overall charge. This is not to say that he or she must exert a degree of stiffing control (something the nursing profession historically resents) but the nurse in surgery must be treated as a vital member of the surgical team, and encouraged to reach their full potential in the delivery of care to patients. Without this commitment nurses in surgery will quickly become disillusioned..Indeed, the point has been made that a career structure should be developed for such nurses to prevent their work becoming unacceptably boring and repetitive. The line between dedication and exploitation is indeed a thin one. Only time will tell how advanced the type of surgical procedures performed by nurses becomes.However, it is not beyond the realms of possibility that appropriately trained nurses could perform such procedures as inguinal herniorrhaphy or varicose vein surgery. This might well entail a degree of direct supervision along the lines of the provision of anaesthetic services in some countries where several nurse anaesthetists work under the direct supervision of an anaesthetist. I have painted a picture of nurses, trained to perform specific surgical procedures, working as part of a surgical team under the overall charge of a consultant. This is what is already happening, and I believe many surgeons support this. However, there is a possibility whether we like it or not, a degree of autonomy develops to the point where the individual nurse no longer works as part of a team but as an independent agent within a hospital trust.
This model has certain attractions to hospital managers, not the least of which is based on the inevitable fact that it is cheaper to pay a nurse to perform a procedure than a doctor. I believe that such short-term financial expediency will condemn nurse-led developments to nothing more than a passing fad. Furthermore, I do not believe that the nurses themselves wish to work in such an environment. They, as much as anyone, are aware of the fact that it is all about teamwork. In the context of surgical procedures the team-leader is inevitably going to be a surgeon but in the modern NHS there are many other teams where nurses, or other health professionals, already fulfil the role of leader.
There are two other important areas involving nurse-led developments, those of diagnostic endoscopy and out-patient clinics. All of us involved in diagnostic endoscopy know that performing the procedure safely is only part of the skill and that recognition of pathology takes considerable experience. We also know that some fibre-optic procedures carry minimal risk whilst others carry more. Perhaps this is one reason why urology has led the way in this field. Nurse-flexible cystoscopy lists are becoming relatively common place. Preliminary reports presented at the British Association of Urological Surgeons Meeting over the last 2 years have been favourable. Careful selection of nurses for such endoscopic training is vital. Only a small minority of nurses wish to develop such skills and not all of these will have the necessary aptitude.
Different attributes are required for nurses involved in surgical clinics. Communication skills are vital and, just as there must be a clear line between diagnostic and therapeutic endoscopy, there must be an equally clear line between a complementary diagnostic clinic role and a therapeutic role. For example, many prostate assessment clinics are nurse-led because such clinics lend themselves to specific diagnostic pathways involving such elements as symptom score, uroflowmetry, bladder ultrasound and blood tests. These generate information on which the general practitioner or consultant can base therapy. In some such clinics nurses are making therapeutic recommendations although most surgeons, I believe, feel this is inappropriate at present.
In summary, the extended role of the nurse in surgery is already established in some areas of surgical practice. It is my contention that we must encourage the development of the concept where appropriate. Surgeons must be involved with training and supervision, and the College may be uniquely placed to co-ordinate such training. A career structure for such nurses must be developed and they should be encouraged to be a vital member of the surgical team. Such nurse-led developments must not be at the expense of training junior surgeons. Financial factors, whilst important, must not be the principal driving force. What are the potential benefits? Firstly, continuity of care (something not always possible with rotating junior medical staff) is achievable with nurse-led developments. Secondly, surgeons are freed to pursue other clinical duties at a time when demands on our time are steadily increasing. At this time of insecurity for surgeons now is the time to demonstrate leadership in making sure that nurse-led developments are for the benefit of patients, nurses and surgeons alike.
Paper accepted 1 September 1998
Correspondence: Mr WJ.G. Murray, Perth Royal Infirmary, Perth PH1 1NX, UK
© 1998 The Royal College of Surgeons of Edinburgh J. R. Coll. Surg. Edinb., 43 December 1998, 372-373