Perioperative nursing

Throughout this assignment I will analyse the impact of the Perioperative Nurse Surgeon Assistant (PNSA) role at MercyAscot hospital where I am currently employed. I will discuss any foreseeable problems, and the support given by the hospital. The position description will be critiqued using current literature, and my own professional development will be addressed.

IMPACT OF PNSA ROLE WITHIN MERCYASCOT

Since the beginning of modern day nursing in the late 1800’s nursing staff have been directly involved in the technical and direct nursing care within the perioperative field (Bridges 1995). This role has changed over the years governed by medical training schemes, and more recently by legal and ethical issues pertaining to the code of professional conduct. (UKCC 2002). I feel that the perioperative nurse has followed the dictations of the medical field with regard to the level of intervention and their defined role within the operating room. However due to financial constraints, and the advanced academic training the role of the perioperative nurse has once again developed into one that is extending the skills of the practitioner (NATN 1993).

The perioperative environment is constantly changing. New and expanding roles within the speciality are being formed. Technological advances in treatment and care, and a continuing reorganisation and redirection of resources is happening (Driscoll and Teh 2001). I agree with Driscoll and Teh, and feel that is important for individual practitioners to develop professional knowledge, in order to cope with the demands and changes within today’s perioperative environment.

In every nurses career many legal or ethical dilemmas are encountered. One dilemma facing the perioperative nurse today is surgical assisting. At the MercyAscot the perioperative nurse is expected to be able to perform the role of the instrument nurse, circulating nurse, and as the surgical assistant. I don’t agree with this, as at present there are no guidelines in place to prevent new staff nurses from assisting for a probation period. The Clinical Nurse educator is attempting to put a six month time frame on this, and is presently in contact with New Zealand Nurses Organisation (NZNO) for their advice. NZNO do not have any recommendations regarding this area of practice. Not every hospital expects their perioperative nurses to perform the role of the surgeon’s assistant. This usually occurs in settings where there are no doctors available to perform this role, i.e. private hospital setting.

MercyAscot is a New Zealand owned private facility, formed from the integration of two private surgical hospitals, Ascot Hospital and Mercy Hospital. At MercyAscot, perioperative nurses assist for many of the cases. I believe this is due to these reasons:-

Financial constraints within the private healthcare system.

MercyAscot hospital is not a medical training organisation, so does not have the use of doctors to assist during procedures.

The relationships that have developed between the surgeons and the perioperative nurses have been built on experience, trust and the necessity to provide an excellent service.

MercyAscot is one of the few hospitals in New Zealand that currently employs a PNSA. This reinforces the MercyAscot vision to supply a world class service in the provision of health care. I believe this vision is beneficial for me, as the role of the PNSA impacts on both clinical and service quality, management and cost effectiveness, colleagues and surgeons and ultimately for optimal patient care. It is exciting to be part of an organisation that holds the continuing education of its nursing staff in such high regard. The acceptance and understanding of the PNSA role from surgeons and perioperative nurses has begun to occur. By undertaking this programme it has cemented the importance of the role within the MercyAscot hospital.

The surgeons I currently work with are enthusiastic and committed to my professional growth. They are aware that I will have an impact on their patient wellbeing, by being able to perform professionally at a more knowledgeable level. After a discussion with a surgeon I assist for regularly, he suggested that I will be able to function with more depth than an assisting doctor, once I have completed the course. He believes that this is due to the multi faceted sides to the PNSA role. In this role I will be able to provide care plans for the entirety of the patients stay within the hospital, using a versatile holistic approach to my relationship with the patients, while maintaining cost containment. (M Insull, FRCOS FRANZCOS, 22nd March, 2004, pers. comm).

Whilst the majority of perioperative nurses are familiar with the PNSA role, there are still some nurses that are unfamiliar with what I am trying to achieve. I have been questioned about my impending role as PNSA, and I have addressed the concerns raised by my colleagues within the organisation:-

Is there a position description

Are PNSA’s credentialed?

Do PNSA’s get increased remuneration for doing the same job as a perioperative nurse?

There is a position description for the PNSA at the MercyAscot hospital which I will critique later in the assignment. However the description is not available for all staff to access. I have addressed this, as I found that this could have inferred that the PNSA role was kept hidden due to underhand reasons, and therefore could fuel antagonistic ideas. I have circulated copies of the position description amongst the perioperative nurses, to broaden their perceptions, thus alleviating any anxieties they may be harbouring, and hopefully create further interest in the PNSA role.

According to the Millard Fillmore hospital (1996) Registered Nurse Assistant Intern’s are required to be credentialed in order to assure that the individual can function appropriately in their role. MercyAscot requires that the PNSA shall apply to the Clinical Service Manager – Theatre to obtain privileges to practice in this capacity. In this way the organisation will ensure that the PNSA has completed a recognised qualification, and their practice will be reviewed to maintain optimal patient care. I believe it is essential for the nurse to take ownership of their professionalism, by embracing the concept of Professional Portfolios and undertaking credentialing. It is imperative that perioperative nurses performing the role of surgical assistant should complete an academic programme in order to reach the standards required to perform at such a level.

Remuneration is addressed at two levels. The PNSA will be paid by the organisation depending on the hours they have worked in the capacity of PNSA. The PNSA can seek further remuneration from the surgeon they are assisting. As the position description for the PNSA is more accessible now to the perioperative nurses, I feel that the role will be more readily accepted, and resentful feelings will be alleviated, due to the awareness of the extended role of the PNSA.

POSITION DESCRIPTION AT MERCYASCOT

The Position Description (Appendix A) at the MercyAscot hospital was devised in 2001. It was a much needed document, as the MercyAscot had a nurse undergoing the PNSA programme at this time. According to Australian Confederation of Operating Room Nurses (ACORN) (1995) every health care facility shall develop a written policy, position description for the role of the PNSA. The PNSA Standards according to ACORN are under review at present, but according to the draft review copy, this standard is still recommended.

NZNO recommends that organisations have sound policies in place, which comply with the Health Practitioners Competence Act (HPCA) (2003), (S. Trim, Professional Nursing Adviser-NZNO 14th April, 2004, pers.comm). I believe that the position description policy should reflect the complexities of the PNSA role, without restricting their scope of practice. The policy should be reviewed regularly as the nature of the PNSA is diverse and theoretically this could leave the practitioner to operate outside the guidelines of the policy.

The HPCA Act (2003) has revised definitions pertaining to the scope of practice of nurses, and upgraded the body of the original Nurse Act (1977). Clause 12 of the HPCA Act (2003) states that each authority must prescribe the qualifications for every scope of practice. I agree with this, and feel that the policy at MercyAscot provides a definition that captures the essence of the PNSA. The updated policy set out by ACORN (2004), extends the definition to include that the PNSA has acquired the competence, knowledge, skills and attitudes, necessary to assist the surgeon, and will collaborate with the surgeon in all phases of patient care. I like this added statement, as it helps raise the profile of the PNSA, and allows the profession to be acknowledged as more than just an assistant in the operating room.

The qualifications needed at MercyAscot for the PNSA have been adapted from Association of Operating Room Nurses (AORN 1998). Other Nursing Associations have similar qualifications listed, ACORN’s draft review copy (2004); the National Association of Theatre Nurses (NATN) (1994), and the Operating Room Nurses Association in Canada (ORNAC) (1998). I agree that there should be a recognised standard of competence and knowledge that PNSA’s should posses. This will keep the role at an academic level, and allow the practitioner to perform at a nationally recognised standard.

The standards set out by the HPCA Act (2003) describing the functions of the nurse; and the hospitals own policies governing the roles of the perioperative nurse, allow the PNSA to function within their own capabilities. This is recognised within most overseas organisations (ibid). Essentially the PNSA has to adhere to local and national policies before that of the extended role. The PNSA is first and foremost a nurse.

Another issue within the HPCA Act (2003) is that of the Nurse Practitioner (NP) status. In New Zealand to gain the title NP, one must have completed an academic programme at master’s level. The PNSA programme does not achieve this educational status. However the HPCA Act (2003) does recognise that some nurses are practicing at an advanced level, and that their practice should not be constrained. (NZNO 2004).

The Position description at the MercyAscot was formulated from overseas organisations, as there is no legislation in New Zealand governing the function of the PNSA. The policy was refined from AORN guidelines (1998), these guidelines were reviewed at AORN Forum and House of Delegates agenda (March 2004). The guidelines have been refined to introduce collaborative practice within the scope of practice required of the Registered Nurse First Assistant (RNFA). This has been documented in ACORN’s draft review for the PNSA role also (ACORN 2004). I believe that MercyAscot’s practice guidelines should reflect the growth within the role of the PNSA. To achieve this, I have recommended that the Clinical Services Manager – Theatre, the existing PNSA, and I should update the guidelines to include the importance of collaborative practice, with all members of the multidisciplinary team, throughout the entirety of the patient’s care.

The position description at MercyAscot recognises the fact that the amount of assisting, and who performs this role perioperatively is determined by the surgeon, based on their requirements for the procedure. The Royal College of Surgeons (RCS) highlight the need that anyone not registered with the Medical Council should not carry out tasks that require the knowledge and skills of doctors (RCS 1999,:5). I agree with this statement, as not every PNSA will be able to perform all tasks that are offered in the practice guidelines. I predominantly assist for laparoscopic procedures, even though I have experience with open surgery, I would be more aware of my limitations within this field.

The Standards at MercyAscot demands that the PNSA should apply to the credentialing committee, in two instances. This is to ensure that the PNSA student is enrolled in an appropriate educational programme, to allow the student to function within the scope of that role; the other is to be granted privileges to function as a PNSA within the hospital setting.

AORN (2004) recognises the need for PNSA’s to be credentialed to ensure the PNSA can perform the required duties to an acceptable level. The review time-span is not suggested, as AORN have left the review date to be decided at hospital level. I suggest that this should be achieved annually, as a performance review. Qualified nurses have a duty to update their practices and knowledge. The Nursing Council of New Zealand (NCNZ) requires all registered nurses to hold a professional portfolio. “The general public are entitled to know that nurses are not only competent to practice, but also maintain their competence to practice” College of Nurses Aotearoa NZ Inc (1999). I believe that being accredited gives the PNSA greater academic ascendancy in the domain of the medical profession.

PROFESSIONAL DEVELOPMENT

The role of surgical assisting has interested me since I witnessed the role being performed in England. At the time I felt I was not experienced enough to take on that role. I am at a juncture in my career, and wish to pursue an avenue within the field of perioperative nursing. Expanding my knowledge of anatomy and physiology and being able to provide a more holistic approach to the care I offer is a pathway that has tempted me.

The other specialist routes I could take at this point in my career are that of Clinical Charge Nurse, or Clinical Nurse Educator. I feel that these roles would be challenging for me, but would take me away from the clinical area too much. Becoming a PNSA encompasses all the aspects of perioperative nursing that I love. I miss the contact that I used to have with my patients when I was employed in the ward, and recovery environment. Completing the PNSA will enable me to regain missing aspects of my initial desire to become a nurse.

Nurses make excellent surgical assistants; they are clinically experienced, and predominantly do not want to perform the operation, or make clinical decisions that require medical training. (M. Insull, FRCOS FRANZCOS, 22nd March 2004, pers. comm).

Nurses have been trained to give a more human approach to the care they deliver. Patients find doctors can be too technical, they can relate to them as an illness rather than a patient. Due to their holistic training, nurses make suitable surgeons assistants as they can approach the patient completely, and have more empathy to the patient, and their family. It was discovered that Acute Care Nurse Practitioners (APN’s) spent more time with their patients and had better communication, counselling, and interviewing skills, but physicians were better at technical problems. It was estimated that 50% to 90% of primary care provided by the physicians could be performed by the APN’s. (Buppert; Safriet, cited in Hodson, 1998: 1003).

The expanded role will develop my knowledge, and allow me to practice at a higher level. I am especially interested in the anatomy and physiology aspects of the perioperative phase. I have designed two anatomy teaching books for MercyAscot. These were developed with new perioperative nurse clinicians in mind. I wanted to have a resource available that was focussed on the procedures performed at MercyAscot, using language that expanded their knowledge base, whilst keeping the reader interested. I have enjoyed the results achieved from these projects. It has allowed me to expand my own knowledge base, whilst educating others.

I am aware that at present I have not had a lot of patient contact pre and post operatively. I have performed pre operative visits on my patients, in the holding bay to check the patient consent has been signed, and the patient is ready for surgery. I also read and discuss the patient clinical history with the surgeon I am assisting, to increase my knowledge base, and take on some extra responsibilities from the surgeon.

The professional relationship between surgeon and PNSA must be based on respect, and a mutual desire to provide the best care for the patients. Health care providers must work together to increase the ability to deliver safe and effective care that is beneficial and cost-effective. Collaboration is needed between all parties to ensure this occurs (Alberta Association of Registered Nurses (AARN) (2003). Collaboration can only be achieved among groups with accountability, responsibility and authority for their own profession and practice (Brennan B 1999).

I believe that the surgeon focuses on the patient illness, whilst the PNSA’s focus is on the patient’s wellbeing. Neither approach is better; instead they compliment each other, and are best combined in collaborative practice. The surgeon will manage the medical complex problems and the PNSA will talk with the patient, involve the family, and counsel the patient about health prevention and promotion. The patient will benefit from receiving care derived from each discipline’s unique strength and capabilities.

Collaborative practice must be outlined between the two disciplines for it to work. Each party must have respect and trust in each others clinical abilities. The two providers share the onus for the care given within their scope of practice. The surgeon will hold the ultimate control of decisions if there was a conflict of care, due to the greater degree of professional competency.

CONCLUSION

MercyAscot have already employed one PNSA and set a high standard nationally. By supporting me in my educational programme, they will have two nurses who will provide cost effective care which will benefit the patient, the surgeon and the organisation. We will serve as educator, mentor and clinical resource to patients, colleagues and other health care professionals.

I believe the role of the PNSA will expand at MercyAscot, and within New Zealand. The PNSA’s will find themselves in a challenging domain, where the use of acquired skills, and cognitive thought processes will enable them to function more autonomously, but within the framework of collaborative practice, whilst maintaining professional accountability.

The definitions of the role must be developed to allow the surgeons to accept and embrace the potential that the PNSA can offer in the provision of excellent care for all aspects of the patient’s treatment.

Legislation within New Zealand should be addressed, by NZNO, to give support, acknowledgement and professional guidelines of the PNSA role. This will increase awareness from perioperative nurses, surgeons and the general public.

REFERENCE

Alberta Association of Registered Nurses 2003, Collaborative Nursing Practice in Alberta, http://www.nurses.ab.ca/Archived%20Pages/Collaborative%20Practice.html (accessed 13/04/04).

Association of Operating Room Nurses 1998, AORN Recommended Education Standards for RN First Assistant Programs: Standards, Recommended Practices and Guidelines: 13-15.

Association of Operating Room Nurses 2004, 2004 Forum and House of Delegates Agenda, http://www.findarticles.com/cf_0/m0FSL/1_79/112686268/print.jhtml

(accessed 14/04/04).

Australian Confederation of Operating Room Nurses 1995, PerioperativeNurse Practitioner-Surgeon’s Assistant Standards.

Australian Confederation of Operating Room Nurses 2004, PerioperativeNurse Practitioner-Surgeon’s Assistant Standards: draft review document.

Brennan, B. 1999, ‘Scope of Practice The Role of the PerioperativeNurse Surgeon’s Assistant, (3): 18.

Bridges, J. 1995, Submission, National review of nursing education, http://www.dest.gov.au/highered/nursing/sub/95.pdf. (accessed 19/03/04)

College of Nurses Aotearoa NZ Inc 1999, Competence to Practice and Professional Portfolios, http://www.nurse.org.nz/Guidelines/GLPortfolio.html
(accessed 12/04/04)

Driscoll J; Teh B, 2001, The contribution of portfolios and profiles to continuing professional development,

http://www.clinical-supervision.com/john_driscoll_files/portfolios_article.pdf (accessed 13/04/04).

Hodson, D. 1998, ‘The Evolving Role of Advanced Practice Nurses in Surgery’. Association of Operating Room Nurses, 67(5): 1003.

National Association of Theatre Nurses 1993 The Role of the Nurse as First Assistant in the Operating Department: NATN Working Party, Harrogate.

National Association of Theatre Nurses 1994, The Nurse as Surgeon’s Assistant, UK.

Nursing and Midwifery Council 2002, Code of professional conduct: clause working together, London.

New Zealand Nurses Organisation 2004, Scopes of Practice for Nursing: Consultation Document, Wellington.

Operating Room Nurses Association of Canada 1998, What’s In A Name?, Canada.

The Millard Fillmore hospitals 1996, RN First Assistant Policy Manual, United States of America.

The Royal College of surgeon’s of England 1999, Assistants In Surgical Practice: A discussion document, London.