The Role of the Nurse as First Assistant - Essay Example

Reflective essay number Word count 2255 This essay was written at the beginning of this Introduction: In the increasing demand for health care services, there are continuous changes within the health care provision that must be adapted and implemented by all health care professionals, including nurses. These changes also reflect the overcrowding, if not confusing expectations as well as legal implications of the nursing profession. This essay is a reflection of my placement experience with a perioperative team where I had to perform a dual role. Reflection of given tasks as well as performed tasks within the nursing process are necessary in order to maintain safe and legal practices as well as improve patient-health care practitioner relationship (Campbell, 1991). In this reflective essay, I shall be using Gibbs (1988) model to reflect on a situation that arose in practice when I was asked to perform a dual role. GIBBS REFLECTIVE CYCLE Description (What happened) Action Plan Feelings (If it arose again what (What were you would you do) thinking & feeling) Conclusion Evaluation (What was good & bad about the experience) Description (What sense can you make of the situation) (Gibbs 1998) Dual role is an area that was regular practice within the operating theatre in which I work. I have chosen this incident to reflect on, as this demonstrates how I am developing and applying my skills and knowledge gained on this course. I have chosen Gibb's model as it provides a structure for reflection: Description The incident occurred late one evening and the procedure was a reversal of sterilisation on a female patient. As an experienced theatre nurse I was scrub for this particular case and a colleague was allocated to assist the surgeon. The surgeon told my colleague that he did not need an assistant and therefore to stop scrubbing. The operation was carried out by the surgeon and I acting as both scrub nurse and ASP. A reversal of sterilisation involves very delicate surgery, and requires the full attention of the ASP throughout the procedure. I felt confident and competent in my own skills that I could carry out the procedure. Before starting the ASP course, I feel I would have readily accepted the combining of roles of scrub nurse and ASP, but because I was now studying, I was unhappy and upset at this demand. I realised that I had left myself open to the possible charge of negligence as stated by Beesley (1998) The Code of Professional Conduct (NMC 2004) states "Know the limitations of your knowledge and competence. No one should agree to undertake a role for which they are not competent. If a nurse is charged with negligence they could be subjected to the Bolan Test. Dearlove and Morris (1998) suggest that assisting and scrubbing could be combined in some cases but not others. Feelings I had felt confident in my role as scrub nurse whereas now I felt like a novice as described by Benner (1984). I felt I was in a difficult position with no clear guidelines to work from or none that I had yet studied as it was only week 4 of the ASP course. Salussolia (1997) mentions that with the development of extended roles such as ASP, there is a danger that nurses could end up in a state of confusion. Dual role had been discussed with the staff in my department but with no backup, I felt that I could not argue with the surgeon. I am left in a no-win situation. This was allowed to happen due to the lateness of the hour and the desire to get the list finished. Hancock and Durham (2007) proposed that the literature of time pressures on decision-making are scarce and "decision theory are suited to nurses in situations that allow sufficient time to consider the various options," (p 112). Time pressure impacts lack of assistance available as well as confusion in my dual role. I felt that I was failing in my duty of care to the patient. The Code of Professional Conduct (2004) states, "Avoid performing dual role or conflicting roles in interdisciplinary or other settings." I had a good working relationship with the surgeon as we all work closely together, and he had confidence in my skills and competence. But by allowing me to perform a dual role, I now felt upset and angry to the position he had now put me in. I feel that in a sensitive case we were in, we are endangering and risking the life and well-being of our patient. I had no backup or support at this time and the patient was already asleep therefore, I felt that I could only carry on and document the incident. I was annoyed by my lack of assertiveness in this situation but due to the changing role and boundaries I did not feel confident enough to challenge him. Evaluation Cooper et al (2004) acknowledged that advanced practice is applied to allied health professions concerning autonomous practice and substitution for medical roles, so that even in the UK, there is a national drive towards emergency care practitioner that encompass issues related to multi-professional roles and links with the aim to reduce accident and emergency attendance. This practice makes healthcare professionals occupy innovative roles and become involved in developing aspects of service delivery and commissioning new patient-focussed services (Marsden et al, 2003) at the same time making healthcare provision more responsive to the needs of service users and increase the degree of autonomy available to practitioners. Nevertheless, the Perioperative Care Collaborative (PCC) in a Position Statement acknowledged that, "practitioners working in these roles require clarification of the expectations and implications of the role, in particular the legal and ethical implications of undertaking the dual role," (PCC, 2003), so that non-medical practitioners acting as first assistant are by law held answerable to the standard of care expected from medical staff. The PCC (2003) released the Position Paper tried to "ensure that practitioners undertaking such roles are informed of the associated risks of taking such roles." The PCC defined the Advanced Scrub Practitioner as "expert practitioners" replacing the first assistant title who also assist agencies completing the job profile evaluation exercise for specialist theatre practitioners then undertaken as part of the Agenda for Change. Likewise, the PCC (2003) added that the ASP is "the role undertaken by a health care practitioner providing competent and skilled assistance under the direct supervision of the operating surgeon while not performing any form of surgical intervention. The advanced scrub practitioner should not be applying direct electrodiathermy to body tissues, apply haemostats or ligaclips to vessels, or apply cast bandages or suture skin or any other tissue layers." Those tasks are for surgical assistants. The PCC recommended that: the ASP undertaking this role should have demonstrable comprehensive skills, competencies and underpinning knowledge beyond the standard level expected of a newly qualified theatre practitioner. The registered practitioners are expected to produce evidence of lifelong learning within the perioperative field before undertaking a validated programme of study for this role. The role of advanced scrub practitioner must be undertaken by a competent practitioner who has received recognised training in this role, which may be in-house or through externally validated sources. Employing organisations ensure that validated training is provided for practitioners undertaking the advanced scrub practitioner role to ensure quality patient care paramount to the provision of a standard of assistance to the surgeon in order to achieve an optimal outcome for the patient. A practitioner undertaking the role of the ASP must be an additional member of the surgical team. The practitioner acting as scrubbed assistant must manage the intra-operative care required by the patient and must not assume additional duties of the ASP. The ASP must always act to identify and minimise any risk to patients and maintain their duty of care to the patient. The practitioner must retain the right to refuse to undertake the role of the advanced scrub practitioner if they believe they are not competent to take on this role The role or practice development of the non-medical practitioner undertaking the role of the ASP should be planned for strategically by employing organisations. Practitioners must not undertake the role of ASP until the relevant organisation has a policy in place to support this clinical practice and the individual concerned has this expanded role specified within their job description and contract of employment In the situation where dual role is necessary due to the lack of availability of a medical first assistant, this must be clearly identified in a local departmental policy that identify the skills, knowledge and competencies required to undertake the role and the category of surgery and situations for which the employing organisation determines the dual role as being acceptable. In the absence of such structure, practitioner must not undertake the ASP or dual role. All ASP interventions must be documented within the patient's notes or integrated care plan. Clearly, the PCC pointed out that ASP practitioners must never assume that a surgeon will be legally liable for the actions of an ASP as "The law states that whoever provides the care is responsible for the care given" and that practitioners "maintain accountability for their actions as according to their relevant Professional Codes of Conduct." Overall, the PCC enumerated the following as expected role of an ASP: enhancing communication link between theatre, patient and ward, including pre-operative assessment and post-operative care evaluation. assisting with patients' positioning, including tissue viability assessment skin preparation prior to surgery draping skin and tissue retraction handling of tissue and manipulation of organs for exposure or access handling instruments male/female catheterisation cutting of sutures and ties assisting with haemostasis in order to secure and maintain a clear operating field use of suction indirect application of electrocautery under supervision camera holding for minimal invasive access surgery use and maintenance of specialised surgical equipment relevant to area of working assistance with wound closure application of dressing, and transfer of patient to post anaesthetic care unit. Generally nurses are not assertive (McCarten & Hargie, 2004). Assertiveness is a skill developed with practice (Siviter, 2004; Timmins & McCabe, 2005). As I develop in the role of ASP my confidence will increase and so will my level of assertion. This reflection has demonstrated that there is still a power imbalance or unequal relationship between doctors and nurses (Mantzoukas & Jasper, 2004; Snelgrove & Hughes, 2000). Campbell (1991) indicated that for the standards of clinical practice be maintained and developed, there must be frequent challenge and reaffirmation of its value. Conclusion Reflecting on this incident I felt it was very difficult at the time to say anything about the surgeon's refusal to have an assistant. It was late in the evening and the Theatre Manager was not in the department. To have insisted on an assistant I felt would have caused a considerable amount of ill feeling from the surgeon in question. I thought it would also have been unlikely that I would have received appropriate support to challenge the surgeon's decision to operate without an assistant. The incident highlights the importance of policy and procedures, and of discussing at the beginning of the operating list whether an assistant is required and who will perform the role. Action Plan I decide that the best course of action that I could take would be to discuss with the Theatre Manager the following morning my concerns regarding the surgeon's refusal to use an assistant and the need to draft policy and procedures so that this situation could not arise again. After discussion with the Theatre Manager it was decided that they should in the first instance talk with the surgeon and explain to him the situation and to let him know that in future he must either bring his own assistant or he would be provided with one. Reflecting on this incident it can sometimes be useful to discuss it with the theatre and other members of staff. Kitchen (1999) wrote that the whole point of reflection is to learn from previous experiences. The expansion of the theatre nurses role is here to stay and it can only be of benefit to the patient, nurses and surgeons. This should only happen if nurses are aware of their Scope of Professional Practice, recognise their personal accountability, and stay within their role limitations. Within my own department we now have in place a new set of guidelines, policies and procedures so that the above incident should not happen again. Also each consultant surgeon has been provided a new written guideline within the department. On reflection this incident happening at the beginning of my training as an ASP has highlighted an area that should have been dealt with before within the theatre department. In the future I need to be more assertive and point out the rationale of certain decision-making with regards to patient and fellow professional relationship where dual role presents conflict in the theatre. Practitioners are facing increased self-directed and clinical decisions but it must be of highest consideration to maintain the welfare of the client/patient by applying knowledge from legal and established sources. In my assertion, I should also be clear and insistent about my limited role as an ASP and that in case where I am insisted on to perform more than what is clearly and legally my duties, I shall exercise my right to refuse to perform a dual role. References Beesley J, (1998). "The nurse as first assistant to the surgeon." British Journal of Theatre Nursing 8 (1) April. Benner P, (1984). From Novice to Expert. Addison-Wesley, USA. Campbell, I. (1991). The Reflective Practitioner Nursing Standard 5 (19) 34-35 Cooper, S., Barrett, B., Black, S., Evans, C. Real, C., William, S., and Wright, B., (2004). "The emerging role of the Emergency Care Practitioner." Emergency Medicine Journal, 21, 614-618. Dearlove O, Morris L. (1998). "The Nurse as First Assistant." British Journal of Theatre Nursing 8 (5) 37-39. Gibbs G (1988). "Learning by doing: A guide to learning methods." Further Education Unit, Oxford Polytechnic. Oxford. Hancock, Helen, and Durham, Lesley (2007) "Critical care outreach: The need for effective decision-making in clinical practice (Part 2)." Intensive and Critical Care Nursing 23, 104-114. Kitchen, S. (1999). "An appraisal of Models of Reflection and Clinical Supervision." The British Journal of Theatre Nursing 9 (7) July. Marsden, J., Dolan, B., and Holt, L. (2003). "Nurse practitioners and the problem of discounting." Journal of Advanced Nursing 29, 9-17. NATN (1993). "The Role of the nurse as first assistant in the operating department." NATN Harrogate. Nightingale F. (1859). Notes on Nursing . Revisited with additions, London, Baillere Tinsdall. Nursing and Midwifery Council (2004) The NMC code of professional conduct. Perioperative Care Collaborative (2003). "The provision of the non-medical perioperative practitioner working as first assistant to the surgeon." Position Paper. Read More