We, like many of our colleagues, have welcomed the introduction of advanced and extended nursing practice within the UK healthcare sector over recent decades.
During this period, a plethora of titles and roles have emerged which, in our opinion, have assisted in slowing the haemorrhage of experienced healthcare staff leaving the NHS, and provided a clinical career ladder to rival the traditional managerial pathway while also providing aspirational career routes for new and existing staff.
However, as these roles have gained greater uptake across the sector, it has become apparent that within our particular area of practice, surgery, that a blurring of the boundary lines has developed in terms of who can do what and when.
A familiar trend within surgery has often seen scope of practice developments go hand in hand with technological strides. Robotic-assisted surgery has seen a steady uptake within the NHS and private sector since its inception at the beginning of the millennium. This particular piece of technology lends itself well to the adoption of a permanent patient-side assistant, responsible for working within the sterile field and undertaking tasks such as retraction, suction, irrigation, use of stapling or clipping devices passed independently into the patient via laparoscopic ports. The operating surgeon, working outside of the sterile field but within the operating room, sits at the surgeon's console performing the operation via the manipulation of controls that are replicated by small robotic instruments residing within the patient.
Both published (Sheridan et al, 2014) and anecdotal evidence suggests that the use of a permanent patient-side assistant, familiar with the workings of the robot and the surgical steps for which it is used, can contribute not only to the streamlining of a theatre list but also provide consistent, experienced assistance to both the consultant and the trainee who is honing their robotic operating skills via the surgeon's console.
Undertaking surgical assistance requires the completion of a recognised course, designed to meet the requirements expected of the non-medical assistant. Typical examples are the surgical first assistant (SFA) and surgical care practitioner (SCP) programmes. The catalyst for these training programmes grew from the need for role-specific regulation, national guidelines and educational standards for non-doctors spearheaded by the Royal College of Surgeons of England, which needed to take steps to address some local, below-the-horizon developments in surgical assistance that had led to differences in practice across the UK.
In some instances, those assisting can be naïve in assuming that any errors accrued during the course of a surgical procedure reside solely on the shoulders of the consultant surgeon, forgetting that they are responsible for their actions as registered health professionals. Slipping into unsafe practice not only risks their registration but may also place the patient in danger.
Any external pressure to go beyond their scope of practice must be met with insistence on the correct level of training being obtained to ensure that the tasks expected of the assistant are met with the appropriate level of expertise. A lengthy illustration of the scope of practice for the SFA and SCP is outside the bounds of this comment piece; however, the administration of therapeutic intervention, such as the use of a stapling device, is typically understood to be a task suited to the scope and level of practice attained by an SCP.
It can be tempting, therefore, to wish to fast track a patient-side assistant alongside a growing robotic programme. The time and financial implications of some recognised training programmes, for example the MSc SCP programme, can mean that alternative options may seem more attractive to departments with stretched resources. Subsequently, the below-radar developments that the Royal College of Surgeons had alluded to in the 1990s may be becoming back in vogue in such guises as ‘in-house training’ and ‘bolt-on’ courses to pad-out a nurse or allied health professional's capabilities.
More must be done to ensure our medical and managerial colleagues are aware of the boundaries of practice for those practising within the field of surgery who are not doctors. It is on those undertaking these roles to recognise and work within their scope of practice while not being tempted to undertake tasks that may place the individuals they are tasked to care for at risk.