As an orthopaedic nursing student in the late 1960s, I found myself suturing complex facial and other lacerations, applying plaster of Paris splints for fractures, trephining nails, applying collodion splints, removing skeletal pins, venepuncture, applying traction and more. When I started training as a general nurse in 1970, I was surprised that I was not allowed to undertake similar procedures. I now realise that the orthopaedic hospital I worked in had few junior doctors and consequently the orthopaedic surgeons delegated a whole raft of procedures to nurses.
I mention this in the context of newspaper reports (Borland, 2020) that, as part of the long-awaited NHS people plan, which was due last year, the government is expected to announce that it will encourage nurses and other healthcare workers to undergo additional training to enable them to perform surgery. Nurses with aptitude will be offered the opportunity to undertake a 2-year course to enable them to become surgical care practitioners (SCPs) as part of an ambition to tackle surgical waiting times.
During times of need, such as conflicts, nurses have often undertaken procedures that are normally within the jurisdiction of a trained medical practitioner. Zarnitz and Malone (2006) discussed how during the Second World War army nurses assumed many of the roles of the surgeon when the number of casualties overwhelmed the cadre of available doctors.
The war also saw the emergence of nurse anaesthetists who filled these roles when there was a shortage of trained medics. Of interest is that these roles have continued and many parts of the world, including the USA and Scandinavia, employ such nurse specialists (Nolte and Hallett, 2019). Keeling (2015), who has explored the historical antecedents of role expansion in nursing, has traced the origins of what we now know as nurse practitioners to the late 19th century, when nurses began to deliver a range of interventions outwith the boundary of nursing to rural communities and deprived inner city areas in the USA.
By the 1960s, we saw the inception of today's nurse practitioner, who is able to deliver advanced nursing skills to a variety of client groups. Although the number of nurse practitioners has expanded in western health care, Barnes (2015) has highlighted some of the problems with the role, such as lowered job satisfaction, which have been linked to high attrition rates. Despite this, role expansion in the guise of nurse practitioners continues and the title is now part of everyday vocabulary, so much so that Netflix series Virgin River has a storyline revolving around a nurse practitioner working in a remote township in northern California.
What is expanded practice?
The Council for Healthcare Regulatory Excellence (2010) uses the term ‘extended practice’ to describe those circumstances when a registered health professional undertakes clinical tasks or roles usually associated with another profession, in this example surgical procedures
A Royal College of Nursing (RCN) (2018) policy document discusses the role of the nurse working at an advanced level of practice and cites the International Council of Nurses' (ICN) definition of an advanced practice nurse as a ‘registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context or country in which [she or he] is credentialed to practice’ (ICN, 2018).
In the UK, the scope of expanded practice for nurses began to accelerate after the introduction of the European Union Working Time Directive in 2003, which stipulated that the average working time for a worker over each 7-day period must not exceed 48 hours, including overtime. This proved difficult for the medical profession, which had in the past relied on junior doctors to work longer hours.
Inevitably, this led to more and more nurses taking on roles formerly undertaken by junior doctors, such as preoperative assessments and working as site practitioners, where senior nurses work in a team with middle grade doctors to answer clinical or managerial queries from the wards, in addition to being part of the emergency resuscitation team and offering practical help for other medical emergencies such as cannula insertion. (Cass et al, 2003).
With regard to nurses in the UK performing surgical procedures, it is interesting to reflect on the case of Valerie Tomlinson, an experienced theatre nurse who in 1995 performed an appendectomy in a Cornish hospital. The patient made a full and uneventful recovery, but Sister Tomlinson was suspended while investigations took place. She was reinstated after a disciplinary hearing, but was given a final written warning (Hall, 1995).
This case is indicative of the fact that some senior clinical nurses want to break through the glass ceiling in their own profession. Clinical nurse specialists (CNSs) have endeavoured to do just that and are now found across a wide variety of specialties, including oncology, endoscopy and respiratory disease, among others.
Such expanded roles offer a mechanism for NHS trusts and individual specialist consultants to retain nurses with specific expertise to advance their careers without leaving clinical practice. There is no doubt that the face of nursing is changing and that worldwide there is the emergence of new roles allied to medicine, such as physician assistants. Aligned with this, many university faculties of nursing in the UK and elsewhere are developing doctorate of nursing practice programmes. Many of the nurses who earn doctorates, such as the Doctorate in Clinical Practice offered by the School of Health Sciences at the University of Southampton, now practise in roles that in the past would have been unthinkable.
Nurses as SCPs
With an overall shortage of trained surgeons and a rise in the number of patients requiring surgical procedures in the NHS, it was inevitable that surgeons would want to develop their own version of the physician assistant. Hence, there is now a growing number of SCPs in the NHS, carrying out work such as minor surgery and wound closure that would have been previously done by a surgeon.
The Royal College of Surgeons (RCS) has embraced the development of SCPs to allow non-medical practitioners, such as nurses, to perform duties traditionally carried out by surgeons—roles that have become critical to the delivery of surgical services in many specialties. The RCS (2014) has produced guidance on the development of the SCP, defining the parameters of the role. Nurses and other non-medical practitioners with aptitude are now able to complete an RCS-accredited training programme to enable them to support surgeons before, during and after surgical procedures. They can also perform some surgical interventions and carry out preoperative and postoperative care under overall supervision of a senior surgeon.
SCPs are being piloted at 24 sites across England and a number of universities have been accredited by the RCS to offer a 2-year SCP course, including the universities of Plymouth, Anglia Ruskin, Edge Hill, Teesside and Cardiff. SCPs are required to spend a minimum of 2200 hours gaining clinical learning, with 1100 hours in theatre. The role encompasses a range of pre-, intra- and postoperative care and comes under the overall authority of a consultant surgeon. Once trained, SCPs will be able to:
Through the SCP programme nurses are being trained to carry out various types of surgery. The Guardian has reported on the case of one nurse who, once trained, will be able to carry out specific interventions, such as facial skin cancer excisions and skin grafts and flap reconstructions, without a consultant being present (Oliver, 2017). In addition, SCPs will assist senior surgeons during major surgical interventions such as bypass surgery and large joint replacements. Qualified nurses who become SCPs will have the skills to bridge the gap between traditional nursing and medicine.
The RCS envisages SCPs being able to offer surgical interventions across a range of specialties, including vascular surgery, orthopaedics, ophthalmology and gynaecology.
Many nurses would normally welcome the breakdown of traditional boundaries and the opportunity to undertake training to allow them to undertake specific surgical procedures. However, the current pandemic is already overwhelming the NHS and exposing historic failures to boost the number of registered nurses in the UK. The Health Foundation (2019) has shown that, although the government has taken steps to boost the NHS workforce within the next 10 years, there could still be a serious nurse shortage.
Although there have been innovative strategies to address this, including the development of the nursing associate, many have concerns that more still needs to be done.
COVID-19 has resulted in final-year nursing students and retired nurses and doctors being co-opted into the NHS workforce. Furthermore, a whole army of volunteers has been recruited to save the NHS during the current crisis, a testimony to how passionate the public feel about their national health service. But all things must pass, including the current pandemic and, once this is over, it will be interesting to gauge the success of the SCP initiative.