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Developing the nurse practitioner's role in minor surgery

VOL: 98, ISSUE: 33, PAGE NO: 39

Shirley Martin, OND, RGN, RNFA, is nurse practitioner in surgical technology, academic surgical unit, St Mary's Hospital, London

A nurse-led clinic has been developed at St Mary's NHS Trust in London to provide minor operative surgery sessions. The service is a 'one-stop' evening clinic with a 'see-and-treat' facility, offering patients a local service for the removal of minor skin lesions, such as suspicious moles, lipomas, sebaceous cysts and papillomas.

A nurse-led clinic has been developed at St Mary's NHS Trust in London to provide minor operative surgery sessions. The service is a 'one-stop' evening clinic with a 'see-and-treat' facility, offering patients a local service for the removal of minor skin lesions, such as suspicious moles, lipomas, sebaceous cysts and papillomas.

The lesions are surgically removed under local anaesthesia by a nurse practitioner. This bypasses the wait for a more traditional outpatient clinic appointment with a doctor and subsequent day surgery. It also cuts waiting lists.

A nurse for minor surgery
Health problems requiring minor surgical intervention are extremely common and can cause patients a great deal of anxiety. However, huge pressure on hospital waiting lists often means that such patients have a long wait for their surgery, and that the surgery is often scheduled at a time which is inconvenient for the patient.

At the RCN Congress in 2000, health secretary Alan Milburn proposed that nurses should be enabled to undertake their own workloads of procedures with minor intervention such as minor operative surgery.

Staff in the surgical unit at St Mary's Hospital believed that the introduction of a minor surgery nurse practitioner to the trust would help it to fulfil the aspirations of Making a Difference (Department of Health, 1999) and The NHS Plan (DoH, 2000). It was envisaged that the nurse practitioner would provide integrated care for patients from admission and consultation through to discharge.

Introducing the role
The hospital's professor of surgery initiated the development of the alternative service in the summer of 2000. Increasing numbers of referrals for minor surgical procedures, and reductions in the number of hours worked by junior doctors, provided an opportunity to develop and extend a nurse's role to meet patients' needs. Nemes (1994) said that the nurse practitioner's role is not that of a doctor's substitute, but one which strengthens and promotes a multidisciplinary approach to patient care, improving the delivery of the care provided.

The nurse practitioner was an experienced theatre sister who demonstrated confidence and ability in the field, and who had commenced the 'First Assistant to Surgeon' course. This course enables experienced theatre nurses to undertake an extended role at the operating table, providing skilled surgical assistance under the direct supervision of the surgeon, and in line with the recommendations in The Scope of Professional Practice (UKCC, 1992).

The surgical team provided intensive training to enable the nurse practitioner to carry out a range of minor surgical procedures independently. The initial four-week training course included practice and theory components. The entire course was taught by one surgeon to ensure continuity. Other members of the surgical team provided additional training and assessment in the next few months.

The support of the trust's board was needed for the nurse to extend her role in this way. The board required: written evidence of the training undertaken, the support and supervision provided, signed statements of competencies, and copies of guidelines relevant to the procedures, before it approved the development of the nurse-led service.

Aims of the nurse-led service
Surgical staff had a number of aims in setting up the nurse-led minor surgery session:

- To enable medical staff to focus on patients with more complex conditions;

- To reduce fears aroused in many patients by busy hospital settings, particularly during the day;

- To ensure patient safety and comfort;

- To reduce current waiting lists;

- To provide quality care at times convenient to patients;

- To create a bridge between primary and secondary care, combining the surgical expertise of a major secondary centre, with the integrated, patient-centred approach of a community-based service.

The minor surgery nurse is an autonomous practitioner, carrying out procedures and making decisions independently (Fig 1). Patient assessment involves obtaining a full, accurate medical history and a list of current medications. The nurse practitioner ensures that the patient's surgical requirements are within her boundaries and limitations of practice, before undertaking any procedure. Teamwork remains crucial to the service, particularly the wholehearted support of the academic surgical team, nursing directorate and the trust.

The service has brought a range of benefits for patients, medical staff and the trust, including:

- An evening service is offered, which is convenient for patients;

- Waiting lists and waiting times are reduced;

- Integrated care is continued by follow-up telephone calls to patients after surgery;

- The nurse has an extended and challenging role;

- The nurse provides enhanced quality and efficiency of care;

- Junior doctors can perform other tasks;

- A model for innovative practice has been created which can be transferred to other areas.

At the time of writing, the nurse practitioner had successfully performed over 200 procedures. Of these, two patients required further specialist management due to worrying pathological results. To date, no patient has refused treatment from the nurse practitioner. An evaluative exercise suggests the service has met patients' expectations: they were seen and treated immediately, at a time that suited them and they valued the postoperative follow-up telephone calls.

The nurse practitioner conducted a patient satisfaction survey as part of a pilot study. A questionnaire was offered to 20 patients after surgery. One did not complete it adequately, so 19 were analysed. The findings were:

- 20% had not expected the nurse practitioner to perform the procedure;

- 80% expected either the consultant or another doctor to perform the procedure;

- 100% were very satisfied to be seen by the nurse practitioner;

- 100% found it acceptable to be operated upon by the nurse practitioner;

- 89% would be prepared to see the nurse practitioner again, instead of a doctor;

- 100% were happy with the overall treatment received from the nurse practitioner.

Further training programmes for nurses
Because of the success of the minor surgical nurse practitioner's role, a surgical skills course has been developed for other nurse practitioners working in areas such as dermatology, theatre, A&E, and primary care. Innovative features of the course include:

- A multimedia training programme;

- Extensive use of simulated tissue models;

- A range of educational techniques that draw on undergraduate and postgraduate medical training carried out at the trust.

Evaluation has revealed an overwhelmingly positive response to the service. Its success has led to referrals from farther afield. At one stage waiting times increased to approximately six to eight weeks. An extra operating session was added last summer to accommodate the increased referrals, making four sessions a week.

The role has contributed to the expansion of nursing roles alongside other medical professionals and the empowerment of nurses as professionals. It has also addressed the problem of insufficient surgical staff to carry out minor surgical procedures.

- Next week: an advanced practice hysteroscopy module

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