This year will see the introduction of two major initiatives to improve patient safety and efficiency in NHS operating theatres – the WHO Safe Surgery Checklist and the Productive Operating Theatre programme. Nurses will be central to their success but there are question marks over whether the specialty is ready for the challenges.
There is little doubt that theatre nursing currently has an image problem.
The Department of Health’s 18-week target for referral to treatment in England – outlined in the 2004 NHS Improvement Plan – has meant that hospitals have had to deal with more patients more quickly and streamline processes. The target, met by the NHS in December 2008, was ‘challenging’, the DH itself admitted. Inevitably, theatres and theatre staff have shouldered much of the burden of this increased patient throughput.
This well publicised target-driven pressure, together with a lack of emphasis on theatre nursing in training, may have contributed to making the specialty less appealing as a career option.
For example, Alena Bate, a former theatre manager who set up the Aberdeen Surgical Nursing recruitment agency at the end of last year, said: ‘Student nurses don’t have to do a theatre placement. In the old days, we all had to do theatre placements for eight weeks.
‘Nowadays student nurses don’t experience theatre nursing. They don’t see how important theatre nurses are, that they are the patient’s spokesperson while they are under anaesthetic – as well as preparing them for surgery, making sure they are safe,’ she added.
Ciaran Hurley, chair of the RCN’s perioperative surgery nurses forum, agreed. ‘I think there is a perception problem. The best way to deal with that is to make sure that students have placements in operating departments during pre-registration. This will help overcome the recruitment barrier,’ he said.
‘They won’t be able to make a good career decision about it unless they have had exposure to it.’
Diane Gilmour, president of the Association for Perioperative Practice, agreed that theatre nursing was no longer seen as an attractive career option by students and called on pre-registration course tutors to do more. ‘We need to educate nursing educators,’ she said.
Students do not realise that theatre nursing can be as interesting and stimulating as any other discipline within the profession, she added.
Ms Gilmour cited the increase in day surgery use as a reason for students to become involved. ‘If you work in day surgery, they see patients in and they see patients out. There is a huge potential for student nurses to do physical assessments of the patient,’ she said.
‘We need to be able to say this is what we can do, then we can create engagement from the students. We deal with pressure ulcers if they are on the table for a long time,’ she added.
Significantly, neither of the major documents mapping the future of nursing education – the NMC’s A Review of Pre-Registration Nursing Education and the DH’s Towards a Framework for Post-Registration Nursing – mention perioperative nursing.
As long as the specialty is overlooked by those shaping nurse education and training, the recruitment problem will persist, warned Mr Hurley.
NHS workforce planners, who are set to have more influence under health minister Lord Darzi’s Next Stage Review, will have a role in encouraging universities to produce more theatre nurses.
The review includes plans to create an overarching Centre of Excellence which will carry out ‘long-term horizon, scanning, capability and capacity development for workforce planning’.
‘What needs to shake down is the Darzi review and the workforce part of that. Certainly within the RCN we have looked at improving support for the operating departments,’ said Mr Hurley.
Despite such problems and perceptions, Unison’s head of nursing, Gail Adams, who has a background in theatre nursing, insisted that the specialty was now more exciting than ever to enter, due largely to major technological innovations. She cited laparoscopy as an example.
‘Laparoscopy was rare 10 years ago and now it is routine. More and more procedures are done with minimum invasive procedures to aid patients. People continue to use technology to push those boundaries,’ she said.
Lord Darzi, himself, is a high-profile proponent of robotics in operating theatres. He is still co-director of the Hamlyn Centre for Robotic Surgery at Imperial College London. Thanks to his work, theatre nurses could now have the opportunity to work side-by-side with colleagues such as ‘Sister Mary’ and ‘Dr Robbie’ – two minimally invasive surgical robots based at St Mary’s Hospital in Paddington, London.
Interestingly, implementation of the WHO Safe Surgery Checklist, while presenting theatre nursing with new challenges, may also help raise the profile of the specialty – which could, in turn, have positive implications for recruitment, retention and workload pressures.
The checklist, launched last June, by the WHO, has been adapted for use in the NHS in England and Wales by the National Patient Safety Agency.
It aims to ‘harness political commitment and clinical will to address important safety issues, including inadequate anaesthetic safety practices, avoidable surgical infection and poor communication among team members’.
An international study in the New England Journal of Medicine – reporting on findings from hospitals where the checklist is being piloted, including St Mary’s in London, showed that the list reduced surgical complications by 36%, and surgical mortality rates from 1.5% to 0.8%.
The list puts a new onus on all members of the theatre team, including nurses and operating department practitioners, to take joint responsibility for the safety of their patients. It is divided into three sections: Sign In, to be performed before the induction of anaesthesia; Time Out, to
be performed just before the start of surgical intervention; and Sign Out to be completed before any member of the team leaves the theatre.
Central to it is the Time Out pause – a final confirmation that every member of the team, including nurses and ODPs, are satisfied that all safety checks have been carried out immediately before a skin incision is made. As well as verifying a patient’s identity and the procedure, it requires all staff to introduce themselves and verify details of the operation.
The guidance accompanying the checklist crucially empowers nurses to speak out if they believe something is contrary to procedure. Perhaps even more significantly, it calls for the selection of a ‘checklist coordinator’ – to lead the process – and suggests that this ‘will often be a circulating nurse’.
Having a single person lead the process is ‘essential for its success’, the guidance states. Having a nurse in this role in the UK, presents a potentially huge shift in the traditional hierarchy of the surgical team.
In fact, the WHO guidance itself seems to suggest that some countries would struggle with such a shift. It notes that role of checklist coordinator may not be an easy job because it could
cause ‘antagonistic relationships’.
‘The checklist co-ordinator can and should prevent the team from progressing to the next phase of the operation until each step is satisfactorily addressed, but in so doing may alienate or irritate other team members,’ the guidance said.
‘Therefore, hospitals must carefully consider which staff member is most suitable for a role. For many institutions this will be a circulating nurse, but any health professional can coordinate the checklist process,’ it added.
The AfPP’s Ms Gilmour also acknowledged an implicit status shift and possible professional ‘resentment’.
‘There is a lot of work that needs to be done. I have spoken to some surgeons who think that it is great. I think there could be some resistance but it could be down to trusts to challenge them. I am sure there will be resistance,’ she said.
Jane Reid, intervention lead for perioperative care at the Patient Safety First Campaign, welcomed the changes but agreed there could be teething problems. ‘Teamwork is best achieved where people are equals,’ she said.
‘But we know that in the UK we have a hierarchical structure… it is about addressing that culture,’ she added.
Ms Reid stressed the importance of this new openness for patient safety.
‘Nurses, doctors, anyone should be able to question, act as advocates for the patient, questioning anything that is untoward,’ added Ms Reid.
A Nursing Times Freedom of Information Act investigation has revealed that currently 24% of trusts in England do not comply with any part of the checklist. The NPSA issued an alert last month in which it ‘demanded’ that the checklist be in place at all trusts in England and Wales within the next 12 months.
The developments with theatre nursing are timely. With increasing publicity on surgical errors and the ongoing pressure of targets, the whole area of NHS elective surgery has come under the spotlight.
To patients, it may seem amazing that almost a quarter of trusts in England are not already carrying out the WHO’s basic safe surgery checks. Health care is a long way from achieving the safety culture of aviation – the checklist was inspired by pre-flight checks.
In addition, the efficiency of theatre use itself is being questioned.
The RCN’s Mr Hurley warned that, if the reduced waiting time targets were to be maintained in the long term, the NHS would have to look at new ways of using its theatres as well as hiring more staff. The challenge is not necessarily building more theatres but finding ways of making staff work more flexibly, he suggested.
For example, many theatres are, in effect, mothballed for at least two days a week. The problem is persuading staff to work overtime and at weekends.
‘If you want to shorten the waiting time, you need to increase capacity. Most theatres stand empty from Friday afternoon until Monday morning. Weekend work is a potential answer to increasing capacity. But you need staff to do that. You can’t rely on goodwill and overtime to increase capacity of departments,’ he said.
On the frontline, theatre nurses themselves will have more control over daily efficiencies of their own operating theatres, thanks to Productive Operating Theatre.
The specialty is perhaps at a crossroads. Despite target pressures, staff shortages and a lack of training emphasis, new initiatives, driven by the government’s patient safety agenda, together with technological advancements are now giving it the opportunity to revamp its image and appeal to the next generation of nurses.
As Ms Gilmour emphasises: ‘Theatre nursing is more than just pass the swab and pass the scalpel.’
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