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Piloting a nurse-led gynaecology preoperative-assessment clinic

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Preoperative-assessment clinics have been introduced in many specialist areas over the last few years. Some are multidisciplinary, others are predominantly medically focused and an increasing number are nurse-led (Sutcliffe and Potter, 2000). They have evolved from the need to deliver quality health care within an environment where there are limited resources, such as theatre time and hospital beds.


VOL: 100, ISSUE: 03, PAGE NO: 38

Hilary Walsgrove, MA, BSc, RGN, DPSN, NPPD, is lecturer practitioner at Bournemouth University/Poole Hospital NHS Trust, both in Dorset


Preoperative-assessment clinics have been introduced in many specialist areas over the last few years. Some are multidisciplinary, others are predominantly medically focused and an increasing number are nurse-led (Sutcliffe and Potter, 2000). They have evolved from the need to deliver quality health care within an environment where there are limited resources, such as theatre time and hospital beds.



Effective preoperative assessment is vital in order to modernise surgical services and the NHS Modernisation Agency has recently set up an ‘Operating Theatre and Preoperative-Assessment Programme’ aimed at improving preoperative assessment at local, regional and national levels (Department of Health, 2003). Many NHS trusts are now committed to staff development to implement improvements in this field (Janke et al, 2002).



The aims of a preoperative-assessment service are to minimise patient risk by ascertaining fitness for surgery, provide information so that informed choices can be made, reduce anxiety about hospital admission and to generally improve the patient’s hospital experience (Janke et al, 2002).



Some elements of assessment will be specific to the specialty involved. For example, for gynaecology patients the focus is likely to be on dispelling misconceptions about gynaecological surgery, body image and loss of fertility (Llewelyn-Jones, 1994; Corney, 1992; Morse and Johnson, 1991).



In addition, evidence suggests that women are generally more anxious about undergoing surgery (Wood and Maher, 1997). Such issues emphasise the need for a particularly sensitive preoperative-assessment service for gynaecology patients, run by health professionals with relevant expertise (Walsgrove, 1997).



The role of the nurse practitioner
The role of the nurse practitioner has expanded since the 1980s (Harris and Redshaw, 1998). Nurse practitioners have incorporated physical examination skills into their assessment strategies, which alongside problem-solving skills and history-taking provide the means for a strong holistic patient assessment (Maclaine, 1998). Nurse practitioners now assess patient health care needs, carry out a wide range of interventions to meet those needs and collaborate with other health care agencies as required. In secondary care, they run an array of nurse-led services within inpatient and outpatient environments (Mackie, 1996). They are involved in preoperative care, patient assessment, care coordination and home discharge (Harris and Redshaw, 1998). In some areas they have taken on a role parallel to that of the senior house officer (Easton and Burns, 2001), and have developed roles in other areas (Marsden, 1995).



The gynaecology preoperative-assessment clinic
The clinic is available for all patients due to be admitted to the inpatient gynaecology ward for surgery. It is situated in the ward and is a joint medical/nursing clinic, run by a staff nurse from the gynaecology ward and a senior house officer (SHO). The nurse conducts a nursing assessment and baseline observations, discusses care, commences a discharge plan and discusses any problems, concerns or queries the patient may have. The SHO conducts a medical assessment, carries out any relevant physical examination, gains operation consent, prescribes medications and answers questions.



Although the current service within the trust appears to be adequate, anecdotal reports suggest that it does not always offer an optimal service. For example, pressures on junior doctors’ workloads, together with their often limited experience of this clinical setting, can lead to patients being kept waiting or receiving duplicated or conflicting information.



Recent initiatives to reduce junior doctors’ hours of work and their workload (NHS Management Executive, 1991) and to enhance their education (DoH, 1993) have resulted in proposals to transfer some of their traditional medical duties to nurses. Together with the drive for efficiency and improved quality of care, these changes have increased the pressure to substitute non-medical staff for house officers (Richardson and Maynard, 1995).



Read and Graves (1994) noted that preoperative-assessment nurses made a considerable impact on reducing junior doctors’ work. It therefore seemed reasonable to develop preoperative-assessment services that were not predominantly doctor-led. Nurse-led preoperative-assessment clinics have been found to be equivalent in quality to those run by doctors, and the nursing role is known to be beneficial and important to the patient’s experience of surgery (Clinch, 1997; Newbold, 1996).



Kinley et al (2002) concluded that there was no reason to inhibit the development of nurse-led preoperative assessment provided that nurses received adequate training. Rushforth et al (2000) concluded that transferring preoperative assessment from SHOs to nurses was appropriate for maintaining and enhancing the quality of care delivery.



Appointments at the nurse-led preoperative-assessment clinic are conducted by one practitioner. This ensures less duplication of information and less risk of conflicting information being provided (Markanday and Platzer, 1994).



The clinic is also a valuable educational resource for staff. Benefits include:



- A training and assessment package to guide staff in the development of knowledge and skills in preoperative assessment;



- Staff observation of the clinic with the nurse practitioner sharing knowledge and expertise;



- The nurse practitioner acts in a supervisory role for other preoperative-assessment staff;



- The preoperative-assessment staff are able to use the knowledge and skills attained through the clinic to improve their clinical practice, which improves the quality of patient care;



- The junior doctors have more time to attend to inpatients and emergencies and more quality time to fulfil the requirements of their training.



The clinic can offer good career progression for experienced nurses wishing to maintain a high degree of clinical practice (Maclaine, 1998).



Project design
This pilot project was conducted using an action research framework. Action research is based on a cyclical process of planning, action and evaluation (Denscombe, 1998), as illustrated in Fig 1. The strength of this type of research within a health care setting lies in its focus on generating solutions to practical problems and its ability to empower practitioners (Pope and Mays, 2000).



The four main elements of action research key to this project were that it was participatory, practical, cyclical and involved change (Denscombe, 1999). Fig 1 also illustrates the action research cycle for this pilot project.



It is anticipated that this project will help in developing a theory of nurse-led preoperative assessment relevant to local practice and that this could inform future care. Thus, action researchers do not endeavour to make claims on the grounds of scientific rigour, but seek to generate findings that are useful and relevant to the local setting (Hart and Bond, 1995).



The subjectivity of action research has led to it being described as lacking in reliability and validity. Also as it is problem-solving and context specific, applying its findings to other situations may be of limited use (Meyer, 1995). However, some findings may be applied to similar situations (Newton, 1995). Dissemination of the project findings will help to increase its validity and the sharing of knowledge, ideas and expertise will help to ensure that the project is conducted rigorously (McNiff et al, 1996).



Action research is a valuable technique for introducing and evaluating change within a practice discipline. It encourages openness and self-criticism and empowers those involved to exercise control over their work situation (Hart and Bond, 1995).



It is also a way of engaging other interested parties in integrating change and maintaining commitment to initiatives designed to improve standards of care and services to patients. These points are in keeping with this project, which was able to demonstrate changes in practice by collaborating with key interested parties in a systematic and effective manner.



This project adopted a multi-method approach to data collection and analysis as described by Hambridge (2000), which is generally considered appropriate within an action-research framework. However, there was an inclination to adopt more qualitative methods in this project, as there was no pre-existing nurse-practitioner role or nurse-led preoperative-assessment clinic at the trust in question that could be used as a framework for a quantitative study (Lathlean, 1997).



A critical analysis of the current medical/nursing gynaecology preoperative-assessment clinic was carried out using observation and informal discussions with staff from the gynaecology ward (Box 1).



Gaining stakeholder support



The key stakeholders were identified because they were likely to be affected by the new preoperative-assessment clinic and would thus potentially influence the development of the new service.



The key stakeholders were:



- Gynaecology ward nursing and administrative staff;



- Patients;



- Consultant gynaecologist;



- Consultant anaesthetist;



- Senior nurse for surgery;



- Director of nursing.



Gaining support from key stakeholders and involving them in the process of the project was important, as active participation and good communication can help to ensure that proposed changes take place and are long-lasting (Kitson, 1997). This led to shared ownership of changes and gave people a sense of control, thus maximising commitment and minimising potential destructive feelings (McPhail, 1997).



The ward staff discussed the proposed project at one of their ward meetings and they demonstrated enthusiasm and support for the development. This involved consideration of the skills and knowledge of a nurse practitioner that could be useful in the clinic, how the clinic could be set up and developed, and what benefits it could bring for patients and staff.



Although some individuals had initial reservations about the new development, once the project had been formally approved by the trust, there was all-round support and interest for it.



Regular meetings were conducted with stakeholders throughout the project to ensure that everyone remained involved and was in agreement about the process of the project. The meetings were also designed to keep people updated with the progress of the clinic and to discuss any other issues that arose. Collaboration is important if changes designed to improve standards of care and services are to be introduced (Hart and Bond, 1995).



As there were no preoperative-assessment clinic guidelines before this project started, guidelines were formulated in consultation with the gynaecology ward staff. These guidelines met with clinical governance requirements (DoH, 1998) and offered a baseline for ensuring quality standards for the clinics, which could then be audited regularly. The NHS Modernisation Agency later published its National Good Practice Guidance on Preoperative Assessment for Inpatient Surgery (DoH, 2003) and our local guidelines matched those advocated at national level, which helped to confirm that they were acceptable and evidence-based.



Once formal approval by the trust had been established, the clinic was set up for a six-month period. The nurse practitioner carried out a thorough holistic assessment of patients, which incorporated both nursing and traditional medical elements and ensured that patients were fit for and agreeable to the proposed surgery.



The nurse practitioner was able to see approximately six patients during a clinic session and during the timespan of the project a total of 140 patients were seen in the new clinic, representing 25 per cent of all patients who attended for preoperative assessment. The remaining 420 patients (75 per cent) were seen in the medical/nursing clinics that were already established within the gynaecology service.



Patient and staff satisfaction with the quality of the service
A diary was kept to chart the progress of the new service and to reflect on practice within the clinic. The data gained through this diary demonstrated that during the project no complaints were received about the clinic from staff or from patients and no operations were cancelled at the last minute due to any inefficiency in preoperative assessment.



The nurse practitioner was found to be instrumental in ensuring suitable patient management within the clinic and the chances of patients being admitted for surgery inappropriately were reduced. Such inappropriate admissions for surgery could have led to a waste of valuable hospital resources and to unnecessary upset for patients and their relatives.



Fifty anonymous patient-satisfaction questionnaires were sent out by post. The respondents were a convenience/purposeful sample of patients who had attended the clinic during the project. The response rate of 80 per cent was considered to be very good (Tarling and Crofts, 2002) and in general a high level of patient satisfaction was demonstrated.



For example, 97 per cent of respondents thought that the information given at their preoperative-assessment appointment was useful and easy to understand, 98 per cent felt that they were well prepared for their stay in hospital and 98 per cent of respondents felt that the service offered to them was either ‘very good’ or ‘good’.



Other responses revealed similar positive results to questions asked. In addition, the patients were asked for further comments in relation to their preoperative-assessment appointments. Some of these responses are listed in Box 2 and they demonstrated good patient support and a high level of patient satisfaction with the new service.



Staff who participated in the interviews and questionnaires included a consultant gynaecologist, a consultant anaesthetist, two gynaecology SHOs and two staff nurses from the gynaecology ward. Two semistructured audio-taped interviews were carried out to obtain more qualitative data from staff directly involved with the clinics or in caring for patients who had attended the clinics. Four other participants were asked to complete a questionnaire, containing the same questions asked during the interviews. The results were very positively in favour of the service (Box 3).



Data analysis demonstrated that the clinic was effective and efficient. The clinic was found to be a sensitive, patient-centred service that offered patients high quality individualised care. It is now a service that has become established within the current gynaecology ward and is highly valued by both staff and patients.



Implications for practice
Due to the success of the project, there is scope for the clinic to become a template for other preoperative-assessment clinics across the trust and elsewhere. It has now been agreed that the clinic will continue as a permanent service, in line with current local policies and guidelines and in line with national guidelines from the Modernisation Agency (DoH, 2003).



The clinic can be used as an educational resource for staff in order to enable them to develop knowledge and skills within a preoperative-assessment environment. It can also be used generally to help improve preoperative-assessment services across the trust. The clinic has provided the opportunity for experienced registered nurses to consider a means of clinical nursing career progression, maintaining a high degree of clinical work and direct patient contact.



This pilot project provided an opportunity to set up and develop a nurse-led gynaecology preoperative-assessment clinic. The new clinic provides a coordinated and sensitive preoperative-assessment service that meets patient needs effectively and efficiently (DoH, 2003).



It is now to continue as a permanent service with room for further expansion across other surgical specialties and may be considered as a template for preoperative-assessment services within other trusts.



- This article has been double-blind peer-reviewed.

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