H U M A N RESOURCES ivJenfe, AHashem

KEYWORDS Advanced scrub practitioner, Extended roles, First assistant, Perioperative Nursing, Scrub practitioner

The role of the

advanced scrub
practitioner
The roles of all healthcare professionals have changed considerably
over the years and the nurse in particular has been affected. These
changes have been influenced by the following guidance, Code of
Professional Conduct {UKCC 1992) and Code of Professional Conduct
(NMC 2004). Such changes involve the whole area of advancing roles in
perioperative nursing, such as the nurse working as advanced scruh
practitioner (ASP) (formally known as first assistant). Boss (2002)
mentions that these new role developments are concerned with
principles such as serving the interests of patients, providing holistic
care, developing professional skills and knowledge and heing
accountahle and responsihle for your individual actions. Nurses acting
as an ASP have many matters to contend with, such as autonomy, duty
of care and other legal issues, and professional accountability. This
paper explores these issues in more detail.

liitroduction such as the ASP, there is a danger that nursing

could end up in a state of confusion. Therefore
According to Morrison (2000) the practice of
nurses need to be aware that when accepting the
nursing is one that is driven by, and constantly
ASP role, issues such as the development and
changing as a result of, the needs of patients and
underpinning education of practice, and the
their families, the needs of the healthcare system
standards of care that patients deserve and require
and of wider society. Salussolia (1997) shares this
need to he considered in the context of the
view and adds to it by arguing that nursing has also
requirements of healthcare management and
changed as a result of the 'professionalisation' of
governing bodies.
nursing. However, she does mention that when
considering the changes taking place in nursing,
for example the development of extended roles

76 JPP Vol 17 No 2 February 07 Jennifer Al-Hsshemi

Definition of the role
In 2003 The Perioperative Care Collaborative
(PCC) redefined the title and job description of the
first assistant role to that of ASP. It defines the role
as, 'providing competent and skilled assistance
under the direct supervision of the operating
surgeon while not performing any form of surgical
intervention' (PCC 2003, p2).
The PCC states that the role of the ASP must be
undertaken by a competent practitioner who has
received recognised training for this role and is
aware that patient care is paramount. This new role
has given the nurse acting in this capacity the
opportunity to provide holistic care to each
patient. The PCC (2003) states that the duties of the
ASP do not involve any surgical intervention (Table
I).
Sutton (2003) and Tanner (2001) mention that the
ASP role does not involve extended practice.
Instead they argue that this role is already
established into the theatre nurse role and doesn't
require any specific training. Tanner (2003) argues
that nurses are doing themselves a disservice when
they view the assisting role as advanced practice.
However the PCC (2003) identifies that non-
medical practitioners must be aware that when
functioning as afirstassistant they would be held
by law to standards of care expected from medical
staff. This statement defines this role as one which
requires specific training needs and assessment of
competence, and also that this role should be
included in the job description and contract of
employment of all who undertake this practice.
Expert practitioners
The PCC also mentions that these practitioners are
expert practitioners. According to Benner (2001)
an expert practitioner is someone who no longer
relies on rules and guidelines to connect their
understanding of the situation to an appropriate
action. Benner argues that this is due to the fact
that an expert nurse operates from a deep and
intuitive understanding of the whole situation and
This role should be included in
the job description and contract
The role of the advanced scrub practitioner
The specification/duties of the advanced scrub practitioner
may include but are not limited to:
enhancing communication links between theatre, patient and
ward, including preoperative assessment and postoperative care
evaluation
assisting with patients' positioning, including tissue viability
i assessment
skin preparation prior to surgery
draping
skin and tissue retraction
handling of tissue and manipulation of organs for exposure or
access
handling instruments
male/female catheterisation
cutting of sutures and ties
assisting with haemostasis in order to secure and nnaintain a clear
operating field
use of suction
indirect application of electrocautery under supervision
camera holding for minimal invasive access surgery
use and maintenance of specialised surgical equipment relevant to
area of working
assistance with wound closure
application of dressing
transfer of patient to post anaesthetic care unit
The Perioperative Care Collaborative recommends that all
advanced scrub practitioner interventions be documented within
the patient's notes or integrated care plan.
TaMe 1 The role of the an awareness of all the rules and guidelines and
advanced scrub practitioner
IPCC2003)
does not have to stop and recollect them white in
practice. Consequently an expert practitioner
should be a professionally qualified, experienced
practitioner who has developed skills and
knowledge enabling them to perform to the extent
that their actions allow procedures to he carried
out effectively (Thatcher 2003).
The expansion of the theatre nurse's role to that of
ASP is a positive one as it is crucial for nurses to
'move with the times' in order to provide continuity
of care (Westwood 1999). Moreover Sutton (2003)
argues that nurses no longer 'monopolise' the O
JPP Vol 17 No 2 February 07 77
 theatre department allowing other healthcare
workers to help deliver routine services. Managers
may wish to employ these other healthcare
workers with the consequent removal of nurses
from theatres (Barker 1996). It is therefore essential
that the caring role of the nurse is not undermined.
It should be acknowledged that theatre
practitioners no longer be seen as 'body
mechanics' but as a single, autonomous, caring
nursing profession (Mardell & Rees 1998).
Questions of competency
White and Coleman (2000) argue that if there is no
expansion of the nursing role in theatre, theatre
nurses' existence will continue to appear
uncertain, with an undercurrent of the threat of
being replaced. In the author's view the
introduction of advanced roles such as the ASP
gives nurses the opportunity to remain in theatre
by providing an extended, highly skilled service
with an emphasis on patient care. Numerous
theatre practitioners are now taking on this new
role, previously undertaken by medical staff, with
the appropriate training and competencies
required for practice.
The NMC (2004) in their Code of Professional
Conduct has no objection to practitioners
developing the scope of their professional practice,
but asks that tlie practitioners concerned are
competent for the purpose, and mindful of the
personal and professional accountability they bear
for their actions. There are points within tbe NMC's
Code that refer to autonomy when considering
professional practice, and are laid down to ensure
best practice. These are:
Protect and support the health of the individual
patient and client.
Nurses are professionally accountahle for their
actions; therefore they are answerable for their
actions or omissions regardless of any
directions from other professionals.
The NMC asks that the practitioners
concerned are competent for the purpose
and mindful of the accountability they bear
78 JPP Vol 17 No 2 February 07
In true autonomy, practitioners should be able
to recognise their strengths and weaknesses in
order to protect the patient in their care.
Dowling et al (1996) and Hughes (2002) emphasize
that practitioners should not carry out any tasks
unless they have undertaken appropriate training,
are practicing within the limits of professional
practice and existing legislation, and are
competent to do so. The interests of the patient are
paramount and without proof of competence, a
nurse who acts in the role of ASP does not act in
accordance with professional statutory
requirements for accountability. For this reason it
is important to exercise high standards of nursing
care and be able to justify any action or omission
while practicing as a professional.
Professional accountability
According lo Dowling et al (1996) accountability
refers to obligation and liability which come from
professional regulations arising from the NMC, the
law on civil wrongs to patients and employment
law covering the relationship between employers
and their employees. Dowling et al (1996) state that
the NMC is required by statute to regulate the
standards of practice of nurses and advise nurses
on issues such as accountability. Negligence and
batter>' are the two areas of civil law which may
involve nurses.
Tingle (2002) states that the common law of
negligence requires that, at all times, a reasonable
standard of care he attained. It is expected that if a
practitioner performs an activity that may usually
be a role performed by a doctor, then the standard
of care should be the same. Battery constitutes
toucbing a patient without consent (Dowling et al
1996). Tbe NMC (2004) mentions that it is
important to respect patients' autonomy, their
right to decide whether or not to undergo any
healthcare intervention, and that consent should
be obtained before any treatment or care is given.
Jennifer Al-Hashemi
 The expansion of the theatre nurse's role to
that of ASP is a positive one as it is crucial
for nurses to 'move with the times'
The PCC (2003) recommends tbat all patients be
informed when an ASP is involved in their delivery
of care. The author believes this is especially
important since the patient has the right to know
who assists in performing their treatment.
Therefore a practitioner performing the tasks
previously undertaken by a doctor sbould
introduce themselves to each patient, tell them
who they are, and inform the patient that they
possess the proper training to perform the tasks.
Consequently, the patient can give their informed
consent, knowing that the nurse will be performing
in an advanced capacity.
Regarding the relationship between employer and
employee, it is tbe practitioner's legal duty to carry
out the reasonable requests of their employer,
while the employee is required to comply with the
policies and protocols put in place hy their
employers (Dowling et al 1996, Hughes 2002).
support the health of their patients. Although
technology may enhance optimum patient care, it
is the author's opinion that there is a strong need
for interaction between perioperative practitioners
and surgical patients.
The ASP role has developed over time and has
become more accepted in the UK. The author
believes that this is due to perioperative nurses
being given tbe chance to voice their opinions
regarding the direction for their professional
development. The PCC and the NMC have set out
guidelines in order to facilitate this development.
Perioperative practitioners are no longer at risk of
becoming confined witbin the physical and
organisational houndaries of the operating theatre.
They are developing their caring roles in response
to the threat of becoming extinct by the
subsequent employment of less qualified
healthcare workers.

Role development should be in line with the needs

Conclusion
The purpose of this article is to focus on the
development of the ASP role, as performed by
theatre practitioners. It is important to be aware
that the role of the ASP is an extended role which
requires validated training. ASPs are obliged to
maintain high standards, bear in mind
professional accountability and protect and
of the patient, the fundamental principles of
nursing and the development of a more
autonomous patient/nurse relationship. However
nurses must always be aware of their limitations
within practice, recognise their accountability and
uphold high standards of care to the patients who
are the reason for their existence.

Additional information
AfPP wishes to highlight that operating department practitioners (ODPs) may also undertake the
role of the ASP As a professional association, AfPP welcomes the development and consolidation
of this aspect of perioperative practice within a clinical governance framework, supported by
validated training tbat bas assessed tbe competency of the individual to undertake this role.The
Perioperative Care Collaborative is currently reviewing its position statement on this aspect of
practice, but remains committed to the need for validated training to support this role for
compliance with legal, professional and ethical issues such as those issues that have been
discussed in this article.

The role of the advanced scrub practitioner JPP Vol 17 No 2 February 07 79


About the author
Perioperative Care Collaborative 2003 The provision of
non-medical perioperative practitioner working as first
Jennifer Al-Hashemi
RGN, PG Dip Perioperative assistant to the surgeon Harrogate, NATN
Nursing
Advanced Scrub
Practitioner, Broomfield
Hospital, Chelmsford
80 JPP Vol 17 No 2 February 07
REFERENCES
Barker M 1996 Should there be a nursing presence in Salussolia M 1997 Is advanced nursing practice a post
the operating theatre? British Journal of Nursing 5 (8) or a person? British Joumal of Nursing 6(16) 928-933
1134-1137
Sutton J 2003The ethics of theatre nurse practice
Benner P 2001 From Novice to Expert: Excellence and under the microscope British Joumal of Perioperative
Power in Clinical Nursing Practice New Jersey, Wurs/ng 13 (10) 405-413
Prentice Hall
Tanner J 2001 First Assistant activities British Joumal
Boss S 2002 Expanding the perioperative role: the of Perioperative Nursing ^^ (4) 172-178
surgeon's assistant British Journal of Perioperative
A/ors/ng 12 (3) 105-113 Tanner J 2003 Advanced practitioners within the
operating theatre Bri^sh Joumal of Perioperative
Dowling S, Martin R, Skidmore R Doyal L, Cameron A, /Vurs/ng 13 (12) 514^518
Lloyd S 1996 Nurses taking on junior doctors' work: a
confusion in accountability British Medical Journal ZM Thatcher J 2003 Assistants in surgical practice British
Joumal of Perioperative Nursing 13 (5) 210-213
1211-1214
Tingle J 2002The professional standard of care in
Hughes S 2002 Law and professional practice:
clinical negWgence British Joumal of Nursing'\^ (19)
accountability and implications British Joumal of
1267-1269
Perioperative Nursing 12 (3) 94-102
United Kingdom Central Council for Nursing,
Mardell A, Rees C 1998The theatre nurse: getting the
Midwifery and Health Visiting 1992 The Scope of
image right Nursing Standard ^3 |4) 46-47
Professional Practice London, UKCC
Morrison J 2000 Evolution of the perioperative clinical
Westwood K 1999The nurse as first assistant: a review
nurse specialist role American Operating Room Nurse
of the literature British Joumal of Theatre Nursing 9
Jouma/72 (2) 227-231
(9) 404^08
Nursing and Midwifery Council 2004 Code of
White J, Coleman M 2000 Threats and opportunities
Professional Conduct NMC, London
facing the theatre nurse British Joumal of
Perioperative Nursing 10 (5) 260-268
Members can search all issues of the BJPN/JPP published since 1998 and download articles free of charge at wvmif.8^p.org.uk.
Access is also available to non-members who pay a small fee for each article download.
Jennifer Al-Hashemi