Are Theatre Nurses Equipped With the Skills Required to Perform Pre-Operative Visits?

¶ … Theatre Nurses Equipped With the Skills Required to Perform Pre-Operative Visits

To Perform Pre-Operative Visits?

Are Theatre Nurses Equipped With the Skills Required

To Perform Pre-Operative Visits?

Dissemination

Are Theatre Nurses Equipped With the Skills Required

To Perform Pre-Operative Visits?

Pre-operative assessment is part of the ER process that many medical professionals believe can be accomplished on the part of nurses in the unit.. The objective listed for pre-operative assessment is that special requirements for the surgery as well as the peri-operative stay should include identification and coordination of all essential resources, should inform the patients and prepare them to proceed and to ensure the patient's fitness for the procedure(s) scheduled. . The nursing team clinically examines as well as assessing all emergency patients before surgery to ensure the fitness of patients to the greatest possible extent. Strategies include, "redistributing cases from emergency to elective theatre schedules, day case emergency surgery, and booking parts of the emergency care process." Stated is that, "these strategies have resulted in significant operational clinical improvements in the care delivery for emergency and surgical patients." (NSH, 2005) Care delivery, autonomy, culture management, information managements, leadership, psychologic management and relationship management processes are all listed as core components in the rose of the critical care nurse"

Are Theatre Nurses Equipped With the Skills Required

To Perform Pre-Operative Visits?

- Research Proposal

Introduction

Pre-operative assessment prior to the patient receiving anesthesia is the responsibility of the anesthetists however, pre-operative screening prior to assessment achieves "several desirable objectives." It ensures that patients are prima facie fit for anesthesia and surgery and that all likely investigations will be completed and available at the time of the pre-operative assessment. Screening first takes place in the general practitioner's surgery or outpatient department, pre-admission screening clinics employ nurses who have been provided with special training and organized by surgical teams or by the anesthesia department. It is crucial that the boundaries between the remit of the pre-anesthesia screening team and the responsibility of the anesthetist be clearly set out.

The aims of pre-anesthesia screening are:

(1) To provide the anesthetist with basic information on the patient's health status which will enable a meaningful assessment of fitness for anesthesia to be made;

(2) To identify and instigate relevant investigations, according to pre-determined protocols;

(3) To increase the patients' understanding of the pre-operative, intra-operative and postoperative care being planned;

(4) In patients scheduled for day surgery to assess the home situation, social circumstances and the availability of support.

(5) Screenings are often conducted through the use of a questionnaire which the patients complete and a checklist completed by a nurse with relevant training and experience for filling this role.

A brief history of medical information concerning the patient along with any allergies to medications or adverse reactions experienced to anesthesia are notes. Other relevant information such as the height, weight, pulse rate and blood pressure of the patient are taken as well as a urinalysis performed. Pre-operative assessment is stated to, "Establish that the patient is fully informed and wishes to undergo the procedure. It ensures that the patient is as fit as possible for the surgery and anesthetic. It minimizes the risk of late cancellations by ensuring that all essential resources and discharge requirements are identified and coordinated."(NHS, 2005) The guide developed by the NHS Modernisation Agency's Operating Theatre & Pre-operative Assessment Programme (the Theatre Programme) is for the purpose of providing guidance before admission for inpatient surgery in the area of pre-operative assessment and is stated to, "Build on the work of the pilot sites that were involved in developing and testing ways to implement pre-operative assessment." (NHS, 2005)

It is the desire of patients that they be informed fully in relation to their operation and that they are fit for surgery on the scheduled date. In order to improve the patient's surgery experience the implementation of pre-operative planning and assessment should be before admission because the patient is allowed the opportunity to receive information and to ask any questions they might have. Hospital efficiency could very well be improved through "ensuring patients are as fit as possible, and identifying any resource requirements for the operation, peri-operative stay and subsequent discharge." (NHS, 2005)

The objective listed for pre-operative assessment is that special requirements for the surgery as well as the peri-operative stay should include identification and coordination of all essential resources, should inform the patients and prepare them to proceed and to ensure the patient's fitness for the procedure(s) scheduled.

Research Questions

This study asks the questions of:

1. Are nurses in the emergency room capable through training to perform pre-operative assessment in lieu of the attending physician doing so?

2. Are the pre-operative assessments of nurses thorough enough to avoid liability and medical error?

Are Theatre Nurses Equipped With the Skills Required

To Perform Pre-Operative Visits?

- Research Proposal

Literature Review

The New Reporter Journal, Volume 14. Number 19, June 30, 1997, in the article entitled "Nurses Could Help Cut Junior Doctors' Hours" states that, "the results of a new study could have far reaching implications for the future roles of doctors and nurses and for the structure of general surgery. " As stated in the report there is not a "career structure for nurses in this area of practice" It was however, "found that nurses can effectively take on the role" which will not only increase their opportunities and bring benefits to the realm of general surgery.

Objectives of Pre-Operative Assessment

Consideration of the objectives of pre-operative assessment are as follows according to the NHS in their work entitled, "Pre-Operative Assessment for Inpatient Surgery" the "Pre-operative Assessment Should:

"Provide the opportunity for further explanation and discussion of the information given by the surgeon. This should minimize fears and anxieties through ensuring the patient's full comprehension of the scheduled procedure.

Assess the fitness for surgery of the patient and as well the patients' fitness for anesthesia and finally make provision of an assessment of the risks and benefits of the proposed procedure and confirming that the patient wishes to have the operation even after having been make aware of the risks and benefits of the procedure.

Make identification of any and all conditions requiring intervention before admission and surgery and take required action. (Example: Patients taking blood thinner, oral contraceptives, etc.)

Refer the patient for optimization of their health prior to surgery if necessary. (Primary Care and/or secondary care specialist)

Make sure that all necessary investigations are conducted with results being available and any necessary action taken thereby reducing any unnecessary dluplication of investigations.

Assess the suitability of the patient for day surgery and assess whether the scheduled procedure can be performed as a day surgery procedure.

Make identification of requirements to aid in the scheduling of the surgical procedure to include specialist equipments, the approximate length of the surgery as well as any other requirements for the post-operative stay. (Critical care beds)

Make provision of information in relation to pre-operative instruction of a specific nature. (e.g. fasting, etc.)

Provide a contact for any further questions, concerns or cancellation of the scheduled procedure.

Information concerning the post-operative recovery, mobilization rate, pain reliever options. Videos, leaflets and picture diaries are suggested as being effective in providing information and relieving anxiety of patients.

Make provision of the opportunity to have a discussion with patients in relation to self-help matters toward improving their surgery outcome. (e.g. stopping smoking, losing weight, etc.)

Identification of cultural requirements and communication and other special need requirements is done in the pre-operative period.

Make assessment of the available home support to the patient post-discharge.

Preparation of the multi-disciplinary pre-operative documentation." (NHS, 2005)

Role of the Pre-Operative Assessor -- Pre-Operative Assessment

Secondly comprehension of the scope of the role of the pre-operative assessor is important in grasping the prevailing issues in the proposed research. Those pre-operative assessors are stated by the NHS to be as follows:

"Work to guidelines and competencies agreed by the anesthetists, surgeons and other allied health professionals to ensure a consistent approach.

Take a targeted history and conduct a relevant physical examination of the patient, including airway assessment.

Refer patients who fall outside the agreed criteria to an anesthetist, who may then make further referrals.

Arrange and perform investigations in accordance with NICE guidelines.

Ensure that the results of tests are evaluated and refer abnormal investigations results to the available anesthetist, surgeon and/or primary care, according to local guidelines.

Refer a patient back to primary care or another healthcare professional to optimize the patient's medical conditions, according to local guidelines.

Take responsibility for following up referrals to ensure the patient remains in the pre-operative system.

Liaise actively with the anesthetic department.

Arrange and co-ordinate for all communication

Take responsibility for all communication with the patient throughout their pre-operative stay and ensure a timely discharge.

Commence necessary planning for the per-operative stay and to ensure a timely discharge

Identity factors that may influence the dates of surgery offered, e.g. school holydays

Collate all information prior to surgery and ensure that the multi-disciplinary documentation is available for anesthetists to see at least 48 hours prior to admission.

Communicate approximate length of operation, any requirement and essential resources to the waiting list office, bed management, operating theatre department and/.or theatre scheduler.

Contact all patients failing to attend pre-operative assessment to identify the reason. Act on the reason, following local protocols for the management of DNAs in pre-operative assessment." (NHS, 2005)

Role of Nursing Team in Pre-operative Assessment

Further needed in comprehension is the role of the nursing team. The nursing team performs clinical examination and emergency assessments of all patients in the ER before surgery takes place for the purpose of ensuring that the fitness of patients is provided for to the greatest possible extent. Strategies include, "redistributing cases from emergency to elective theatre schedules, day case emergency surgery, and booking parts of the emergency care process." Stated is that, "these strategies have resulted in significant operational clinical improvements in the care delivery for emergency and surgical patients." (NSH, 2005) This is inclusive of the following:

'50% reduction in cancellation of minor emergency surgery from emergency lists.

Reduction by half of the admission to surgery time for minor emergency surgery.

97% of minor procedures have their emergency operation complete within 24 hours of admission with man y not having to stay in as an inpatient.

Fractured neck or femur, admission to theatre time has halved to 1.6 days with a reduction in length of stay of 10 days.

Theatre utilization has risen to 73% from 37%.

Reduction in 'out of hours' operating by 23% with only 12% emergency patients operated on during this time." (NHS, 2005)

Research shows specifically from conduction of a general study focused on inpatient pre-operation assessment the following findings and results of the general study:

100% attendance for operations.

100% of patients reported they did not expect this level of input at their outpatient appointment and all were please that it was so.

80% of patients had further investigations completed in accordance with their diagnosis and general health.

100% of patients felt prepared for their operation.

In a study entitled "Preoperative Information" written by Knobel & Hassfeld (2005) which states that many empirical studies have identified the quality a communication of patient information as a major weak point in the treatment process. In this study it was shown that multimedia presentations improved the quality of preoperative patient information making it 'sensible' to use modern media toward the end of provisioning graphic information to the patient. In a separate study which "quantified the accuracy of trained nurses to correctly assess the pre-operative health status of surgical patients as compared to anesthetists." (van Klei, 2004) In this study of 4540 adult surgical patients the health status of the patient was assessed first by the nurse and then by the anesthetists. The question which an answer was being sought for was: "Is this patient ready for surgery without additional workup?" Stated to be the secondary outcome was the amount of time utilized for completion of the study. The nurses and anaesthetists and nurses did not know the results of one another's answers. Results were as follows:

87% of the patients were classified similarly by the nurses and anaesthetists.

The sensitivity of the nurses assessment = 83% (95% CI: 79-87%) and the specificity 87% (95% CI: 86-88%).

In 1.3% (95% CI: 1.0 -- 1.6) or patients were classified as 'ready' by nurses and anaesthetists did not classify them as such.

Nurses required 1.95 (95% CI: 1.80 -- 1.90) times longer than anaesthetists.

Findings are that by anaesthetists allowing the nurses to "serve as a diagnostic filter' in making identification of the subgroup of patients who are 'fit' to undergo surgery in lieu of further diagnostic testing frees the anaesthetists to focus on other patients that might require further attention prior to surgery. (van, Klei, 2004)

In a 2002 case study by Hastings and Rother for the NHS Trust it is reported that even the seemingly effective hospital ER has potential for improvement as is evidenced in the report of this case. The methodology of the study was questionnaires for patients (these proved to be ineffective) staff workshops, interviews with key staff and a patient's focus group all proved effective. This case study found that the pre-assessment nurse and anaesthesiologist working in coordination to "improve communication and patient informattion designed to reduce cancellations after admission for medical reasons was effective as to productivity. Recommendations from the study were as follows:

"Review the preparation of patients prior to surgery, including pre-operative checklist, patients' information and pre-operative assessment.

Review the management, roles and terms and conditions of SDU staff.

Introduce appropriate catering and other facilities for staff within theatres.

Redesign structures and multidisciplinary meeting arrangements within theatres to facilitate communication and analysis and monitoring of clinical standards." (Hastings and Rother, 2002)

Also recommended were the following:

"Evaluation of the potential benefits of an explicit operational theatre co-coordinator role.

Evaluation of the benefits of a unified theatre practitioner grade.

Likely to lead to major improvements, but is complex and may need external skills or resources.

The introduction of an improved theatre clinical information system.

Establish project team to assess the management of theatre scheduling and booking of operating lists." (Hastings & Rother, 2002)

For each recommendation it is stated in the report of the study that the following recommendations were added to each:

(1) Set clear objectives for the proposals,

(2) Provided an 'audit trail' to indicate the basis for the recommendation, for example whether it arose from the staff workshops and interviews, from the patient survey/focus group and/or from the literature.

(3) Set out the actions required to deliver the proposal.

Further revealed by this study is that progress is being made citing as an example a "multidisciplinary working group which includes the anesthesiologist, surgeons, nurses, ODP in addressing issues concerning emergency theatre arrangements. A second development is stated to be "joint work by an Anesthetist and an orthopedic pre-assessment nurse to improve communication channels. The aim is to test new patient information (in paper and later electronic format) designed to reduce cancellations after admission for medical reasons. This work is in line with recommendations from the Pre-assessment Project within the Modernization Agency." (Stock, 2002) Listed as "main challenges faced by the team" was the space and time, or 'headroom' in which to do the work as well as the challenge of handling the work while handling a busy clinical workload simultaneously. Fatigue was listed to be a problem. Key lessons learned by the team were noted to be:

1) Make sure that the team has adequate time set aside for the work;

(2) It may not be possible to squeeze it in between other commitments;

3) Make sure from the outset that you have adequate secretarial and administrative support - don't wait until you are desperate for help!

(4) Be realistic about the scope of any review - keep the agenda manageable. The scale of this review was probably too broad.

(5) Recognize that the pace of the work will slow when other activities have to take priority.

(6) When you are asking people to work with you make sure that you work with them - help them to help you. Your priority may not be theirs - they will be facing their own pressures.

(7) If the work shows that you have got to build bridges between different parts of the organization - build them yourself. Don't expect others to do it for you.

(8) Think carefully before using a questionnaire to collect the views of patients - is it the best way?

(9) Take care when approaching patients - choose the 'right' time and the 'right' messenger. Nurses may be best equipped to tackle this task. (10) be aware that your efforts might be affected by any local merger agenda - be flexible and ready for change!" (Stock, 2002)

In the work entitled "Institutional Changes in Hospital Nursing" (Krall & Prus, 1995) it is stated that concerns related to the "recurrent shortages [of nurses] led many economists and health care specialists to explore the dynamics of the nursing labor market using neoclassical labor market analysis." Further stated is that, "As the length of hospital stay and severity of patient illness have increased, less custodial and more acute care is required by nursing personnel. As a result, many of the tasks performed primarily by lesser skilled nursing personnel may have been eliminated." The article states that the role of the licensed practical nurse are "rapidly disappearing from acute care hospitals as the shift to all RN staff picks up momentum across the country. The reasons are clear: As patient acuity grows and cost-containment pressures increase, nursing directors believe they must employ only nurses able to deliver the "broader range of care." Where staff cuts must be made, they say, the axe is bound to fall heaviest on LPNs and Aides" [American Journal of Nursing 1985, 1165].

In the work entitled "Day Surgery in Australia: Qualitative Research Report" it is stated that day surgery is on the increase worldwide. One consideration is that explained by Light et al. (1996) in the work entitled, "Task Complexity in Emergency Medical Care and Its Implications for Team Coordination" which states that, "Multiple, concurrent tasks. When multiple tasks are attempted concurrently, one challenge facing emergency care personnel is to resolve potential conflicts among the members. The team is prone to problems in team coordination, such as goal conflicts, task interference, and competition for access to the patient."

Further stated is that, "Compressed work procedures and high workload. High workload under time pressure creates challenges not only for individuals but also for the resuscitation staff as a whole to coordinate activities. They may have to deviate from traditions and usual procedures and skip certain tasks in favor of more critical tasks. Such a strategy can create ambiguity in terms of which steps should be skipped and how a team should reorganize its members' activities when often-adopted procedures are not followed." And finally the report states that "Based on the findings of the study, we identified four components of task complexity in emergency medical care: multiple and concurrent tasks, uncertainty, changing plans, and compressed work procedures and high workload. These components of task complexity in emergency medical care pose challenges for team coordination and increase the potential for breakdowns in team coordination, such as conflicts in access to the patient, in goals, and in tasks. We suggested two approaches to help caregivers in emergency medical care to cope with task complexity: training in explicit communications and the design of work procedures to facilitate team coordination."

Stated in the work entitled, "Where Have all the Nurses Gone" is that, "In truth, however, nursing lacks an independent knowledge base. Nurses are taught the same material as physicians, only less of it. Nursing textbooks, for example, differ from physician textbooks only in being less rigorous. When nursing tries to distinguish itself on the basis of scientific knowledge alone, nursing loses status among doctors and para-professionals who have knowledge bases of their own. Thus, the professionalization of nursing and the lingering sense that it is a women's profession have had devastating consequences for nurses." (Dworkin, 2002)

In the work entitled "Organizational Culture and Consultant Nurse Outcomes: Part 2. Nurse Outcomes" states that the longitudinal three-year study's aim was the investigation of the development of "a consultant nurse post" and consideration as to whether it "contributed to a new organizational culture." The method of study was one of action research focused on developing practitioners, their developing practice and the contribution to comprehension of that which was being studied as well as the utilized processes. The results stated that "a number of factors, including transformational leadership, other facilitative processes, expertise in the practice of nursing, and other sub-roles of the consultant nurse were shown to be influential." (Author unknown)

Stated in the work entitled, "Role Development and Effective Practice in Specialist and Advanced Practice Roles in Acute Hospital Settings: Systematic Review and Meta-Synthesis" is that, "The number of clinical nurse specialist, nurse practitioner, advanced nurse practitioner and consultant nurse roles has grown substantially in recent years."

In the work entitled, "A Dimensional Analysis of Role Enactment of Acute Care Nurses" conducted at Yale University School of Nursing in New Haven Connecticut was toward the purpose of identifying the dimensional role enactment of acute care nurses. The dimensional analysis was rooted in grounded theory methodology toward analyzing the role enactment process. Findings of the study states that, "initial analysis of the articles indicated 37 separate dimension in role enactment" (Squires, 2004) of these acute care nurses with the "final integrative analysis reducing the initial 37 to 7 core dimensions listed as "care delivery, autonomy, culture management, information managements, leadership, psychologic management and relationship management processes." The conclusion of the study that that the "multidimensional nature of the role of acute care nurses was indicated in the dimensional analysis. The findings have implications for the administration and education of nurses, as we as for human resource development of nurses in many part of the world." (Squires, 2004)

Psychological Considerations

From a psychological standpoint the consideration must be focused toward the fact that "any illness that is serious enough to require admission to the critical care unit will intensify the physical and psychological effects that the patient and their significant others experience. Hence the discharge needs to patients admitted to critical care are unquestionably complex." (Watts, et al., 2005)

The study conducted by Watts, et al. (2005) "utilizing an exploratory descriptive approach" (Watts, et al., 2005) in conjunction with 502 critical care nurses by a questionnaire found that there existed a lack of time in terms of discharge planning and further that communication could either "enhance or impede" (Watts, et al., 2005) the planning process for critical care discharge. In the work entitled "Intensive Care Nurses' experiences of Assessing and Dealing with Patient's Psychological Needs" stated is that the psychological effects of an intensive care unit (ICU) stay has been the focus of the work of many authors. In this study 23 nurses currently working in ICU were "interviewed using a semi-structured technique." There were six categories concerning issues in psychological care. Implications were that practice included the "important roles of the family, need for improved communication and improved staff awareness of the issues." (Price, 2004)

In the work entitled "OR Nurses' Career Paths Diverse and Continue to expand" it is stated that, RN First Assistants often serve in the same role that a secondary physician would perform in a surgical procedure ....Prior to surgery, the RN First Assistant may take a physical assessment of the patient and provide patient education, giving the patient continuity of care -- before, during and after surgery." (Paulson, 2005)

Obstacles and Challenges in the Pre-operative Theatre Setting

Surgeries that are cancelled increase the amount of work significantly for the hospital in rearranging scheduling for the surgeries. The chart below labeled Figure 1.0 illustrates the reason and percentage for inpatient cancellations from August, 2001 to November 2002.

Figure 1.0

Source NHS (2005)

The closer the time to surgery that cancellations took places the more impact experienced by the hosptpital in view of scheduling of lists and utilization in the hospital theatre. In order to achieve the optimal pre-operative assessment including discussion about risks and benefits the pre-operative assessment must be "properly planned to engage all necessary healthcare professionals." (NHS, 2005)

The NHS report further states that, "Pre-operative assessment is an important part of the surgical patient's pathway. It must be integrated within the wider system. Including waiting list, management, elective and emergency admissions, booking of dates, operating theatre list compilation, bed management and discharge planning. A single central contact point within secondary care with links to primary care and social services, should enable planning and optimization of care to occur across the whole health community. This central coordination should benefit both staff and patients by reducing confusion and duplications improvement programmes should be linked at NHS Trust. Strategic Health Authority to ensure a whole systems approach. The primary focus of the guidance of NHS is toward the processes that are necessary for "efficient pre-operative assessment." That focus is not inclusive of clinical issues such as:

Detailed guidelines for referral from a pre-operative service.