Surgeon’s assistants take nursing in a new direction

Perioperative nurse surgeon assistants are a dynamic group of advanced-practice nurses redefining traditional roles. Linda Belardi reports

With historical origins tracing back to the Crimean war, nurses have long acted as first assistants to surgeons, opening and closing wounds and assisting in the amputation of combat-ravaged limbs.

Beginning with Florence Nightingale in the 1850s and continuing throughout most of the globe’s theatres of war, large numbers of nurses have served as surgical assistants.

But despite years of practising in an expanded role, perioperative nurse surgeon’s assistants (PNSAs) remain largely underdeveloped in a civilian context.

In Australia there are fewer than 200 practicing PNSAs in a workforce of 283,000 nurses and midwives, and 19,000 perioperative or operating room nurses.

PNSAs are not defined in any industrial award or formally recognised by the national regulator, the Australian Health Practitioner Regulation Agency (AHPRA). This specialty area is invisible in the research literature and Australian media, and has no mandated educational requirement.

PNSAs variously practise with or without formal postgraduate training and can work towards a graduate certificate, graduate diploma or a master of clinical science (perioperative nurse surgeon’s assistant) at Southern Cross University, the only provider of the PNSA course in the country.

Professor John Stevens, head of the department of nursing and health care at Southern Cross University, said the role of the PNSA in Australia was still in the early stages of development.

Due to competition from medical registrars in the public sector, most PNSAs find work in the private health system. To date, PNSAs are concentrated in plastic and reconstructive surgery (which is largely an out-of-pocket expense for patients) and in orthopaedics. They predominantly work part-time and, due to higher volumes of surgeries in major hospitals, PNSAs have a stronger presence in metropolitan areas.

Financial viability remains an issue for this group because they are unable to access the MBS surgical-assisting item numbers available to medical assistants. Attempts to lobby the Department of Health and Ageing to extend Medicare rebates to PNSAs have been unsuccessful.

Like private-practice nurse practitioners and nurse entrepreneurs, many PNSAs operate a fee-for-service model, directly charging the surgeon or patient.

Working to their full scope of practice, PNSAs deliver care in the three phases of a patient’s perioperative journey – preoperative, intraoperative and postoperative. The PNSA is well positioned to deliver holistic care to the patient through patient education and preparation, discharge planning and postoperative rehabilitation.

Some nurse surgical assistants, however, work exclusively during surgery. Estimates suggest at least 50 per cent of PNSAs work in this way, offering their services to multiple surgeons or practices as a sole practitioner.

Professional recognition

Until the early 1990s, perioperative nurses carried out the role of the surgeon’s first assistant on an ad hoc and informal basis, often in rural areas, filling in when a GP or junior doctor was unavailable.

In 1991, the Australian Confederation of Operating Room Nurses (ACORN), now the Australian College of Operating Room Nurses, agreed to formally recognise the advanced-practice role and developed an industry partnership with Southern Cross University to introduce a postgraduate training program. The US had adopted the role more than a decade earlier.

Since then, ACORN has established a set of guidelines and competency standards to begin to define this extended perioperative nursing role.

A single voice

In March, the Australian Association of Nurse Surgical Assistants (AANSA) was established to raise the profile and representation of PNSAs at a national level.

Its inaugural president, Toni Hains, says the association is intended to seek formal recognition for the role as a legitimate health professional and to clear some of the obstacles standing in the way of advancement.

Remuneration, professional recognition and consistent education standards have been identified as professional priorities.

The executive team is drafting a document to articulate the PNSA’s scope of practice and to build the networking capacity of the new association. “It’s really hard for practitioners who are starting out to find their feet with hospital accreditation, professional indemnity insurance and knowing how to go about running a business as a PNSA,” Hains says.

“We want to pave the way for people who are coming behind us, so they can consider this as a viable career choice.”

Hains says it would be important to require all PNSAs to have formal postgraduate training in the future and to ensure the role stays within the nursing profession, resisting a push to employ cheaper technicians.

An extended role

Lloyd Dodds is the unit assessor for the Southern Cross University course and a PSNA in the private sector.

He says the role is highly skilled, technically demanding and focused on holistic care. The course has accepted students from all parts of Australia, as well as Canada and New Zealand.

“I don’t see it as nurses doing a doctor’s role; I see it as an advanced role for nurses,” Dodds says. “Rather than stepping away from nursing, it’s about delving deeper into nursing.”

He says there has been a lack of understanding of the role, especially from nursing colleagues who mistakenly believe it is non-nursing.

“I had a choice - I could go and do medicine and be like any other doctor or I could do something a bit different, be a nurse and push the boundaries of nursing and demonstrate what nurses can do,” he says.

Dodds is optimistic about the future of the specialty and believes greater numbers will bring a stronger, more coordinated voice for the specialty. He advocates requiring all students to complete the masters program rather having the option to opt out at a graduate certificate or graduate diploma level.

A higher educational requirement would demonstrate a commitment to professionalisation and help PSNAs mount a case to government for access to Medicare rebates, he says. The potential to combine the PNSA and nurse practitioner training programs may also be explored in the future.

PNSA and nurse practitioners

Jennifer Furness was one of the first eight graduates to complete the formal PNSA course through Southern Cross University in 2001 and the first endorsed perioperative nurse practitioner in Victoria.

Furness fell into the role of the PNSA after a surgeon asked her to fill in for a surgical assistant who failed to show up for an operation. She loved the work immediately. After completing the postgraduate course via distance, she worked for a plastic and reconstructive surgeon and a general thoracic surgeon in regional Victoria.

“The PNSA was an excellent role in our area, where we only had a single plastic and reconstructive surgeon. When he was away at another hospital I was able to take follow-up calls and manage patients,” she says.

“In a private hospital setting where there are no medical registrars or residents, a perioperative nurse surgeon’s assistant is extremely valuable because we understand the hospital system, we know how the procedure is going to go and we are well prepared for all eventualities. Patients really enjoyed the time the nurse spent explaining procedures and their postoperative journey.”

However, Furness says remuneration remains a constant challenge, especially when the only option is to charge patients out-of-pocket expenses.

In 2008 Furness began a masters in nurse practitioner studies and became one of only three endorsed PNSA nurse practitioners in the country. “As a nurse practitioner, I could make decisions about a patient at the point of care,” she says.

Furness has since moved into a role as a nurse practitioner with the acute pain service at Bendigo Health, where she is involved in post-operative pain management.

Public sector PNSAs

Roger Willows is one of the few PNSAs employed by a public hospital in Australia. In 2008, he was approached by the head of the cardiothoracic unit at the Royal Hobart Hospital to close the leg wounds of patients having coronary artery bypass grafting – a task previously performed by resident medical officers.

Following hospital approval and postgraduate training, Willows became the first nurse in the Tasmanian public health system to work as a PNSA. Surgeons suspected that if responsibility was given to one health professional it would reduce the hospital’s high rate of donor-site infections. Under Willows, the infection rate has dropped to zero over a period of 18 months.

Willows says initial reaction from his nursing and medical colleagues was mixed and sometimes hostile. “Although the PNSA role is a nursing role, nursing peers consider it as medicalised. Medical personnel are typically cautious, unsure if it represents a threat,” he wrote in the April edition of Day Surgery Australia.

However, he says professional acceptance has increased significantly with exposure to the role. Willows says the PNSA role improves patient care by acting as a conduit of information between the patient, surgeon and nursing teams.

Within cardiothoracic surgery, the PNSA role extends to the harvesting of the great saphenous vein and radial artery, as well as first assisting when necessary.

Without an industrial award, Willows has been employed as a grade-four clinical nurse.
“Undertaking the PNSA role represents an exciting and challenging opportunity to extend the clinical knowledge, skill and experience of all perioperative nurses,” he says.

The role evolves

1991 The Australian Confederation of Operating Room Nurses (ACORN) Council [now the Australian College of Operating Room Nurses] decides an advanced practice role will be developed with the title of perioperative nurse surgeon’s assistant (PNSA)

ACORN issues the first policy statement on the registered nurse as first assistant, defining the role and articulating nine guidelines

1995 ACORN develops an outcome standard for the role

1996 Professor Bernadette Brennan is awarded an ACORN fellowship to study the advanced-practice role overseas

1997 ACORN and the Australian Nursing Federation wins support from the Royal Australasian College of Surgeons for the role and the development of an educational course. The college president appoints a surgeon to work with ACORN to provide surgical input to the course

The PNSA course begins at Southern Cross University

2000 An educational requirement is introduced into the revised ACORN standard

2001 The first eight PNSAs graduate in May

2012 The Australian Association of Nurse Surgical Assistants (AANSA) is established in March.

What’s in a name?

Internationally, the role of the nurse surgical assistant has a number of titles. In the US, registered nurse first assistant or RNFA is widely used. In the UK, it is better known as a surgical care practitioner or SCP.

When ACORN was deliberating on a title for the role, registered nurse first assistant was thought not to reflect the role’s full scope. Perioperative nurse practitioner surgeon’s assistant was preferred.

Meanwhile, the position of nurse practitioner was developing in Australia. State and territory legislation placed an embargo on the use of the term “practitioner” as a protected title for endorsed nurse practitioners.

ACORN settled on perioperative nurse surgeon’s assistant (PNSA) but critics said the use of the word “assistant” denigrated nurses. The title harked back to the nurse as the doctor’s handmaiden, they argued.

While the title remains debated, a formal name change is yet to be pursued.

The PNSA was an excellent role in our area, where we only had a single plastic and reconstructive surgeon. When he was away at another hospital I was able to take follow-up calls and manage patients

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