In the operating theatre, scalpel in hand, Sara Dalby is reminded of snow: “When you’re making the first incision, it’s like making a set of footprints in it. It’s never going to be the same.”

Patients may expect a surgeon to operate on them, but Dalby is one of a small group of nurses who have advanced to the role of surgical care practitioner (SCP).

Soon Dalby’s role will become even more special: come September, she will be able to carry out surgeries, such as facial skin cancer excisions, with possible skin grafts and flap reconstructions, without a consultant by her side.

Unlike other nursing roles in the surgical team, an SCP, as defined by the Royal College of Surgeons (RCS), is involved with the patient from the moment they set foot in the hospital until the moment they go home. Dalby’s nursing background has certainly helped her to this point. She says: “I have a wealth of knowledge from being a nurse that’s helped me take the next step into advanced practice.”

The new SCPs take part in everything from preoperative assessments – including taking histories and conducting physical exams – to assisting in theatre, training trainee surgeons, and postoperative care, such as wound assessment and discharging patients.

The NHS does not currently record an overall figure for how many SCPs are employed by the service, but a recent report from the RCS, which included studies of surgical teams in eight NHS hospitals, counted no SCPs at St George’s hospital in London, but as many as seven at University Hospital of North Tees.

Becoming an SCP requires a background as a registered healthcare professional, such as a nurse, a love of clinical practice and academic aptitude. Dalby had an MSc in advanced nursing and took on additional training and study for the post. Now the recommended training is a two-year master’s programme at university – a much higher barrier to entry than training for general nursing roles.

Having qualified as a nurse in 2003, Dalby’s interest in surgery has grown throughout her career – from observing a hip replacement as a student nurse to training as one of the hospital’s first surgical first assistants, tasked with camera holding for laparoscopic surgery when the service was introduced by a colorectal consultant.

Becoming an SCP was a chance to push herself professionally, develop her clinical skills and still work directly with patients. She is now Aintree University hospital’s only SCP and works across two specialities – the maxillofacial unit and upper limb orthopaedics.

Dalby says: “I feel a responsibility to ensure that I provide high standards of patient care in my capacity as an SCP and to evidence the role as a success, to prove non-medical practitioners are worth investment.” She adds: “Being in advanced roles give nurses with experience an alternative career path to management. It keeps them on the frontline providing clinical care for patients.”

Matthew van Loo, a senior lecturer at Teesside University’s school of health and social care and a former SCP, adds: “There hasn’t been a huge investment in careers on the clinical side of nursing, so this role is attractive to people. Not everyone wants to get a pay rise by going into management, so it does open up another door.”

Ian Eardley, vice president of the Royal College of Surgeons, says such non-traditional roles can help create a “flexible and permanent workforce” for hospitals. While junior doctors move between specialities for their training, for example, SCPs will remain in post.

The RCS report looked at changes to the surgical workforce, including the use of SCPs and other non-medical roles, and suggests that patient care and continuity of care has improved where such jobs have been introduced.

The nursing background of many SCPs is particularly beneficial. “Medical training is quite different from a nurse’s training, in the way that you approach things.” says Eardley.

“The nursing approach is often more holistic, often more caring than we are. The two styles are slightly complimentary, but it’s now becoming clearer that there are certain things that can be done for surgical patients by people with different training.”

Dalby adds: “My consultants and I may have different viewpoints about things and I think that’s to the benefit of the patient, because then all aspects of care are considered. Sometimes I know what the nurses are going through on the ward or what the theatre staff will be thinking.”

The role now shows signs of improving junior doctors’ surgical experience. SCPs may take on activities in theatre, allowing a consultant more time to focus on training or perform duties outside theatre that allow juniors to spend more time operating.

“We’ve moved from a situation where there were doctors and nurses doing very different things to functioning far more as a team with overlapping roles,” says Eardley.

But this is no fast-track to becoming a surgeon. While traditional roles may blur at a lower level – an SCP may lead ward rounds and carry out surgical procedures for very specific conditions and within certain limits, for example – a clear distinction between the responsibilities of consultants and SCPs remains. Consultants lead the surgical team, perform far more complicated surgeries and oversee the work and training of everyone on that team. They will also have medical training, qualifying first as doctors before undertaking extensive further training to specialise.

Andrea Thomas, deputy director of nursing and quality at Aintree University hospital says the introduction of SCPs is about the changing shape of surgical teams and, in addition to other advanced clinical roles, a response to broader hospital and patient needs. These posts can help the NHS face the future, explains Thomas, by helping services plan for anticipated shortages in junior doctors training for surgery and other specialities.

She says: “Who’s going to replace [junior doctors] in the clinics, in the theatres, in the wards? What will that look like and who will it be? Developing some of these roles in those areas is an absolute must do.”

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