1. Day surgery: Nursing’s contribution to this new surgical era Dr. Mark Mitchell Faculty of Health and Social Care University of Salford Greater Manchester UNITED KINGDOM m.mitchell@salford.ac.uk +44 (0)161-295-6480

2. INTRODUCTION   Throughout the expansion of day surgery, surgical nursing has largely shadowed medical advances. Consequently, medical developments have pre-determined many of the present day surgical nursing practices.   Little or no ‘nursing knowledge’ has so far greatly influenced modern, adult day surgery practices (Pearson 2004). A perceived lack of modern surgical nursing issues in nurse education may be a contributing factor. Pearson et al (2004) The care of patients whilst in the day surgery unit: A systematic review. Health Care Reports. 2 p.22 – 54.

3.   Additionally, the vast majority of nurses employed within dedicated day surgery units in the United Kingdom work within a multi-skilled role. Predominately, this involves undertaking numerous delegated medical tasks (DoH 2000, 2004). Department of Health (2000) The N.H.S. Plan - Creating a 21st Century N.H.S. London: HMSO. Department of Health (2004) The N.H.S. Improvement Plan: Putting People at the Heart of Public Services. London: DoH.   The adoption of such numerous quasi-medical tasks by the Profession is vital to ensure the safe and efficient throughput of patients in the limited time available.

4.   However, such a change in surgical healthcare delivery has ensured a major shift of emphasis in surgical nursing intervention (Edwards 1996). Intermediate, elective surgical episodes once requiring lengthy hospital admission are fast disappearing from the in-patient ward, never to return. Moreover, the extensive physical care once required by such patients is diminishing. Edwards, N. (1996) The implications of day surgery for in-patient hospital wards. Nursing Times. 92 (37) p. 32 - 34.

5.   In 1999 the British Association of Day Surgery (Cahill 1999) recommended that at least 50% of all cholecystectomies should be possible in day-case facilities. Such innovation provides just one example of how the extensive physical pre and post-operative nursing interventions once required by such patients are becoming obsolete in modern surgical practices. Cahill, J. (1999) Basket cases and trollies: Day surgery proposals for the millennium. Journal of One-Day Surgery. 9 (1) p. 11 - 12.

6.   Moreover, if the wholesale adoption of delegated medical tasks continues, from where is the future of ‘true’ adult, surgical nursing intervention to originate? Are we merely to persist with the indiscriminate accumulation of quasi-medical tasks and re-label them as nursing intervention?   The aim of the study was therefore to evaluate the consideration given to modern surgical practices in the pre-registration programmes of study of recently qualified staff nurses employed within day surgery in the United Kingdom.   The rationale being that new surgical nursing knowledge will not emerge while modern, surgical practices remain largely absent from programmes of study.

7. METHOD   A postal questionnaire was sent to n=247 Day Surgery Units within the United Kingdom. All items on the questionnaire related to the inclusion of day surgery practices in nursing programmes of study. The questionnaire employed a Likert Scale format for most items. A response rate of 42% was achieved with data from a total of n=277 staff who became qualified nurses between 2000 - 2004. RESULTS   58% (n=158) of staff nurses surveyed did not have a day surgery clinical placement during their 3 year programme of study whereas 43% (n=119) did experience a day surgery placement.

8. Day surgery placement

9.   However, 67% (n=186) experienced no theoretical input into modern day surgery nursing practices at any time throughout their 3 year nursing programmes of study.   This is followed by 11% (n=31) who received one hour of day surgery theory.   Collectively, this indicates that 79% (n=217) of staff nurses who responded to this survey experienced minimal theory relating to day surgery.

10. Theoretical input - day surgery focus

11.   Respondents were also invited to specify, which phrase best described the post-operative care taught. The majority (57% or n=158) indicated they had received traditional in- patient care only.   The second largest group (28% or n=78) was in-patient and out-patient post-operative care.   Therefore, 85% (n=236) of staff nurses here received no tuition regarding the post- operative management applicable to the modern, elective day surgery patient.

12. Post-operative management - day surgery focus

13.   77% (n=214) of staff nurses indicated they had undertaken no theoretical assignments relating to day-case surgery.   This is followed by 20% (n=54) who had undertaken one such assignment.   Collectively, this suggests that 97% (n=268) of staff nurses experienced minimal theoretical analysis in the form of assignments in relation to modern day surgery.

14. Assignments - day surgery focus

15.   The vast majority of respondents (94% or n=260) had undertaken their nurse education within the United Kingdom. Seventeen staff nurses (n=17) had qualified outside the European Union.   Finally, respondents were asked to indicate what formal programmes of education, specifically relating to day surgery had been undertaken since becoming a qualified nurse.   90% (n=248) had undertaken no formal post- qualifying programmes specifically relating to day surgery.

16. Formal post-qualifying day-case surgery education

17. RECOMMENDATIONS - Nurse Education in UK   Over two-thirds of day surgery staff nurses who responded to this survey received no theoretical insight into the nursing challenges confronting day surgery.   On a positive note, 43% of the staff nurses experienced a day surgery placement during their programme of study.   However, with 85% experiencing no day surgery post-operative management, 79% virtually no theory and 77% no specific assignments – is 43% gaining a placement truly concerned with day surgery enhancement or merely a convenient placement within a very congested United Kingdom clinical placement programme.

18. Day surgery clinical placement

19.   The staff nurses who responded to this survey were therefore manifestly not prepared during their pre-registration studies for their new roles within modern day surgery either clinically or theoretically.   The emphasis within surgical nurse education must in future be reversed, that is, the majority of surgical nurse education should be more concerned with modern surgical practices and patients who experience 24 hours or less in hospital.

20. RECOMMENDATIONS - Clinical Nursing Roles   90% of staff nurses had undertaken no formal education concerning day surgery since their pre-registration course although many stated they had made requests.   The Profession must therefore petition for more nursing based post-qualifying courses as the trend for modern surgical nursing to constantly adopt devolved medical tasks in the United Kingdom must not continue to go unchallenged.   In addition, prior to the future acceptance of student nurses within a Day Surgery Unit, clinical staff should question their Schools of Nursing regarding their day surgery theoretical component.

21.   The number of theoretical assignments encompassing modern, elective day surgery practices should also be questioned.

22. FUTURE of SURGICAL NURSING With the continued expansion of ambulatory surgery plus surgical nursing becoming increasingly competency based, two nursing challenges may arise - education and future day surgery nursing intervention. Firstly, how will nurses be educated to undertake the competences as suggested (Moore 2003) -   anaesthetic care   ECG reading   taking of blood samples   cannulation, etc? Moore (2003) No problem. Nursing Standard. 17(42) 16-17.

23. This present study noticeably indicated that inadequate post-qualifying education is already an issue prior to any additional expansion. Without further action such training will invariably continue to be informal and ad hoc? Secondly, vital nursing issues remain a challenge, that is, pain management, psycho-educational intervention, nurse-led pre-assessment clinics and post-operative care. With the planned expansion of day surgery such challenges are likely to increase if they remain unresolved.

24. To conclude, the nursing profession must pursue the opportunities available during this new era of surgical intervention to extend nursing roles and attain greater evidence-based, nursing knowledge. An increase in research into day surgery nursing must therefore be more widely considered. Not only can expanded nursing roles then be further developed but more importantly, modern evidence-based nursing intervention, fit for the 21 st Century can be acquired to help inform future day surgery nursing practices.