Scrub Practitioner Research Articles

Easier, quicker, safer: an enhanced instrument count procedure.

Andrea Szekretar, Theatre Scrub Team Leader and Advanced Scrub Practitioner, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust was runner up in the Innovation Award category of the BJN Awards 2021.

Exploring the use of high and low demand simulation for human performance assessment during multiorgan retrieval with the joint scrub practitioner

IntroductionThe National Organ Retrieval Service (NORS) 2015 review recommended a Joint Scrub Practitioner for abdominal and cardiac teams during combined organ retrieval. To evaluate the feasibility of this role, and...

How do team experience and relationships shape new divisions of labour in robot-assisted surgery? A realist investigation.

Safe and successful surgery depends on effective teamwork between professional groups, each playing their part in a complex division of labour. This article reports the first empirical examination of how introduction of robot-assisted surgery changes the division of labour within surgical teams and impacts teamwork and patient safety. Data collection and analysis was informed by realist principles. Interviews were conducted with surgical teams across nine UK hospitals and, in a multi-site case study across four hospitals, data were collected using a range of methods, including ethnographic observation, video recording and semi-structured interviews. Our findings reveal that as the robot enables the surgeon to do more, the surgical assistant's role becomes less clearly defined. Robot-assisted surgery also introduces new tasks for the surgical assistant and scrub practitioner, in terms of communicating information to the surgeon. However, the use of robot-assisted surgery does not redistribute work in a uniform way; contextual factors of individual experience and team relationships shape changes to the division of labour. For instance, in some situations, scrub practitioners take on the role of supporting inexperienced surgical assistants. These changes in the division of labour do not persist when team members return to operations that are not robot-assisted. This study contributes to wider literature on divisions of labour in healthcare and how this is impacted by the introduction of new technologies. In particular, we emphasise the need to pay attention to often neglected micro-level contextual factors. This can highlight behaviours that can be promoted to benefit patient care.

Factors that affect scrub practitioner non-technical skills: a qualitative analysis.

Context Non-technical skills are the cognitive and affective behaviours that underpin clinical practice in surgery. The purpose of this study was to explore the factors that affect how scrub practitioners use non-technical skills during surgery and their behavioural responses to those factors. Methods Eight scrub practitioners participated in a qualitative semi-structured interview study. Results Five major categories were found to affect scrub practitioner non-technical skills. These categories were democratises surgery, learns from experiences, comprehends situations, comprehends behaviours and insidious threats. Key findings and implications: A scrub practitioner’s ability to use non-technical skills results from the interdependent relationship of intrinsic and extrinsic motivators that affect their own behaviours, and those of their colleagues, during surgery.

Factors that affect scrub practitioner non-technical skills: A literature review.

Non-technical skills are the cognitive and interpersonal behaviours that compliment clinical competence in surgery. Effective use of non-technical skills is essential for scrub practice, because they facilitate anticipation of the surgeon's requirements and promote appropriate communication behaviours. This literature review analyses the factors that may influence a scrub practitioner's use of non-technical skills during surgery. Recommendations are made that are intended to improve their use by reducing behavioural variations during surgery.

A realist process evaluation of robot-assisted surgery: integration into routine practice and impacts on communication, collaboration and decision-making

BackgroundThe implementation of robot-assisted surgery (RAS) can be challenging, with reports of surgical robots being underused. This raises questions about differences compared with open and laparoscopic surgery and how best to integrate RAS into practice.ObjectivesTo (1) contribute to reporting of the ROLARR (RObotic versus LAparoscopic Resection for Rectal cancer) trial, by investigating how variations in the implementation of RAS and the context impact outcomes; (2) produce guidance on factors likely to facilitate successful implementation; (3) produce guidance on how to ensure effective teamwork; and (4) provide data to inform the development of tools for RAS.DesignRealist process evaluation alongside ROLARR. Phase 1 – a literature review identified theories concerning how RAS becomes embedded into practice and impacts on teamwork and decision-making. These were refined through interviews across nine NHS trusts with theatre teams. Phase 2 – a multisite case study was conducted across four trusts to test the theories. Data were collected using observation, video recording, interviews and questionnaires. Phase 3 – interviews were conducted in other surgical disciplines to assess the generalisability of the findings.FindingsThe introduction of RAS is surgeon led but dependent on support at multiple levels. There is significant variation in the training provided to theatre teams. Contextual factors supporting the integration of RAS include the provision of whole-team training, the presence of handpicked dedicated teams and the availability of suitably sized operating theatres. RAS introduces challenges for teamwork that can impact operation duration, but, over time, teams develop strategies to overcome these challenges. Working with an experienced assistant supports teamwork, but experience of the procedure is insufficient for competence in RAS and experienced scrub practitioners are important in supporting inexperienced assistants. RAS can result in reduced distraction and increased concentration for the surgeon when he or she is supported by an experienced assistant or scrub practitioner.ConclusionsOur research suggests a need to pay greater attention to the training and skill mix of the team. To support effective teamwork, our research suggests that it is beneficial for surgeons to (1) encourage the team to communicate actions and concerns; (2) alert the attention of the assistant before issuing a request; and (3) acknowledge the scrub practitioner’s role in supporting inexperienced assistants. It is beneficial for the team to provide oral responses to the surgeon’s requests.LimitationsThis study started after the trial, limiting impact on analysis of the trial. The small number of operations observed may mean that less frequent impacts of RAS were missed.Future workFuture research should include (1) exploring the transferability of guidance for effective teamwork to other surgical domains in which technology leads to the physical or perceptual separation of surgeon and team; (2) exploring the benefits and challenges of including realist methods in feasibility and pilot studies; (3) assessing the feasibility of using routine data to understand the impact of RAS on rare end points associated with patient safety; (4) developing and evaluating methods for whole-team training; and (5) evaluating the impact of different physical configurations of the robotic console and team members on teamwork.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Considerations of the dual role.

‘What you practice you become and what you become has consequences’ was part of the title for my dissertation when studying for my masters degree in health law. This piece of work engaged in looking at the legal, ethical and professional dilemma faced by perioperative practitioners undertaking a dual role. We all understand that the dual role is a combination of the role of the scrub nurse/practitioner and the surgical first assistant (SFA), previously known as the advanced scrub practitioner.

Assessing scrub practitioner non-technical skills: a literature review.

A review by Catchpole et al (2009) into the causes and types of harm experienced by the surgical patient emphasised the high risk nature of the perioperative period. Investigations into recent failures at NHS organisations have emphasised the relevance of non-technical skills education in improving clinical performance and patient outcomes. However, scrub practitioner non-technical skills are often developed on a tacit basis, making assessment of performance difficult. This literature review identifies strategies that facilitate assessment of non-technical skills during surgery. Recommendations are made that will assist scrub practitioners in using a validated scrub practitioner non-technical skills assessment framework reliably.

Coming to a theatre near you soon a witnessed CPR event'.

A current review of the last thirty years is indicative of improvement in outcome across surgical specialities with the implementation of safer working practices and initiatives in enhanced recovery, preparing patients to be 'fit' for surgery. The focus of training for nurses and operating department practitioners lies with assuring technical competence and the drive is to establish best practice based on evidence. Once qualified, training for professionals within the perioperative environment is developed to enable participation in areas of anaesthesia, surgery and recovery roles. Advanced, intermediate and basic life support as well as advanced scrub practitioner courses are available, further aspects for patient safety have been implemented and pathways developed.

Becoming an Advanced Scrub Practitioner: My Personal Journey

Theatre nursing has been my life for over twenty years and I have regularly assisted the surgeon, often taking on the 'dual role'. However, the realisation that I was not legally covered to undertake this role, along with desiring to improve my knowledge and skills, led me to enrol on the advanced scrub practitioner course run by Edge Hill University. This article is about my journey of personal and professional development.

Hide and Seek, the Search for a Missing Swab: A Critical Analysis

This article explores the root causes of a missing swab incident. It reinforces the scrub practitioner's responsibility for the surgical count as reflected on by a student operating department practitioner. With environmental pressures and methods upheld by the operating room culture it is recognised that mistakes do sometimes arise from human error when the stress from workload becomes apparent. Through reflection, mistakes can become learning opportunities, as sought through this critical appraisal.

Development of a behavioural marker system for scrub practitioners' non‐technical skills (SPLINTS system)

Adverse events still occur despite ongoing efforts to reduce harm to patients. Contributory factors to adverse events are often due to limitations in clinicians' non-technical skills (e.g. communication, situation awareness), rather than deficiencies in technical competence. We developed a behavioural rating system to provide a structured means for teaching and assessing scrub practitioners' (i.e. nurse, technician, operating department practitioner) non-technical skills. Psychologists facilitated focus groups (n = 4) with experienced scrub practitioners (n = 16; 4 in each group) to develop a preliminary taxonomy. Focus groups reviewed lists of non-technical-skill-related behaviours that were extracted from an interview study. The focus groups labelled skill categories and elements and also provided examples of good and poor behaviours for those skills. An expert panel (n = 2 psychologists; n = 1 expert nurse) then used an iterative process to individually and collaboratively review and refine those data to produce a prototype skills taxonomy. A preliminary taxonomy containing eight non-technical skill categories with 28 underlying elements was produced. The expert panel reduced this to three categories (situation awareness, communication and teamwork, task management), each with three underlying elements. The system was called the Scrub Practitioners' List of Intraoperative Non-Technical Skills system. A scoring system and a user handbook were also developed. A prototype behavioural rating system for scrub practitioners' non-technical skills was developed, to aid in teaching and providing formative assessment. This important aspect of performance is not currently explicitly addressed in any educational route to qualify as a scrub practitioner.

Evaluation of the Scrub Practitioners’ List of Intraoperative Non-Technical Skills (SPLINTS) system

BackgroundThe Scrub Practitioners’ List of Intraoperative Non-Technical Skills (SPLINTS) system is a new tool for training and assessing scrub practitioner (nurse, technician) behaviours during surgical operations. ObjectivesThe aim of the study was to test the psychometric properties including inter-rater reliability of the prototype SPLINTS behavioural rating system. MethodsExperienced scrub practitioners (n=34) attended a one-day session where they received background training in human factors and non-technical skills and were also trained to use the SPLINTS system. They then used SPLINTS to rate the scrub practitioners’ non-technical skill performance in seven standardized simulated, surgical scenarios. ResultsReliability, measured by within-group agreement (rwg) for the three skill categories and six out of nine elements, was acceptable (rwg>0.7). Participants were within one scale point of expert ratings in >90% of skill categories and elements, and could use SPLINTS to score performance with a reasonable level of accuracy. There was good internal consistency of the system: absolute mean difference was M<0.2 of a scale point for all three categories. Participants were surveyed and they indicated that the system was complete and usable as an assessment tool. ConclusionThe reliability of the SPLINTS system was deemed to be adequate for assessing scrub practitioners’ non-technical skills in simulated, standardized, video scenarios. On the basis of these results, the system can now move on to usability testing in the real operating theatre.

Evaluation of the SPLINTS system for scrub practitioners' non-technical skills

Background: The Scrub Practitioners’ List of Intraoperative NonTechnical Skills (SPLINTS) system is a new tool for training and assessing scrub practitioner behaviours during surgical operations. Method: Experienced scrub practitioners (n = 34) attended a single day session where they received background training in human factors and nontechnical skills and were trained to use the SPLINTS system. They then rated the scrub practitioners’ nontechnical skill performance in seven videorecorded simulated scenarios and completed a posttraining questionnaire. Results: Withingroup agreement for all three skill categories, and for six of the nine elements, was acceptable (rwg>.70). Participants could use SPLINTS to accurately score performance compared with expert ratings and were within one scale point of expert ratings in > 90% of skill categories and elements. There was good internal consistency between elements and their categories (M<.2 of a scale point) and participants reported that the system was complete. Conclusion: The SPLINTS system was deemed adequately reliable, for rating scrub practitioners’ nontechnical skills, using standardized filmed scenarios. Usability of the SPLINTS system in the real operating theatre environment is still to be assessed.

‘Pass the Buzzy Thing, Please.’ Recognising and Understanding Information: An Essential Non-Technical Skill Element for the Efficient Scrub Practitioner

Adverse events are unintended injuries or complications that are caused by the management of a patient's care rather than by their underlying medical condition. Research into adverse events in hospitals has demonstrated that the operating theatre is one area of healthcare where there is room for improvement, with 41% of all adverse events occurring in the operating theatre, according to one systematic review (deVries et al 2008). Despite technical guidelines, there are still instances of sponges and instruments being retained within patients (Gawande et al 2003) and the factors contributing to this may include assertiveness issues and communication between perioperative and medical staff, i.e. non-technical skills.

The Advanced Scrub Practitioner Role: A Student's Reflection

This article will reflect on my experiences in becoming an advanced scrub practitioner (ASP), using a reflective model to support the structure. Since Dewey's simple claim (1938, cited by Rolfe 2001) that 'we learn by doing and realising what came of what we did', many other authors have advocated and adapted this mantra (Rogers 1983 cited by Rolfe 2001, Gibbs 1988). A reflective model enables learning whilst utilising experiential knowledge from previous reflections (Rolfe 2001). Using Gibbs' reflective model this article reflects and evaluates the experience of becoming an ASP looking at both positive and negative issues, benefits to patients, colleagues and the organisation I work within. It examines issues of accountability and concludes by asking the question 'what next?'

Thinking Ahead of the Surgeon: Developing a Behavioural Rating System for Scrub Practitioners' Non-Technical Skills (SPLINTS)

Efforts to reduce adverse event rates in healthcare have revealed the importance of identifying the essential non-technical (cognitive and social) skills for safe and effective performance and developing tools for rating and training those skills. The focus of studies to date has been surgeons, anaesthetists, or the whole team, with less attention paid to other professionals. The aim of the study was to develop a behavioural rating system for non-technical skills of the scrub practitioner (nurse/technician). This paper reports an interview study, as part of a task analysis, to identify the critical non-technical skills for this role, and the development of a prototype behavioural rating system. Experienced scrub practitioners (n = 25) and consultant surgeons (n = 9), from four Scottish teaching hospitals, were interviewed using a semi-structured design. Data that described generic non-technical skills were extracted from the interview transcripts and thereafter, psychologists and panels of perioperative practitioners (n = 4) used an iterative process to develop a skills taxonomy. Three categories of non-technical skills were identified as critical for safe and effective scrub practitioner performance. These were; situation awareness, communication and teamwork, task management. Three underlying skill elements for each of the three categories were labeled by the expert panels and they provided examples of good and poor behaviours for each of these skill elements, drawing on their domain knowledge. The reliability and psychometric properties of the prototype skills taxonomy and behaviour rating system are currently being tested using standardized, simulated scenarios.

Perioperative Role Development: Evaluating a Fast-Track Approach to Advanced Scrub And/Or Dual Role Practitioner Training

This report describes the service evaluation of a newly developed fast-track advanced scrub practitioner (ASP)/dual role training programme. The evaluation examines whether the introduction of new policies and training based on risk assessment have strengthened quality assurance measures and controls which aim to ensure that staff work safely within their scope of practice. A further aim is to establish if the fast-track route is adequately meeting the training and development needs of staff within the organisation and supporting service requirements.

A Reflection on the Development of the Advanced Scrub Practitioner

From the time in 1990 when I began my career in the operating theatre it has been the unwritten assumption that a member of the theatre team will assist the surgeon with his work. This has always been done on an ad hoc and, some might say, casual basis, as no member of the team was qualified to take this role upon their shoulders. There was the assumption that these 'first assistant' activities were performed with accountability and liability. But where was the evidence for this practice? This article considers the evolution of the Advanced Scrub Practitioner (ASP) role from its beginnings to the position it is today.

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 scrub 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 being accountable and responsible 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.