CLINICAL

Caballero C (1998) The role of the laparoscopic nurse praclitioner. Nursing Standard. 12,44,43-44,

The role of the laparoscopic

nurse practitionerSince the appointment of the author as laparoscopic nurse practitioner at Milton Keynes Hospital Trust, there have been more cholecystectomy operations, but fewer patients

have required open surgery or inpatient admission, with substantial cost savings. The author describes how the role developed and the opportunities it presents for nurses.

Date of acceptance: April 27 1998.

Catherine Caballero RGN, DipNS, BSc(Hons)Nursing, is Laparoscopic Nurse Practitioner, Milton Keynes General NHS Trust.

KEYWORDS■ NURSE PRACTITIONER

■ SURGICAL NURSE

These key words are based upon woik undertaken by the RCN Library.

This article has been subject to double-blind review.

In May 1995 the author was appointed as the first laparoscopic nurse practitioner (NP) in the UK. The role was to provide a seamless service for patients undergoing laparoscopic general surgery. Three factors influenced the development of this role:□ The reduction in junior doctors’ hours (NHSME 1991)□ The Caiman Report (1993) which redefined

surgical training□ The NHS Executive Report (1994) stating that 60

per cent of all elective surgery should be performed on a day-case basis by the year 1996/97.

The idea of an NP for laparoscopic surgery was floated in 1994 through informal discussions between a consultant surgeon, a consultant anaesthetist and the deputy director of nursing. The NP would have full responsibility for patients through the complete surgi­cal cycle from referral clinic to follow-up appointments.

The author was appointed to this position in May 1995. The legal and professional implications of the post were addressed by developing rigorous proto­cols within the hospital’s framework for expanding practice. These are based on the principles of the UKCC’s Scope of Professional Practice (1992). The NP is accountable to the consultant surgeon and the deputy director of nursing. The title ‘nurse practitioner’ reflects advanced nursing practice based firmly in the clinical field. It enhances the traditional care delivered to patients by providing a combination of medical and nursing skills to meet the growing needs of patients.

PRE-OPERATIVE ASSESSMENT The NP first meets patients at the pre-operative assessment clinic, where their suitability for inpatient or day surgery is assessed. This includes a ques­tionnaire about past and present medical health. If the NP has any doubts about the patient’s fitness for the

procedure, he or she can contact the registrar or con­sultant for advice. The NP investigates liver function tests (LFTs) and ensures that a recent ultrasound scan is available before laparoscopic cholecystecto­my. The pre-operative assessment provides an excel­

lent opportunity for counselling and focusing on patient anxieties. The NP describes the operation in detail, including its possible complications and expec­tations, so ensuring that the patient is fully informed about the procedure.

The patient is reviewed again on the day of admission to make sure his or her physical condition has not changed since the pre-operative assessment. The NP reassures the patient and answers any last minute questions, accompanies the patient to the anaesthetic room and stays there until the anaesthetic is administered.

PERI OPERATIVE ASSISTANCE Table 1 shows the theatre procedures in laparoscopy, and where the responsibility for each task lies. The procedures are all observed directly on camera, but the NP's role as surgeon’s assistant is much more than simply holding the camera steady.

POSTOPERATIVE CAREThe NP follows the patient into recovery so that a familiar face and voice are there to reassure at a dis­tressing time. The patient returns to the inpatient ward or day surgery unit with an analogue pain chart which allows quantitative assessment of pain so that appro­priate analgesia can be administered.

When the patient is ready to go home, the NP completes the family doctor’s letter and dispenses the pre-prescribed medication. If the patient has had day surgery, he or she is provided with a direct line telephone number to call if any problems should develop in the subsequent 24 hours. If the NP does not hear from the patient, he or she routinely contacts him or her within 24 hours of discharge to ensure that

all is well.

JUSTIFICATION OF THE ROLEIn Milton Keynes the business plan was based on cost savings for the procedure of laparoscopic chole­cystectomy. It was hoped that by having another per-

JULY 22/VOLUME 12/NUMBER 44/1 998 NURSING STANDARD 43

CLINICAL

Table 1. Theatre procedures in laparoscopic cholecystectomy

TASK NURSE SURGEON OTHER THEATREPRACTITIONER STAFF

Prep and drape Yes No Yes

Set up equipment Yes No Yes

The first incision No Yes No

Placement of first trocar No Yes No

Pneumoperitoneum No Yes No

Fashion the remaining port site incisions

Yes Yes No

Insert remaining trocars Yes Yes No

Operate camera Yes Yes No

Remove gall bladder No Yes No

Retract and manipulate tissues Yes Yes No

Suction irrigation Yes Yes No

Suture primary wound Yes Yes No

Administer local anaesthetic to wound sites

Yes Yes No

Table 2. Justifying the role of the nurse practitioner in laparoscopic cholecystectomy

BEFORE AFTER

Conversion toopen procedure 16% 2%

Day cases 16% 43%

Overnight admission 44% 25%

REFERENCES

Caiman K (1993) Hospital Doctors:

Training lor the Future. The

Report of the Working Group

on Specialist Training. London,

Department of Health.

NHS Executive (1994) Day

Surgery Task Force Report and

Toolkit Upgrade. London,

NHSE.

NHS Management Executive

(1991) Junior Doctors: The

New Deal. London, NHSME.

United Kingdom Central Council

for Nursing, Midwifery and

Health Visiting (1992) The

Scope ol Professional Practice.

London, UKCC.

manent and skilled member of the laparoscopic team:□ There would be less need for conversion to the

open procedure□ The operating time for laparoscopic

cholecystectomy would be reduced to between 45 and 60 minutes, bringing the procedure into the realms of day surgery.

Table 2 shows how the introduction of the role affected procedures. The overnight admission rate of 25 per cent was still unacceptably high, but audit data show what can be achieved with a dedicated laparo­scopic team. During 1996, one particular surgical team achieved a 0 per cent conversion rate with 43

per cent of laparoscopic cholecystectomies attempt­ed as day cases and only an 8 per cent overnight

admission rate.Without a randomised controlled trial it is difficult

to apportion success to individual contributions, but these good outcomes have set new standards in the hospital and provide a new baseline for improving the

quality of patient care.Cost savings Inpatient stay for laparoscopic cholecystectomy patients has reduced from a mean of 4.3 days in 1994 to a mean of 3.1 days in 1996. In the same number of bed days, there have been 25 more laparoscopic cholecystec­tomies, generating fundholding income for the hospital of approximately £30,500. It can be argued that the laparoscopic NP offers both holis­

tic and cost-saving care.

CAREER PATHAt present there is no career structure for this role, although the options might include a career in nurse education or management. The NP crosses many tra­ditional boundaries and follows patients through the whole surgical process. This offers an excellent overview of the interactions between the surgical department and hospital management, providing good training in managerial skills.

In relation to education, the NP has gained presentation and lecturing skills through running an intensive two-day practical course in the development of the laparoscopic NP role. The course includes theory and practical sessions, with the opportunity of gaining ‘hands on’ surgical skills. Over the past two and a half years, 75 candidates have completed the course and have been awarded 20 Continuing Education points by the Royal College of Nursing. This course provides an overview of the skills required to develop such a role, and outlines the legal impli­cations. If such roles are to be developed further, ongoing educational enhancement is mandatory. This could be done by developing formal education pack­ages, either at first degree level or by further in-house development of the Scope of Professional Practice guidance (UKCC 1992).

CONCLUSIONThe laparoscopic NP is one of a series of new nurs­ing roles that has been developed in the 1990s. With new surgical techniques and modern technology com­ing on stream constantly, there is no doubt that fur­ther roles will soon evolve, providing further exciting career opportunities for the nursing profession. These roles offer theatre nurses the opportunity to break the shackles of traditional roles in theatre and become actively involved in perioperative care. They can become independent, autonomous practitioners and make sure that a strong nursing presence remains in theatres to protect the needs of the patient ■

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