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Career development: becoming a surgical nurse practitioner

Michael Smith
Educational Lead for NWL Faculty
RCGP

Dan Marsh
BSc MB ChB MRCS(Eng)
Specialist Registrar in Plastic and Reconstructive Surgery
East of England Deanery

The term 'minor surgery' usually refers to skin surgery carried out under local anaesthetic in the GP surgery or in the hospital outpatient setting. With the push for expanded roles for nurses and other healthcare professionals there are increasing opportunities for nurses to carry our minor surgical procedures that, traditionally, were the preserve of the senior practice partner.

The most common surgical procedure is excision of a skin lesion and subsequently wound closure following excision. Typically, the surgical nurse practitioner (SNP) will have a half-day 'list' of six to eight patients referred by other healthcare professionals, either from within their own practice or from neighbouring practices.

There are a raft of skills required for the excision of a skin lesion, including:

  • Knowledge of common skin lesions; the nurse performing the procedure must concur with the original clinician's diagnosis.
  • Practical skills for the lesion excision.
  • Record-keeping skill for documenting the procedure carried out and pathology specimens  sent away.
  • The Department of Health guidelines for skin surgery clearly outline the need for the operating surgeon to make a comprehensive assessment of the patient. The SNP would have to embrace the role as being a diagnostician and surgeon, and not just a service provider.

Other common procedures carried out by SNPs include the use of cryotherapy for the treatment of benign and premalignant skin conditions. Currettage and cautery are other alternative treatments the SNP should be comfortable with as these treatment modalities certainly have a place in primary care. Common skin conditions that may be treated on a minor surgery list include lipomata, epidermal ('sebaceous') cysts, incision and drainage of abscess and skin tags.

Often, an interest in minor surgery stems from having observed and assisted at minor surgical procedures carried out by others in the practice and this leads to a desire to personally carry out the procedures. A good place to start is by practising on inanimate objects, such as citrus fruits or pigs trotters, which are readily available and do not require any anaesthetic. There are several suppliers of medical
training simulators who provide realistic fake skin for practising suture tying and lesion excision (Limbs and Things is one supplier). Once you feel comfortable handling the instruments and tying simple interrupted sutures it is time for more formal training.

A good place to start is to attend a specialised two-day minor surgery course, such as those run at the Royal Society of Medicine or the Royal College of General Practitioners (or visit www.minorsurgerycourses.com to see a summary of courses). These highly practical and interactive courses offer hands on training using the latest medical simulators and intensive one-on-one tuition covering all the skills required for performing minor surgery. They also can act as a lower cost gentle introduction to the specialty before investment in a substantive diploma.

There are various diplomas offered and one successful programme is a collaborative module between Glasgow Caledonian University, Nursing Education Development Unit and Canniesburn Plastic Surgery Unit in Scotland. The University of Nottingham offers a two-day Dermatology Surgery Course for Nurses and the University of Huddersfield offers a week-long course on Minor Surgery Interventions.

All SNPs in minor surgery are required to keep a log of their activity and this log book can be used as an audit tool to assess the SNPs progress. This is in addition to any service monitoring audit that any commisioners may require. We would also support the use of clinical photography (following all guidelines) to keep a record of your work. It may come in useful for any teaching you decide to do in the future.
Following the basic course, some mentorship in practice, is recommended. Your relationship with this mentor is paramount. One must look for a practising surgical mentor and start off as an able assistant (keen assistants are incredibly valuable). While assisting (and with patient consent), one can branch out and put into practice the techniques acquired on the course.

After a few sessions one would aim for the mentor to become assistant, and the SNP to be the main surgeon. A letter of competency (although not officially part of accreditation) can help in building up your training portfolio.