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Practice nurses performing minor surgery: the story

Jayne Elton
RGN BSc(Hons) Nursing
Practice Nurse/Minor Surgery Lead
E:jayne.elton@fromemedicalpractice.nhs.uk

Lucilla Bevan
RGN DipNursing
Practice Nurse
Frome Medical Practice
Somerset

The original concept of a practice nurse performing minor surgery was put forward at the Frome Medical Practice, Somerset, in 2002. The rationale for implementing the role was examined, including issues around improving patient access in primary care.(1) The educational demands in training a nurse for a role that had historically belonged to the GP were explored, along with the complex issues of assessing competence.(2) All points considered, it was decided that the role required formal training and ongoing mentorship by a GP trainer.
Jayne Elton, a practice nurse at Frome Medical Practice, began performing minor surgery in the summer of 2002, and the innovation proved to be a huge success, winning a nursing award by demonstrating a cascade of clinical skill and workload from a GP to a practice nurse. Following that, a second practice nurse, Lucilla Bevan, has been trained, together with healthcare assistants (HCAs) who provide support to the nurses in the minor surgery clinic.

Training
Bath University runs a two-day minor surgery course. It is designed for GP trainees and registrars, but the course leaders, Dr Rupert Gabriel and Dr Roger Kneebone, have consented to nurses accessing the course, and it has subsequently formed the basis of the minor surgery training forum.
Jarvis states that, while the issue around the theory- practice gap remains unresolved, accessing practical knowledge in relation to theory must be flexible to enable the increasing educational changes and subsequent needs in healthcare today to be met.(3)
Initially, GP trainer Dr Mark Vose was appointed as mentor to Jayne. This complex role included practical teaching sessions, observation, assessment of competence and audit. Jayne kept a reflective diary, performed a patient questionnaire and monitored her own histology reports. As a result, when Lucilla Bevan started her minor surgery training, the role of mentor was successfully shared between Dr Vose and Jayne.
Lucilla has run her own minor surgery session for the past year and has joint responsibility for training and developing HCAs in a supporting role in the minor surgery clinic. Many of the learning outcomes for the national vocational qualification in care at level three can be evidenced through the elements of knowledge required in minor surgery. They include infection control, sterilisation, resuscitation and caring for the patient during and after surgical procedures.
In addition to their knowledge and application of basic wound care, and as a direct result of their involvement in the nurse-led minor surgery clinics, the HCAs have been taught the procedure for removing sutures. Initially, all sutures were removed by the practice nurses who had undertaken the surgery. This enabled them to assess the wound healing process and examine the sutures for the correct wound tension. Now that Jayne and Lucilla are more experienced, they no longer feel it necessary to check every wound and therefore have been able to cascade this role to the HCAs. That has extended the HCAs' clinical skills within their learning remit and resulted in better continuity of care for patients following their minor operations.
A second teaching role revolves around GP trainees. The Frome Medical Practice is a training centre for GP registrars. Lucilla and Jayne have previously completed teaching modules as part of their professional development and are thus able collectively to support and mentor GP registrars in achieving their learning outcomes in minor surgery. Their role includes observational assessment, discussion, audit and supporting the completion of the registrar's surgical logbook of experience.
 
Techniques and procedures
Jayne and Lucilla perform basic surgical procedures, including:

  • Excision of skin lesions, for example moles, sebaceous cysts, lipomas and naevi.
  • Cautery, for example for skin tags.
  • Partial or complete removal of toenails.
  • Curettage, for example for seborrhoeic keratosis.
  • Cryosurgery - applying liquid nitrogen to viral warts when correct use of over-the-counter (OTC) products has failed.

They currently do not perform surgical procedures on faces, but this is an area where they hope to expand their expertise within the remit of their professional practice.(4) Equally, the present protocol for referral to the minor surgical clinic states that the skin lesion must be examined by a GP first, who will then advise what intervention is required, such as shave excision, curettage or cautery. During the last two years, Jayne and Lucilla admit that their recognition of dermatological lesions has increased, but malignant melanomas and basal carcinomas do not always have a textbook presentation. They hope to be able to access a dermatology module at either degree or master's level with a view to providing a more seamless service to patients.

New techniques
Jayne and Lucilla are currently examining the use of dissolvable sutures, which would reduce the need for follow-up appointments for removal of sutures.
Topical skin adhesives, such as Dermabond (Johnson & Johnson), are increasingly used in minor injury units. Initially, when adhesive products were compared with the use of Ethilon sutures (Ethicon), the adhesives were not found to be cost-effective. However, nurse time, patient access and convenience have led to further consideration of this material.
Radiosurgery is becoming an increasingly attractive option for use in minor surgery. The cosmetic results are favourably documented, with limited or no scarring. Unlike the use of some cautery equipment, the tissue is essentially undamaged, because of the minimal amount of lateral heat generated by the filter-cutting current. Performing radiosurgery is quite different from other procedures, and Brown suggests that the surgeon must "forget all skills acquired with a scalpel".(9) Interestingly, Dr Rupert Gabriel has designed a radiosurgery course at Bath University. The cost of a radiosurgical unit is around £3,000, but the saving in time and improved surgical outcome makes it a strong contender for the future.

Equipment and environment
Since starting the minor surgery, Jayne and Lucilla have looked more closely at issues relating to infection control, sterilisation techniques and evidence supporting the Department of Health guidelines.(5) Subsequently the practice has reviewed its sterile supplies procedure and purchased a new washer and steriliser. All instruments, including those used for minor surgery, are now packed and recorded. However, the government proposes that in 2007 all surgical instruments used in primary care should be sent to a "Central Sterile Supply Department" (CSSD). This could pose a problem for practices that may be considering replacing their current sterilisers to meet infection control guidelines. However, sterilisation equipment is expensive, and therefore some practices have opted to rent until government legislation changes practice in 2007.
Perhaps not unsurprisingly, research by Finn states that most surgeries do not have a separate dedicated area for minor surgery.(6) In approximately two years time, the Frome Medical Practice is looking forward to moving to a purpose-built practice. The building will be integral to the new community hospital, and plans have been made to include a minor surgery theatre. According to the new General Medical Services (GMS) contract,(7) nurses could become specialist providers of services, including minor surgery, sexual health, vaccinations and immunisations, since practices can choose to opt out of providing additional services.(8) The new contract provides opportunities for better networking, including cross-practice activity.
 
Record-keeping and audit
All health professionals have a responsibility to keep accurate records.(9) Frome is a paperless practice, and therefore Read coding and detailed templates are essential tools for data collection and audit. The minor surgery template includes details of the procedures undertaken, local anaesthetic used, suturing material, consent and histology. Jayne and Lucilla are looking at expanding the template to include details of dressings, analgesia and postoperative advice. Currently this information is entered under freetext, but this is time- consuming and not conducive to data collection.
To confirm competency, audits are run on histology results and the number of patients requiring antibiotics following minor surgery. The latest audit on wound management demonstrated that, of the 366 patients operated on over the last 12 months, none required antibiotics for postoperative wound infections. Although this audit is limiting, it does suggest a degree of safe practice.
 
Conclusion
Jayne and Lucilla currently undertake a weekly minor surgery session of six patients each. However, there is a waiting list, and considering that the practice has 33,000 registered patients, it is conceivable that another nurse be trained. Clearly, with the development of the new purpose-built practice and minor operating theatre, this will be possible.
Since the launch of the nurse-led minor surgery clinic two years ago, nurses throughout the UK have contacted Jayne and Lucilla for advice on how to set up this service in their own practice. The issues of accessing appropriate training and overcoming resistance within the medical profession have patently not been completely resolved. However, with the continuing development of new working practices, coupled with educational support, Jayne and Lucilla are confident that more nurses could take on this exciting challenge in primary care.

References

  1. Department of Health. The NHS plan: a plan for investment, a plan for reform. London: The Stationery Office;2000.
  2. Ashworth PD, Saxton J. On ­competence. J Further Higher Educ 1990;14(2):3-17.
  3. Jarvis S. Skill mix in primary care - implications for the future. London: Medical Practices Committee; 2001.
  4. Nursing and Midwifery Council. Code of professional conduct. London: NMC; 2002.
  5. Available from URL: http://www.decontamination.nhsestates.gov.uk
  6. Finn L, Crook S. Minor surgery in general practice - setting the standards. J Public Health Med 1998;20(2):1-6.
  7. The role of nurses under the new GMS contract. 2003. Available from URL: http://www.natpact.nhs.uk
  8. Available from URL: http://www. modern.nhs.uk
  9. Brown J. Radio surgery for minor operations in general practice. Cosmetic Surg 2000;July:33-6.
  10. Nursing and Midwifery Council. Guidelines for records and record ­keeping. London: NMC; 2002.

Resources
Minor Surgery course details Course organiser:  Dr Rupert Gabriel
Course ­administrator:Lisa Fricker
E:Lisa.Fricker@gp-J83046.nhs.uk
Spa Medical Centre
Snowberry Lane
Melksham
Wiltshire
SN12 6UN
Cost of the course: £375
Please note:while Dr Gabriel has consented to nurses accessing the course, it is still primarily designed for GPs and GP registrars.
I would therefore ­advise that any nurse wishing to secure a place on the course should first ask their GP mentor to contact the course organiser and ask whether
he is happy for the nurse to apply