Sisters are doing it for themselves

Properly trained nurses have routine surgical procedures all sewn up. Annabel Ferriman reports

While the country appeared to reel in shock at the news that an operating theatre sister in Cornwall had removed a patient's appendix, allegedly unsupervised by a consultant, another nurse, Suzanne Holmes of the John Radcliffe Hospital, Oxford, quietly operated for about the 2,000th time. Her job is to remove veins from patients' legs for use in coronary artery bypass surgery. She has been doing it since 1990, in one of the first and most successful experiments in training nurses in certain surgical techniques.

So as Sister Valerie Tomlinson of Treliske Hospital, Truro, faced a disciplinary tribunal on Friday, Ms Holmes was busy operating in Oxford. But how common is it for nurses to carry out surgical procedures?

Brendan Devlin, of the council of the Royal College of Surgeons, said: "I was amazed that this episode regarding the appendix hit the headlines. A very experienced theatre nurse who has been working with a surgeon for a long time will undertake large chunks of the operation, with the surgeon by her side.

"When it comes to nurses doing procedures independently, if they are properly trained, it is not an unreasonable idea. The issue needs speeding up. We need better evaluation and better facilities to train non-medical and non-surgical staff to do routine work."

Suzanne Holmes is one of about 10 nurses who have been trained to strip out leg veins. She followed a six-month course in Cleveland, Ohio, in the US, where many nurses and technicians carry out medical and surgical procedures to contain health-care costs. Her work has helped to reduce the cost of heart surgery in Oxford.

"We do 1,400 heart operations a year here with only two heart surgeons, whereas other leading centres do about 1,200 cases a year with seven or eight. It makes us very cost effective. That is partly because of our use of nurses," said Stephen Westaby, consultant cardiac surgeon at the hospital, who pioneered the scheme.

"The idea that properly trained nurses cannot master these surgical techniques is ridiculous. There has been a great deal of hysteria about the Cornwall case. With training and supervision, nurses could do much more than they do at the moment."

The scheme aimed to improve the quality of vein removal by introducing continuity; until Ms Holmes came, the operation was done by junior doctors, who change jobs every six months. While the heart surgeon is opening the patient's chest, Ms Holmes removesthe long saphenous vein in the leg to replace part of the diseased coronary artery. Since her arrival, the surgeons receive the veins more quickly and in better condition. Her salary,advertised as up to £16,400, is equivalent to that of a junior doctor,so the financial savings are not huge.

"But the quality is much better," says Mr Westaby. "Most junior doctors don't want to be heart surgeons, so might not be well motivated, and with the reduction in their hours, we could not perform as many operations as we do without non-medical staff."

But while Mr Westaby thought the experiment's success was apparent after six months, it took four years for the Royal College of Surgeons to give its approval and allow similar schemes elsewhere.

Nurses are extending their surgical skills in other areas, as well. Jean Thomas, the Royal College of Nursing's assistant director of nursing policy, says: "There is a pilot scheme in the East Midlands, where nurses are removing sebaceous cysts and ganglions [bumps on the back of the wrist]. It has been going five months and appears to be working out fine.

"There are nurse practitioners in many accident and emergency departments who do suturing [stitches] and other minor surgery. In some departments, such as St Charles Hospital, west London, patients do not see a doctor at all.

"Suturing a wound with jagged edges or on a child's eyelid is much more difficult than doing appendectomies, which mainly involve sewing up many layers of muscle "Nurses now put fine tubes to deliver drugs or intravenous feeding into veins.These tubes goin a long way and it is very skilled work.

"Some nurses also do gastroscopies and sigmoidoscopies [procedures in which flexible tubes are inserted into the stomach or bowel for diagnostic investigations].

"There is no limit to learning. There is a huge mystique surrounding medicine, and the British public has an enormous respect for surgeons, but many of these techniques can be acquired through training and experience.

"Many nurses, however, do not want to do this sort of work. They did not go into nursing because they were not clever enough to be doctors or surgeons but because they do not want to fiddle about with veins or arteries. They went into nursing to care forpeople who are vulnerable and in need of help."

Nurse practitioners are being employed in the new minor treatment centre that is replacing the accident and emergency department at St Bartholomew's Hospital, London, and running a minor treatment centre at the South Westminster Centre for Health in central London, set up when the casualty department at Westminster Hospital closed.

One experiment in which nurses undertook surgical work was carried out at the Southampton Eye Hospital, where they were trained to remove cysts from patients' eyelids. The project was recently abandoned, however. "It was felt that knife-to-skin work was not part of the nurses' role," says Professor Andrew Elkington, consultant ophthalmologist at the hospital.

It is not just nurses who are undertaking more sugical procedures, however. Podiatrists (chiropodists who have gone through advanced training) now remove bunions; GPs are responsible for the removal of lumps and bumps, and midwives have long been responsible for episiotomies (cutting the perineum during childbirth to prevent extensive tearing).