Name: Sue Clynes

Job title: OR nurse/Maxillofacial team leader

Location: Onboard the Africa Mercy

5.45 AM Wake:

My alarm chirps and I quickly turn it off before it disturbs my husband John. I like to get up and spend some time in prayer before I start my day. I then shower, get dressed, and head up to breakfast with my husband and friends in the dining room. I live on board the Africa Mercy, which is a hospital ship giving free operations to the poorest of the poor.

At the time of writing this, we are working in Madagascar. Approximately 450 people from all around the world are living on board so mealtimes are interesting and fun. After breakfast I head back to my cabin, take my antimalarial tablet, clean my teeth, put my hat on and leave for work, which takes me about 30 seconds as I just have to walk down one staircase.

7.45 AM Start work

I like to get to work before everyone else so I can call into the ward and introduce myself to the patients and get the theatre set up in plenty of time. I turn the bed warmer on, and check the theatre lights and the suction unit. By then other nurses start to arrive so I can start to delegate tasks like fetching local anaesthetic and saline. Most staff are experienced theatre nurses but they only come for two to four weeks so have to be guided and supervised.

We also have some who come for eight or 11 weeks or longer so they can also supervise and teach, which is a help as it can be quite exhausting constantly teaching, especially when every two weeks you have a completely new group of people. Actually it’s more like teaching a new group every two to three days as all nurses want to work in ‘maxfax’ during their time on the ship.

The surgeon I work with, Dr Gary Parker, has been on the ship for 28 years! He came to see how he liked it, then met his wife and brought up his family here. He is the kindest person I have ever met. I love working with him.

I have been the maxillofacial team leader for 18 months and at the end of July will have been on the ship for two years. I started training at Middlemore Hospital 40 years ago and left in 1981 to bring up my children. I did some part-time work as a practice nurse but returned full time as a theatre nurse at Mercy Hospital in Auckland in 1996 and was a theatre nurse at Tauranga Hospital for 10 years before joining the ship.

8.00 AM Team briefing

Staff gather for the team briefing on today’s theatre list, which is part of the WHO Surgical Safety Checklist. We first introduce ourselves to each other and everyone in the room is allowed to speak and query anything they don’t understand.

It’s such a valuable tool and so many things are picked up at the briefing. Instrument and equipment requirements are discussed at this time so the surgeon and nurses know ahead of time if there will be any issues with availability.

Today we have three cases. The first patient is a 61-year-old man who had an anterior mandibulectomy three months ago to remove an ameloblastoma (a benign tumour that originates from the enamel on the teeth). He is coming today to have an iliac crest bone graft (ICBG) to cover the titanium plate that we used to reconstruct the mandible. In a certain percentage of cases involving speaking and chewing, the plate will wear through the skin either in the mouth or externally, so on Mercy Ships we endeavour to bring all our mandibulectomy patients back at three to six months and do an ICBG so this doesn’t occur.

It also gives us an opportunity to remove any remaining excess skin that hasn’t retracted. This isn’t removed at the time of the initial surgery as the skin’s memory tightens the skin up so well that the patient will actually end up with facial deformities. This surgery takes about three hours.

The second case is a 23-year-old with a parotid tumour for parotidectomy and the third case is an incisional biopsy of a maxillary tumour. This patient is also 23 and has quite a large tumour that she says first appeared 10 months ago. We are all hoping that it was longer than just 10 months because otherwise she will not have a very good prognosis. If it is not malignant, we can do a maxillectomy, but there is no point doing that if it will regrow in six months (sadly, there is no radiotherapy or chemotherapy follow-up support available).

If it is malignant, she will be referred to the palliative care team and we will pray for a miracle.

Today we have two maxillofacial medical students from Antananarivo (Madagascar’s capital city) where the country’s only maxfax surgeon works. Mercy Ships does a lot of education of health professionals so that once the ship leaves the country, the impact lives on through the ongoing education.

Also in theatre today is a Canadian nurse Mandy (new to maxfax), a Korean nurse Molly who has been in OR for two days, and Esther from Australia who has been in our OR for four weeks so is my right-hand girl. We usually have three nurses in the OR but one theatre isn’t working today so we have an extra. Esther asks to scrub up for the ICBG so that frees me to catch up on some admin. And we should all get breaks today!

12.10 PM Scrub up after quick lunch

I have to snatch a quick 10-minute lunch as thefirst case is coming to a close and I need to relieve Esther, who has been scrubbed all morning and needs to have a proper lunch break. I’ll catch up later.

1.00 PM Theatre break

We don’tusually stop at lunchtime, as it takes longer to get restarted, but the anaesthetic nurse needs to have her break as well so we have a break. During that time, I coach Mandy and Molly about scrubbing for the parotidectomy. Molly scrubs for it and Mandy is to scrub for the third case.

As Esther is to circulate, I have a chance in the afternoon to add some screws to one of the plating sets we found was short on screws yesterday and to replace a drill bit in another set. I have a long tea break during the parotidectomy to make up for my short lunch break. I also start thinking about a recent shipment of boxes of sutures that need to be stored somewhere during my admin day tomorrow.

5.15 PM Back to cabin

I often get back to our cabin before John so check my emails and bank account. I ring him about 5.30 and remind him it’s time to come home. We usually meet in the dining room. Tonight is Tuesday night so it’s ‘Africa night’, which I like but isn’t to everyone’s liking! Chicken with Sake Sake – yum! One of the girls we sit with comments that it looks like it’s already been processed. And plantain!

6.00 PM Laundry slot

We have to sign up to do our laundry. You get an hour slot to use the washing machine and then another hour to use the dryer. There’s someone following you so you have to be on time or you will miss your slot!

7.00 PM Fellowship group

On Tuesday nights I drop into Fellowship Group. There is no Bible study so I don’t get behind and if I am working late (and I often am) it doesn’t matter if I don’t make it. I am getting to meet all sorts of interesting people from all parts of the ship whom I may not normally meet hidden away in the OR. The rest of the time I am surfing the net or reading. We have a great library on the ship so it’s easy to slip up and grab a new book.

In Madagascar some lovely person has paid for us to have fast internet so we are able to watch videos and Skype our families, which is a real treat. Other evenings I go for a walk on the dock with a friend for half an hour that gets us out in the fresh air. Otherwise sometimes I get to the end of the week and realise I haven’t actually been outside.

10.00 PM Sleep time

Should be sleep time but I can’t stop thinking about storing those sutures. So John and I have a talk about them as he is the Engineering Stores manager and is very experienced in managing supplies. I then ask God for wisdom tomorrow as we are a bit overstocked at the moment and I need to do some readjusting of our stores. Then I manage to get off to sleep.

All Africa Mercy crew are volunteers, having either self-funded or, if staying longer, raised sponsorship from family, friends, colleagues, churches or community groups to cover the room and board costs of living and working on the ship. www.mercyships.org.nz

Name | Sue Glover
Job title | Clinical Nurse Specialist / Registered Nurse First Surgical Assistant, Paediatric and Congenital Cardiac Services
Location | Starship Children’s and Auckland City Hospitals, Auckland District Health Board

05.00 AM: Wake
Alarm usually set for 5.15am but the cat jumps on my chest at 5am so that’s my day started! Up at 5.15am, cat fed and happy, partner still snoring! Ready and out the door at 5.45am.

06.15 AM: Arrive at work
Traffic and parking are not an issue at this time and I like to get in early and spend the journey planning my day in my head!

I have been nursing for 32 years, the last 13 years within the Greenlane cardiac theatre team and for the past three I’ve been a clinical nurse specialist / registered nurse first surgical assistant (CNS/RNFSA) for the paediatric and congenital cardiac services. My position was the first official RNFSA appointment for the Auckland District Health Board and coincided with the first intake of the RNFSA course now being offered by the University of Auckland. RNFSA is a very adaptable role and in my case covers the complete perioperative journey as I see my patients preoperatively, assist the surgeon during surgery and am also involved with their postoperative care through to discharge and clinic follow-ups. Many of our children have staged surgeries throughout their childhood and it is a great privilege to be involved with them and their families.

Before heading to my office I review and chat with our adult patient in cardiovascular intensive care (CVICU) who had a pulmonary valve replacement and pacemaker/AICD implant yesterday.
Then to my desk to complete my preop preparation for today’s case, a two-day old 2.8kg baby with Hypoplastic Left Heart Syndrome having a Stage I Norwood procedure. I add the final touches to the preop summary sheet I have devised for theatre staff, check latest blood results, weight etc and ensure the blood bank has issued bypass bloods.

07.00 AM: Meet the family
Head to paediatric ICU (PICU) to check the baby has been stable overnight and everything is ready to go for surgery. This is also the time to introduce myself to the parents. I explain my role in today’s surgery, what the day will involve for them and their baby plus answer any further questions they have.

The preop visit is a very important link that I’ve worked hard to establish. Being involved from pre-op to discharge and follow-up provides parents with a constant person they are comfortable with, especially at the very daunting time of handing over their precious child to a team of “strangers” in the operating room. It’s also an important link between the operating room (OR) and ward teams.

07.30 AM: Baby to theatre
Time to take baby through to theatre. I give the parents further reassurance before heading into OR to begin prep for surgery. Normally, if not in theatre, I do morning ward rounds and reviews with the consultant. As the surgical fellow is actually listed to be first assistant today I hand over to him when he arrives and head to PICU to catch up with my consultant. Then another quick change of plans when she requests that I be first assistant today! So I hightail it up to CVICU to confirm that patient’s plan, make a quick stop at the paediatric ward to explain I’m now in theatre for the day and am back to OR in time to scrub and complete the prepping and draping of patient before the consultant arrives to start surgery.

2.30PM: Surgery complete
After seven hours in the OR and a very successful surgery, baby is transferred back to PICU with chest left open and a duoderm patch secured to the wound to allow the heart to recover and swelling to subside before the sternum is wired shut and the chest closed (about one to two days post-surgery).

3.00PM: Another baby to review
After handing over to PICU staff and completing the paper work I head with the cardiology registrar to review a baby who was discharged four days prior but has been extremely unsettled. Clinically there are no indications for his extreme distress and the wound shows no signs of active infection so I remove the drain sutures and redress the wounds. The child settles within five minutes of having dressings done and some panadol – parents think I am a miracle worker! Arrange admission of baby for observation and spend time reassuring parents. Then it is off to follow-up other phone messages and I carry out several more wound and drain reviews then liaise with the coordinator over the weekend patient plans as I am on call.

5.00PM: Weekend surgery alert
Consultant calls me to do a ward round with the on call consultant for the weekend. It’s at this point I hear we will be operating tomorrow morning on a three-week-old, 2.1kg premature neonate for a hypoplastic arch repair.

6.00PM: More prep
So begins again my usual preop preparation – liaise with theatre team, surgeon, anaesthesia and perfusion to confirm case. Discover there are no bypass bloods issued so resolve this with blood bank. Liaise with NICU to confirm theatre start time and fasting times and check notes to ensure all relevant documentation is present. I will introduce myself to the parents tomorrow as it has been a rather mammoth day for them and they need to spend precious time with their baby tonight.

7.00PM: Out the door… nearly
Head back to finalise a few things at the desk for tomorrow’s case, check on my patients in the adult and paediatric wards and the PICU before heading out the door

8.00PM: Head home
Finally on the way home, definitely takeaway dinner tonight! Hmmm now I think about it, whatever happened to breakfast and lunch today?? And looks like my partner and the cat will be looking after themselves this weekend too…

9.00 PM: Home
Feed cat, eat dinner, sit on the couch to rest for five minutes…Wake up a lot more than five minutes later – thank goodness for MySky and I can watch that program again some other time!!

10.30 PM: To sleep
Time for bed and another day closes on my busy but very rewarding working life. Put aside the guilt about no exercise again today…and takeaways…tomorrow is another day!

The nurses were part of the first cohort of the new postgraduate programme for registered nurse first surgical assistants (RNFSAs) run by The University

of Auckland and supported by Health Workforce New Zealand (HWNZ).

Thirteen experienced theatre nurses from across the country signed up for the one-year programme that got under way in July last year as a HWNZ innovation project. Twelve of those nurses graduated this spring and while the HWNZ evaluation continues, the initial feedback is good enough for a second cohort to be already waiting in the wings to get under way in February.

Yvonne Morgan, a first surgical assistant and the programme’s clinical co-coordinator is not surprised the demand is there. Her own training as a FSA was prompted after moving into the private hospital sector in 2001 and finding herself increasingly in a de facto FSA role traditionally carried out by doctors in the public sector. “You’d never be allowed to have that role without formal training in the UK,” says the English-trained nurse who came to New Zealand in 1998 with three years of theatre work behind her. Morgan sought out and completed an Australian perioperative nurse surgeon assistant (PNSA) training programme in 2006 and since then has been a self-employed first surgical assistant working across the private and public sectors.

She was also approached by The University of Auckland, that was interested in finding out the potential demand for a FSA programme here. So in 2007-2008, as part of her master’s thesis, she surveyed the College of Surgeons and was “astounded” at the surgeons’ level of support for the advanced nursing role.

Work began on developing a programme and word of mouth had filled the first cohort last year with private sector nurses before HWNZ stepped in to support the programme as an innovation project and nurses from Auckland District Health Board also come on board.

HWNZ project manager Laura Aileone says HWNZ funding helped ensure a more transparent and robust introduction of the new advanced role, including a qualitative and quantitative evaluation of its impact.

The successful dozen

The first graduate cohort of 12 nurses was made up of nine nurses from the private sector (based in areas from Dunedin to the North Shore, including one who now works across the public and private sectors in Christchurch) and three from the Auckland District Health Board. HWNZ met the cost of all students’ fees and in addition provided some back-fill cover for the public health nurses.

This first cohort had eight to 24 years theatre experience under their belts and worked in the fields of orthopaedics, urology, cardiac, general surgery, plastics, paediatric and otorhinolaryngology (ORL or ENT).

All of the students – private and public – had to have the backing of a surgeon mentor as well as their nurse unit manager to ensure they had the support to complete the programme. The programme was made up of two papers, the equivalent of a postgraduate certificate, the first focusing on the intraoperative

role and the second on the pre and post-operative role of a FSA. Each student also kept a clinical skills logbook and they were required to meet at least the basic level for each skill to pass. They were also encouraged to carry on using the logbook until they met the advanced level.

Morgan says most of the private sector nurses on the programme had been carrying out a first assistant role to varying degrees, even if this was just holding a clamp.

It was a new role, however, for the public sector nurses who were used to working in a tertiary training hospital with registrars or junior doctors taking the first assistant role. “So first of all, they were second assistants and the registrar was operating as first assistant, then they started to share the first assistant role, and then they moved onto acting as first assistant for all or part of the procedure.”

There were 12 study days in all during the programme, including reinforcing the nurse’s anatomy and physiology knowledge with a cadaver workshop lead by three surgeons. The nurses had a hands-on learning experience of dissection through tissue during a simulation workshop using four anaesthetised live pigs, carried out under the supervision of four surgeons. The nurses found out more about the structure of the abdominal wall and how to cope with a venal or arterial bleed.

Morgan says one nurse declined to take part for religious reasons and the others were initially really squeamish. “In the end they totally forgot it was a pig. It’s got drapes on it and looks like a routine surgery scenario that we work in.” Morgan says the similarity between a pig’s anatomy and a human’s made it a “very, very effective way of teaching”.

She adds that getting clinical practice experience could prove to be difficult for the three public sector nurses, as they work in the same area of paediatric cardiac surgery.

Beyond the theatre doors

The focus of the programme was not only on what happens on the operating table but what happens before and after the theatre doors swing shut.

Morgan says many theatre nurses – including herself some time ago – know little of what’s happened pre or post-operatively with the patient under the drape sheets.

The programme fills the gap by teaching the FSAs about tests required before and after surgery, how to interpret the results and the post-operative process, including discharging a patient after surgery.

Morgan says doctors and nurse specialists on the ward have had access to this information but it hasn’t always been provided to the theatre nurse. She says one of her own patients provides a good example of what a difference knowing your patient can make. Morgan had phoned the woman prior to surgery and met her on the ward before she was due to go to theatre. “I saw she was extremely anxious and was getting herself worked up,” recalls Morgan. She also observed the patient was obese. She was able to pre-warn the theatre team that the very fearful patient would needs lots of hand holding and comforting to allay the anxiety. Morgan was also able to ensure that an operating table was used that could bear the patient’s weight and that specially adapted surgical instruments were on hand. The result of that ward visit was a much smoother event which prevented the already stressed patient from arriving into theatre to find they didn’t have an appropriate table or instruments to carry out her surgery.

Morgan says her students are also reporting the rewards of being informed, like finding out early about abnormal test results so patients don’t have to be ‘starved’ and readied for surgery, only to be informed at the last minute that their surgery has had to be delayed.

Aileone says this is backed up by initial feedback from the evaluation researchers that the programme was breeding a ‘culture of inquiry’ amongst the students. It was also providing more continuity for patients before and after their surgery.

Evaluation still under way

While the first cohort finished the year-long programme midway through 2011, the evaluation continues for a further six months. The final report is due in February 2012. Aileone says the report will present a qualitative evaluation of the new programme and role from the trainees, surgeons and other members of the surgical team, and quantitative measures of what impact the role has had on surgical through-put, reduction in surgical list cancellations and time released for surgeons and registrars to perform more complex tasks.

Aileone says HWNZ has confirmed it will support a second cohort, with 14 prospective students already expressing interest for the February intake.

Meanwhile, one of the project’s first ADHB graduates is working in a dedicated FSA role, which Morgan believes is the first such role in a DHB. The paediatric cardiac RNFSA works across the ward and theatre in a unique model that could be shared with other DHBs.

Aileone says sharing and learning across the public and private sectors is a major focus of the HWNZ-supported project so the role can be embedded in “business as usual”. “A HWNZ innovation proposal has to demonstrate it’s not just a one-off bright idea that fizzes out,” says Aileone. “It’s got to demonstrate it can embed and be sustainable in New Zealand.” ✚

Tasks of the RNFSA

The tasks of the RNFSA include traditional surgical assistant roles like skin preparation, clamping of vessels and retracting of tissue, along with extended practice roles like bone graft harvesting, suturing, tissue dissection, haemostasis and infiltration of local anaesthetic.

Background

In late 2008 the Nursing Council decided that as the first surgical assistant (FSA) role included cutting into tissue, it was outside the regular role of the registered nurse. At the time it was estimated that there were about 30 experienced nurses in the private hospital sector working in some version of the FSA role and a further 20 or so public hospital nurses trained to work in a specialist PEG tube-placement FSA role in endoscopy units.

The council’s decision was prompted by a Private Surgical Hospital Association query and lead to all FSAs being required to seek council authorisation if they wanted to continue practising in the role. Meanwhile, the council consulted on whether the RN scope of practice should be revised to allow expanded practice by suitably qualified and endorsed nurses.

About eight FSAs successfully sought authorisation before the council introduced a new enabling RN scope of practice midway through 2010. The scope allows suitably trained and qualified RNs who meet endorsed national standards to work in expanded roles like the RNFSA.

Physician assistant vs first surgical assistant

Down the road at Counties Manukau DHB, a HWNZ pilot of the physician assistant role has also just been completed.

The two American-trained physician assistants (PAs) worked to support the surgical team in a ward-based pre and post-operative role. Initial feedback has been very favourable.

Aileone says the two project teams kept each informed of their work, as neither wanted duplication or overlap. She believes the two roles are quite discreet, as the PA didn’t take an intraoperative role.

However, Morgan believes there potentially is some overlap, as the RNFSA model developed at ADHB involves a similar pre and post-operative role to the role that PAs had been filling in Counties Manukau.

She points out that in the US the PA role is very similar to the RNFSA role and there is also overlap with the American NP role. It has been argued that while the US has the population to support all three roles, New Zealand doesn’t. So communication over any overlap has been important. “One of the worries is that if there was too much similarity between them the role wouldn’t become viable.”

Morgan says the FSA qualification is on the master’s degree pathway and some could carry on to seek nurse practitioner status. She has a master’s degree herself but says unfortunately her role includes all the NP-required elements bar prescribing. But she says that doesn’t mean that other FSAs practice in the future couldn’t include prescribing, making them eligible to seek NP status.