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Preoperative assessment by nurses
ARTICLE IN PRESS Evidence-Based Healthcare & Public Health (2005) 9, 376–380
www.elsevier.com/locate/ebhph
SYSTEMATIC REVIEW
Preoperative assessment by nurses Bazian Ltd London, UK
Key points
Patients undergoing elective surgery are assessed beforehand to check that they still need the procedure and can safely undergo it. Junior doctors usually carry out these assessments but workforce changes have prompted a search for alternatives to doctors in this role. This review found that appropriately trained nurses can undertake the preoperative assessment of patients as safely and effectively as doctors. There is still a need to systematically evaluate whether or not an appropriately trained nurse can also substitute for junior doctors in other clinical functions.
Background A nurse is now usually the first professional encountered by patients using the UK National Health Service (NHS). More patients are being treated, but junior doctors are working fewer hours, with nurses taking on many of their previous roles, including history taking, physical examination and initial diagnosis. This is not an unusual solution to the problem of optimising healthcare delivery. In the United States and Australia, nurses are routinely involved in history taking and medical assessment procedures. In the UK, the Royal College of Nursing provides a Nurse Practitioner Programme designed to enable nurses to take on more advanced clinical activities, such as assessing a patient autonomously, performing a physical examination, screening patients for
disease risk factors and early signs of illness, and making decisions about treatment, independently and as part of a team.1 There are several issues that need to be addressed if these nurse practitioners are to take on the roles currently performed by junior medical staff. For example: What procedures should they carry out? What is an acceptable level of competence, and how will this be measured? And most importantly, are there any implications for the patient such as quality and continuity of care? One role usually performed by a junior doctor is preoperative assessment. This is carried out before an elective operation to check that it is still necessary, that the patient is well enough to undergo the procedure, to identify and note any existing medical conditions that have not previously been recorded, and to provide the patient with adequate information about the procedure. It is important: one UK hospital reported that 3% of its scheduled operations are cancelled annually due to the operation no longer being required, or because the patient is not well enough to undergo the operation.2 It is not clear whether nurses, even with appropriate training, can safely and effectively replace doctors in the preoperative assessment of patients. This review addresses that question.
Review of the evidence In this review, we systematically examine the evidence for the safety and effectiveness of an appropriately trained nurse assessing patients before a surgical procedure, compared with preoperative assessment performed by a doctor.
1744-2249/$ - see front matter & 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ehbc.2005.09.001
ARTICLE IN PRESS Preoperative assessment by nurses
Search strategy In April 2005, we searched the following databases: Medline, EMBASE, and CINAHL (to date), and Cochrane Library Issue 1, 2005.
Inclusion/exclusion criteria We only included randomised and non-randomised controlled trials which directly compared preoperative assessment by appropriately trained nurses with preoperative assessment by doctors, in people awaiting any kind of surgery, and reporting both clinical and non-clinical outcomes.
Data extraction and synthesis We extracted data from the studies on the results of preoperative assessments, both clinical and nonclinical. Outcomes were synthesised narratively.
Results Four studies met our inclusion criteria. The first study involved 1907 people awaiting general, vascular, urological, or breast surgery, at four different hospitals in the UK.4 Trial participants were randomly assigned to a preoperative assessment carried out by an appropriately trained nurse versus assessment by a junior house officer. Nurse training involved the anatomy, test ordering, and physical examination modules of a masters degree in advanced practice. The preoperative assessment involved history taking, physical examination, and the ordering of tests. Each patient was independently re-examined by a specialist registrar in anaesthetics who compared the accuracy of the nurse’s or house officer’s assessment with their own. The registrar scored the assessments as: correctly assessed, under-assessed (not affecting management), or under-assessed (affecting management). The registrar was not blinded to the initial assessments. However, any assessments scored by the registrar as affecting management were reviewed by a panel of consultants. The trial was designed to test whether nurses made important mistakes during preoperative assessments more often than junior house officers. Important mistakes were defined as errors which had implications for the medical management of the patient. Recruitment of participants ended early because of delays in undertaking assessments arising from a lack of appropriately trained nurses. However the study was still adequately powered to
377 detect a difference between assessments made by nurses and house officers. The study found that overall, appropriately trained nurses performed as well as junior house officers and did not make important assessment mistakes more often than house officers during history taking, examination, or test ordering (see Table 1). House officers ordered nearly twice as many unnecessary tests as nurses. This was the main difference between the two groups: the nurses’ and doctors’ performances in history-taking and examination were similar. The second study randomly assigned 339 people requiring insertion of a cardiac catheter to a preoperative assessment carried out by an appropriately trained nurse or a house officer.3 Nurse training involved attending the advanced nursing history and physical examination programme at the Royal Brompton Hospital, London, in addition to a period of clinical practice with a house officer. The assessment involved history taking, physical examination, ordering tests, and reviewing medication. The preoperative assessments were subsequently reviewed by the senior cardiologist in charge of the case. Assessment group allocation was not concealed. All patients were asked to complete a questionnaire rating their treatment experience. The safety outcome was the occurrence of a major clinical event (death, myocardial infarction, emergency cardiac surgery or percutaneous intervention, stroke or another vascular event) recorded from randomisation to discharge or death. Recruitment did not reach the target of 600 people mainly because of consultant cardiologists not consenting to the participation of patients in the study. The study found no difference between the preoperative assessments made by nurses and house officers, as rated by the senior cardiologist (see Table 1). It also found that more people assessed by nurses were ‘very satisfied’ with the care they received compared with people assessed by a house officer. The study found no difference between the two groups in the risk of a major clinical event. The third study was a small pilot study involving 60 children aged 3 months to 15 years who were awaiting minor orthopaedic surgery.5 The participants were randomly assigned to assessment by an appropriately trained nurse or a senior house officer. The nurses took part in a 30-hour training programme based on nurse practitioner training in the UK and Canada. The assessment involved history taking and physical examination aimed at identifying problems of potential perioperative importance. All children were independently reassessed by a specialist registrar in anaesthetics
ARTICLE IN PRESS 378
Bazian Ltd
Table 1 Outcomes of trials comparing preoperative assessments made by an appropriately trained nurse or a house officer. Reference
Details of study
Main outcomes
Comments
Kinley et al.4
Setting: four different hospitals in the UK; recruitment from April 1998 to March 1999 Participants: 1907 people awaiting general, vascular, urological, or breast surgery Comparison: pre-registration house officers (HO) versus three experienced, appropriately trained nurses (ATN)
Mistakes made at physical examination affecting management: 13% made by ATN v 15% made by HO; ARR 0.8, 95% CI 2.6 to 1.1 Mistakes made at history taking: 6.7% made by ATN v 5.7% made by HO; ARR 0.8, 95% CI 2.6 to 1.1 Tests ordered: 218 by HO v 129 by ATN; ARR 9.9, 95%CI 13.4 to 6.4
Each patient was independently examined by a specialist registrar. The registrar was not blinded to the assessment groups. Independent review of the registrar’s assessments found no evidence of bias.
Stables et al.3
Setting: a British university hospital; recruitment from April 1997 to May 1998 Participants: 339 people requiring insertion of a cardiac catheter Comparison: one appropriately trained senior cardiothoracic staff nurse (ATN) versus 33 junior medical staff members (HO)
Mistakes made at assessment: no significant difference between groups, data not reported Patient satisfaction: 94.3% ‘very satisfied’ with ATN v 86.8% ‘very satisfied’ with HO; p ¼ 0.04 Major clinical events: 0% with ATN v 1.2% with HO; ARR 1.2%, upper 95% CI +2.0%
Recruitment did not reach the target of 600 people. This study was therefore not powered to detect small differences in clinical outcomes. Group allocation was not concealed. Preoperative assessments were reviewed by a senior cardiologist.
Rushforth et al.5
Setting: a general paediatric day surgery facility and a preclerking clinic in a British university hospital; recruitment time scale not stated Participants: 60 children aged 3 months to 15 years awaiting minor orthopaedic surgery Comparison: five appropriately trained nurses (ATN) (two staff nurses, one ward sister, two clinical nurse specialists) versus six senior house officers (HO)
Problems correctly identified at history taking: 94% with ATN v 42% with HO; p ¼ 0.04 Problems correctly identified at physical examination: 75% identified by both ATN and HO
All children were independently assessed by a specialist registrar who was blind to both the group allocation and previous assessment. No firm conclusions regarding the safety, efficacy, and generalisability of preoperative assessments carried out by nurses in a paediatric setting could be reached by this pilot study.
Whiteley et al.6
Setting: a British district hospital; recruitment from February to April 1995 Participants: 100 people awaiting elective surgery for varicose veins or hernias, cholecystectomy or colonic surgery Comparison: specialist nurse (ATN) versus pre-registration house officer (HO)
Problems missed at history taking: 12% with nurse v 13% with HO; ARR 0.010 95% CI 0.102 to 0.820 Anaesthetic risk: assessment made by the ATN was in agreement with anaesthetist in 81% of cases, differing by a single grade in 8% of cases There was no significant difference between the two groups in the accuracy of investigations ordered (no data reported)
All patients were first assessed by an ATN, and then by a junior HO. The HO was blind to the assessment made by the ATN. Assessments made by the ATN and HO were compared after the patients surgery, by a surgeon in training, who did not examine the patient.
ARTICLE IN PRESS Preoperative assessment by nurses who was blind to both the group allocation and the previous assessment results.5 The study found that nurses were better at history taking, identifying 94% of detectable problems compared with the senior house officer who identified 42% (see Table 1). However, it found no difference between nurses and house officers in the number of problems correctly identified during physical examination (75% in both groups). The authors note that a much larger study is required before any firm conclusions regarding the safety, efficacy, and generalisability of preoperative assessments carried out by nurses in a paediatric setting can be reached. The fourth study included 100 people awaiting elective surgery for varicose veins or hernias, cholecystectomy or colonic surgery.6 All patients were first assessed by a specialist nurse. The assessment involved history taking, anaesthetic risk assignment, and measurements of blood pressure, weight and peak flow rate. The nurse also ordered preoperative investigations when necessary. All patients were then assessed by a junior house officer who also took a history, examined the patient, and ordered preoperative investigations considered necessary. The house officers were blind to the assessments made by the nurses. Following surgery, the assessments made by the nurses and house officers were compared by a surgeon in training, who did not examine the patient. The study found that there was no significant difference in the important current medical problems missed by nurses and house officers during history taking. There was no difference between the two groups in the appropriateness of investigations ordered. Anaesthetic risk assessment made by the nurse was in agreement with that of an anaesthetist in 81% of cases, and differed only by a single grade in another 8% of cases.
Review findings Appropriately trained nurses are able to carry out preoperative assessments at least as accurately and effectively as house officers. The nurses involved in all four studies were experienced and had received additional training for this extension to their role. Two studies did not meet recruitment targets but both were adequately powered to detect a clinically important difference in assessments. However, the pilot randomised controlled trial was too small to reach any firm conclusions about the performance of nurses compared with house officers in assessing children.
379 The studies had a variety of approaches to blinding, but it is unlikely that the results are attributable to observer bias. The specialist registrar in the first study was not blinded to the assessment groups, but assessment ratings by the registrar were reviewed by an independent panel of consultants who found no evidence of bias.4 The second study had an open design, where both the participants and cardiologists were aware of group allocation.3 In this study, blinding was considered both impractical and unethical. In the third study, the independent assessor was blinded to both the assessment results and the group allocation of the children.5 The fourth study was not randomised.6 The house officers were blind to the initial assessments made by the nurses and a single independent observer compared the assessments made by the nurses and house officers, after the patient had undergone surgery. Only one of the four included studies addressed the issue of patient satisfaction, reporting that it was significantly greater in people assessed by a nurse.3 The large number of people willing to participate in the studies suggests that many patients have no objection to assessment by a nurse. One study evaluated the attitudes of the doctors involved in the trial, to nurse-led assessments.3 It found that consultants had concerns regarding the role of nurses and the potential impact on the learning experiences of junior medical staff. However, all of the house officers who responded to the questionnaire (20/33 [65%]) supported the role of the nurse. In addition, the majority of those who responded felt that the new approach had been of benefit to them and should continue. The nurses involved in these studies were carefully selected and trained. To ensure that the benefits are also secured in routine care, the role, training and qualifications needed by nurses for this role need to be agreed. The impact on continuity of care would also need to be considered. If the junior doctor or nurse who carries out a preoperative assessment is also involved in the patient’s care in hospital, then their knowledge of and relationship with the patient may improve quality of care throughout the admission. Making care more episodic and increasing the number of professionals involved in its delivery has the opposite effect. Would instituting this change be cost-effective? This question was not addressed by any of the included studies and would be difficult to assess. One study commented that training nurses for this role was unlikely to involve greater cost than the training of junior medical staff, though the doctors would have to be trained in any case.3
ARTICLE IN PRESS 380 In summary, appropriately trained nurses are likely to be at least as safe and effective as junior doctors in assessing patients before elective surgery. In introducing the change, it is important to make sure that their training and experience is at least as good as that of the nurses in the studies included in this review, and that their performance is audited.
References 1. Royal College of Nursing. Nurse Practitioners–an RCN guide to the nurse practitioner role, competencies and programme approval. London: RCN. Available from: www.rcn.org.uk
Bazian Ltd 2. Reed M, Wright S, Armitage F. Nurse-led general surgical preoperative assessment clinic. J R Coll Surg Edinb 1997;42: 310–3. 3. Stables RH, Booth J, Welstand J, et al. A randomised controlled trial to compare a nurse practitioner to medical staff in the preparation of patients for diagnostic cardiac catheterisation: the study of nursing intervention in practice (SNIP). Eur J Cardiovascular Nursing 2004;3:53–9. 4. Kinley H, Czoski-Murray C, George S, et al. Effectiveness of appropriately trained nurses in preoperative assessment: randomised controlled equivalence/non-inferiority trial. BMJ 2002;325:1323. 5. Rushforth H, Bliss A, Burge D, et al. A pilot randomised controlled trial of medical versus nurse clarking for minor surgery. Arch Dis Child 2000;83:223–6. 6. Whiteley MS, Wilmott K, Galland RB. A specialist nurse can replace pre-registration house officers in the surgical preadmission clinic. Ann R Coll Surg Engl 1997;79(suppl):257–60.
www.elsevier.com/locate/ebhph
SYSTEMATIC REVIEW
Preoperative assessment by nurses Bazian Ltd London, UK
Key points
Patients undergoing elective surgery are assessed beforehand to check that they still need the procedure and can safely undergo it. Junior doctors usually carry out these assessments but workforce changes have prompted a search for alternatives to doctors in this role. This review found that appropriately trained nurses can undertake the preoperative assessment of patients as safely and effectively as doctors. There is still a need to systematically evaluate whether or not an appropriately trained nurse can also substitute for junior doctors in other clinical functions.
Background A nurse is now usually the first professional encountered by patients using the UK National Health Service (NHS). More patients are being treated, but junior doctors are working fewer hours, with nurses taking on many of their previous roles, including history taking, physical examination and initial diagnosis. This is not an unusual solution to the problem of optimising healthcare delivery. In the United States and Australia, nurses are routinely involved in history taking and medical assessment procedures. In the UK, the Royal College of Nursing provides a Nurse Practitioner Programme designed to enable nurses to take on more advanced clinical activities, such as assessing a patient autonomously, performing a physical examination, screening patients for
disease risk factors and early signs of illness, and making decisions about treatment, independently and as part of a team.1 There are several issues that need to be addressed if these nurse practitioners are to take on the roles currently performed by junior medical staff. For example: What procedures should they carry out? What is an acceptable level of competence, and how will this be measured? And most importantly, are there any implications for the patient such as quality and continuity of care? One role usually performed by a junior doctor is preoperative assessment. This is carried out before an elective operation to check that it is still necessary, that the patient is well enough to undergo the procedure, to identify and note any existing medical conditions that have not previously been recorded, and to provide the patient with adequate information about the procedure. It is important: one UK hospital reported that 3% of its scheduled operations are cancelled annually due to the operation no longer being required, or because the patient is not well enough to undergo the operation.2 It is not clear whether nurses, even with appropriate training, can safely and effectively replace doctors in the preoperative assessment of patients. This review addresses that question.
Review of the evidence In this review, we systematically examine the evidence for the safety and effectiveness of an appropriately trained nurse assessing patients before a surgical procedure, compared with preoperative assessment performed by a doctor.
1744-2249/$ - see front matter & 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ehbc.2005.09.001
ARTICLE IN PRESS Preoperative assessment by nurses
Search strategy In April 2005, we searched the following databases: Medline, EMBASE, and CINAHL (to date), and Cochrane Library Issue 1, 2005.
Inclusion/exclusion criteria We only included randomised and non-randomised controlled trials which directly compared preoperative assessment by appropriately trained nurses with preoperative assessment by doctors, in people awaiting any kind of surgery, and reporting both clinical and non-clinical outcomes.
Data extraction and synthesis We extracted data from the studies on the results of preoperative assessments, both clinical and nonclinical. Outcomes were synthesised narratively.
Results Four studies met our inclusion criteria. The first study involved 1907 people awaiting general, vascular, urological, or breast surgery, at four different hospitals in the UK.4 Trial participants were randomly assigned to a preoperative assessment carried out by an appropriately trained nurse versus assessment by a junior house officer. Nurse training involved the anatomy, test ordering, and physical examination modules of a masters degree in advanced practice. The preoperative assessment involved history taking, physical examination, and the ordering of tests. Each patient was independently re-examined by a specialist registrar in anaesthetics who compared the accuracy of the nurse’s or house officer’s assessment with their own. The registrar scored the assessments as: correctly assessed, under-assessed (not affecting management), or under-assessed (affecting management). The registrar was not blinded to the initial assessments. However, any assessments scored by the registrar as affecting management were reviewed by a panel of consultants. The trial was designed to test whether nurses made important mistakes during preoperative assessments more often than junior house officers. Important mistakes were defined as errors which had implications for the medical management of the patient. Recruitment of participants ended early because of delays in undertaking assessments arising from a lack of appropriately trained nurses. However the study was still adequately powered to
377 detect a difference between assessments made by nurses and house officers. The study found that overall, appropriately trained nurses performed as well as junior house officers and did not make important assessment mistakes more often than house officers during history taking, examination, or test ordering (see Table 1). House officers ordered nearly twice as many unnecessary tests as nurses. This was the main difference between the two groups: the nurses’ and doctors’ performances in history-taking and examination were similar. The second study randomly assigned 339 people requiring insertion of a cardiac catheter to a preoperative assessment carried out by an appropriately trained nurse or a house officer.3 Nurse training involved attending the advanced nursing history and physical examination programme at the Royal Brompton Hospital, London, in addition to a period of clinical practice with a house officer. The assessment involved history taking, physical examination, ordering tests, and reviewing medication. The preoperative assessments were subsequently reviewed by the senior cardiologist in charge of the case. Assessment group allocation was not concealed. All patients were asked to complete a questionnaire rating their treatment experience. The safety outcome was the occurrence of a major clinical event (death, myocardial infarction, emergency cardiac surgery or percutaneous intervention, stroke or another vascular event) recorded from randomisation to discharge or death. Recruitment did not reach the target of 600 people mainly because of consultant cardiologists not consenting to the participation of patients in the study. The study found no difference between the preoperative assessments made by nurses and house officers, as rated by the senior cardiologist (see Table 1). It also found that more people assessed by nurses were ‘very satisfied’ with the care they received compared with people assessed by a house officer. The study found no difference between the two groups in the risk of a major clinical event. The third study was a small pilot study involving 60 children aged 3 months to 15 years who were awaiting minor orthopaedic surgery.5 The participants were randomly assigned to assessment by an appropriately trained nurse or a senior house officer. The nurses took part in a 30-hour training programme based on nurse practitioner training in the UK and Canada. The assessment involved history taking and physical examination aimed at identifying problems of potential perioperative importance. All children were independently reassessed by a specialist registrar in anaesthetics
ARTICLE IN PRESS 378
Bazian Ltd
Table 1 Outcomes of trials comparing preoperative assessments made by an appropriately trained nurse or a house officer. Reference
Details of study
Main outcomes
Comments
Kinley et al.4
Setting: four different hospitals in the UK; recruitment from April 1998 to March 1999 Participants: 1907 people awaiting general, vascular, urological, or breast surgery Comparison: pre-registration house officers (HO) versus three experienced, appropriately trained nurses (ATN)
Mistakes made at physical examination affecting management: 13% made by ATN v 15% made by HO; ARR 0.8, 95% CI 2.6 to 1.1 Mistakes made at history taking: 6.7% made by ATN v 5.7% made by HO; ARR 0.8, 95% CI 2.6 to 1.1 Tests ordered: 218 by HO v 129 by ATN; ARR 9.9, 95%CI 13.4 to 6.4
Each patient was independently examined by a specialist registrar. The registrar was not blinded to the assessment groups. Independent review of the registrar’s assessments found no evidence of bias.
Stables et al.3
Setting: a British university hospital; recruitment from April 1997 to May 1998 Participants: 339 people requiring insertion of a cardiac catheter Comparison: one appropriately trained senior cardiothoracic staff nurse (ATN) versus 33 junior medical staff members (HO)
Mistakes made at assessment: no significant difference between groups, data not reported Patient satisfaction: 94.3% ‘very satisfied’ with ATN v 86.8% ‘very satisfied’ with HO; p ¼ 0.04 Major clinical events: 0% with ATN v 1.2% with HO; ARR 1.2%, upper 95% CI +2.0%
Recruitment did not reach the target of 600 people. This study was therefore not powered to detect small differences in clinical outcomes. Group allocation was not concealed. Preoperative assessments were reviewed by a senior cardiologist.
Rushforth et al.5
Setting: a general paediatric day surgery facility and a preclerking clinic in a British university hospital; recruitment time scale not stated Participants: 60 children aged 3 months to 15 years awaiting minor orthopaedic surgery Comparison: five appropriately trained nurses (ATN) (two staff nurses, one ward sister, two clinical nurse specialists) versus six senior house officers (HO)
Problems correctly identified at history taking: 94% with ATN v 42% with HO; p ¼ 0.04 Problems correctly identified at physical examination: 75% identified by both ATN and HO
All children were independently assessed by a specialist registrar who was blind to both the group allocation and previous assessment. No firm conclusions regarding the safety, efficacy, and generalisability of preoperative assessments carried out by nurses in a paediatric setting could be reached by this pilot study.
Whiteley et al.6
Setting: a British district hospital; recruitment from February to April 1995 Participants: 100 people awaiting elective surgery for varicose veins or hernias, cholecystectomy or colonic surgery Comparison: specialist nurse (ATN) versus pre-registration house officer (HO)
Problems missed at history taking: 12% with nurse v 13% with HO; ARR 0.010 95% CI 0.102 to 0.820 Anaesthetic risk: assessment made by the ATN was in agreement with anaesthetist in 81% of cases, differing by a single grade in 8% of cases There was no significant difference between the two groups in the accuracy of investigations ordered (no data reported)
All patients were first assessed by an ATN, and then by a junior HO. The HO was blind to the assessment made by the ATN. Assessments made by the ATN and HO were compared after the patients surgery, by a surgeon in training, who did not examine the patient.
ARTICLE IN PRESS Preoperative assessment by nurses who was blind to both the group allocation and the previous assessment results.5 The study found that nurses were better at history taking, identifying 94% of detectable problems compared with the senior house officer who identified 42% (see Table 1). However, it found no difference between nurses and house officers in the number of problems correctly identified during physical examination (75% in both groups). The authors note that a much larger study is required before any firm conclusions regarding the safety, efficacy, and generalisability of preoperative assessments carried out by nurses in a paediatric setting can be reached. The fourth study included 100 people awaiting elective surgery for varicose veins or hernias, cholecystectomy or colonic surgery.6 All patients were first assessed by a specialist nurse. The assessment involved history taking, anaesthetic risk assignment, and measurements of blood pressure, weight and peak flow rate. The nurse also ordered preoperative investigations when necessary. All patients were then assessed by a junior house officer who also took a history, examined the patient, and ordered preoperative investigations considered necessary. The house officers were blind to the assessments made by the nurses. Following surgery, the assessments made by the nurses and house officers were compared by a surgeon in training, who did not examine the patient. The study found that there was no significant difference in the important current medical problems missed by nurses and house officers during history taking. There was no difference between the two groups in the appropriateness of investigations ordered. Anaesthetic risk assessment made by the nurse was in agreement with that of an anaesthetist in 81% of cases, and differed only by a single grade in another 8% of cases.
Review findings Appropriately trained nurses are able to carry out preoperative assessments at least as accurately and effectively as house officers. The nurses involved in all four studies were experienced and had received additional training for this extension to their role. Two studies did not meet recruitment targets but both were adequately powered to detect a clinically important difference in assessments. However, the pilot randomised controlled trial was too small to reach any firm conclusions about the performance of nurses compared with house officers in assessing children.
379 The studies had a variety of approaches to blinding, but it is unlikely that the results are attributable to observer bias. The specialist registrar in the first study was not blinded to the assessment groups, but assessment ratings by the registrar were reviewed by an independent panel of consultants who found no evidence of bias.4 The second study had an open design, where both the participants and cardiologists were aware of group allocation.3 In this study, blinding was considered both impractical and unethical. In the third study, the independent assessor was blinded to both the assessment results and the group allocation of the children.5 The fourth study was not randomised.6 The house officers were blind to the initial assessments made by the nurses and a single independent observer compared the assessments made by the nurses and house officers, after the patient had undergone surgery. Only one of the four included studies addressed the issue of patient satisfaction, reporting that it was significantly greater in people assessed by a nurse.3 The large number of people willing to participate in the studies suggests that many patients have no objection to assessment by a nurse. One study evaluated the attitudes of the doctors involved in the trial, to nurse-led assessments.3 It found that consultants had concerns regarding the role of nurses and the potential impact on the learning experiences of junior medical staff. However, all of the house officers who responded to the questionnaire (20/33 [65%]) supported the role of the nurse. In addition, the majority of those who responded felt that the new approach had been of benefit to them and should continue. The nurses involved in these studies were carefully selected and trained. To ensure that the benefits are also secured in routine care, the role, training and qualifications needed by nurses for this role need to be agreed. The impact on continuity of care would also need to be considered. If the junior doctor or nurse who carries out a preoperative assessment is also involved in the patient’s care in hospital, then their knowledge of and relationship with the patient may improve quality of care throughout the admission. Making care more episodic and increasing the number of professionals involved in its delivery has the opposite effect. Would instituting this change be cost-effective? This question was not addressed by any of the included studies and would be difficult to assess. One study commented that training nurses for this role was unlikely to involve greater cost than the training of junior medical staff, though the doctors would have to be trained in any case.3
ARTICLE IN PRESS 380 In summary, appropriately trained nurses are likely to be at least as safe and effective as junior doctors in assessing patients before elective surgery. In introducing the change, it is important to make sure that their training and experience is at least as good as that of the nurses in the studies included in this review, and that their performance is audited.
References 1. Royal College of Nursing. Nurse Practitioners–an RCN guide to the nurse practitioner role, competencies and programme approval. London: RCN. Available from: www.rcn.org.uk
Bazian Ltd 2. Reed M, Wright S, Armitage F. Nurse-led general surgical preoperative assessment clinic. J R Coll Surg Edinb 1997;42: 310–3. 3. Stables RH, Booth J, Welstand J, et al. A randomised controlled trial to compare a nurse practitioner to medical staff in the preparation of patients for diagnostic cardiac catheterisation: the study of nursing intervention in practice (SNIP). Eur J Cardiovascular Nursing 2004;3:53–9. 4. Kinley H, Czoski-Murray C, George S, et al. Effectiveness of appropriately trained nurses in preoperative assessment: randomised controlled equivalence/non-inferiority trial. BMJ 2002;325:1323. 5. Rushforth H, Bliss A, Burge D, et al. A pilot randomised controlled trial of medical versus nurse clarking for minor surgery. Arch Dis Child 2000;83:223–6. 6. Whiteley MS, Wilmott K, Galland RB. A specialist nurse can replace pre-registration house officers in the surgical preadmission clinic. Ann R Coll Surg Engl 1997;79(suppl):257–60.