Understanding the role of the scrub nurse during robotic surgery
Intended for healthcare professionals
Evidence and practice    

Understanding the role of the scrub nurse during robotic surgery

Bradley Russell Surgical care practitioner, Urology, The Royal Marsden Hospital, Royal Marsden NHS Foundation Trust, London, England

Why you should read this article:
  • To enhance your awareness of the latest developments in surgery, including robotic techniques

  • To recognise the knowledge and skills required by scrub nurses

  • To understand what the scrub nurse’s role entails during robotic surgery

In the operating theatre, the scrub nurse has a wide range of roles, including responsibility for organising and ensuring that the correct instrumentation is available to the surgeon in the operating field, while maintaining stringent adherence to the principles of asepsis. Robotic techniques have revolutionised many procedures, providing surgeons with improved tissue access and tool control compared with open or laparoscopic techniques. However, adopting this technology has created additional challenges in the scrub nurse’s role in areas such as team dynamics and the need to gather and disseminate vital patient information. This article explores the role of the scrub nurse and the challenges that may be encountered in the developing area of robotic surgery.

Nursing Standard. doi: 10.7748/ns.2022.e12003

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

Bradley.Russell@rmh.nhs.uk

Conflict of interest

None declared

Russell B (2022) Understanding the role of the scrub nurse during robotic surgery. Nursing Standard. doi: 10.7748/ns.2022.e12003

Published online: 28 November 2022

The operating theatre is a complex environment where interdisciplinary groups of healthcare professionals with a variety of skills work together interdependently to deliver optimal patient care (Kang et al 2014). In terms of professional roles and responsibilities, the composition of theatre teams has remained relatively static for decades, and typically consists of surgeons, anaesthetists, nurses, operating department practitioners and healthcare assistants (Abraham 2019). One of the primary roles in the team is that of the scrub nurse. The origins of the scrub nurse role are closely aligned with Florence Nightingale’s belief in the implementation of sanitary principles, which developed as hospitals began to require the services of a skilled and professional nursing workforce (Hamlin 2020).

The modern scrub nurse has a distinct role, which has evolved alongside medical and technical advances in surgery. Typically, their expertise differs from that of nurses in other settings; for example, a scrub nurse’s patients are often experiencing the effects of anaesthesia, while technical skills form the foundation of their daily practice (Barry 2009). The acquisition of the scrub nurse’s skills has primarily been based in the workplace, with techniques and knowledge passed from peer to peer without any formal teaching or assessment (Miller 2014). For example, there is no requirement for scrub nurses to complete a secondary theatre qualification or specialist post-registration course to work in UK operating theatres (Radford and Fotis 2018).

One small-scale study explored the acquisition of technical scrub skills, detailing that the pathway to learning these skills was diverse and involved a variety of teaching and learning methods (Radford and Fotis 2018). Similarly, practice educators have often established local induction and training programmes alongside competency assessments to support newly registered nurses who want to learn the skills involved in the scrub nurse role. Consequently, standards and the quality of scrub nurses’ education vary across the UK.

Many surgical procedures have been revolutionised by robotic techniques, which have provided enhanced tissue access and tool control to surgeons than those provided by open or laparoscopic (also known as ‘keyhole’) surgical techniques. An example is prostatectomy, which was originally performed via an open operation and involved a large incision in the lower abdomen and significant loss of blood. The same operation conducted laparoscopically reduced both the need for a large incision and patient blood loss; however, the laparoscopic technique still placed substantial ergonomic stress on the operating surgeon (Catchpole et al 2019). In contrast, robotic surgery uses tiny incisions, cameras and small surgical tools, which are attached to robotic arms. A surgeon can control the robotic arms from a console booth, which is usually situated in the theatre.

This article explores the role of the scrub nurse in theatres generally, before examining their role in the developing area of robotic surgery in greater detail. Due to the multidisciplinary nature of theatre roles, occasionally the term ‘scrub practitioner’ is used when referring to members of the operating theatre team. However, the term ‘scrub nurse’ will be used in this article.

Role of the scrub nurse

Scrub nurses have specific roles in the operating theatre. For example, they are typically responsible for organising and ensuring that the correct instrumentation is available to the surgeon, while maintaining stringent adherence to the principles of asepsis (Hamlin 2020). The term asepsis refers to the absence of potentially pathogenic microorganisms (Loveday et al 2014), and while in practice it is often related to aseptic technique, it is a general term involving practices that minimise the introduction of microorganisms to patients during treatment. Asepsis also reduces the risk of post-operative events such as surgical site infection (Shawish et al 2015).

As well as the application of aseptic technique, scrub nurses also have a significant role in the observance of infection prevention procedures such as appropriate hand hygiene and thorough hand-washing, maintaining a clean environment, and ensuring the availability of clean linen and staff uniforms (Shawish et al 2015). The scrub nurse’s role also involves maintaining accurate counts of surgical instruments and consumable items (for example, surgical swabs and needles) to prevent these being inadvertently retained inside the patient, observing the operative procedure, and ensuring clear and concise communication with other theatre staff and the surgical team.

Throughout a patient’s time in the operating theatre, the scrub nurse acts as their advocate (Kang et al 2014). This reflects the principle outlined in The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council 2018), which states that nurses must ‘be aware of, or reduce as far as possible, any potential for harm associated with practice’.

The introduction of a safe surgery checklist by the World Health Organization (WHO) (2009) has assisted in altering the traditional hierarchical imbalance between surgeons and other theatre staff such as scrub nurses, enabling each member of the team to raise any concerns before commencing surgery (Miller 2014). Theatre checklists are akin to safety procedures used in the aviation industry, whereby pilots hold a ‘silent cockpit’ briefing session before take-off to enable the systematic completion of pre-flight checks and reduce the risk of error. Similar safety briefings in the operating theatre have been found to enhance the communications skills of theatre teams (Papaconstantinou et al 2013), and to assist in maintaining patient safety (Shah and Barksfield 2020).

Non-technical skills

The non-technical skills of scrub nurses complement their technical skills and include cognitive, social and personal resource skills, which contribute to the efficient and safe completion of surgical tasks (Flin et al 2008).

Cognitive skills include situational awareness, effective decision-making and planning (Kang et al 2014). Situational awareness was summarised by Bracq et al (2021) as the ability to gather information from the environment, recognise and understand it, and anticipate its future state. Situational awareness remains a major non-technical skill for scrub nurses, who are not only responsible for hygiene and safety but are expected to ‘think ahead’ of the surgeon during an operation and anticipate what instruments or techniques might be required. This may be as simple as the scrub nurse handing the surgeon a scalpel to begin the operation, or understanding that the surgeon may also require a surgical swab following the incision (Bracq et al 2021).

Social and personal resource skills include teamworking, communication and leadership (Kang et al 2014). In addition, the management of stress has been identified as an important non-technical skill required by scrub nurses (Mitchell et al 2011, Kang et al 2014).

Application of these non-technical skills is regarded as essential for safe and effective patient care in the operating theatre (Rutherford et al 2012), while failures that are not captured by the scrub nurse and wider operating theatre team can contribute to surgical ‘never events’.

Never events

Never events are significant patient safety incidents, which take place despite guidelines being available to prevent their occurrence (NHS England 2022). In surgical terms, never events may include surgery at the incorrect site, unintentional swab retention and incorrect prosthesis implantation (NHS England 2022). To prevent never events, the scrub nurse has many responsibilities, including technical aspects such as ensuring that all instruments and swabs are accounted for at the end of the surgical procedure. Non-technical aspects of the instrument count are also important; for example, the scrub nurse should know where the instruments and swabs are once they are placed in the operating field, and should have the awareness to immediately alert the team if any of these items are misplaced.

The UK’s Association for Perioperative Practice (2022) has produced guidelines that aim to prevent swab retention. These guidelines are embedded in clinical practice and were strengthened by the WHO (2009) safe surgery checklist. However, possible factors leading to instrument and swab retention include communication failure in the nursing team and/or between nurses and surgeons, which Hu et al (2012) asserted was a common contributor to adverse events.

Scrub nurses’ training

Operating theatre placements are usually available during preregistration nurse training; however, inconsistencies in the level of nursing students’ involvement permitted during these placements means that many scrub nurses can begin working in theatres only having observed patients and lacking ‘hands-on’ experience (Radford and Fotis 2018).

Given scrub nurses’ importance in maintaining patient safety, calls have been made to move away from the traditional method of peer-to-peer learning towards a structured formal educational model, whereby newly registered nurses are provided with the knowledge and skills required to deliver safe and effective care, as well as cognitive and social skills (Miller 2014). Koh et al (2011) stated that such training for scrub nurses was essential considering their role during surgery, which typically involves a high cognitive workload due to the number of simultaneous tasks and priorities required. For example, the scrub nurse may be preparing a surgical stapling device, while simultaneously monitoring that the correct instrumentation is being provided to the surgeon.

Key points

  • Robotic technology is used worldwide for a diverse range of procedures such as cardiothoracic, gynaecological, urological and paediatric surgery

  • Beneficial patient outcomes achieved using robotic technology include reduced intraoperative blood loss, shorter hospital stays and recovery periods, and reduced post-operative pain

  • In robotic surgery, the scrub nurse’s role requires technical skills, verbal and non-verbal communication skills, situational awareness, technical awareness and for the nurse to act within their scope of practice

  • Challenges associated with robotic surgery include communication issues – which have been linked to human error – as well as initial purchase costs and an increased training burden

Robotic surgery

At the turn of the new millennium, surgical robots were introduced into operating theatres in the US, followed by swift expansion into Europe (Schuessler et al 2020). While these surgical tools are referred to as robots, they are not autonomous devices and rely on input from the surgeon to function. An evolution from minimally invasive surgery to robotic surgery occurred in the late 1980s when engineers adopted laparoscopic principles and applied them to robotic platforms. This combined minimally invasive surgery, stability (because the robot rather than the surgeon ‘holds’ the instrument) and three-dimensional imaging, with further benefits such as eliminating the risk of tremor in the surgeon’s hand and enhanced instrument control, particularly in restrictive surgical spaces (Schuessler et al 2020).

Robotic technology is used worldwide for a diverse range of procedures such as cardiothoracic, gynaecological, urological and paediatric surgery (Watanabe 2014). Examples of the beneficial patient outcomes achieved using robotic technology include reduced intraoperative blood loss, shorter hospital stays and recovery periods, reduced post-operative pain, and improved cosmesis (physical appearance) when compared with traditional laparoscopic and open surgical approaches (Hussain et al 2014, Raheem et al 2017).

Role of the scrub nurse in robotic surgery

During robotic surgery, the operating surgeon sits behind a console, typically in the operating room, and manoeuvres the surgical robotic arms by manipulating the controls at the console. The operating surgeon is physically separated from the patient, while the patient-side assistant (commonly a junior surgeon or surgical care practitioner) and scrub nurse are the only team members working in the sterile field next to the patient. The scrub nurse has the relevant instruments such as scissors and needle holders available to hand, while the patient-side assistant undertakes the retraction of tissues in the patient, suction and the introduction of sutures and swabs into the patient via laparoscopic access ports. These access ports are used to bring instruments, a camera and swabs into the body, and are inserted through small incisions in the skin at the beginning of the operation, before the robot is brought alongside the patient (Hussain et al 2014).

The introduction of this complex surgical technology initially gave rise to new challenges in surgical teams, particularly with communication. Although each person in the surgical team has a specific role, effective interprofessional working relies on optimal teamwork and communication (Gill and Randell 2016). Patient safety is also significantly associated with teamwork and communication, and research has identified that breakdowns in these areas are the leading cause of preventable patient injury and death in operating theatres (Arriaga et al 2014). However, the theatre setup required for robotic surgery involves the operating surgeon being seated alone at the operating console, and they are dependent on the other team members to gather information and inform any intraoperative decisions. Therefore, in the event of an intraoperative error requiring a swift conversion from robotic to open surgery, communication and team dynamics are crucial (Barry 2019).

Situational awareness

In a qualitative study of scrub nurses’ non-technical skills, Mitchell et al (2011) noted that these nurses used situational awareness to gain vital information from cues in the operating theatre. In traditional non-robotic surgery, changes in the surgeon’s body language such as the way they accepted instruments from scrub nurses provided non-verbal cues that contributed to nurses’ situational awareness and enabled them to gauge the status of the operation. For example, a surgeon might have held out their hand to receive an artery clip but then snatched at the clip suggesting an urgent situation such as a bleed. In this way, scrub nurses were able to monitor the progression of the surgery and anticipate the surgeon’s requirements.

In contrast, in robotic surgery where the surgeon is seated at the robotic console, the scrub nurse is deprived of such information and has to rely on the surgeon’s tone of voice. For example, were the surgeon to begin sounding tense, this might suggest complications with the operation; conversely, relaxed conversations between the surgeon and other members of the operating theatre team would inform the scrub nurse that the operation was progressing smoothly (Mitchell et al 2011, Catchpole et al 2019).

Non-verbal communication

Tiferes et al (2016) observed that non-verbal communication was a highly developed skill in the robotic operating theatre, due to the distance between the surgeon at the console and the patient. Therefore, inexperienced scrub nurses should be given the opportunity to observe and assess experienced scrub nurses (McClelland 2015). Additionally, experienced scrub nurses working in robotic surgery will have learned to adapt to the lack of surgeons’ hand gestures and face-to-face contact by becoming familiar with the steps of the operation; therefore, they will not need to rely as much on visual or verbal prompts (Gill and Randell 2016).

Technical awareness

While surgery is in progress, the scrub nurse needs to be mindful of the robotic system itself and the effect robotic arm movements can have on patient safety, particularly if they knock against the patient, potentially causing tissue damage (Raheem et al 2017). One qualitative, descriptive study conducted in a South Korean robotic operating theatre found that scrub nurses were constantly concerned about patient safety and being able to ‘troubleshoot’ effectively should the robot malfunction (Kang et al 2016). This vital technical skill is unique to robotic surgery, where the system itself is a piece of stand-alone technology that requires the scrub nurse to become an ‘expert’. Such technical expertise on the part of the scrub nurse would be expected by the operating surgeon (Raheem et al 2017, Barry 2019).

Scope of practice

The International Council of Nurses (2020) defined an advanced practice nurse as a nurse who has acquired the ‘expert knowledge base, complex decision-making skills and clinical competencies for expanded nursing practice, the characteristics of which are shaped by the context in which they are credentialed to practice’. However, the expectation of expert knowledge in robotic surgery can lead to the scrub nurse inadvertently stepping beyond their scope of practice (Russell and Fletcher 2021).

Familiarity with surgical procedures and the workings of the robot can mean that certain routine actions become ‘second nature’ to the scrub nurse, and they may begin to undertake tasks that represent unsafe practice, and which may place their registration and the patient at risk (Russell and Fletcher 2021). A common example is where the scrub nurse takes on the role of advancing a robotic instrument into the patient’s body once it has been installed into the robotic arm, a role usually reserved for the patient-side assistant. Because the nurse is not familiar with guiding instruments, they might advance an instrument into an artery or other vital structure. While such procedures can appear straightforward, they potentially place the patient at risk of tissue damage if undertaken inappropriately, or where the nurse has not obtained the required level of training and is thereby acting outside their scope of practice.

Training scrub nurses in robotic surgery

Robotic technology lends itself to the role of patient-side assistant, with typical tasks including the introduction of instruments, needles and swabs into the patient via the laparoscopic access ports. Typically, undertaking a surgical care practitioner training programme – which is shortly to become a three-year master’s level qualification in the UK – is becoming the educational standard that non-medical patient-side assistants are expected to achieve (Britton et al 2022, The Royal College of Surgeons of Edinburgh 2022). While scrub nurses commonly learn through peer-to-peer learning, once they become experienced they can consider becoming a patient-side assistant by undertaking the surgical care practitioner training programme. Following this training programme, nurses will be able to undertake surgical interventions and preoperative and post-operative care under the supervision of a senior surgeon, and will attain the professional scope and level of practice to safely undertake the role of patient-side assistant (Royal College of Surgeons of England 2014).

Most patient-side assistant roles are now taken by nurses who have gone on to train as surgical care practitioners (Fletcher and Russell 2019). The patient-side assistant role is often taken by junior surgeons initially when a robotic programme has just begun. However, as a robotic surgery programme develops, a permanent patient-side assistant will commonly be sought and nurses in this role do not rotate to other hospitals as junior doctors do. Completing a surgical care practitioner training programme is the next step for nurses hoping to follow a clinical career pathway in theatres, and is similar to other senior nursing roles such as advanced nurse practitioner or clinical nurse specialist.

Patient-side assistant roles offer a mechanism for NHS organisations to retain staff with specific expertise (Glasper 2020). The surgical care practitioner training programme may provide alternative pathways to managerial roles for scrub nurses who want to remain focused on clinical practice, as opposed to taking on managerial tasks to gain promotion (Russell and Fletcher 2021).

While robotic surgery has some notable advantages over traditional surgery, the remoteness of the surgeon at the console places demands on the scrub nurse and the wider operating theatre team, particularly in terms of communication. Human error in surgery has been consistently linked to gaps in communication (Tiferes et al 2016). Additionally, any benefits of robotic surgery should be balanced against initial purchase costs and the increased training burden associated with robotic techniques. The cost benefits of robotic surgery appear to vary depending on the procedure being conducted, with the most positive evidence found in urology and gynaecology (Hussain et al 2014).

Conclusion

Scrub nurses have a close working relationship with all members of the surgical team, while remaining an advocate for the patient by preserving their rights and ensuring their safety while under anaesthesia. This requires a significant capacity for interpersonal communication, as well as a broad range of specialist skills such as a comprehensive knowledge of surgical instruments. Scrub nursing practice is inherently technical and specialist, with innovations such as robotic surgery presenting new challenges and opportunities. The role of the scrub nurse is an expanding field of practice with the potential for nurses to attain advanced surgical roles by undertaking accredited training.

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