Knowledge and perceptions of the NMSA role in Australia: A Knowledge and perceptions of the NMSA role in Australia: A perioperative

In Australia, the role of the Non-Medical Surgical Assistant (NMSA) lacks recognition and professional regulation. This paper reports the findings of a recent survey of Australian perioperative staff [n=116] to determine their knowledge and perceptions of the NMSA role. The survey findings confirm that the role is not well established across the Australian health care system. Of concern is that perioperative staff are required to fill the role of surgical assistant on an impromptu basis. NMSAs with no post-graduate qualifications are perceived by perioperative staff to be less equipped in mentoring, leadership, theatre efficiency, safety and procedural knowledge. There was evidence that some perioperative praxes necessitate the role of the NMSA to avoid practices that compromise patient safety.


Introduction
Practising perioperative nurses work in a relatively flat hierarchy in the clinical setting in which their roles are largely dictated by differences in the context of care. On occasion, variances in contexts and resources require Registered Nurses (RNs) to perform roles, such as surgical assisting, not typically associated with their scope of practice and this is a reflection of the leadership often displayed by perioperative clinicians [1][2][3] . Recently, the role of Nurse Practitioner (NP) has paved the way for nurses to expand their autonomy and scope of practice into the realm of other health care disciplines. As many possible Advanced Practice Nursing (APN) roles emerge in the Australian health care context, perioperative nurses will be required to consider the role of the NMSA and its relationship to scope of practice within the perioperative environment. Perioperative nurses may be able to develop pathways towards the role of the NMSA in ways that assure equality of cost and care delivery with those who currently perform the role 1,4-6 . This paper investigates the knowledge, perceptions and need for the role of NMSA in Australia.

Background
In a recent study on the role of the NMSA in Australia, it was reported that only RNs and NPs were performing the role 5,7,8 . The role of the NMSA presents a potential domain for advanced practice in Australia, particularly for perioperative nurses 9 . Depending on the qualification of the clinician, the scope of their practice and degree of autonomy they have may vary within the bounds of national or state legislation 10,11 .
In a recent practice audit of the role of the NMSA in Australia only RNs and NPs responded as performing the role of the NMSA 12 . Since orthopaedic and general surgery are the most commonly performed surgeries in Australia it was anticipated that orthopaedic surgery would have the highest NMSA involvement Peer-reviewed article and general surgery the second highest 13 . This was confirmed by a recent practice audit of NMSAs in Australia 12 .
In a study conducted in New Zealand on the role of the NMSA, most of those training for the role felt supported by other perioperative nurses, non-nursing staff and surgeons. The majority of surgeons who were surveyed as part of this report also felt the NMSAs were supported by other nursing staff. One surgeon and one NMSA from the private sector strongly disagreed that nursing and non-nursing colleagues understood or supported the role 33 . A paper generated from the implementation of NMSAs for public lists in a private hospital program in Australia highlighted that both perioperative staff and surgeons were very supportive and positive about the role of the NMSA 34 .
Very little literature exists about the opinions or perceptions of key stakeholders such as perioperative staff. Nurses, in particular, constitute a large proportion of the health care profession so surveying nurses on health-related research can yield valuable information 35 .

Aim
The aim of this study was to survey perioperative nurses' knowledge and perceptions of the role of the NMSA to identify current perioperative practice relevant to the role of the NMSA.

Method
This research takes the form of a descriptive, quantitative paper using survey method with convenience sample. Data analysis is descriptive. Institutional ethics approval for the survey was obtained from The University of Queensland (#2015000084). Permission from the Australian College of Operating Room Nurses (ACORN) to administer the survey at the national conference was obtained. Implied consent was achieved by participants progressing through the survey to final submission.

Participants and sampling
Convenience sampling was adopted for this survey. As the total population of perioperative staff in Australia is difficult to accurately estimate, a sampling frame of the perioperative population who attended the 2016 ACORN National Conference was used. Using a specialty association of this type for sampling is time efficient and the researcher can access a geographically diverse sample 36 . The Australian attendees at this conference were approximately 900. Using an industry standard confidence interval of 95 per cent and margin of error of 5 per cent the sample size required to allow generalisability from the survey was 270 37 . As outlined in Table 2, of roles exclusive to the NMSA role, Perioperative Nurse Surgeon's Assistant (PNSA) was the most familiar with 83.6 per cent (n=102) of respondents currently working with an NMSA in their unit. The generalist role of NP scored 95 per cent (n=116), which is higher than PNSA but NPs work in many specialties in the health care system. Perioperative Nurse Practitioners who work as NMSAs scored 51.6 per cent (n=63), much lower than the PNSA.
The specialty with the highest involvement of NMSAs in this survey was orthopaedics surgery (39.8 per cent, n=49), followed by general surgery with (33.3 per cent, n=41). For uptake in other surgical specialties see Table 2. Utilisation was highest in metropolitan private perioperative units.  If perioperative staff members are required to fill the role of surgical assistant this would add weight to the argument that a need exists in the Australian health care system for the role of the NMSA. The first issue this raises is that the health care facility must provide a staff member in this situation. The second issue of concern is that, while some of the tasks performed by perioperative staff members who fill in as surgical assistants may seem very rudimentary -for example 'pointing the camera' for vision during laparoscopic procedures -using untrained assistants has implications related to medico-legal outcomes and patient safety in the event of a complication both intraoperatively and in the postoperative period 39 .
Staff who perform but are not formally designated to the role of surgical assistant leave themselves exposed to organisational and medico-legal ramifications 40 .
2. The instrument nurse is performing a dual role of surgical assistant, in some cases, on a daily basis Twenty-two per cent of respondents indicated that the instrument nurse was required to also perform the role of surgical assistant on a daily basis. Standards of practice from both ACORN and the Association of Perioperative Registered Nurses (AORN), the peak perioperative nursing body in the United States of America, state that the NMSA cannot concurrently function as an instrument nurse and cannot partake in the counting procedure 41,42 . When the instrument nurse is also performing the surgical assistant role, patient safety is considered to be compromised. This compromise is related to issues with establishing priorities between assisting the surgeon and conducting a comprehensive count 43 .
3. NMSAs with no post-graduate qualifications are perceived by perioperative staff to be less equipped in the skills of mentoring, leadership, theatre efficiencies, safety and procedural knowledge.
This poses the question: What differences in their ability to execute advanced practice tasks exist between diploma-prepared ENs, degree-prepared RNs, RNs with post-graduate NMSA qualifications and master's level NPs? 44 The differences in specialty practice and advanced practice lie in the level of education which, in turn, promotes the clinician's ability to execute complex tasks 45 .
Regarding governance of the NMSA role in Australia, almost 85 per cent of respondents thought AHPRA via the NMBA should govern this role. This would ensure that the role of NMSA in Australia was a nursing role based on a nursing model of care. This varies from some of the international NMSA roles that have developed based on the medical model of care rather than patient-centred care.

Limitations
Surveys are considered a costeffective mode of collecting information across an immense array of clinicians and practice settings 46 : however, surveys of health care providers are characterised by low response rates 35,47 . Low response rates raise concerns about the generalisability of the results. Nurses are reluctant to participate in a survey if the value or relevance is not clear . 35 . As the role of NMSA is not a mainstream health care role in Australia, many nurses are not familiar with the title or the role. Entry in a draw of a non-monetary prize was used as incentive to participate in the survey but this technique has been shown to yield varying success 35,46 .

Conclusion
A need exists in the Australian health care system for the NMSA role. This need is reinforced by perioperative staff reporting they regularly fill in for absent surgical assistants when there is no pre-arranged assistant, the pre-arranged assistant needs to leave and in out-of-hours cases. Survey findings also indicate that the dual role of instrument nurse and surgical assistant is being performed in Australian perioperative units. Support for the formal recognition and regulation of the NMSA role in Australia is evidenced by perioperative staff perception that NMSAs with a higher level of qualification consistently perform tasks related to mentoring, leadership, theatre efficiencies and procedural knowledge at a 'good' or higher level. In the interests of patient safety, a dialogue should commence between ACORN, the Royal Australasian College of Surgeons and the Nursing and Midwifery Board of Australia to determine the best approach for recognising, educating and professionally regulating the NMSA role in Australia.