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Call forClarity Over Names 7
CALL FORCLARITY OVER NAMES
Despite NAASP and the PCC promoting the use of the ASP title from the early
2000s, several different titles used by non- medical surgical assistants continued to
be used in practice. A position statement by the Royal College of Surgeons (RCS) in
2010 recommended the public be informed about the background and meaning of
job titles in use within the surgical setting (RCS2010). The RCS then issued another
position statement that recognised how crucial non- medical surgical assistant roles
had become to the delivery of some surgical services but called for clarity regarding
the varied titles in use by practitioners who were assisting with surgery to prevent
confusion for patients and clinicians (RCS2011). See Quick et al. (2015) for titles
that have previously been used. With NAASP dissolved, the PCC responded by
issuing an updated position statement in 2012 that provided a consensus in the
United Kingdom regarding the job titles appropriate for perioperative practitioners
who provide three different levels of assistance (PCC2012). Each of the three roles
recognised by the PCC (2012) in Figure 1.1 can be undertaken by a registered
perioperative practitioner.
TABLE1.2 List of PCC members (Adapted from
PCC,2018).
Association for Perioperative Practice
Association of Independent Healthcare organisations
British Association of Day Surgery
British Anaesthetic and Recovery Nurses Association
College of Operating Department Practitioners
Royal College of Nursing
• Performs limited surgical assistance where local governance in
place to guide and support dual role.
Scrub
practitioner
Surgical first
assistant
Surgical care
practitioner
• Provides ad hoc competent and dedicated assistance under the
direct supervision of the operating surgeon throughout the
procedure, whilst not performing any form of surgical intervention.
• Performs surgical intervention and other elements of care under
the supervision and direction of a consultant.
FIGURE1.1 The three levels of surgical assistance as clarified by the PCC (2012).
8 Chapter 1 The Historical Context ofthe Surgical First Assistant
In an updated position statement in 2018, the PCC defines the SFA as,
... the role undertaken by the registered practitioner
1
who provides continuous,
competent and dedicated surgical assistance to the operating surgeon throughout
the surgery: Surgical First Assistants practice as part of the surgical team, under
the direct supervision of the operating surgeon.
(PCC2018)
A NATIONAL SFA TOOLKIT
Despite a clear new title as well as clear responsibilities previously set by NAASP, the
number of universities who offered the accredited SFA post- registration modules
declined after 2012, most likely due to the dissolution of NAASP. Consequently, prac-
titioners struggled to find national- accredited courses and healthcare organisations
developed their own in- house courses for registered theatre staff. One problem with
in- house courses is that that they are not usually transferable from one employer to
another, and so in response to their pledge to continue the work started by NAASP,
AfPP performed an extensive update to the NAASP ASP curriculum and published
the first edition of the AfPP surgical first assistant toolkit. The purpose of the toolkit
was twofold: in the absence of university- accredited courses, it primarily acted as a
national training tool for practitioners by defining the knowledge and skills required
by SFAs. Practitioners completed the toolkit alongside in- house or other SFA training
packages. Second, it acted as a reference source for employers to assist with the stra-
tegic planning and roll out of the SFA role in the operating theatre.
ACCREDITED UNIVERSITY COURSES
With the role of the SFA becoming widely accepted within the NHS and Independent
Healthcare Sector, a number of universities once again offered post- registration
modules. The updated PCC SFA statement (PCC2018) states that the role of the SFA
should only be undertaken by someone who has successfully completed a validated
university programme of study. There was also demand from employers and
practitioners as registered nurses and ODPs looked to expand their skill set for personal
and professional development. In a service evaluation conducted by Lowes etal. (2020),
ODPs indicated that in relation to continuing professional development (CPD), surgical
first assisting was a popular area for further study. It is envisaged that demand by ODPs
to undertake SFA post- registration training will eventually decline with the PCC (2018)
statement recognising the College of Operating Department Practice (2018) Bachelor
1
A nurse registered with the NMC or Operating Department Practitioner or other AHP registered
with the HCPC.
The Responsibilities ofthe SFA 9
of Science (Hons) in ODP (Bachelor of Science in Operating Department Practitioner
in Scotland) now being a validated programme of study for SFA training.
While the current Standards of Proficiency for ODPs (HCPC2023) identifies that
ODPs need to ‘understand the role of the surgical first assistant in assisting with
surgical intervention’, the professional body for ODPs expect ODP learners to also
‘demonstrate proficiency in enhanced surgical skills, commensurate with a surgical
first assistant’ (CODP2018: 29).
THE RESPONSIBILITIES OFTHE SFA
The PCC set out the technical and non- technical responsibilities of the SFA in 2012
but in 2018 updated it to reflect the development of the SFA role in extended surgical
teams (PCC2018). The responsibilities of the SFA are listed in Table1.3 this list is
not a definitive list of skills required in every surgical speciality but rather general
guidance on the SFA’s role which means that the SFA will need to liaise with their
manager and surgical teams to identify their exact duties based on these
responsibilities which should be reflected in their job description, person
specification and supported by organisational policy (PCC 2018). Part two of this
book examines the responsibilities of the SFA role throughout each phase of the
patient’s perioperative journey.
This historical development of the SFA role has been presented from the early
days of international nursing to the UK- specific role definition of a registered practi-
tioner who performs assistance to the operating surgeon throughout a patient’s sur-
gery. Furthermore, the history of the ODP role development and the incorporation of
SFA roles at both pre- and post- registration levels have been discussed. The perspec-
tives of professional bodies and their contribution as a collaborative have also been
identified and are a useful starting point for the preceding chapters of this book.
TABLE1.3 Responsibilities undertaken by the SFA (Adapted from PCC,2018).
Assisting with patient positioning, including tissue viability
Skin preparation and draping prior to surgery
Superficial skin and tissue retraction with cutting of superficial sutures
Handling of tissue and manipulation of organs for exposure or access
Nerve and deep tissue retraction (The SFA can only move or place retractors under the
direct supervision of the operating surgeon)
Cutting of deep sutures and ligatures under direct supervision of the operating surgeon
Assisting with haemostasis to secure and maintain a clear operating field including
indirect application of surgical diathermy by the surgeon
Use of suction as guided by the operating surgeon
Camera manipulation for minimal invasive access surgery
Applications of dressings as required
10 Chapter 1 The Historical Context ofthe Surgical First Assistant
REFERENCES
Calman, K.C. (1993). Consultation on report working group on specialist medical
training, p. 1.
Clinical Surgery Journal (2012). NAASP to become part of AfPP. March.
College of Operating Department Practitioners (2018). Bachelor of Science (Hons) in
Operating Department Practice: Curriculum Document. CODP.
College of Operating Department Practitioners (2021). History of the College of Operating
Department Practitioners and the ODP profession. London: Unison.
Collins, J. (2010). Foundation for Excellence: An Evaluation of the Foundation programme.
London: NHS.
Department of Health (1999). Making a Difference: Strengthening the Contribution of
Nurses, Midwives and Health Visitors to Health and Healthcare. London: DH.
Department of Health (2001). A Framework for Lifelong Learning for the NHS. London: DH.
Department of Health and Social Security (1977). The Extending Role of the Clinical
Nurse– Legal Implications and Training Requirement. London: DHSS.
European Community (1993). Council directive 93/104/EC. Official Journal of the
European Community. L307 (18): 18–24.
Farrell, J. (1999). Enhancing perioperative nursing practice: Developing a course for the
surgeon’s assistant. British Journal of Theatre Nursing 9 (5): 202–208.
Hains, T., Strand, H., and Turner, C. (2017). A selected international appraisal of the role
of the Non- Medical Surgical Assistant. Journal of Perioperative Nursing 30 (2): 37–42.
HCPC (2023). Standards of Proficiency for Operating Department Practitioners.
London: HCPC.
Lowes, R., Duxbury, A., and Garth, A. (2020). The evolving roles of Operating Department
Practitioners in contemporary healthcare: A service evaluation. Journal of Perioperative
Practice 30 (3): 46–56.
McHale, J. and Tingle, J. (2007) 3 Law & Nursing UK: Butterworth Heinmann.
Modernising Medical Careers (2007). About Modernising Medical Careers. NHS.
http://www.mmc.nhs.uk/medical_education/about_modernising_medical_
care.aspx (accessed 8July 2012).
National Association of Theatre Nurses (1993). The Role of the Nurse as First Assistant in
the Operating Department. Harrogate: NATN.
National Association of Theatre Nurses (1994). The Nurse as Surgeons’ Assistant.
Harrogate: NATN.
National Association of Theatre Nurses (1997). Developing New Roles for Non- Medical
Staff Within Perioperative Care: Guidelines for Organisations and Employers.
Harrogate: NATN.
National Health Service Management Executive (1991). Executive Junior Doctors- the New
Deal. National Health Service Management Executive.
References 11
Nursing and Midwifery Council (2018). The Code: Standards of Conduct, Performance and
Ethics for Nurses and Midwives. London: NMC.
PCC (2012). Position Statement: Surgical First Assistant. PCC.
PCC (2018). Position Statement: Surgical First Assistant, 2e. PCC.
Pope, E.S. (1962). Beadles, porters and attendants. British Journal of Anaesthesia 43: 489.
Quick, J., Hall, S., and Jones, A. (2015). Are you prepared to take the risk: Extending
governance for perioperative roles. Journal of Perioperative Practice 25 (9): 169–172.
Rothrock, J. (1999). The RN First Assistant: An Expanded Preoperative Role, 3e. Philadelphia:
Lippincott, Williams and Wilkins.
Royal College of Surgeons of England (1994). Cardiac Surgical Assistants: Guidelines for
Heads of Departments. London: RCS.
Royal College of Surgeons (2010). Position statement: surgical titles in the NHS.
Surgical Titles in the NHS - Position Statement — Royal College of
Surgeons. rcseng.ac.uk. (accessed 9th March 2023).
Royal College of Surgeons (2011). Position statement: surgical assistants. rcs position
statement surgical assistants.pdf (accessed 5th March 2023).
Royal College of Surgeons (n.d.). Surgical care team: guidance framework. Surgical
Care Team Guidance – Royal College of Surgeons. rcseng.ac.uk (accessed
22nd March 2023).
Thatcher, J. (2007). The Advanced Scrub Practitioner Toolkit. NAASP.
13
Surgical First Assistant: The Essentials of Practice, First Edition. Editedby JulieQuick andMarkOwen.
© 2025John Wiley & Sons Ltd. Published 2025 by John Wiley & Sons Ltd.
CHAPTER 2
Ethical, Legal and Professional
Considerations of the SFA
Role
Mark Owen
1
and Julie Quick
2
1
University of Gloucestershire, Cheltenham, UK
2
Birmingham City University, Birmingham, UK
Chapter 1 provides the context for the reader in relation to the development of
enhancing surgical roles for non- medical registered practitioners. The aims of this
second chapter are to consider the ethical, legal and professional aspects of the sur-
gical rst assistant (SFA) role. This will be accomplished by the use of scenarios and
will signpost the reader to useful resources for wider reading. It is hoped that this case
study approach will aid clinical decision- making while undertaking the SFA role as
well as encourage critical reection by the reader, be it pre- registration operating
department practitioner learners, or post- registration registered practitioners, who
are developing their surgical skills as part of their continuing professional development.
At the time of publication, relevant UK laws and professional standards have
been cited in this chapter and others; however when practicing as an SFA, the rele-
vant legislation of English, or the devolved nations where the SFA practices, must be
upheld, alongside current professional standards which may be subject to change in
the future. It is the responsibility of the SFA to ensure that they practice in accordance
with their regulatory standards, ethical principles and associated legislation that
applies to them as a registered practitioner.
In relation to ethics, the four ethical principles, respect of autonomy, nonmalefi-
cence, beneficence and justice, presented by Beauchamp and Childress (2019) will be
utilised to support the discussion in each of the scenarios presented. A brief summary
for each is presented below.
14 Chapter 2 Ethical, Legal and Professional Considerations of the SFA Role
AUTONOMY
This ethical principle is concerned with respecting the rights of individuals to make
an informed decision and in healthcare this extends to choices made on the information
provided by healthcare professionals. In the context of the SFA, the registered practi-
tioner should respect each patient’s decision and promote and not obstruct the
patient’s autonomy (Booth and Daly2024, p.184).
BENEFICENCE
As an ethical principle, beneficence is defined as a moral obligation to do good. In
order to promote beneficence, registered practitioners, including SFAs, should ensure
that all actions undertaken benefit the patient (Booth and Daly2024, p.184).
NONMALEFICENCE
As well as doing good, the SFA is required to protect the patient from harm. All sur-
gical interventions involve some form of harm or risk; however the harm should not
be disproportionate to the benefits of the intervention undertaken (Booth and
Daly2024, p.184).
JUSTICE
This is based on the principle that fairness and equality are afforded to all who access
healthcare. In addition, person- centred care should focus on the individual needs of
the patients, recognising their differences (Booth and Daly2024, p.184).
CASE STUDIES
The following case studies will explore the ethical, legal and professional aspects that
the SFA may encounter in practice.
Scenario 1
The SFA is asked by the operating surgeon to place a deep tissue retractor.
Undertaking tissue retraction, both deep and superficial, is identified as a responsibility
of the SFA (PCC2018). The PCC (2018) state, however, that the SFA can only move
or place retractors during deep retraction under the direct supervision of the
operating surgeon.
Case Studies 15
The Royal College of Surgeons of England (RCSEng, n.d.a) in their ‘Surgical Care
Team, Guidance Framework’ that was published after 2018indicate that retractors
should not be placed by the SFA but by the operating surgeon. The RCSEng (n.d.a)
also recommend that the registered practitioner performing this role, must risk assess
their knowledge, skills and experience to determine the appropriate action to take in
relation to tissue retraction. In relation to ethics, the SFA should select the most
appropriate method of retraction in order to act in ways to benefit the patient (benef-
icence) and protect the patient from harm (nonmaleficence). Regulatory bodies man-
date that registered practitioners must manage risk. The HCPC (2016, p.8) states that
registrants must ‘identify and minimise risk …’ and furthermore ‘establish safe envi-
ronments for practice, which appropriately manage risk’ (HCPC 2023, p.18). Simi-
larly, the Nursing and Midwifery Council (NMC) in The Code (NMC2018a) also
identifies that nurses and midwifes must preserve safety and ensure the quality of
care is maintained and improved. To reduce harm to the patient, prior to undertaking
tissue retraction, the SFA must have knowledge of the structure and function of the
human body (NMC2018b; HCPC 2023) and the SFA should also have procedural
knowledge to understand the associated risks of placing a retractor and the potential
for harm. The SFA should also ensure they select the right retractor to ensure ade-
quate exposure and reduce the risk of injury. For more information on the selection
and use of retractors, see Chapter7 on Tissue Handling and Retraction and Chapter8,
Instrument Handling.
In law, from the Donoghue versus Stevenson 1932 case, the judge ruled that a
person ‘must take reasonable care to avoid acts or omissions which you can reason-
ably foresee would be likely to injure your neighbour’ and as Lord Atkins stated,
‘Who then in law is my neighbour? The answer seems to be in persons who are
so closely and directly affected by my act that I ought reasonably to have them in
contemplation as being so affected when I am directing my mind to the acts of
omissions which are called in question’.
(Dimond2015, p.47)
In the context of the SFA, a duty of care exists if one can see that their actions
could reasonably cause harm to another person. As a registered practitioner performs
the SFA role, the registrant therefore owes a duty of care to their patients. To establish
this duty of care, and whether it has been breached, the importance of the standard of
care owed must be established (Dimond2015, p.50).
The case of the Bolam versus Friern Hospital Management Committee is an
example where a breach in the duty of care was cited. This case led to what is com-
monly referred to as the ‘Bolam test’. The standard of care should not be judged against
‘that of an ordinary member of the public …’ (Booth and Garbett2024, p.89) but one
‘that involves the use of some special skill or competence …’ (Dimond2015, p.165)
and therefore an SFA would not be negligent if they act in accordance with accepted
standards of care in performing deep tissue retraction. These standards should be the
16 Chapter 2 Ethical, Legal and Professional Considerations of the SFA Role
reasonable standard of practice shown by an individual who regularly performs the
same role. As Chapter1 has highlighted, the development of the non- medical surgical
roles was to overcome the decline in the availability of doctors to assist routine
operating lists. The significance of this is that, while the number of non- medical SFAs
is increasing, the standard of care should remain that of a junior doctor who tradition-
ally performs this role.
Signpost
For an example of a case of medical negligence in the United States by a surgical tech-
nician causing nerve damage from a retractor, read Quick etal. (2015).
Scenario 2
The SFA is delegated the task of superficial wound closure by the operating surgeon.
Delegation is the transfer of a specific task from one person to another. The General
Medical Council (GMC2024) has specific requirements for the delegating operating sur-
geon and indicate that ‘You [the operating surgeon] must be confident that any person
you delegate to has the necessary knowledge, skills and training to carry out the task
you’re delegating. You must give them clear instructions and encourage them to ask
questions and seek support or supervision if they need it’. As a registered practitioner, the
SFA should only accept delegation if it falls within their defined scope of practice.
Both regulatory bodies have specific standards regarding a registrant’s scope of
practice (HCPC2016; HCPC2023; NMC 2018a). In order to determine a defined scope
of practice for the SFA, the PCC (2018) provides a position statement on the roles and
responsibilities of the SFA.
1
Within this statement, suturing of skin layers is identified
as an SFA’s extended scope of practice; therefore, if the SFA has not completed addi-
tional skills and attended an appropriate surgical skills course (PCC2018), the task in
this scenario would not be considered within their scope of practice as an SFA. As a
registered practitioner, the SFA must work within their defined scope of practice and
identify the limits of their practice and refuse to perform any duties that sit outside of
this. In making such decisions, the SFA must reflect critically on whether they have
the knowledge, skills and experience to practise in a way that upholds the law and
professional standards and is safe and effective.
The Royal College of Surgeons of England in their ‘Surgical Care Team, Guidance
Framework’ (RCSEngn.d.a) is also a useful resource that includes the SFA role defi-
nition and an overview of the tasks and activities of the SFA which may assist the SFA
in defining their scope of practice. Within the framework, there is specific reference
to ‘simple wound closure and skin suturing’ in that within an extended scope of prac-
tice, the SFA can ‘undertake skin suturing to close simple wounds provided they have
1
The PCC (2018) presents a table that distinguishes the role boundaries between the registered scrub
practitioner and the SFA. The PCC (2018) highlights that the table is not an exhaustive list of all tasks
undertaken by registered scrub practitioners nor is it intended to be a competency framework.