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Case Studies 17
received appropriate training and assessment (e.g. through the Intercollegiate Basic
Surgical Skills course or through demonstrating competence at the same level)’. Ethically,
undertaking additional responsibilities only after appropriate training ensures the
SFA aligns to the principles of beneficence and nonmaleficence.
The PCC (2018) indicates that the registered practitioner must not undertake the SFA
role until the organisation has a policy in place to support this clinical practice. As an
employee, the PCC (2018) also recommends that this role is specified within the practitio-
ner’s job description, person specification and contract of employment. As a requirement
of registration, both the HCPC and NMC indicate that a registered practitioner must have
professional indemnity in place. Therefore, the SFA must ensure they have an appropriate
level of cover to undertake the role, when performed within a given setting.
Dimond (2015, p.805) provides a definition of vicarious liability: ‘liability of an
employer for the wrongful acts of an employee committed in the course of their
employment’, and it is therefore crucial that the SFA checks with their employer that
specific guidelines and policies are in place for their employer to be responsible for
their acts of omissions in the SFA role within the scope of their employment. In rela-
tion to the scenario presented, if the SFA accepted the delegation without having the
knowledge, skills and experience, it is likely that the employer would not take respon-
sibility and the individual would be personally liable and professionally accountable
for the decision to perform the task of superficial skin suturing delegated. The regis-
trant may also have their employment terminated and be subject to an investigation
from their statutory regulator under their procedure for fitness to practice.
Signpost
Read Quick etal. (2015) for the only example the chapter authors are aware at the
time of writing, of a case where an SFA was working outside of the boundaries and
training of the role of the SFA. The case indicates that the practitioner was performing
surgical intervention, outside of the remit of the SFA.
Scenario 3
The SFA is asked to dual role by the operating surgeon while undertaking the scrub prac-
titioner role.
The PCC (2018) position statement for the SFA makes key recommendations to
ensure safe surgical practice, one of which is that ‘The SFA should be rostered as an
additional member of the perioperative team’. Specific guidance on the dual role,
with a distinction made between the registered practitioner in the scrub practitioner
role and the SFA, is also provided. The registrant in the scrub practitioner role
must befocussed on the management of the patient’s surgical care and should not
accept the request for delegation of the additional role of the SFA from the operating
surgeon in a dual role. The SFA also has defined roles and responsibilities and
should be allocated to the surgical team in addition to the other members of the surgical
care team (PCC2018).
18 Chapter 2 Ethical, Legal and Professional Considerations of the SFA Role
There may be circumstances where a dual role is considered, in minor surgery,
however this must only performed where the organisation has a policy in place to
support this specific dual role (PCC 2018). In accordance with the organisation’s
clinical governance frameworks, the policy should include a full risk assessment of
the types of surgeries for which the dual role is appropriate and determine the required
knowledge, skills and competence needed to perform this dual role. An individual
risk assessment should be undertaken for each specific surgery to reduce the risk of
harm and ensure patient safety.
Professional and regulatory bodies have specific standards that ensure registrants
minimise harm to patients. The registered scrub practitioner who has not successfully
completed a validated university course that meets nationally recognised standards
(PCC2018) must consider their scope of practice to perform the additional roles and
responsibilities of the SFA, alongside their roles and responsibilities as the scrub prac-
titioner. Likewise, a registrant who has successfully completed an appropriate course
for the SFA role must also use their autonomy as a registrant to determine the poten-
tial for a risk of harm when acting in a dual role as scrub practitioner and SFA. In this
scenario, the professional and ethical considerations overlap. In accordance with the
ethical principles (Beauchamp and Childress2019), a registered practitioner in either
the SFA or the scrub practitioner role must always act in ways that benefit the patient
(beneficence) and protects the patient from harm (nonmaleficence) and avoid working
in a dual role unless appropriate governance arrangements are in place to support this.
Signpost
Perioperative Care Collaborative (2018) Position Statement: Surgical First Assistant.
Scenario 4
The SFA attends the preoperative ward with the operating surgeon and while the surgeon is
obtaining consent to treatment, the patient informs the surgeon that they refuse to have a
non- medical SFA providing their care during the surgery.
The regulatory bodies of the NMC and HCPC have specific standards that relate to
informed consent. These standards apply to the role of the SFA, for example, the HCPC
state ‘you must make sure that you have consent from service users or other appropriate
authority before you provide care, treatment or other services’ (HCPC2016, p.5) and
‘understand the need to provide service users or people acting on their behalf with the
information necessary, in accessible formats, to enable them to make informed decisions’
(HCPC2023, p.11). Similarly, the NMC state that you [the registrant] must ‘make sure
that you get properly informed consent and document it before carrying out any action’
(NMC2018a, p.8). Informed consent has ethical dimensions in relation to beneficence,
autonomy and justice. If the patient refuses to have a non- medical SFA providing their
care during the surgery, this decision must be respected. The operating surgeon may
discuss the possible alternatives with the patient, including having medical personnel
providing surgical assistance for the proposed surgery and provide information to the
patient on the possible timeframe to arrange medical assistance for their surgery.
References 19
The legal case of Montgomery v Lanarkshire Health Board (2015) rejected the
Bolam case in relation to consent which was based on the judgements of medical
practitioners, instead shifting the focus of consent on the patient’s needs, and placing
a responsibility on practitioners to provide a patient with all the information they
need to make an informed decision (RCSEngn.d.b).
When the facts are put to the patient and the patient still declines the use of a non-
medical SFA, in respecting the patient’s decision, the SFA should respect the patient’s
wishes and inform the surgeon. This benefits the patient (beneficence) and furthermore it
promotes and does not obstruct the patient’s autonomy to make reasoned choices based
on the information provided. A further ethical dimension in this scenario relates to jus-
tice, in that the SFA ensures fairness and equity is afforded to the patient as an individual
in recognising their individual needs. This scenario also emphasises the statutory Duty of
Candour (2014) introduced by the Care Quality Commission that applies to the SFA role
by identifying the importance of an open, honest and transparent culture which should be
demonstrated in all healthcare settings including the perioperative environment.
Signpost
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Booth and Garbett (2024) provide some further examples for wider reading on
legal aspects of perioperative care.
REFERENCES
Beauchamp, T. and Childress, J. (2019). Principles of Biomedical Ethics, 8e. Oxford: Oxford
University Press.
Booth, H. and Garbett, L. (2024). Legal frameworks for operating department practition-
ers. In: Foundations for Operating Department Practice: Essential Theory for Practice
(ed. H. Abbott and H. Booth), 154– 177. Maidenhead: Open University Press.
Booth, H. and Daly, R. (2024). Ethics for operating department practitioners. In: Foundations
for Operating Department Practice: Essential Theory for Practice (ed. H. Abbott and H.
Booth), 178– 196. Maidenhead: Open University Press.
Care Quality Commission (2014). New NHS regulations to improve openness and transparency.
https://www.cqc.org.uk/news/stories/new- nhs- regulations- improve-
openness- transparency (accessed 27 April 2024).
Dimond, B. (2015). Legal Aspects of Nursing, 7e. London: Pearson.
General Medical Council (2024). Delegation and Referral. Manchester: GMC.
Health and Care Professions Council (2016). Standards of Conduct, Performance and
Ethics. London: HCPC.
Health and Care Professions Council (2023). Standards of Proficiency, Operating
Department Practitioners. London: HCPC.
Montgomery v Lanarkshire Health Board (2015). UKSC11.
Nursing and Midwifery Council (2018a). The Code, Professional Standards of Practice and
Behaviour for Nurses, Midwives and Nursing Associates. London: NMC.
20 Chapter 2 Ethical, Legal and Professional Considerations of the SFA Role
Nursing and Midwifery Council (2018b). Future Nurse: Standards of Proficiency for
Registered Nurses. London: NMC.
Perioperative Care Collaborative (2018). Position Statement. Surgical First Assistant.
London: Perioperative Care Collaborative.
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.
Royal College of Surgeon of England (n.d.). Surgical Care Team. Guidance Framework.
London: RCSEng.
Royal College of Surgeon of England (n.d.). Consent: Supported Decision Making.
London: RCSEng.
PART II
THE PERIOPERATIVE
ROLEOFTHE SFA
23
Surgical First Assistant: The Essentials of Practice, First Edition. Edited by Julie Quick and Mark Owen.
© 2025 John Wiley & Sons Ltd. Published 2025 by John Wiley & Sons Ltd.
CHAPTER 3
Preoperative Assessment
Jenny Abraham
University Hospitals Coventry and Warwickshire NHS Trust,
Senior Teaching Fellow, Coventry University, UK
This chapter aims to explore the importance of preoperative assessment and risk
management of the surgical patients to ensure their safety. It will include a brief overview
of the purpose of common comorbidity assessments, risk assessment/screening tools, sur-
gical site marking, informed consent, patient education, mobility and preoperative fasting.
It is acknowledged that some surgical first assistants (SFAs) may not be involved
in the preoperative care of the patient and must decline to undertake any elements of
the role for which they are not competent or those elements that are outside their
individual scope of practice, as covered in the previous chapter. Nonetheless, the pre-
operative phase of the patient’s journey is essential to reduce intraoperative and post-
operative complications. Clinical practitioners are required by their professional
regulatory standards to utilise their skills, knowledge, experience, and the information
available to them to make informed decisions and take appropriate action (NMC2018;
HCPC 2023). Therefore, the SFA’s understanding of the patient’s preoperative
management is important for maintaining accountability for their actions in accor-
dance with relevant professional standards of practice, ensuring they act to identify
and minimise any risks to patients.
Nationally, the Royal College of Anaesthetists (RCoA) (RCoA2019), and internation-
ally, the American Society of Anesthesiologists (ASA) (ASA2020), recommend that all
patients scheduled for elective surgery undergo a preoperative assessment using a
classification system. The preoperative assessment process can improve a patient’s surgical
outcomes by mitigating risk factors through assessment and optimisation prior to surgery.
24 Chapter 3 Preoperative Assessment
Optimisation should include evaluations of physical, nutritional, functional capacity,
cognitive status, physiological health and social support, using validated risk assessment
tools and investigations (Centre for Perioperative Care (CPOC)2021). It is therefore impor-
tant that the SFA recognises the impact of preoperative preparation on the patient to
reduce poor outcomes and avoid cancellation of surgery on the same day, which can be
distressing for the patient and their family, as well as a waste of healthcare resources.
PREOPERATIVE ASSESSMENT
All patients requiring surgery under general or regional anaesthesia are medically
assessed prior to surgery. This assessment involves a process of shared decision-
making (SDM), where both clinicians and patients share information about available
investigative and treatment options to empower patients and individualise their care.
These outpatient clinics are typically run by nurses, with support from anaesthe-
tists and other multidisciplinary team services, such as pathology, radiology and
cardiology, to complete complex assessments and optimise the patient’s fitness for
surgery (CPOC2021). CPOC (2021) recommends:
• Every patient requiring surgery and/or anaesthesia/anaesthesia- led sedation
should undergo a formal preoperative assessment before the day of admission.
• Patients should be assessed for the impact of comorbid conditions on functional
capacity, perioperative pathways and surgical outcome.
• Patients should be screened for cognitive impairment, psychological distress
and the risk of malnutrition using validated tools.
The purpose of the assessment is to identify risks such as blood loss, mobility
issues, past medical and surgical history, including medication and allergies. From an
SFA’s perspective, being aware of these risks is particularly important and should be
communicated to the wider theatre team, as they may affect the equipment and mate-
rials used in surgery, such as surgical gloves, adhesive drapes, cell salvage availability,
wound dressings, drains, positioning and transfer equipment. Frequently, patients
with a natural rubber latex allergy are scheduled first on the list to reduce airborne
latex contamination (Association for Perioperative Practice2022). If this is not pos-
sible, the theatre should be rested to allow ventilation air changes to remove the air-
borne latex. There continues to be debate regarding the appropriate rest time for an
operating theatre; the Australasian Society of Clinical Immunology and Allergy (2010)
recommends three hours. Given this, the rest period will depend on local guidance
and may differ according to the theatre ventilation system. Consequently, the opera-
tional management team must also be aware of whether the patient has a natural
rubber latex allergy during the planning stages to formulate the operating list.
There are many risk assessment tools that can be used preoperatively for surgical
patients. The most well-
known general risk assessment tool is the ASA physical
classification, which evaluates the patients’ medical preoperative status to predict
Preoperative Assessment 25
perioperative risk and postoperative complications and to plan the patient’s care
(Sweitzer2019). The ASA classification ranges from 1 to 6 (see Table3.1). It is worth
noting, however, that agreement on a classification can be subjective; therefore, more
than one tool may be needed to identify risks to the patient.
The ASA classification is also included in the Surgical Outcome Risk Tool v2
(SORT), which estimates the predicted mortality within 30days of the operation and
considers the type of surgical procedure and its urgency (Wong et al. 2020). Using
SORT v2in conjunction with the scheduled surgery type and clinical urgency can
facilitate a clearer discussion with the patient by estimating risks, which can then be
documented in the consent process.
The optimisation of the patient’s comorbidities prior to admission may involve the
use of diagnostic screening (see Table3.2) to determine the baseline status ofthe
patient and identify the presence or absence of any underlying disease preoperatively.
TABLE3.1 ASA classification simplified ASA (2020).
ASA classification Health description of the patient
ASA 1 Normally healthy
ASA 2 Mild systemic disease not affecting functional status
ASA 3 One or more moderate–severe systemic disease with substantial
functional limitation
ASA 4 Severe systemic, incapacitating disease with constant threat to life
ASA 5 Moribund patient, not expected to survive 24 hours with or without
an operation
ASA 6 Declared brain dead, patient’s organs are being removed for donation
TABLE3.2 Diagnostic screening.
Vital
physiological
observations
Radiological
investigations
Cardiac investigations Other investigations
Temperature Ultrasound scans Echocardiograms (ECG) Oeophagogastro-
duodenoscopy (OGD)
Blood pressure Computerised
tomography (CT)
Arteriograms 24- hr pH manometry
Pulse Magnetic resonance
imaging (MRI)
Venogram Respiratory/lung function
tests
Pulse oximetry Barium/contrast
swallows
Cardiopulmonary
exercise tests (CPEX)
Colonoscopy
Respiratory rate X- ray chest/
abdominal/limb
Echogram
26 Chapter 3 Preoperative Assessment
The investigations requested will be appropriate to the individual patient and
reviewed for any abnormalities to facilitate prompt treatment plans. The preoperative
assessment team follows NICE guidance NG45 (2016) and local guidance to request
routine investigations, ensuring that the patient is adequately screened without being
overburdened with investigations, which can be expensive, cause anxiety to patients
and may not be required.
Patients with obesity have specific perioperative requirements (AAGBI2015) that
should be included in the preoperative team brief and the World Health Organisation
(WHO) surgical safety checklist, which follows the eight-
step National Safety Stan-
dards for Invasive Procedures (NatSSIPs) process (CPOC2023). These requirements
include the availability of appropriate equipment, such as suitable wedges and sup-
ports, operating tables, beds and trolleys capable of accommodating patients weigh-
ing 250 kg or more with large girths. Extra time should be allocated for positioning
patients with obesity and performing anaesthesia. Frequently, additional trained
anaesthetic, surgical and theatre staff are necessary; the experience of the anaesthe-
tist, surgeon and surgical assistant should also be considered. It is recommended that
patients withobesity considering surgery should undergo a Mortality Risk Score (OS-
MRS) assessment (Thomas and Agrawal2012). The OS- MRS risk assessment catego-
rises patients into low, moderate and high risk of mortality. A score of 2–3 (moderate)
should prompt discussion with a consultant, whilst a score of 4–5indicates a high risk
of mortality and should be managed by an anaesthetist experienced in the caring for
patients with obesity. An experienced surgeon and SFA can help reduce operative
time, which can subsequently reduce perioperative morbidity (Schuster etal.2021).
The SFA should be aware of the individual patient requirements, local guidance
and relevant investigations to ensure the availability of equipment and effective com-
munication with the surgical team. In addition, the SFA should recognise common
comorbidities and the potential complications and risks associated, as well as how
some of these risks can be mitigated (see Table3.3).
PATIENT EDUCATION
Preoperative assessment also provides an opportunity to reduce patient and family
anxiety by providing valuable information on their treatment and care throughout
theperioperative surgical pathway, including postdischarge, as well as highlighting
potential risks and complications. Patient information can take various forms, such as
video links, podcasts, written materials and verbal communication, and the most
appropriate options should be available for each individual patient. This may include
language translation and consideration of the availability of new technologies.
Although, according to Baker etal. (2018), patients prefer written information, this
preference may change in the era of advancing digital technology. Physiological and
social factors can hinder the patient’s recovery, and providing patient education
andempowerment can improve this. For example, smoking can affect wound healing
and increase surgical complications (Young-
Wolfe et al. 2019; Liu et al. 2022).