THE PRE-ASSESSMENT CLINIC AND THE ROLE OF THE PRE-ASSESSMENT NURSE

GENERAL AIMS OF PRE-ASSESSMENT

Pre-assessment is a service provided by some health care Trusts to patients waiting for elective surgical procedures. Its purpose is to enable health care staff to prepare patients both physically and psychologically for their forthcoming admission. By carrying out a full assessment of each individual, staff are equipped with the necessary information to identify any problems or needs likely to arise and thus deal with them prior to admission.

The pre-assessment of vascular patients is absolutely vital, as very often these patients present with co-morbidity, which place them in a high-risk category for anaesthesia. A close liaison between the pre-assessment staff and anaesthetic department is therefore essential in order to prevent last minute cancellation of these patients. This can be achieved in the following ways:

• The provision of health education may help to achieve the optimum level of fitness needed prior to surgery.

• Patients may be offered the opportunity for referral to appropriate services, such as smoking cessation, dietetics and vascular nurse specialists.

• Leaflets on health issues, such as dirt and alcohol intake, exercise tolerance and blood sugar control, can also be offered.

ROLE OF THE PRE-ASSESSMENT NURSE

The role of the pre-assessment nurse is to ensure that the aims of pre-assessment are met fully and that safe preparation of the patient for elective surgery takes place. Pre-operative assessment offers an opportunity to enhance the nursing role.

Nurses working in the expanded role of prescriber will frequently be faced with prescribing decisions. This text provides easily accessible information upon which to base these decisions, ensuring safe and effective prescribing practices. Each chapter examines preparations available to nurses in the extended formulary and their effects on the human body. These preparations can be prescribed in the following four areas:

• Minor ailments

• Minor injuries

• Health promotion

• Palliative care

Information including product dosage, contraindications, adverse effects, drug interactions, and specific nursing points is presented in detail. This text adopts the same approach as Nurse Prescribing: Principles and Practice, written by the same authors, in that it provides key background information from the relevant life sciences, as it applies to modern clinical practice.

The authors have brought together widely available information in the form of a single, easy to use, practice based text, which, in conjunction with the NPF/BNF, Drug Tariff and manufacturers' product information sheets, provides an essential guide to nurse prescribing.

In 1986, recommendations were made for nurses to take on the role of prescribing. The Cumberlege Report Neighbourhood Nursing: A Focus for Care (Department of Health and Social Security (DHSS), 1986), examined the care given to patients in their homes by district nurses (DNs) and health visitors (HVs). It was identified that some very complicated procedures had arisen around prescribing in the community, and that nurses were wasting their time requesting prescriptions from the general practitioner (GP) for such items as wound dressings and ointments. The report suggested that patient care could be improved, and resources used more effectively, if community nurses were able to prescribe, as part of their everyday nursing practice, from a limited list of items and simple agents agreed by the DHSS.

During 1989 a report was published which made a number of recommendations involving the categories of items for which nurses might prescribe, together with the circumstances under which they might be prescribed (Department of Health (DoH), 1989). The report suggested that a number of benefits would occur as a result of nurses adopting the role of prescriber. As well as improved patient care, this included improved use of both patients' and nurses' time and improved communication between team members.

During 1992, the primary legislation permitting nurses to prescribe a limited range of drugs was passed (Medicinal Products: Prescribing by Nurses Act 1992). The necessary amendments were made to this act in 1994 and a revised list of products available to the nurse prescriber was published in the Nurse Prescribers' Formulary (NPF) (see Table I.1).

CASE

“Does being a doctor include being a social worker?”

As a fourth year medical student I was assigned to care for an elderly Hispanic woman with frequent hospital admissions. As I got to know her it became clear that there were a number of nonstrictly medical issues that were having a decided impact on her health. She lived alone in a small unheated inner city apartment, accessible only by a long flight of steps. Because of her severe arthritis she seldom went outside. Her decreased mobility made it difficult for her to shop properly; she favored an ethnic grocery store at some distance from her neighborhood. The resulting poor nutrition contributed to her anemia. My patient was an extremely private woman who had few personal contacts and valued her solitary life. She confided in me that her greatest fear was losing her independence.

What are the boundaries of the doctor's professional responsibilities in such a situation? Does being a doctor also involve being a social worker? Was it part of my duties to be concerned about the separate, but not medically unrelated, issues of food and housing for this patient?

Professional regulation and self-regulation are essential ingredients in medicine. This regulation requires monitoring, not only of one's self, but also of one's peers. The responsibility to report risks that colleagues and other health professionals may pose to the public lies in the obligation to prevent serious foreseeable harm. Since disclosing often comes with considerable personal cost, how vigilant should trainees be expected to be in disclosing such information? If, for example, trainees perceive professionals abusing drugs or alcohol, how should this be handled? If they are part of a team where patients are mistreated, is there a way to improve that situation? If they are asked to cover up a mistake that has been made, what are the options? When, if ever, is it appropriate to step in and take action?

The power imbalance between supervisors and trainees that makes perceived misconduct and whistle-blowing so complicated also exerts a powerful force in the area of clinical research. How should authorship be determined? How should coauthors, consultation, mentoring, editing, etc. be expressed? What are the obligations of students? Of supervisors? When should trainees challenge or report misconduct?