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Occupational boundary disputes in the Australian operating room

Allegra Schermuly, Monash University and Andy Schermuly, Clinical Facilitator, Theatres, Royal Children’s Hospital. Please note, this article was originally published in the online TASA publication Nexus. It has been reprinted here with the Editors’ permission. The article is the final of the 5 in the Professionalisation series.

Timmons and Tanner have explored occupational boundary disputes involving theatre nurses and Operating Department Practitioners (ODPs) in the UK (2004). In Australia, conflict over whether nurses or anaesthetic technicians (ATs) should assist the anaesthetist in the operating theatre is a classic example of an occupational boundary dispute. By suggesting a framework for how this dispute manifests itself – titles, territory, scope of practice, registration, compliance with national standards, alliances – this brief article aims to contribute to the way such disputes are conceptualised.

The working environment in theatres is conducive to boundary disputes because it is hierarchical with employees having clearly prescribed roles. Incursions into another profession’s ‘territory’ are generally frowned upon as a form of implied criticism. Although this article is not specifically about doctors, they are a central part of everything that happens in theatres including disputes amongst other professional groups. Much of the conflict between theatre nurses and ATs is in order that their role be more favourably positioned in relation to the surgeons and anaesthetists (doctors) – the professions with real power in theatres.

The titles by which theatre practitioners are known form the basis of professional boundary marking. Types of knowledge inform titles and different knowledges have different status. ‘Technician’ is a pejorative term, implying the possession of machine-based knowledge rather than academic or patient-centred knowledge. Practitioner, technologist, clinical nurse specialist, assistant, anaesthetic health practitioner – some titles imply autonomy (a myth in theatres as doctors are in charge) and some imply subservience. Theatre nurses identify themselves occupying the interstitial space between patients and doctors, their role not just technical but that of patient advocate. ATs on the other hand, pride themselves on being experts on the anaesthetic machine – a vital piece of equipment used in the operating theatre.

Territory includes actual spaces in the theatre department itself which belong to one group or another (anaesthetic room, parts of the theatre itself, the scrub room, the ‘head end’ of the patient), but also to different jobs in the theatre being the domain of different occupations. If one profession carries out a job ‘meant’ for another, it is implicit criticism that the practitioner concerned was not doing that job fast enough or well enough or was absent from theatre at the time it needed to be done. Examples where this may occur include when moving the operating lights, plugging in the diathermy machine, getting the dressings, bringing the plaster trolley and being ready with the equipment to wake up the patient. Incursions are part of continual boundary encroachment attempts that happen during a theatre list, challenging who has the right to do what in theatres and who performs that task more efficiently.

A silo mentality exists between theatre practitioners premised on what is better: A broad-based qualification in nursing followed by a course specialising in theatres – scrub, anaesthetics and recovery − or training from the outset in anaesthetic practice, very often results in greater in-depth knowledge especially in relation to the anaesthetic machine; and thus representing the advantages of holism over specialisation (Norris 2001). In itself, knowledge of the anaesthetic machine (the skills to take it apart, troubleshoot it and explain its inner workings) has long been emblematic of technician-based theatre roles and such knowledge has gained mythical status in theatres. Further complicating matters, however, hospital management are often encouraged to opt for multi-role, generic theatre practitioners (in Australia, that means exclusively nurses) who can be rotated to other areas of the theatre department should the need arise and so help in alleviating perennial rostering issues with the possibility of fewer staff being needed overall with this model. Such a situation rarely, in reality, eventuates because nurses also tend to remain in one particular area of theatres despite the theoretical possibility of being a ‘jack (or jill) of all trades’. Hospital management are often also complicit in stoking tensions between different professional groups, as these groups are then less likely to band together to challenge management on workplace issues of common interest.

Professionalisation and existing registration of nursing has made the nurse’s claim stronger in this domain while technicians are still fighting for the professional registration which will be an important step in that occupation being recognised as professional rather than technical. ATs are not currently registered with AHPRA[1]. Registration is a key phenomenon which will represent recognition of ATs as a profession as well as opening up additional areas of theatre practice to them where only nurses are currently allowed to practice. There are structural, legal and regulatory barriers, however, to new professions attaining registration, which is possibly why it remains a privilege open only to more established professions such as nursing and medicine.

Anaesthetic nurses, while holding a holistic nursing degree, may not in many cases satisfy the specific requirements of the ANZCA[2] 2016 Statement on the Assistant for the Anaesthetist (known as PS08[3]) which clearly states who should be permitted to assist the anaesthetist in Australia. In some cases, hospital management have advised anaesthetists to remain silent on non-compliance due to reluctance to upset the large, powerful nursing unions who wield considerable political influence. In their private practice, some anaesthetists have even chosen to self-assist rather than rely on inadequately trained or non-compliant assistants. This latter scenario is clearly not in anyone’s interests – patient, anaesthetist or anaesthetic practitioners.

The position of being the most valued professional assistant to the anaesthetist is at the core of many manifestations of this boundary dispute. This is because doctors are the ones with real power in theatres. Alliances with management are also at stake here and it is common for one profession to blame the other for ‘hold-ups’ in the pace of the theatre list – disputes about this often comprise end of list debriefs.

By considering the occupational boundary dispute between ATs and theatre nurses in Australia in terms of the sites in which the dispute manifests – titles, territory, scope of practice, registration, compliance with national standards, alliances –  a more inclusive conceptualisation of a complex phenomenon is possible. Further work on this topic could also reveal how these issues impact on the practitioners involved and affect their everyday experience of the workplace.

References

Norris, P. (2001) ‘How “we” are different from “them”: occupational boundary maintenance in the treatment of musculo-skeletal problems’, Sociology of Health & Illness, 23, 1: 24-43.

Timmons, S. & Tanner, J. (2204) ‘A disputed occupational boundary: operating theatre nurses and Operating Department Practitioners’, Sociology of Health & Illness, 26, 5: 645-666.

 

[1] Australian Health Practitioner Regulation Agency. The regulatory body for Australian health practitioners, see https://ahpra.gov.au

[2] Australian and New Zealand College of Anaesthetists. The representative body for anaesthetists in Australia, see www.anzca.edu.au

[3] For more information on PS08 see  http://www.anzca.edu.au/documents/ps08-2015-statement-on-the-assistant-for-the-anaes.pdf