1 Surgical nursing in context
• To introduce the meaning of surgery and surgical nursing
• To introduce various healthcare personnel a student may meet during a surgical placement
• To introduce the terminology a student may come across in relation to surgical nursing
• To identify key learning points to ensure a successful learning experience
Introduction
You are now undertaking a course at a university which will lead to a qualification as a nurse and also an academic award of a diploma or degree. From September 2013, all pre-registration nursing programmes in the UK will be undergraduate degree programmes. The Nursing and Midwifery Council (NMC) which sets out the standards and competencies expected from a qualified nurse also sets out the expected time required for learning in practice. This varies in different countries, but in the UK this has to be 50% of your programme. This 50% can be experienced in many ways, including short visits to learn what happens in such places as the school nurse service or the law courts. These may be part of a theoretical-based module in the university or part of a much longer placement experience. This book mainly focuses upon these longer placement experiences, although different aspects of caring for someone who is undergoing a surgical procedure of any kind are also explored.
Some of you may also experience what is called a ‘hub and spoke’ placement experience, where you have a base in your main placement but, during the whole of that placement, you may undertake shorter periods of time in other linked areas. Examples of these kinds of placements are found throughout the book.
Depending on the structure and management of your learning experiences in the practice environment and, of course, which field of practice or branch of nursing you are undertaking, you may have a placement which is known as a ‘surgical placement’. Most surgical placements are encountered within a hospital, although you may see surgical procedures and care in other contexts such as a health centre.
What is surgery ?
Before we determine what a surgical placement is, it is important to determine what we mean by surgical and surgery. The term ‘surgical’ implies some kind of surgery which involves an operative or invasive intervention – an operation normally involves ‘cutting into’ various parts of the body. An example is removal of the gall bladder through a laparoscope, which is a long, thin telescope with a light and camera lens at the tip which is passed through a number of small cuts in the abdomen but doesn't involve large wounds. This allows the surgeon (the doctor who performs the surgery) to view the internal organs on a monitor. Surgery may be exploratory and diagnostic, or it may be life-saving following a serious life-threatening trauma. Although the principles of surgery remain the same, the way in which surgery is carried out has changed significantly. A brief overview of the development of surgery over time will enable you to understand why some patients may be frightened of undergoing any kind of invasive procedure and also why some procedures, such as removing sutures from some surgical wounds, are no longer carried out following surgery due to advances both in surgical techniques and technology.
Brief history of surgery
Although there is evidence of various types of what we would call surgical procedures taking place in the Middle Ages and before, for the purpose of this overview we focus on the nineteenth century onwards (1800 to the present day) and the images that many of us will have seen in relation to early surgical work, such as amputation without anaesthetic, management of pain or dying due to wound infection.
An excellent overview of the history of surgery over time can be found on the Channel 4 website: http://www.channel4.com/explore/surgerylive/history.html. As well as specific information about surgery generally, this site also has short videos of patients talking about their experiences of surgery and why it was necessary, for example a patient who underwent surgery for a pituitary tumour (http://www.channel4.com/explore/surgerylive/surgical4.html). This website also offers an insight into some of the roles of individuals during the intraoperative period, and in these short videos there are visual images of what the environment in an operating room or anaesthetic room is like.
Surgery today is, of course, very different due to advances both in surgical techniques and what we know about the human body. The most common cause of death after surgery used to be infection, but following the initial findings of Louis Pasteur (that the death of body tissue was due to bacteria in the air) and Ignaz Semmelweis (who discovered that ‘transmission of infectious diseases could be reduced by handwashing’ (Kozier et al 2008:644)), Joseph Lister, a British surgeon, introduced the use of carbolic acid and other antiseptic techniques ‘to kill bacteria in his operating theatres’ (Kozier et al 2008). Effective hand washing, as part of the much wider infection control agenda, is one of the key skills that you will need as a student and qualified nurse, not only in a surgical placement but every placement.
Alongside these discoveries and practices was the introduction of anaesthetic during surgery, early ones being ether and chloroform, which subsequently led to the more sophisticated techniques and preparations in use today (see Ch. 7).
Types of surgery
There are two main types of surgery: emergency and elective. Kozier et al (2008:644) define these as follows:
Emergency surgery is performed immediately to preserve function or the life of the patient. Surgeries to control internal haemorrhage or repair a fracture are examples of emergency surgeries. Elective surgery is performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening (but may ultimately threaten life or well-being) or to improve the patient's life. Examples of elective surgeries include cholecystectomy for chronic gall bladder disease, hip replacement surgery or plastic surgery procedures such as breast reduction surgery.
Access the website of the Royal College of Surgeons of England, for general information on different types of surgery:
http://www.rcseng.ac.uk/patient_information/faqs/different_surgery.html (accessed December 2011).
You will find a number of resources that you might find useful prior to starting your clinical placement. Access the patient information section and consider how the information will help you to explain to a patient their journey through an elective surgery.
The following is a link to a guide to help teams make the most of a patient's journey through elective surgery (Patient Liaison Group/RCSE 2007):
http://www.rcseng.ac.uk/publications/docs/patient_journey.html (accessed December 2011).
In addition to the two different types of surgery, there are two further subdivisions, namely major and minor. Major surgery involves a bigger risk to the patient, not only in terms of the organs of the body that may be involved but the intricacy of the surgery and possible postoperative complications that may occur (see Ch. 12). An example of this is a heart and lung transplant.
Minor surgery can also be intricate, but there is less risk and fewer complications. This kind of surgery is usually undertaken as ‘day care surgery’ (see Ch. 11). An example of this is removal of a skin lesion.
You might meet nurse practitioners who have undertaken specialised training to undertake minor surgical procedures (see Martin 2002) and choose to spend a day observing their work as part of your main placement experience.
Surgical nursing placement
During your course, you may be allocated to a placement in an environment where surgery takes place. In the main, this will be in a hospital; however, more and more healthcare practices are now undertaking minor surgical procedures and you may be able to gain some experience of the basic principles of surgical intervention in a community placement.
For the purpose of this book, we consider a surgical placement as an area within a hospital where operative or invasive interventions take place. A nursing term often used in relation to surgery is ‘perioperative care’, which involves caring for the patient before admission to hospital, during the admission process, preoperative care (i.e. prior to going to the operating theatre), care during the operation and post-operative care (both immediately and until discharge home). The learning of principles underpinning these stages is transferrable to other placements where you may encounter a surgical procedure but where the focus of care for the patients is not surgery.
Surgical nursing, therefore, involves caring for patients throughout their perioperative journey. To care for patients during this time requires both general and specific knowledge and skills, depending on the nature of the surgical intervention and the individual needs of the patient. A knowledge of the following is required:
• The principles of surgical nursing.
• Normal and abnormal physiological processes and illnesses.
• Risks and complications of surgery for different age groups.
• Most importantly, effective assessment, goal setting and planning, implementing and evaluating care delivered.
See Chapter 2 for further information regarding preparation prior to undertaking a surgical placement. Also, access specific placement learning information relevant to your local NHS organisations on your university website.
What do the terms preoperative and postoperative mean? How would you explain these to a relative who asked you what they meant, after telling you they were going into hospital for an operation?
You will find some of the answers in this chapter.
Explaining terminology that is unfamiliar to patients is a key aspect of your role and is an important communication skill. This activity could form the basis of a goal in relation to achieving competence in communicating effectively with patients and their relatives (NMC Standard 2010: Domain–Communication and Interpersonal Skills: NMC Standard 2004: Domain–Care Delivery).
Healthcare personnel on a surgical placement
As well as nurses with various titles, you will come across a number of other healthcare personnel while on a surgical placement. Table 1.1 lists those you might encounter in the preoperative period (some of whom you may also meet in a pre-admission clinic), with a brief summary of their roles. Tables 1.2 and 1.3 list those you might encounter during the intraoperative and postoperative periods, respectively, some of whom you will see at every stage of a patient's journey.
Table 1.1 Roles of healthcare personnel in the preoperative period
| Named role | Role description and responsibilities |
|---|---|
| Qualified registered nurse | A person who has been approved by the NMC as being ‘fit for practice’ at the end of a course of study and who has met all the NMC Standards and Competencies for Registration as a Nurse |
| Ward sister/manager/charge nurse | A senior nurse who is responsible for the immediate management and leadership of a group of staff, together with overall management of the patients in their care This will include clinical leadership in a specific field of practice |
| Specialist nurses such as pain management nurse, infection control nurse | A specialist nurse is someone who has a senior clinical role in an organisation and has developed their knowledge and skills to an advanced level in a particular area of clinical care and offers additional expertise in the care of a patient |
| Radiographer | A person who has undertaken a course of study to enable them to register as a radiographer, who takes images of various internal parts of the body as well as undertaking some investigative tests These include X-ray images, computed tomography (CT) scans and magnetic resonance imaging (MRI) |
| Anaesthetist | A qualified doctor who has specialised in the giving of anaesthetics and managing the care of the patient while anaesthetised There are also nurse anaesthetists who have undergone advanced training to manage the care of patients in certain situations and they work under the guidance of the anaesthetist |
| Physiotherapist | A person who has undertaken a course of study to register as a physiotherapist, who treats patients with musculoskeletal problems/physical problems in the main, with activity and other therapies |
| Phlebotomist | A person who is a qualified technician trained to take blood from a patient in order that it can be tested as part of a diagnosis |
| Social worker | A person who has undertaken a course of study to register as a social worker, who specialises in social, emotional and financial support to individuals and/or families and liaises with other professionals in ensuring effective discharge home from hospital |
Table 1.2 Roles in the intraoperative period
| Named role | Role description and responsibilities |
|---|---|
| Anaesthetic nurse | Receives the patient in the reception area of the anaesthetic room and checks details Key role is to help relieve patient anxiety prior to surgery |
| Anaesthetist | Visits patients preoperatively to ensure they understand what is going to happen, if they are fit for an anaesthetic and to prescribe premedication They manage the giving of the anaesthesia and monitor the patient's condition during surgery as well as prescribing postoperative analgesia |
| Circulating nurse | This is the nurse who manages a range of roles in the theatre, from managing equipment, supporting the scrub nurse, helping to position the patient, cleaning and sterilising any equipment and, most importantly, ensuring safety with regards to instruments and swabs |
| Scrub nurse | Has a key role in assisting the surgeon; protects the patient's dignity and should be the patient's advocate during the surgery Ensures safety with regards to instruments and swabs and prevents diathermy and pressure injuries |
| Recovery nurse | Has a key role in the recovery room, ensuring safety and care of the patient in the immediate postoperative period Ensures patency of airway, undertakes essential observations, assesses pain and nausea and gives medication for both according to the prescription Key role in ensuring total patient care, including reassurance, reducing anxiety and maintaining appropriate documentation and communication with ward staff and surgical team involved in the surgery |
| Consultant surgeon | A consultant surgeon is a registered medical practitioner who has undergone approved training and acquired appropriate experience in a surgical specialty such as to allow entry on to the UK Specialist Register and who has been appointed by a recognised procedure such as an Advisory Appointment Committee to provide a surgical service as part of a clinical team. The consultant surgeon, in providing this service, is expected to manage the main condition of the patient, but recognise the need to call in others from the same or different specialties at his or her discretion; to delegate clinical and administrative responsibility at his or her discretion; and to act as the advocate of the patient in relation to their treatment and wellbeing. (RCS 2009;1) |
| Registrar (surgical) | A registrar is normally a surgeon who has undertaken a period of about 6 years in a surgical field under the supervision of a consultant They choose an area to specialise in or become a general surgeon, able to carry out a range of surgery To achieve consultant status requires further exams and membership as a Fellow of the Royal College of Surgeons (FRCS) |
(adapted from Alexander et al 2006:915)
Table 1.3 Roles in post-operative period, including post-discharge home
| Named role | Role description and responsibilities |
|---|---|
| Registered (ward) nurse | A nurse who has undertaken a programme of learning in practice and Higher Education and successfully attained registration as a nurse with the Nursing and Midwifery Council. The nurse can be newly qualified or have extensive experience and expertise in caring for patients who have surgical intervention. This nurse is often either the main nurse for the patient, the nurse in charge of the ward or a specialist nurse focusing on helping the patient with managing pain for example or works in a specialist field such as breast cancer care. |
| District nurse | District nurses play a crucial role in the primary health care team. They visit people in their own homes or in residential care homes, providing care for patients and supporting family members. As well as providing direct patient care, district nurses also have a teaching role, working with patients to enable them to care for themselves or with family members teaching them how to give care to their relatives. District nurses play a vital role in keeping hospital admissions and readmissions to a minimum and ensuring that patients can return to their own homes as soon as possible (NHS Careers, http://www.nhscareers.nhs.uk/details/Default.aspx?Id=916%20) |
| Health visitor | A health visitor is a qualified and registered nurse or midwife who has undertaken further (post registration) training in order to be able to work as a member of the primary healthcare team. The role of the health visitor is about the promotion of health and the prevention of illness in all age groups (NHS Careers, http://www.nhscareers.nhs.uk/details/Default.aspx?Id=807) |
| Healthcare assistant | Healthcare assistants can work within hospital or community settings under the guidance of a qualified healthcare professional. The role can be very varied depending upon the area in which the person is employed. Working alongside nurses, for example, they may sometimes be known as nursing auxiliaries or auxiliary nurses. Healthcare assistants also work alongside qualified midwives in maternity services. The types of duties include the following: • generally assisting with patients overall comfort • monitoring patients conditions by taking temperatures, pulse, respiration’s and weight (NHS Careers, http://www.nhscareers.nhs.uk/details/Default.aspx?Id=807) |
Make a list of all the members of the surgical team and find out as much about their roles as possible prior to starting your placement.
Work out which of the roles you would like to find out more about during the placement. Discuss with your mentor on arrival the possibility of spending time with at least two of these during your placement to understand more about how they contribute to the care of the patients you will be nursing.
For example, you may be asked as part of an assignment to consider various roles during your placement and discuss how they have made a contribution to a patient in your care (interprofessional working). Make notes from your observations of their role and invite them to explain how this contributes to the care given (this must be under the supervision and agreement of your mentor).
Terminology related to care for patients undergoing a surgical procedure
Students reading this introduction will already be considering the meaning of some of the terminology used, which will underpin much of what we discuss in Sections 2 and 3. It is essential that, prior to beginning your placement, you become familiar with some of these terms, as this will help you to understand what nurses and other professionals are talking about when discussing patient care as well as allowing you to explain them to patients and their families.
Let us look initially at some of the key broad terms used in this book.
Pre-admission
Patients who are to attend hospital for surgery, or to undergo a minor surgical procedure in a community health centre, will require information on what is going to happen to them beforehand, in order to reduce anxiety (Walker 2002, Kielty 2008).
Preoperative
Preoperative literally means before operation (surgery). Normally this term is used after admission to hospital for a surgical procedure, whether elective or emergency surgery. There are key steps that must be taken before surgery of any kind (see Ch. 5).
Perioperative
This term means before (pre-), during (intra-) and immediately after (post-) surgery and usually refers to interventions during those periods (Pudner 2010).
Postoperative
Postoperative care takes place in the immediate period after surgery and the period until the patient is discharged home from hospital. It could be argued that the time after a patient is home from hospital until the surgeon decides they no longer need to be seen should also be termed postoperative.
Anaesthetic room
For many patients undergoing surgery, an anaesthetic (given by injection or through inhaling as a gas) is required to prevent any painful physical sensations while the invasive procedure is carried out. Anaesthesia can be achieved either locally or generally, as it is not always necessary for a patient to be unconscious during an operation. The anaesthetic room is usually situated next to the operating theatre (Stewart & Huntington 2007).
Theatre
The theatre is sometimes known as the ‘operating room’ and is a very specific organised space which is immediately identified as being the place where surgery takes place. It is also an area that must be free from the possibility of causing infection (sterile environment).
Recovery room
Patients having undergone a general anaesthetic require a varied period of time in which to recover safely prior to returning to the ward area. This takes place in the recovery room, where nurses and other healthcare personnel undertake close observation of the patient for any immediate effects of the surgery and anaesthetic.
Remember to explain abbreviations and avoid their overuse. Also avoid using nursing ‘jargon’ in your nursing assignments.
Prior to your placement, check your university practice placement information site (which might look like that in Box 1.1) where you may find examples of types of surgery such as those in Table 1.4. Your university may only be accessible via the Intranet and you will require your own password
Box 1.1 Example of a clinical placement website for students
Clinical placement
Intensive Care Unit (ICU), Ravenscourt Hospitals NHS Trust (pseudonym), London Road, Manchester
Your contact(s)
Michelle Roxburgh: e-mail: XXX
Further information can be obtained via telephone/address: XXX
What is organised for students on commencement of placement?
A session on the role of the practice education team including mentors and practice education facilitators.
All students will be given a welcome letter with the name of their main mentor and all members of the main multidisciplinary team.
Whenever possible, and in accordance with NMC requirements, the student and mentor will work together throughout the placement and off duty will be coordinated to reflect this.
An introduction booklet (containing detailed information about the ward and orthopaedic surgical nursing, including a brief outline of nursing procedures and observations that students can engage in under direct and indirect supervision) will also be given on arrival and discussed in the first interview with the named mentor.
What are the arrangements for mentors and students?
Students will be allocated a mentor, usually on arrival, who will undertake the main assessor role. It is envisioned that you will mostly work with your mentor, but supporting learning in practice is a team effort and, as such, the main mentor will discuss student progress with a range of other members of the healthcare team.
What shift patterns are students allocated for learning?
Early: 07.30–15.30 with half hour break
Late: 13.00–21.00 with half hour (unpaid) break as per trust policy
Long day shifts are optional for students. Students are required to undertake their learning to experience the whole 24-hour care of patients and night duty is arranged in relation to your goals for the placement and requirements of your programme.
If you are going to be late or are sick, you must contact the ward at the first opportunity.
What patient care situations are available in this placement?
Students are involved in pre- and postoperative care for patients undergoing joint replacements, arthrodesis, arthroscopes and other elective orthopaedic surgery.
What nursing model is used for planning care?
The Roper, Logan and Tierney model, adapted for the specific needs of patients undergoing elective orthopaedic surgery.
What core clinical skills can be learnt?
Generally, students can gain experience in the following:
A systematic approach to patient assessment, planning, implementing and evaluating care (holistic care).
A good foundation in physiological knowledge and how to measure a patient's progress through clinical measurements.
Insertion/removal of urinary catheters.
Care of venflon sites and intravenous infusions.
Observations pre- and postoperatively.
What additional clinical skills can be learnt?
Care of patients undergoing joint replacement surgery, including the patient journey through perioperative care such as in the anaesthetic room, recovery and the actual theatre, and key skills that can be learnt in each area. Airway management is a major skill.
What resources are available to help learning?
Organised, planned teaching sessions: teaching packs are available with a focus on key types of management of the care of patients undergoing orthopaedic surgery.
A wide range of nursing journals and access to the NHS trust library and computer databases.
A wealth of experienced staff who are keen to make the student's experience a positive one: discussion with mentor about learning goals.
Students are actively encouraged to attend the NHS trust acute care study sessions for all staff after discussion with their mentor.
Table 1.4 Surgical terminology and meanings (examples only)
| Surgical terminology | Meaning |
|---|---|
| Cholecystectomy | Removal of the gall bladder |
| Thyroidectomy | Removal of the thyroid gland |
| Angioplasty | An operation to repair a damaged blood vessel or unblock a coronary artery |
| Tracheostomy | An opening in the trachea which can be surgically created to ensure a safe airway through inserting a tube |
| Transurethral resection of bladder | A procedure used to diagnose bladder cancer and remove unusual growths or tumours on the bladder wall The bladder is approached via the actual urethra See: http://hcd2.bupa.co.uk/fact_sheets/htmt/turbt.html |
| Nephrectomy | Removal of a kidney |
| Cystoscopy | Examination of the bladder using an instrument called a cystoscope See: http://www.patient.co.uk/health/Cystoscopy.htm |
| Hysterectomy | Removal of the uterus |
| Bilateral salpingo-oophorectomy | Removal of both ovaries and fallopian tubes |
| Amputation | Removal of part of the body, either surgically or by trauma Usually a limb or part of a limb |
| Arthroplasty | Reconstruction (refashioning) of a new movable joint, e.g. total hip replacement |
| Laminectomy | Removal of part of a vertebral bone called the lamina in the lower spine |
| Craniotomy | A cut into the cranium where a temporary bone flap is made into the skull, either to relieve pressure or to access parts of the brain |
| Tonsillectomy | Removal of the tonsils |
| Laryngectomy | Removal of the larynx |
| Oesophagectomy | Removal of the oesophagus |
| Pancreatectomy | Removal of the pancreas |
| Gastrectomy | Removal of the stomach |
| Hemicolectomy | Removal of part of the large bowel |
| Ileostomy | Making a surgical opening in the abdomen and raising a part of the small bowel, the ileum, onto the surface Usually for serious digestive problems such as cancer of the bowel See: http://www.nhsinform.co.uk/health-library/articles/i/ileostomy/introduction.aspx |
| Abdominoperineal excision of rectum (colostomy) | An operation where the anus, rectum and sigmoid colon are removed (usually for cancer) |
| Appendicectomy | Removal of the appendix |
| Haemorrhoidectomy | Removal of haemorrhoids |
| Cystectomy | Removal of the bladder |
| Prostatectomy | Removal of the prostate gland |
| Vasectomy | The vas deferens (tubes through which sperm travel to the semen) are tied off as contraception See: http://hcd2.bupa.co.uk/fact_sheets/html/vasectomy.html#anim |
| Laparoscopy | A procedure to look into the abdomen by making small cuts and inserting a laparoscope See: http://www.patient.co.uk/health/Laparoscopy-and-Laparoscopic-surgery.htm |
| Colporrhaphy | A surgical repair of a prolapse deficit in the vaginal wall See: http://hcd2.bupa.co.uk/fact_sheets/html/qanda/vaginal_repair_surgery_qanda.html |
| Mastectomy | Removal of the breast See: http://hcd2.bupa.co.uk/fact_sheets/html/vaginal_repair_surgery_qanda.html |
If there are new terms for your particular placement, make a list of these and consult a surgical textbook or nursing dictionary to find out their meaning and make a note in your pre-placement notes to discuss with your mentor (see Ch. 3 for more information about this).
Discharge from hospital
It is important to consider what will happen or needs to happen for patients once their surgery (minor or major) is over, and the decision about this (i.e. going home from hospital) should be made both before and at admission (NHS Institute for Innovation and Improvement 2008).
Table 1.4 lists some more commonly used terms you will encounter on a surgical placement. Other terms are defined and discussed at other points throughout the book, in particular the use of abbreviations commonly used by nurses and the inherent dangers associated with this.
Word meanings
• -ectomy at the end of a word implies ‘surgical removal of’.
• -plasty means ‘refashioning’ or ‘plastic repair of’.
• -ostomy means surgically creating an opening connecting the internal organ(s) with the external surface of the body.
A useful tip is to keep a notebook for use at home and at university. Make notes about the care of patients undergoing various surgical interventions, why they are having the surgery, what signs and symptoms they had been experiencing prior to surgery, what the nursing management was and any general aspects of care. Alternatively, you might keep notes in a ring-binder file and add articles you have found related to various aspects of care or underpinning physiology, etc. Add notes about medications patients have received – this is essential because, as a qualified nurse, you will be expected to know most of the ‘basic’ drugs, their side effects and correct dosages. This is a useful tip for all placements as it helps to build up a collection of notes which you can use to share with others or as a record of learning for your portfolios.
During your surgical placement, make a list in your notes of all the different types of surgical interventions you come across. A list of some of these may already be available on the university placement website.
Find out what each one involves and make notes on the signs and symptoms patients requiring this surgery may be experiencing and also the care they require following the procedure. Use an up-to-date textbook to help you with this. This will begin to focus your learning in preparation for the placement and help you to set goals with your mentor with regards to total patient care experiences.
Although most students undergoing surgical placements may be from either an adult or child health field of practice (branch), some students from mental health and learning disability fields of practice may also experience this placement. Also, patients in these latter fields of practice may have to be admitted to hospital for a surgical procedure and it would be an excellent learning experience for the student caring for them to consider an opportunity for following the total patient pathway. Discuss it with your mentor if this occurs while you are undertaking a placement in either a mental health or learning disabilities field of practice.
Alexander M., Fawcett J.N., Runciman P.J. Nursing practice: hospital and home: the adult. Edinburgh: Churchill Livingstone; 2006.
Kielty L.A. An investigation into the information received by patients undergoing a gastroscopy in a large teaching hospital in Ireland. Gastroenterology Nursing. 2008;31(3):212–222.
Kozier B., Erb G., Berman A., et al. Fundamentals of nursing – concepts, process and practice. Harlow: Pearson Education; 2008.
Martin S. Developing the nurse practitioner's role in minor surgery. Nursing Times. 2002;98(33):39–40.
NHS Institute for Innovation and Improvement. Discharge planning. London: NHS; 2008. Online. Available at: http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/discharge_planning.html (accessed September 2011)
Patient Liaison Group. Improving your patient elective journey. London: Royal College of Surgeons; 2007.
Pudner R. Nursing the surgical patient, third ed. Edinburgh: Baillière Tindall; 2010.
Stewart L., Huntington S. The peri-operative phase. In: McArthur-Rouse F., Prosser S. Assessing and managing the acutely ill adult surgical patient. Oxford: Blackwell; 2007:17–38.
Walker J.A. Emotional and psychological preoperative preparation in adults. British Journal of Nursing. 2002;11(8):567–575.
Brooker C., Waugh A. Foundations of nursing practice. Edinburgh: Mosby; 2007.
McArthur-Rouse F., Prosser S. Assessing and managing the acutely ill adult surgical patient. Oxford: Blackwell; 2007.
Waugh A., Grant A. Ross and Wilson anatomy and physiology in health and illness, 11th ed. Edinburgh: Churchill Livingstone; 2010.
For an insight into the role of the anaesthetist: http://www.nhs.uk/conditions/anaesthetic-general/Pages/Definition.aspx (accessed December 2011).
For an explanation of different roles in the NHS: http://www.nhscareers.nhs.uk/career.shtml (accessed December 2011).
For those of you undertaking a surgical experience in a children's ward or visiting as part of a ‘hub and spoke’ placement learning opportunity, there are two publications linked to children's experience of surgery available on the Royal College of Surgeons website: http://www.rcseng.ac.uk/publications/docs/going-into-hospital-for-an-operation and http://www.rcseng.ac.uk/publications/docs/children_hospital.html (accessed December 2011).