Vet Legislation Reform: 2. Enhancing the VN Role

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Arlo Guthrie — Tue, 20 Apr 2021 12:49:21 GMT

Update. I have replied to the consultation representing VetSurgeon.org, trying to represent the views shared here

Here is what I wrote WRT to section 2

2.1 Extending the VN role in anaesthesia

My remarks reflect points raised by veterinary surgeons / nurses on www.vetsurgeon.org:

Whilst there is a recognition that giving veterinary nurses more responsibility may give greater job satisfaction, and that ...

Veterinary nurses may be 'better' and 'more competent' and 'more motivated' than vets at anaesthesia,

There are concerns that:

a) There are a number of veterinary surgeons and nurses who would not want RVNS to be responsible for induction without the VS present, both in case of emergency and because it keeps the vet better involved.

b) The drive for RVNs to be able to do more may be driven by vested commercial interests, not patient wellbeing.

c) That additional training/revalidation may be needed

2.2 Allowing VNs to undertake cat castrations

My remarks reflect points raised by veterinary surgeons / nurses on www.vetsurgeon.org:

Whilst there is a recognition that giving veterinary nurses more responsibility may give greater job satisfaction, and that ...

There are concerns that:

a) That by allowing RVNs to do more minor acts of surgery (which may be more interesting and more rewarding), their attention will be distracted from actual nursing and other, perhaps more mundane tasks that nevertheless need doing.

b) That allowing RVNs to do more minor acts of surgery may remove opportunities for new grad vets to learn. One commented that minor surgery is the ceiling of an RVN's surgical career, where for the new grad, it is the start. Should there be some further qualifying requirement for RVNs to practise additional acts of veterinary surgery?

c) That whilst an RVN may be capable or even better than a VS at an act of minor surgery, they might equally (or might not) take longer to do the task than a VS, which may not be in the patient's best interest. Is research needed to demonstrate no negative impact on patient welfare? (as for increasing delegation of any sort).

d) The drive for RVNs to be able to do more may be driven by vested commercial interests, not patient wellbeing.

e) That additional training/revalidation may be needed.

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Iain Richards — Tue, 09 Mar 2021 09:27:17 GMT

[quote userid="6550" url="~/001/nonclinical/f/life-in-practice-discussions/29663/vet-legislation-reform-2-enhancing-the-vn-role/228975#228975"]Do we want practices using nurses to induce anaesthesia and do a cat neutering, potentially independent of a qualified vet?[/quote]

So that's a reasonable argument, that I've taken time to refect upon. I think there are two aspects to this. Firstly the VN isn't acting completely independently, as the consultation suggests an agreed protocol. There is some precedent for this in the human, "Patient Specific Directive" and each animal would have it's anaesthetic regime agreed upon. I think it valuable that a vet induces, not so much for competencey, but to keep them more involved in the case and maintain skills.
Secondly, VNs have been used in this role since the RANA days and have shown the relevant competencies needed. With a post VN course, regularly updated, the role can be enhanced. There are similar roles in human work - ODAs I think, who assist the senior anaesthetist.
There is a thirdly, in my experience, nurses don't want to operate, but they do want to control the anaesthetics - becuase that is patient care. THe quality of analgesia that my pateints got increased as the nurses took on a more involved role in their perioperative care.

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Bob Russell — Mon, 08 Mar 2021 13:40:44 GMT

I am not suggesting that inexperienced staff monitor anaesthetics but it does not automatically make it risky.

My staff know what they are doing (and because of city & Guilds level training, why they are doing it).

I can monitor the anaesthetic throughout using experience and monitors. Routine use of capnographs give respiratory rates, CO2 levels. Our machine gives anaesthetic levels and oxygen levels. It would record the results if I could be bothered to figure out how to get it to connect with a PC. I can hear the heart thanks to the oesophageal stethoscope.

Is it the right thing to do? Not in my opinion and I do rely on a qualified member of staff to back up my monitoring. I just do not accept it is automatically dangerous or unacceptable to have a non-RVN doing the job.

Do we want practices using nurses to induce anaesthesia and do a cat neutering, potentially independent of a qualified vet?

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Alison Clare Hickman — Mon, 08 Mar 2021 12:45:02 GMT

Iain Richards thank you. Yes, exactly this...and I do agree that there are times when you *can* or *have* to function without a formally qualified (and professionally accountable) anaesthetist but why would you if the better option is not to? The argument is clearly in the detail "better option". Go to human medicine for our exact parallel I guess...

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Iain Richards — Mon, 08 Mar 2021 12:26:49 GMT

[quote userid="6550" url="~/001/nonclinical/f/life-in-practice-discussions/29663/vet-legislation-reform-2-enhancing-the-vn-role/228953#228953"]There are plenty of occasions (perhaps most) where a vet is capable of monitoring anaesthesia and operating at the same time.[/quote]

Really? Monitoring is a continuous process, just like surgery is so an instant look becasue the patient is now huffing a bit will be very limited in how accurate it will be. No disresepct Bob, but this has been a regular theme over the last 20 years that some of us have been trying to get nurses to legally do what they are best suited to. And it's false. Would we perhaps care to fill in an AHC whilst spaying a bitch, or read a radiograph, or perform cytology?

I'll put it to the list that a lot of the reluctance from some in the profession is that they do not recognise aneasthesia as a discipline, it's just a means of keeping the patient still. It was fine in the eary days when there were no well-trained nurses, but not acceptable today. The only exception is in very remote practices and I haven't found an answer to that. And yes I have done an op 9Bleed post spay) with just me, no other person.

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Bob Russell — Sat, 06 Mar 2021 10:54:45 GMT

There are plenty of occasions (perhaps most) where a vet is capable of monitoring anaesthesia and operating at the same time. He or she just cannot twiddle the knobs!

This would allow someone with little or no experience to help out. Not ideal but rarely or automatically unsafe.

Of course we want to do better and should constantly aspire to improve the situation.

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Alison Clare Hickman — Sat, 06 Mar 2021 09:27:42 GMT

Jill Butterworth when I first started in 1999 as a lay 'nurse' in a one man SA practice, with my previous experience as a bank manager (yep, that really stood me in good experience stead) my first day was monitoring the anaesthetic (Oh Halothane I miss you..not)... for what was supposed to be a mass removal on a liver but turned out to be, once the dog was opened up, a diaphragmatic hernia (I think) and lung mass instead (for sure). So my surgeon had a good look around whilst I effected IPPV... I calmly did as he instructed whilst he rootled inside the poor beast. Sadly the dog was PTS due to grave prognosis, not lack of our skills, but you are 100 percent right Jill I had zero clue what I was doing. On the other hand I guess that helped me to be calm. All I can say years later is F*CK and Eeeeeeeek!

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Jill Butterworth — Fri, 05 Mar 2021 17:38:41 GMT

Absolutely! I enjoyed surgery much more since properly trained nurses became widespread. When I started you could practically pull someone off the street and they would be 'monitoring' an anaesthetic the next day. It was very unsatisfactory and very unsafe.

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Iain Richards — Fri, 05 Mar 2021 17:12:04 GMT

[quote userid="2131" url="~/001/nonclinical/f/life-in-practice-discussions/29663/vet-legislation-reform-2-enhancing-the-vn-role/228896#228896"]We don't want nurses turning stuff up and down without asking[/quote]

The royal we?!

I do. All the nurses I've worked with have a far better understanding of the needs of the patient than most vets do, and I'll include myself (CertVA holder, but a bit rusty now). However the conversation you describe is about right, usually the nurse asking, "What are you pulling on now?"

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Evelyn Barbour-Hill — Thu, 04 Mar 2021 01:01:19 GMT

[quote userid="4367" url="~/001/nonclinical/f/life-in-practice-discussions/29663/vet-legislation-reform-2-enhancing-the-vn-role/228854#228854"]most VNs care about care and take the time and effort that is needed to look after the animal under the anaesthetic. [/quote]

Well of course they are and they do. That's their job!

That's their role, given that very very few practices will ever have the closer to ideal arrangement of a veterinary surgeon operating, another veterinary surgeon as anaesthetist, a scrubbed nurse assisting the operator and another nurse or two buzzing round fetching, carrying and what have you and not answering the phone. So the operating veterinary surgeon is also responsible for the anaesthetic management. So he relies very much on the nurse to monitor the patient and tell him when anything's happening.

Nurse: The heart rate went up a little when you did that. Shall I turn the isoflurane up?

Veterinary surgeon: We must deepen the plane a bit until I've finished that part. Turn the isoflurane up one notch.

OR Veterinary surgeon : I don't need to do it again. What's the heart rate now? Good, don't alter anything.

We don't want nurses turning stuff up and down without asking.

[quote userid="4367" url="~/001/nonclinical/f/life-in-practice-discussions/29663/vet-legislation-reform-2-enhancing-the-vn-role/228858#228858"]This distracts the vet from the task in hand. [/quote]

Seeing as the vet is responsible, and there is no anaesthetist vet, I guess the vet should learn to cope.

[quote userid="6406" url="~/001/nonclinical/f/life-in-practice-discussions/29663/vet-legislation-reform-2-enhancing-the-vn-role/228893#228893"]

Marianne Thomas said:
it's not like our nurses don't have enough to be doing without doing surgeries too

exactly that. I worry that the things we should be doing will become less interesting if minor surgery comes onto the menu and little things that keep a practice running efficiently are the first things to get neglected.

[/quote]

Just what I've been banging on about for years. You want to give nurses a bigger role and more responsibilities? Fine! There are many ways in which YOUR practice could be improved by employing nurses to do all the nursing tasks that at present just aren't done.

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Minnie — Wed, 03 Mar 2021 21:34:27 GMT

[quote userid="7898" url="~/001/nonclinical/f/life-in-practice-discussions/29663/vet-legislation-reform-2-enhancing-the-vn-role/228892#228892"]it's not like our nurses don't have enough to be doing without doing surgeries too[/quote]

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Marianne Thomas — Wed, 03 Mar 2021 21:19:25 GMT

Thanks Minnie. I hope RVNs are also invited to take part in this consultation?

In terms of the efficient surgeon- I think this comes with experience. We all start with none. Having said that, I hadn't considered Jill's point. The thinner we spread the practise, the more we delay the perfect? & it's not like our nurses don't have enough to be doing without doing surgeries too.

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Minnie — Wed, 03 Mar 2021 21:08:51 GMT

Can I add a VN perspective to this thread? I have quite a few miles on the clock and have the misfortune in that time to see 3 fit, healthy animals undergoing 'routine' surgery drop off the needle on induction. Would I want to be inducing anaesthesia? No I wouldn't - they can drop off somebody else's needle thank you very much, I want a vet present so that if anything untoward happens it can be dealt with quickly and effectively and the patient stands a better chance.

Nurses doing minor surgery? My aim is to get the patient asleep, prepped and on and off the table in the shortest, safest time possible I don't want any fannying about that will make that anaesthetic any longer than it has to be - if you genuinely have a nurse who can carry out the procedure faster than a vet (not unknown I have to say) then crack on but if you don't consider is it fair on that patient.?

So as a nurse what am I good for? Well if your patients anaesthetic is going south a pound to a penny I will know about it before you and will be wanting to do something about it. Just as I trust a vet with the surgery I would like to think a vet could trust me to watch an anaesthetic as Bob Russell posted 'It is called team work!'

I'm not happy with what is being proposed I don't see it as being conducive to patient welfare.

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Bob Russell — Tue, 02 Mar 2021 13:20:47 GMT

Our staff may not make the decision to twiddle the knob however they will tell me they need twiddling. I almost always agree and the knobs get twiddled.

It is called team work!

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Iain Richards — Tue, 02 Mar 2021 13:04:30 GMT

Of course they are. Some are better than others, but it's my observation that, on the whole nurses are far more aware of changes that are happening. They are also more keen to learn more about anaesthesia. It's a given that to do this the VN needs to do further training.
I'd persoanlly want the vet inducing, not least as it keeps them involved and they should be involved as they are part of the descisions taken about what to use and when.
What we really need is an end to the nonsense that a VN cannot twiddle the dials without the vet saying where to twiddle them. This distracts the vet from the task in hand.

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Bob Russell — Tue, 02 Mar 2021 11:49:22 GMT

But they are able to monitor and look after the animals under anaesthetic. This is a big part of the job and is how it is now.

What changes are being suggested? Nurses inducing patients? If the RCVS are so hellbent on mimicking our human treating colleagues why is this an issue? Human nurses do not induce patients.

The RCVS cannot have it both ways!

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Iain Richards — Tue, 02 Mar 2021 10:20:00 GMT

[quote userid="2131" url="~/001/nonclinical/f/life-in-practice-discussions/29663/vet-legislation-reform-2-enhancing-the-vn-role/228824#228824"]Nick Jackson, Marianne Thomas Would you people care to explain exactly – exactly, please – what you mean by that?[/quote]

Most vets don't like anaesthesia, it's not a sexy as surgery or complex medicine, and it's dull. They are, of course, wrong. Many vets are in the one jab to sleep one to wake up camp, they too are wrong!
IN contrast most VNs care about care and take the time and effort that is needed to look after the animal under the anaesthetic.

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Bob Russell — Mon, 01 Mar 2021 17:40:28 GMT

We use an RVN and or a veterinary nursing assistant that have completed a one year course. I expect them to supervise and suggest changes in anaesthetic settings. They are very good at it!

Responsibility remains mine but we work as a team. Not sure we would want a change. Induction is the vets responsibility just as it is for a human anesthetist. What are the motives for this changing?

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Jill Butterworth — Mon, 01 Mar 2021 10:52:03 GMT

Another Dr Cynical with an alternative view: I started as an (unqualified) animal nurse and decided to do my A levels at night school to get into vet college, so I've seen both sides. I always adored surgery, it was the sole reason I wanted to become a vet, and I view it as an absolute privilege to cut a live animal.

Routine surgery is one of the satisfying parts of general practice and paves the way for more advanced surgery as you improve in both skill and confidence to work swiftly and safely, and I believe passionately that we need to protect this as a resource for our developing vets.

Losing routine surgery, like mass removal and cat castrates, could inadvertently worsen the retention crisis due to lower job satisfaction.

These small ops can be perceived as easy, but they are only so with practice. What surgeon has not noticed that just 2 weeks on holiday gives a small but perceptible deterioration in hand eye co-ordination which has to be caught up again? This could be important due to increasing numbers of part time workers.

After reaching 'flow' in surgery (10, 000 hours?) you become comfortable with widening your skillset or attempting something new and unexpected. If we move this milestone, we may create a generation of vets who are over-faced too early in their career, which takes a toll on mental health.

Many nurses want to be nurses for the very fact that they don't carry so much responsibility and it is still perceived by clients that the vet is in charge.

I think the view that nurses (being cheaper) are better employed with minor surgery is fallacious: an experienced nurse and a new graduate are on similar salaries, but the vet has paid a high price to get to this point (tuition fees and 5 years of lost earnings). They should be allowed to learn to enjoy the job and maximise their potential. For the nurse: minor surgery is the ceiling of their (surgical) career, for a vet, it's just the start.

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Mark Hedberg — Mon, 01 Mar 2021 08:56:02 GMT

No great mystery there - there are several advanced qualifications in anaesthesia available for veterinary nursing staff, and a veterinary nurse or technician with such a qualification may well have a higher level of anaesthetic knowledge than a veterinary surgeon without such additional qualifications.

Home - Academy of Veterinary Technicians in Anes and Analgesia, AVTAA (avtaa-vts.org)

Postgraduate - Advanced Veterinary Nursing (Anaesthesia) PgC / PgD / MSc | Harper Adams University (harper-adams.ac.uk)

Nurses Certificate in Anaesthesia - Improve International

[quote userid="2131" url="~/001/nonclinical/f/life-in-practice-discussions/29663/vet-legislation-reform-2-enhancing-the-vn-role/228824#228824"]Would you people care to explain exactly – exactly, please – what you mean by that?[/quote]

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Evelyn Barbour-Hill — Sun, 28 Feb 2021 23:40:15 GMT

[quote userid="18277" url="~/001/nonclinical/f/life-in-practice-discussions/29663/vet-legislation-reform-2-enhancing-the-vn-role/228664#228664"]There are plenty of nurses out there far more competent with anaesthesia than vets, rightly or wrongly,[/quote][quote userid="7898" url="~/001/nonclinical/f/life-in-practice-discussions/29663/vet-legislation-reform-2-enhancing-the-vn-role/228666#228666"] As you say, plenty of RVNs better at anaesthesia than vets. [/quote]

Nick Jackson, Marianne Thomas Would you people care to explain exactly – exactly, please – what you mean by that?

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Arlo Guthrie — Thu, 25 Feb 2021 08:50:34 GMT

I've added a summary of the discussion so far to the original post appearing at the top of each page. Anyone else got anything else to add. I notice no comment from anyone about finding a way to extend the VN role prior to any change in the VSA by, for example, creating a nurse prescriber role. Any thoughts about that?

[quote userid="7898" url="~/001/nonclinical/f/life-in-practice-discussions/29663/vet-legislation-reform-2-enhancing-the-vn-role/228660#228660"]I'm overdue a dispensary course because covid, but my understanding has been that RVNs aren't automatically SQPs unless they take a SQP course. Based on the studies I've seen SVNs undertake, & seeing the SQP course content, this seems wrong to me.[/quote]

Marianne Thomas Talking of which, someone tipped me the wink the other day that one of the SQP training providers is no longer invigilating the written exams. They've had to go online as a result of coronavirus (which is understandable). Possible problem now is that they don't know who is actually sitting the exam any more.

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Nicola Cole — Sun, 21 Feb 2021 14:40:08 GMT

[quote userid="18277" url="~/001/nonclinical/f/life-in-practice-discussions/29663/vet-legislation-reform-2-enhancing-the-vn-role/228668#228668"]I am also regularly reminded by nurses that inspite of the above when it comes to anaesthesia my word as a vet is supposedly final, whether this is because the nurses dont want to take the responsibility or because they are not aware that they can? Can they? [/quote]

They can’t.
As far as I’m aware it’s because they are not allowed to decide what dose of a drug is given, so technically speaking, by adjusting the isoflo without the vet saying so they are choosing the dose, not the vet. Likewise they can give a set amount of injectable anaesthetic induction agent, but they can’t titrate to effect.

Happy to be corrected if my reading of ‘the rules’ is incorrect!

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Marianne Thomas — Sat, 20 Feb 2021 15:24:37 GMT

Objectively, the answer to all your questions should be yes. The veterinary nursing students I oversaw as clinical coach had veterinary medicine level pharmacological education, to the point where I was regularly asking why on earth their college thought they needed to know so much. Of course, it may vary between colleges, but I've worked with nurses from several. The RCVS should review the learning objectives, but I doubt much change would be needed, if any.

I'm not worried about anatomy re castration, but surgical technique isn't covered, so a top-up course should be a requirement. The same question might be asked re pharmacology of nurses who graduated a long time ago. Revalidation could be one path to ensuring consistent minimum skill levels?

RE: Vet Legislation Reform: 2. Enhancing the VN Role

Cool — Sat, 20 Feb 2021 14:12:48 GMT

I will just try to be objective here. Do nurses have adequate knowledge of the pharmacology of anaesthetic drugs? Do they have adequate knowledge of the interactions of these drugs when used together? Are we departing from science and just looking at this as a vocation? Yes nurses may have done castrations without many going wrong but you will still need another nurse to monitor the cat while under GA, so you end up needing two nurses for the procedure. In some practices the 2nd nurse could be well utilised helping another vet with another surgical procedure. Do nurses have adequate knowledge of feline anatomy to enable them perform this procedure? I am not against nurses performing a cat castration but I think we need to consider some questions. Why do we need nurses to perform cat castrations? I am sure most vets will be happy to pass this procedure to nurses