Clinical Governance of the Surgical Care Team
All extended roles in the surgical team should work within a local clinical governance framework. This ensures that:
- Quality of patient care can be assured.
- There is consistency and standardisation of practice.
- The boundaries of the extended roles are documented in written protocols.
- Appropriate responsibilities and supervisory arrangements are clarified and agreed with the extended team member, senior members of the surgical team and service managers.
- Every member of the multidisciplinary team is aware of the accountability, responsibility and scope of practice of those roles and how they fit into the surgical team.
- There are clear arrangements and support for the professional development, monitoring and review of the roles.
A register of all practitioners acting as extended members of the surgical team should be kept in each department where these roles have been introduced.
Scope of practice
All surgical care team members must work within the limits of their competence. The scope of practice of the practitioner, their autonomy and level of supervision needs to be agreed in advance and on a case-by-case basis with the responsible surgeon and ratified by the hospital management. It should reflect their training and experience while allowing for professional development and learning.
Typically, newly qualified practitioners will need closer support and supervision (with direct supervision during training). Over time and as the supervising consultant surgeon is satisfied that the surgical care team member works safely and competently within their role there will be less need for direct supervision, and the surgical care team member can carry out his or her responsibilities under proximal supervision. Experienced practitioners should work with a level of autonomy, but with the supervising surgeon available for consultation even if he or she are not physically present.
Surgical care team members may develop specialist expertise through practical learning and continuing professional development, but where possible they should maintain relatively broad clinical knowledge and not allow their role to become too narrow, so that there is flexibility in the service, as well as space for their own longer-term professional development and career progression.
Scope of practice in the operating theatre
Supervision and support will be necessary in all hospital environments, but this will be particularly important for practitioners who work in the operating theatre environment. Under these circumstances the following levels of supervision are possible.
- Direct – with the supervising surgeon scrubbed and standing alongside the practitioner, usually during training.
- Indirect – with the supervising surgeon un-scrubbed but in the theatre.
- Proximal – with the supervising surgeon not in theatre but within the hospital and easily contactable.
Senior surgical care practitioners can potentially perform surgical procedures independently at a level equivalent to a core surgical trainee year two level (and sometimes up to a specialty trainee year three level). However, surgical first assistants should not perform procedures that might be considered surgical intervention, with the exception of skin suturing to close simple wounds, provided they have received appropriate training and assessment (eg through the Intercollegiate Basic Surgical Skills course or through demonstrating competence at the same level). It is important that local policies are in place to reflect the role and responsibilities of surgical care team members.
Liability
In secondary care delivered by the NHS, extended practitioners are normally covered by their employer through vicarious liability, provided they have an employment contract and an agreed job description. However, this only applies if the conditions outlined in the practitioners’ job descriptions are met and the practitioners work within the scope of their practice. They also have to act within the policies and protocols of the department in which they are working, and comply with current national guidelines relating to surgical care team roles.
Vicarious liability does not apply to the private sector, so separate professional indemnity insurance has to be agreed with their employer in that case, or it can be sought independently through other organisations such as the Medical Protection Society, the Medical Defence Union or the Association for Perioperative Practice.
It is the responsibility of the practitioners working in an extended role to ensure that they have liability cover that is up to date and sufficient for their level of practice.
Regulation
Currently, surgical care team members have no statutory regulatory body for their specific surgical care team role. Most practitioners (SCPs, SFAs, ACPs and ANPs) will normally hold a registration with the Nursing and Midwifery Council or the Health and Care Professions Council, but this applies only to their original qualification (eg as a nurse or as an operating department practitioner). It does not cover their extended practice in surgery. This means that extended practitioners work outside their primary (and registered) scope of practice. It is therefore crucial that local clinical governance mechanisms are able to establish the validity of their qualifications and competence before they are recruited, as well as ensure the surgical care team member is able to maintain his or her skills once he or she is part of the team.
For those surgical care team members who have qualified through the physician associate route, or the physician assistant (anaesthesia) route, there are voluntary registers operated by the Royal College of Physicians and the Royal College of Anaesthetists, with the Professional Standards Authority regulating organisations holding such voluntary registers.
The Royal College of Surgeons of England is currently exploring the development of a voluntary register for surgical roles, but we are also of the view that eventually all extended roles should be subject to statutory regulation. At the time of writing, the government had announced a consultation on the potential options for future regulation of PAs, SCPs, PAAs and ACCPs.
Lack of statutory regulation also results in some limitations on practice. Practitioners in extended roles cannot request ionising radiation unless they are registered Healthcare Professionals and have undergone additional certification in Ionising Radiation (Medical Exposure) Regulations (IRMER). Practitioners in extended roles also have no prescribing authority, until they have received appropriate training for non-medically qualified prescribers defined by their employing trust. The RCS would encourage facilitating surgical care practitioners’ ability to prescribe basic medicines and to request ionising radiation within the limits of their competence.
Accountability and management
It is important that there is clarity over the specific lines of clinical, managerial and professional accountability for extended surgical roles, as well as how their ongoing performance will be assessed. Surgical care team members should work to the medical model that includes professional accountability to consultant surgeons, and compliance with the same set of procedures that doctors are trained to follow including presenting complaint, history, physical examination, diagnosis and treatment.
The surgical care team member is clinically responsible to the supervising consultant surgeon who will delegate aspects of surgical care and will work with him or her as an integral part of the surgical care team. The supervising consultant surgeon must be satisfied that the practitioner has the appropriate qualifications, skills and experience to provide competent and safe care to the patient. During their training, surgical care team members will normally be assigned a named clinical supervisor and a mentor for the duration of the training programme, while other senior surgeons may provide day-to-day supervision. The responsibility for the overall management of the patient’s care remains with the supervising consultant surgeon.
Managerial and professional accountability is currently varied, and reflects the ad hoc development of these roles. Given that these practitioners work closely with the medical team, providing care for surgical patients, there is a rationale for managerial and professional responsibility to lie within the medical team (including performance management, leave, expenses, mandatory training and rotas). This would have implications for such issues as appraisal and governance, and would likely also have budgetary implications. It should be noted that line management involves skills that are not intuitive, so those taking on this responsibility may need some training and support. Each trust may also consider the possibility of having a faculty board comprising clinical supervisors of all staff in extended roles.
Working with consultants and trainees
The leadership and support from consultant surgeons is crucial for the successful and sustainable implementation of care models that include members of the surgical care team. Consultant surgeons need to be committed to supporting these roles and integrating them into their teams. They have the responsibility, with the support of the hospital’s management team, to create an environment that encourages questioning and learning and is suitable for training and supervising surgical care team members, trainees, and other clinical and non-clinical staff. Sufficient time needs to be built into their job plan to support these activities.
Consultant surgeons also have the responsibility for the supervision and ongoing performance appraisal of the extended roles. They are responsible for the delegation of tasks to surgical care team members and for ensuring that training opportunities are spread appropriately across the team. This should ensure the best quality of care for patients while enabling the training of future surgeons and the development of surgical care team roles. Good leadership will allow teams to make the best use of extended practitioners’ skills to support the learning environment for surgical trainees, and may help to free up time for training rather than restrict valuable training opportunities. Surgical care team roles can be particularly useful in helping trainees to settle into their new posts, and providing them with ‘on the ground’ learning opportunities and assistance in surgery that supports them when they start to operate independently.
To support team-working between trainees and extended surgical practitioners, it is recommended that trainees receive a specific induction into the development and use of these roles to help them understand the nature and scope of their practice, as well as its value. It will also help them to understand how responsibilities will be shared and delegated within the team.
Working with patients
Members of the extended surgical care team often provide continuity of care for patients and can be in much more frequent contact with the patient than other medical professionals throughout their care pathway. They therefore have a significant impact on patient experience and satisfaction.
Research carried out by the Royal College of Surgeons of England in collaboration with Health Education England found that patients were happy to be treated by a member of the extended surgical care team, provided firstly that the surgical care team member was competent to perform the tasks they were undertaking, and secondly that he or she was working as part of a team under the supervision of the consultant surgeon. Patients also said that it was important to them to be told in advance who would be involved in their care. They preferred to receive information at the moment it was practically relevant. While they indicated that they did not need to be overloaded with too much information about the background of the individual role, they did value clear explanation and the familiarity and reassurance that such roles could offer from the perspective of continuity of care.
Patients should always be informed that a surgical care team member forms part of the surgical team that will be caring for them. This should be through discussion with patients in advance of their treatment, reinforced by the provision of patient information leaflets, available in a range of formats and community languages. Where applicable, it might also be useful to create ‘branding’, by choosing a specific type or colour of hospital uniform to create clear identities for the different staff groups.
Refusal to be treated
Patients are entitled to refuse care by a surgical care team member in just the same way as they can refuse care from any healthcare professional. The patient’s decision should be respected by all team members.
Professional development and career progression
Once qualified, practitioners within the surgical care team are responsible for keeping themselves up to date and maintaining competence in all areas of their practice. This should form the basis of a role-specific annual appraisal and continuing skills assessment, using the competencies outlines in the relevant curriculum or the AfPP competency toolkit (for surgical first assistants). Like all members of the surgical team, they can undertake 50 hours per year of continuing professional development and educational activities across all aspects of their work to support their skills, knowledge and career development. Once training is complete, it is good practice to have a mentor who is different from the clinical supervisor and who has no line management responsibility for the practitioner.
A surgical care team member should have a formal educational and professional development plan agreed with their consultant supervisor, which should be reviewed on a regular basis and at least once a year. Placing value on education and offering further training to extended practitioners also helps retain them over time. Employers should support these roles’ development by allocating the necessary budget as well as adequate time into their job plan (including study leave) to allow them to carry out such activities and meet the objectives of their agreed personal developmental plan. The funding for such a budget will depend on available resources and should be offered when existing contractual requirements around internal mandatory training and performance targets are met. NHS Employers recently launched the Apprenticeship Levy scheme, which could also be used to support the training and development of practitioner roles.
Surgical care team members should keep a diary of their CPD activity as well as an accurate portfolio of evidence of all their procedures and clinical activity, (eg a logbook). They should engage in quality assurance processes and quality improvement activities including participation in local audits and annual appraisals/performance reviews, and they should participate in their surgical team’s collection of patient and colleague feedback at least once every five years.
They should participate in multidisciplinary team meetings as well as morbidity and mortality meetings to avoid isolated practice.
Career progression for surgical care team members often takes place through gaining more autonomy, more responsibilities, and dealing with more complex patients, in line with the advancement of their knowledge and practical skills. They may also take on management and teaching roles such as leading audit or service development, or delivering training to other extended roles or junior trainees. Career progression can also take place by moving from junior to more senior roles, eg from surgical first assistant to surgical care practitioner by following the career pathway for SCPs offered by the RCS, or by moving to more specialised roles. Career progression should be structured with remuneration and banding appropriate to the responsibilities of the roles.
It is important that employers develop a clear career path and opportunities for advancement for surgical care team members in order to retain their skills. This will be particularly important for stability of the care team when there are workforce shortages.
Assesment
The appropriate assessment of competence in any role is critical for patient safety. It enables those in clinical practice to demonstrate that they are able to undertake the identified requirements of that role to an appropriate standard. Such assessment can be identified in a number of different contexts, enabling individuals to demonstrate:
- the ability to undertake a specific role after completion of a specific training programme;
- the ability to move from one role to another role or another training pathway based on clinical experience; and
- the ongoing ability to continue in a role through continuing professional development and review of practice.
Each of these contexts could require different approaches to assessment. For example, contexts that require the demonstration of appropriate progression towards an identified standard of practice will necessarily be formative in nature (assessment for learning).
Meanwhile, contexts that require the demonstration of the achievement of this standard will necessarily be summative in nature (assessment of learning), or at least look to formulate a picture of competence based on a synthesis of information gained from a range of formative assessment encounters.
Irrespective of the specific context, however, all assessment needs to be sufficiently focused on the tasks required for the specific role in question to ensure that the information provided is sufficiently relevant to contribute to the overall ability of an individual to fulfil that role safely and effectively.
In terms of assessment to demonstrate ability to undertake a specific role, the surgical care practitioner role has an established Curriculum Framework (RCS, 2014), in which a number of specific workplace-based assessments adapted from the Intercollegiate Surgical Curriculum Programme (ISCP) are recommended.
Key relevant tools are the following:
- Case Based Discussion
- Mini-Clinical Evaluation Exercise
- Mini-Peer Assessment Tool
- Direct Observation of Procedural Skills
- Procedure Based Assessment
- Multi-source Feedback
- Acute Care Assessment Tool
All these tools are available through the ISCP website.
Each tool will contribute to an overall picture of an individual’s ability to apply clearly defined skills – be they clinical, procedural or in communication, with a patient or a colleague – to demonstrate progression and achievement of the required standard of a practising SCP.
Similarly, the surgical first assistant has an established list of competencies identified in the Association for Perioperative Practice Surgical First Assistant competency toolkit, which also contains a list of assessment tools.
For those wishing to move into an extended surgical role from other roles, it may be possible to use existing experience in lieu of some of the identified training time of an established curriculum. Assessment in this context will aim to allow the individual to demonstrate that he or she has applied the skills identified in the part of the training from which they are exempt in another clinical context that is sufficiently similar to illustrate equivalence. For example, a current SFA wishing to move into a SCP role could demonstrate this relevant experience through the assessment of a submitted portfolio of evidence documenting the appropriate foundation of knowledge and skills in key areas of the SCP curriculum. This assessment, in addition to the completion of the relevant conversion module, could enable the individual to enter a two-year programme at the start of the second year.
Finally, where an individual is already undertaking a specific role within the surgical care team, regular appraisal is required to enable the demonstration of ongoing competence in a specific clinical context, much as a registered medical or surgical practitioner is required to undergo cyclical revalidation. For some surgical care team roles where the scope of practice remains unchanged, such appraisal should follow the evidence submitted for the revalidation process, as set out in the GMC Good Medical Practice Framework for Appraisal and Revalidation (GMC, 2013), and the RCS Guidance on Supporting Information for Revalidation (RCS, 2013):
- evidence of carrying out approximately 50 hours of CPD activity per year;
- quality improvement activity and audit/review of practice based on a portfolio documenting the volume of procedures and the associated clinical outcomes;
- documentation and discussion of significant events; and
- feedback from colleagues and patients.
Where the scope of practice has changed within a role, observation of practice by the responsible consultant surgeon can be undertaken and documented using the relevant workplace-based assessment tool for the clinical practice observed. Such reviews of practice should be undertaken on an annual basis, or at six-monthly intervals during an individual’s first year within a given role.
If assessment within the surgical care team is approached judiciously, it should serve the interests of patient safety whilst providing practitioners with the confidence that their skills are sufficient to undertake the requirements of their role, and remain so over time. The burden of assessment – placed on both the assessors and those being assessed – should be proportionate in providing sufficient opportunities, but not excessive requirements, for practitioners in training and in practice to demonstrate the appropriate skills and competence. The framework for such assessment is already in existence and, where necessary, can be tailored to ensure that, in each of the contexts identified, members of the extended surgical care team have demonstrated their ability to carry out a specific role to the appropriate standard.