Extended Roles and Their Scope of Practice

Role definition

Surgical care practitioners are registered healthcare professionals who have extended the scope of their practice by completing an RCS-accredited training programme (or other programme in the case of those practitioners who have been practising since before the establishment of the RCS-accredited training). They work as members of the surgical team and their main responsibilities are to support surgeons and other professionals before, during and after surgical procedures. They can perform some surgical interventions and carry out preoperative and postoperative care under the supervision of a senior surgeon.

Area of practice

Intra- and perioperative environment, including theatre, wards and clinics, usually within a specific surgical specialty. This can include both elective and emergency work within the practitioner’s scope of practice.

Overview of tasks and activities

• Clinics – seeing specific preoperative patients and listing them for surgical procedures, as well as seeing postoperative patients for follow-up.
• Preoperative assessment processes including clinical examination and enhanced recovery education as directed by the surgical team.
• Arrangement of pre- and postoperative investigations as part of the MDT.
• Participation in the consent process in their areas of practice.
• Liaison with surgical staff, as well as theatre, ward and clerical staff, on relevant issues including theatre lists to support coherent service provision.
• Participation in the WHO safe surgery checklist.
• Preparation of patients for surgery including venepuncture, male and female catheterisation, patient positioning and preparation.
• Undertaking of surgical procedures as part of the MDT for the respective surgical specialty under the supervision and direction of the operating surgeon.
• Acting as first or second assistant as directed by the supervising surgeon.
• Facilitation of continuity of care.
• Daily ward rounds, making assessments and formulating plans for postoperative care.
• Writing of operation notes and ward round note taking.
• Postoperative care, including wound assessment, initial treatment and identification of surgical problems and complications.
• Identification of acute deterioration of patients with knowledge of early warning scores.
• Provision of support to on-call and emergency services.
• Evaluation and documentation of care, including the discharge process and follow-up care arrangements, including writing discharge summaries and liaising with primary care.
• Facilitation of the training by supporting a training session or providing delegated care to a patient while the supervising surgeon is conducting a training session.
• Research, development, education and audit within the surgical department.
• Prescription of medications relevant to their individual specialty following appropriate training for non-medically qualified prescribers.

Supervision and management

• Clinical responsibility to the consultant surgeon.
• Day-to-day work under the direction of the operating surgeon and as a member of the surgical care team.
• Line management as part of the surgical team and under the direction of the responsible consultant.
• During the two-year training, the SCP will be assigned a named responsible consultant who will serve as clinical supervisor and mentor for the duration of the training programme.
  

Autonomy and independent work

• Pre-determined level of autonomy and supervision, agreed on a case-by-case basis with the responsible consultant surgeon.
• Once the surgeon is satisfied the SCP works safely and competently within his of her role, the surgeon can arrange for proximal supervision (where the consultant surgeon is not in theatre but his or her location is within the hospital, and can be easily contactable).

Training

• Two-year programme at master’s level, accredited by the RCS and comprising both a theoretical and a practical element.
• In the second year there is specialisation in a chosen surgical specialty.
• All competencies should be assessed and signed off by the responsible consultant. These should be documented in the SCP training portfolio.

Eligibility for entry into the training

• Registration as a healthcare professional (eg nurse, operating department practitioner, or physiotherapist).
• 18 months of post-registration experience.
• Evidence of ability to study at master’s degree level.
• Aptitude for clinical and operative practice.

Professional accountability

• Nursing and Midwifery Council, or Health and Care Professions Council, for their original, non-extended roles.
• It is recommended that SCPs follow the Association for Perioperative Practice voluntary code of conduct for registered practitioners working in advanced surgical roles, as well as the codes of conduct and performance of their regulatory bodies.

NB. At the time of writing of this document, the UK health departments were consulting on further options for professional assurance and appropriate regulation for medical associate professions, including SCPs.

Banding

Between 7 – 8b

Trained SCP: Band 7

Senior SCP: Band 8a

Lead SCP: Band 8b

Role definition

Surgical first assistants are registered healthcare professionals who provide continuous competent and dedicated assistance under the direct supervision of the operating surgeon throughout the procedure, while not performing any form of surgical intervention.

Area of practice

Primarily intraoperative work, although pre- and postoperative visits may also be part of the role.

Overview of tasks and activities

• Improving communication between theatre, patient and ward.
• Involvement in the team completion of the WHO surgical safety checklist for all surgical interventions.
• Male and female urethral catheterisation.
• Assistance with patient positioning, including tissue viability assessment.
• Skin preparation prior to surgery and draping.
• Use and maintenance of specialised surgical equipment relevant to the area of their work.
• Handling of tissues and manipulation of organs for exposure or access under direct observation of the operating surgeon.
• Superficial and deep tissue retraction (NB. retractors should not be placed by the SFA but by the operating surgeon).
• Assistance with haemostasis to secure and maintain a clear operating field, including indirect application of surgical diathermy as directed by the operating surgeon (NB. activities such as application of direct electro surgical diathermy to body tissue, applying haemostats or ligaclips to vessels and cast bandaging are the remit of the surgeon, supervised surgical trainee or surgical care practitioners and not the SFA).
• Use of suctions guided by the operating surgeon.
• Camera and instrument manipulation under the direction of the surgeon during minimal access surgery (NB. camera insertion and application of instruments should be performed by the operating surgeon).
• Cutting of deep sutures and ligatures.
• Simple wound closure and skin suturing (see below *)
• Application of dressings.
• Assistance with the transfer of patients to the postoperative anaesthetic care unit.

Supervision and management

• Clinical responsibility to the consultant surgeon once trained.
• Day-to-day work under the direction of the operating surgeon and the theatre management team.
• Line management as part of the theatre team. 

Autonomy

• The surgical first assistant works under the direct supervision of a surgeon who must remain in theatre until surgery is completed.
• (*) SFAs are not allowed to undertake tasks considered to be surgical interventions. However, they are allowed to undertake 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).

Training

• Successful completion of a nationally recognised programme of study. There are two training routes:
  
  - A university accredited programme, such as the College of Operating Department Practitioners’ BSc in operating department practice. NB. Universities that offer accredited modules for SFAs must ensure that the programme offered follows the recommendations of the Perioperative Care Collaborative.
  
  - An in-house training package supported by the AfPP SFA Competency Toolkit

Eligibility for entry into the training

• Registration as a healthcare professional (eg nurse, operating department practitioner or physiotherapist).
• 12 months of post-registration experience
• Aptitude for clinical and operative practice

Professional accountability

• Nursing and Midwifery Council, or Health and Care Professions Council, for their original, non-extended roles.
• It is recommended that SFAs follow the AfPP voluntary code of conduct for registered practitioners working in advanced surgical roles, as well as the codes of conduct and performance of their regulatory bodies.

Banding

Band 5-7

Other practitioner roles such as advanced critical care practitioners and physician associates are frequently recruited to support the surgical care team within the scope of their competence and expertise.

Physician associates (PAs)

Physician associates (PAs) are healthcare professionals who have undertaken an accredited two-year postgraduate qualification following a degree in a medical science. They are trained to the medical model. They are not required to be registered healthcare professionals although they are regulated through a voluntary register run by the Faculty of Physician Associates at the Royal College of Physicians. Their scope of practice includes a number of surgical interventions and are set out in detail the guidance An Employer's Guide to Physician Associates (Faculty of Physician Associates, 2017).

Advanced clinical practitioners (ACPs) and advanced nurse practitioners (ANPs)

Advanced clinical practitioners (ACPs) and advanced nurse practitioners (ANPs) are experienced registered healthcare practitioners who have undertaken a master’s qualification or equivalent that encompasses the four pillars of clinical practice, management and leadership, education, and research, with demonstration of core and area-specific clinical competence. Training is delivered locally. According to Health Education England, advanced clinical practice is “a level of practice characterised by a high level of autonomy and complex decision-making […] Advanced Clinical Practice embodies the ability to manage complete clinical care in partnership with patients/carers. It includes the analysis and synthesis of complex problems across a range of settings, enabling innovative solutions to enhance patient experience and improve outcomes” (HEE, 2016)

At the time of writing of this document, there is no nationally agreed curriculum or portfolio for ACP training programmes. An apprenticeship standard has been approved with the end-point assessment standard currently under review. This will eventually support the standardisation of training programmes for advanced clinical practice. However, for those practitioners who wish to work within the surgical care team such a curriculum is currently under development by the RCS, due to be completed in the coming year. This offers the potential for the formal recognition of such practitioners’ skills and knowledge if they wish to work in surgery. A similar programme has been completed in emergency medicine.

Advanced critical care practitioners (ACCPs)

Advanced critical care practitioners (ACCPs) are registered healthcare professionals who have undertaken a dedicated two-year full-time academic programme in compliance with the Curriculum for Training for Advanced Critical Care Practitioners set out by the Faculty of Intensive Care Medicine. Their scope of practice focuses on the delivery of critical care and emergency medicine and is set out in detail by the Faculty of Intensive Care Medicine in alignment with the National Education and Competence Framework for Advanced Critical Care Practitioners (Department of Health, 2008) and The Advanced Practice Toolkit for Scotland (Scottish Government, 2008).

All ACCPs, ACPs, ANPs and PAs have attitudes, skills and knowledge to deliver care and treatment within the team under defined levels of supervision. As with all other members of the surgical care team, their scope of practice, 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.