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The Faculty of Perioperative Care seeks to support practitioners working as part of the extended surgical team in a variety of ways. Educational and developmental opportunities number amongst these endeavours and those readers who have attended the annual conference will know that the poster abstract competition is an ongoing commitment by the Faculty to the development of beginning researchers. The publication of this paper is an example of the Faculty supporting a practitioner’s professional development.
RCSEd has established a memorandum of understanding with the universities delivering RCS England accredited Surgical Care Practitioner education, with students undertaking the MSc offered free Affiliate membership of the Faculty of Perioperative Care. This enables students to profit from membership benefits that will support their time as a student and beyond completion of the course.
Mike Kay, an affiliate member, has contributed this article on the need for an ethical, educated practitioner working in the Surgical Care Practitioner role, although this could also be applied to Surgical First Assistants. Comparisons are often made between the surgical environment and that of aviation; with the development of manual dexterity likened to the commitment required of professional musicians; in this essay, Mike has considered elite team training in the context of SCPs and other surgical roles, an approach that will resonate with many readers and provide a trigger for reflection.
Service pressures compounded by the impact of the SARS-CoV-2 pandemic and a reduction in the number of newly qualified doctors choosing a career in surgery has necessitated increasing reliance on interprofessional members of the extended surgical team; amongst these are Surgical Care Practitioners (SCPs), (Rimmer et al, 2018; NHS England, 2022, RCSEd, 2022). Although the role was established in cardiac surgery in the late 1990s it was not until 2006 that the first structured, non-cardiac educational programmes were established. The most recent revision of the national curriculum framework published in late 2022 as the result of a bi-collegiate initiative between the Royal College of Surgeons of England and that of Edinburgh has further improved the parity of expectation between SCPs and surgical trainees (Griffith & Dowie, 2019). Between 2018 and 2019, a total of 106,530 elective operations were cancelled. The reasons for this vary, however, a lack of staff, both medical and non-medical was a documented factor, (NHS England, 2020). The operational planning guidance for the year 2022 to 2023 takes account of this factor, as does the National Health Service (NHS) Five Year forward view, which introduces advanced clinical practice roles as a service improvement strategy. NHS England and Health Education England (HEE) support the development of advanced roles and those of Medical Associate Professionals (MAPs) such as SCPs as being a key component in workforce planning. The commissioning of a new core capabilities framework for the MAP group compliments the curriculum framework published by the Royal College of Surgeons (HEE, 2022; RCSEd, 2022).
When developing any role, regardless of how long it has been established, it is important to consider the need for thorough training and education of practitioners both from a professional and ethical standpoint. A critical analysis of the need for the thorough training of SCPs may help the reader who may be planning to implement the role in their extended surgical team. Key factors to consider are the ethical principles established by Beauchamp and Childress of autonomy, justice, beneficence, and non-maleficence (Beauchamp and Childress, 2019). The concepts of this ethical model can be seen running through the codes of conduct established by those healthcare regulators working within and supporting surgical care practitioners (HCPC, 2016; NMC, 2018; GMC; 2019).
Autonomy requires an individual to possess capacity and the ability to engage with the decision-making process free from external constraints, (Taylor, 2018). The Mental Capacity Act (2005) is integral to ensuring informed consent is valid, with the delivery of information from the practitioner being assimilated and a decision given freely by the patient balanced on risks versus benefits, (MCA, 2005; RCSEd, 2016; General Medical Council (GMC) 2019; GMC, 2020). Capacity for an autonomous decision requires both a functional test of the individual’s ability to form a decision and for the choice to be made free from impairment, (NICE, 2018). Capacity is governed by the standards of the MCA (2005). Within the context of the MCA this is assumed, however the practitioner should assess if there are any concerns with capacity, (MCA, 2005; NICE, 2018). This is critical should capacity require challenging, as a surrogate advocate may need to be appointed, (Beauchamp and Childress, 2019). Additional considerations for practitioners must include the effects of terminal diagnosis and the effect of anxiety leading to a temporary loss of capacity, (Wheeler, 2021).
Historically the information given to patients was considered as the material risk deemed by physicians on the Bolam principle arising from the case of Bolam v Frier (1957). However, this has been challenged on numerous occasions by cases achieving the Bolam principle but failing autonomy, outlined in Table 1.
Table 1. Case laws involving a breach in informed consent.
|
Legal Case. |
Bolam Test Applied. |
Breach Of Informed Consent. |
|
Rogers v Whitaker (1992) |
Yes |
Yes |
|
Appleton v Garrett (1996) |
Yes |
Yes |
|
Chester v Afshar (2004) |
Yes |
Yes |
|
Border v Lewisham and Greenwich NHS Trust (2015) |
Yes |
Yes |
|
Montgomery v Lanarkshire (2015) |
Yes |
Yes |
Albeit historical cases, they have demonstrated a breach in informed consent despite the Bolam principle being established. This created a longitudinal precedent for updating informed consent. Montgomery v Lanarkshire (2015) revolutionised the information being discussed with patients judged on what a patient would classify as material risk and not that of a panel of surgical peers. Although somewhat dated, Sokol’s hypothesis (2007) considers omitting information can be morally justified as a therapeutic omission when consulting with dementia patients, (McKenzie et al, 2021). However, this seems to be the only exception to argue full disclosure to patients, with non-disclosures being regarded in the same context as direct falsehoods to patients, (Cox and Fritz, 2016). Scharf et al (2021) support this with a case whereby family members requested that practitioners withhold a cancer diagnosis from their relative. However, this is the antithesis of autonomy and patient consent would not be considered valid, (Beauchamp and Childress, 2019). Furthermore, to ensure the patient’s autonomy is supported, they should be informed of the involvement of non-medical practitioners in their care with their agreement, (RCSEd, 2018).
The RCSEd (2022) identifies tasks that the consultant surgeon can delegate to the SCP such as gaining informed consent, as a nominated delegate once the supervising surgeon validates competence. Wald et al (2019) conducted a study on the costs of litigation to the NHS following the Montgomery v Lanarkshire (2015) case and found a fourfold increase of failure to inform. An increase of £62 million per year in litigation since 2015, was reported (Wald et al, 2019). It is proposed that improvements in the quality of patient safety will reduce litigation costs, with the NHS patient safety strategy (2019) aiming to reduce claims by £750 million per year, (Yau et al, 2020). Therefore, it could be argued that the thorough training in the legal aspects is imperative to ensuring the SCP navigates through the labyrinth of legal conundrums in a litigious society.
The symbiotic relationship of autonomy and informed consent can occasionally conflict with the remaining medical ethics, (British Medical Journal, 2019). Donaldson LJ in Re T (Adult) (1992) contributed to case law on consent which relates to an objection to blood transfusion on the grounds of religious belief; with arguments before the court that the patient was influenced by family members rather than personal belief. The court upheld the decision of the physicians to transfuse in an emergency on the grounds that capacity of the decision at the time did not commensurate with the outcome. However, Donaldson LJ in Re T (Adult) (1992), established that practitioners respect autonomous decisions surrounding how patients choose to live, despite those decisions leading to early onset mortality. This may in some circumstances lead to advance directives such as the case of B v An NHS Hospital Trust [2002] whereby mechanical ventilation was withdrawn. Although such cases may be unique, the SCP should be aware of the legal aspects surrounding the care of these individuals to ensure dignity in autonomy; advocating the holistic care of the patient is respected and the ethical principle of non-maleficence is upheld, (Moore et al, 2019; Beauchamp and Childress 2019). Therefore, it could be posited that the SCP should be aware of the legal and ethical implications of the care they provide and appropriate education in keeping with current national expectations will support this.
Non-maleficence would normally be described as not inflicting harm but could also be inclusive of not imposing risks of harm as well, (Beauchamp and Childress, 2019). The seminal report by the Institute of Medicine (1999) demonstrated a growing demand for an improvement in patient safety initiatives, (IOM, 1999). Subsequent publications by the IOM (2005); World Health Organisation Guidelines for Safe Surgery (2009); NHS Five year forward view (2015) and the SCP national curriculum (2022) have built upon principles established in 1999 surrounding the involvement of non-medically trained practitioners within patient care.
The WHO (2009) guidelines for safe surgery contain the surgical safety checklist which aims to reduce patient harm. The use of checklists has been demonstrated to reduce the human factors element in avoidable patient care errors, (WHO, 2016; RCSEd, 2022). Stress and lack of situational awareness have been linked to adverse patient outcomes in an integrative review within patient care, (Orique and Despina, 2018). Lowes et al (2016) introduce the notion of “Bandwidth” relating to an individual’s cognitive load. The narrowing of bandwidth and subsequent deterioration of situational awareness is affected by psychological stressors such as increased cognitive load. Poor surgical assistance is detrimental to patient safety and the negative effect on the operating surgeon such as increased cognitive load of additional thinking for the assisting practitioner, (Hall, Quick and Hall 2016; Lowes et al, 2016). Hotton et al (2019) support this with investigations into performance anxiety and the negative effects on individual performance. Myint (2018) expands upon this by stating assistants will improve the operating surgeon’s performance and patient safety by demonstrating an in-depth understanding of the procedure leading to improved situational awareness.
The quality of training has been correlated to impacting on the ability to perform under pressure. It has been argued within US Navy Seals’ training that the individual does not rise to the pressure related task but relies on the quality of their training and exposure to balancing cognitive load, (Weisnger, and Pawlin-Fry, 2016). This is supported by the systematic review conducted by Kent et al (2018) that synthesised studies to ascertain interventions that improve performance under pressure. Conclusively, repeated exposure, educational interventions, and simulation all had a positive influence on the ability to perform under pressure to help avoid adverse outcomes by training within human factors, (Kent et al, 2018).
Hall et al (2014) distinguish the simple act of holding a retractor does not equate to good surgical assistance, but knowledge and understanding of: anatomy, physiology and the procedural steps defines the difference. There are few legal cases that specifically mention poor surgical assisting, making that published by Murphy (1998) relevant to the assertions of Hall et al (2014) regarding knowledge and understanding of anatomy and physiology. Understanding abnormal anatomy and physiology is dependent on the appreciation of normal parameters, (Villa, 2016). The fundamental knowledge of anatomy and physiology is also acknowledged by Hall et al (2016) and addressed within the recently revised SCP curriculum framework (2022) alongside the Intercollegiate Surgical Curriculum Core Surgery programme, (ISCP, 2017). The synthesis of normal parameters will provide the ability to project the proceeding necessary steps, (Lowes et al, 2016). Understanding of a situation and the ability to anticipate the next steps forms part of human factors and situational awareness, (Lowes et al, 2016). Without the fundamental aspect of perception and secondly understanding an individual will be unable to project, (Lowes et al, 2016). Orique and Despina (2018) established higher levels of situational awareness in practitioners who understood the next steps and were able to anticipate in advance. Therefore, it could be argued that comprehension of anatomy, physiology and procedural steps will address human factors positively by improving situational awareness and subsequently reducing stress on the operating surgeon, (Hotton et al, 2019).
Whilst patient positioning may seem a rudimentary task, which may be undertaken by many members of the perioperative team, it is the ability of the SCP to apply knowledge of anatomy, physiology, and the surgical steps to ensure surgical access is optimised and patient harm minimised, (Rothrock, McEwen and Alexander, 2019; Armstrong and Moore, 2020). The risk of prolonged positioning is synonymous with peripheral nerve and pressure injuries, (Rothrock, McEwen and Alexander, 2019). This is a weighted decision balanced against surgical access to conduct the procedural steps, (Rothrock, McEwen and Alexander, 2019). Wood et al (2019) reported the cost of pressure injuries to the NHS as being between £1.4-£2.4 billion per annum. A recent prospective cohort study (Espejo et al, 2018) identified the risk of secondary infections arising from initial pressure injuries. The associated cost of such events adds to the financial burdens placed on the NHS, (Espejo et al, 2018; Wood et al, 2019). Pressure injuries and morbidity associated with urinary tract infections are two of the four areas recorded by the NHS Safety Thermometer to track patient harm and analyse harm free care, (Department of Health and Social Care, 2018). Urinary catheterisation, patient positioning, and infection prevention are associated skills of the SCP role with concomitant risk of patient harm, (Department of Health and Social Care, 2018, RCSEd, 2018). Therefore, the cascade of events from pressure injury to wound infection and ultimately patient safety could be negated through the understanding of anatomy, physiology and aetiology of disease when applied to the task of patient positioning.
Beneficence is synonymous with patient safety and involves a combined approach of positive beneficence and utility that can conflict with autonomy and should be the opposing ethic of non-maleficence, (RCSEd, 2018; Beauchamp and Childress, 2019). Herring (2020) supports this notion that beneficence is not independent of autonomy to include situations whereby practitioners acknowledge the limitations within their scope of practice and the care they provide. The Dunning-Kruger effect, where individuals overestimate skill due to illusory superiority is the result of being incompetently unaware of their incompetence, (Welsby, 2018). This is supported by Wilsher v Essex Area High Authority (1988) which established material increase of risk. However, the resultant judgement from the House of Lords also established that healthcare professionals undertaking training will be judged to the standard of a trained professional. Robson et al (2020) expand upon this by discussing the culpability of healthcare professionals and negligence. Reference to the English tort law of ignorance will not be an excuse in the defence of an individual’s actions or accepted by the practitioner’s governing body, (HCPC, 2018; NMC, 2018; Robson et al, 2020).
The limitations and scope of practice for practitioners working within extended roles such as that of the SCP is based upon the General Medical Council’s Good Medical Practice guidelines addressed within clinical governance of the surgical care team, (RCSEd, 2018; RCSEd, 2022). Whilst education and training forms one of the seven pillars of clinical governance, the SCP curriculum framework places the onus on practitioners to acknowledge limitations of their knowledge and skills, (RCSEd, 2022). Registrants are also accountable to their awarding bodies and have codes of conduct against which they will be judged, (HCPC, 2016; NMC, 2018). This is supported by individual regulating bodies with the current lack of professional assurance and national regulation for SCPs, (RCSEd, 2018). The RCSEd acknowledge that the lack of national regulation impacts on limited practice in areas such as requesting ionising radiation and non-medical prescribing, (RCSEd, 2018). As the first step towards regulation a managed voluntary register for SCPs will enhance the role and mitigate the gap in training, (RCSEd, 2014; RCSEd, 2021).
Benner (1984) produced her seminal work outlining the journey of competence from entry level trainee to expert practitioner. Thomas and Kellgren (2017) support the use of Benner’s contextual model within current training and acknowledge the regression of experts to novices when introduced within new roles and environments. The RCSEd (2022) address this in the SCP national curriculum framework by outlining the need for a consultant surgeon to supervise the actions of trainee SCPs. Tasks delegated must be within the scope of competence of the individual and appropriate supervision applied accordingly, (Griffith and Dowie, 2019; RCSEd, 2022). As practitioners transition through Benner’s contextual framework the level of supervision required can change from direct to indirect, indirect to proximal, (Benner, 1984; RCSEd 2022; RCSEd 2018). Ultimately, accountability and adherence to the scope of practice with awareness of limitations improves patient safety whilst ensuring the education process is transitional from novice to expert.
Griffith and Dowie (2019) establish the criteria for non-medically qualified assistants to be of the equivalent standard to the role they are bridging. The RCSEd (2016) outline in a case study that SCPs correlate to the equivalent of a surgical foundation year trainee with more experienced practitioners operating at an advanced level within the surgical trainee framework. Health Education England (2019) support this by arguing that the level an SCP performs at could equate to a speciality trainee year three (ST3). This could be linked to Benner’s contextual framework with the initial stages of novice; advanced beginner and competent meeting the SCP national curriculum framework competency sign off, (Benner, 1984; RCSEd, 2022). The stage of competent to expert would then relate the competent SCP with foundation year trainee and developing experience leading to a similar level of an ST3, (Benner, 1984; HEE, 2019; RCSEd, 2022). The importance of correlating the transferable level of care from physician to non-medical practitioner will ensure the delivery of standardised care and adherence to the ethical principle of justice whilst maintaining beneficence.
In the context of healthcare, justice is the principle of allocating resources and equal access to medical care, (Herring, 2020). The NHS (2020) reported a significant decrease in the availability of physicians. The NHS five year forward view supported advanced clinical roles such as the SCP to provide continuance to patient care, (NHS, 2014; Campaner, 2019). Whilst Griffith and Dowie (2019) establish the criteria for non-medically qualified assistants to be of the equivalent standard to the role they are bridging, Quick (2013) argues that surgical trainees should meet the same standards as the SCP. Whilst similarities within the role of the surgical trainee and an SCP overlap it could be argued SCPs detract from surgical training, however, it has been suggested that SCPs can take a step back during conflicts of training, (RCSEd, 2016). Conversely, the role of the SCP has been shown to improve surgical trainee exposure by distributing roles that detract from surgical training, (HEE, 2019). It is imperative to establish a parity of education to consolidate the principles outlined and ensure the ethical principle of justice is enforced to allow equal healthcare standards to all patients.
Gibbs et al (2004) introduced the original debate surrounding the difference between training and education within healthcare. The concept of education requires the synthesis of knowledge, skills, and application within the contextual environment, in comparison training is the application and mastery of a skill, (Gibbs et al, 2004). To expand upon this, training may be compared to education but forms one of the foundations of education, (Gibbs et al, 2004). Education forms one of the pillars of clinical practice, (RCSEd, 2018). Clinical practice is assessed through a combination of education, skills, and work-based assessments (WBA), (RCSEd, 2018). Table 2 outlines the volume of evidence required to ensure competence is established within trainee SCPSs that was updated within the new curriculum framework, without the volume of evidence established within the (2014) curriculum, (RCSEd, 2014; RCSEd, 2022). Whilst the curriculum framework (2014) placed a quantitative number to be achieved within the 12-month period, the updated curriculum (2022) has placed the emphasis on learning events, that has seen a change of word description from work-based assessments, (RCSEd, 2014; RCSEd, 2022).
Table 2. Supervised Learning Events (SLE) of SCPs in training, (RCSEd, 2014; RCSEd, 2022).
|
Work Based Assessment (WBA). |
Frequency per annum. |
|
Direct Observational Procedural Skills (DOPS). |
12 |
|
Case Based Discussion (CBD). |
6 |
|
Consultation Evaluation Exercise (CEX). |
6 |
|
Procedure Based Assessment (PBA). |
6 |
|
Multi Source Feedback (MSF) |
1 |
|
Annual CPD hours |
50 |
Health Education England (2022) propose that the ethical practitioner should continue a similar portfolio of evidence post registration with 50 hours of continuing professional development annually. The evidence should be recorded alongside a surgical logbook and reflections, (HEE, 2019; RCSEd, 2022). The parity demonstrated by logbook maintenance supports practitioner growth by acting as a reflective tool, (RCSEd, 2022).
This aggregation of evidence could be assimilated to the Great British cycling marginal gains theory, whereby an accumulation of one percent in each area produces a cumulative improved outcome, (Denyer, 2013). Therefore, each of these assessments individually do not ascertain competence, but collectively the aggregation produces evidence of thorough training. Surgery has been compared to high performance sports with marginal improvements at an elite or professional level only attained by improving 1% in each area, but has already demonstrated tangible benefits within cardiothoracic surgery, (Denyer, 2013; Rosner and Gonzalez, 2019). Therefore, the application of marginal gains within the context of training could support the argument that optimising each area within the training and education is essential to producing the outcome of competence when combined collectively. Furthermore, the “15 steps to peak performance”, demonstrates how to produce a high performing cycling team, that can be transferrable to the impact of the SCP national curriculum framework (2022) whereby a structured approach produces a parity of professionalism, (Denyer, 2013; RSCEd, 2022).
It could be argued that prior to the SCP curriculum framework there was thorough training already established for cardiothoracic SCPs, however the SCP curriculum framework has introduced a parity of training across all specialities. Upon exploration of the legal and ethical aspects surrounding the role of the SCP the debate becomes more complex to validate the importance of such a question. The ethical principle of autonomy is an integral aspect within patient centred care and with the involvement of non-medical practitioners will gain the confidence of patients with evidence of thorough training.
The debate surrounding education versus training and skills is nullified when the observational stance of marginal gains is applied. Removing comparison and applying aggregation achieves a consolidated outcome. The development of competency is a transitional journey achieved by assimilating knowledge and practising skills. This enables practitioners to fulfil the requirements of the educational requirements of those higher education institutions delivering the SCP curriculum whilst validating the transferable skills required of practitioners undertaking a role historically undertaken by physicians. Parity of competence between these roles is essential to ensure patient safety is upheld with a defined scope of practice. This is currently addressed within the SCP curriculum framework and by the individual’s governing body in the absence of a national regulator. Competence within the extended role of the SCP is assessed by both theoretical knowledge and practical skills. When undertaken competently team performance and arguably patient safety is enhanced by reducing cognitive load across the perioperative team.
In a litigious society it is essential that continued professional development is recorded; logbooks maintained, and annual competence assessed to avoid the pitfalls of the ethical and legal aspects of the role. The notion that this is the foundation of training that requires a consistent effort to continually develop will benefit the individual when under pressure, as their response will undoubtedly reflect on the quality of their training and may be the difference that defines the patient’s outcome.
For a full list of references visit: Surgeons' News September 2023 - References | RCSEd
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