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The non-medical workforce and its role in surgical training: Consensus recommendations by the Association of Surgeons in Training
Accepted Manuscript The Non-Medical Workforce and its Role in Surgical Training: Consensus recommendations by the Association of Surgeons in Training Vimal J. Gokani, Adam Peckham-Cooper, David Bunting, Andrew J. Beamish, Adam Williams, Rhiannon L. Harries PII:
S1743-9191(16)30939-6
DOI:
10.1016/j.ijsu.2016.09.090
Reference:
IJSU 3136
To appear in:
International Journal of Surgery
Received Date: 12 September 2016 Accepted Date: 27 September 2016
Please cite this article as: Gokani VJ, Peckham-Cooper A, Bunting D, Beamish AJ, Williams A, Harries RL, On behalf of the Council of the Association of Surgeons in Training, The Non-Medical Workforce and its Role in Surgical Training: Consensus recommendations by the Association of Surgeons in Training, International Journal of Surgery (2016), doi: 10.1016/j.ijsu.2016.09.090. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT The Non-Medical Workforce and its Role in Surgical Training: Consensus recommendations by the Association of Surgeons in Training Vimal J Gokani*, Adam Peckham-Cooper, David Bunting, Andrew J Beamish, Adam Williams, Rhiannon L Harries, On behalf of the Council of the Association of Surgeons in Training
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The Association of Surgeons in Training, 35-43 Lincoln’s Inn Fields, London, WC2A 3PE, UK www.asit.org
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*Corresponding author: [email protected]
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https://twitter.com/ASiTofficial @ASiTofficial.
The Non-Medical Workforce in Surgery
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3509 (excluding abstract and references)
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Keywords: Non-medical work force; Surgical training; Surgery; Education; Surgical Care
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Practitioners
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ACCEPTED MANUSCRIPT Abstract: Changes in the delivery of the healthcare structure have led to the expansion of the nonmedical workforce (NMW). The non-medical practitioner in surgery (a healthcare professional without a medical degree who undertakes specialist training) is a valuable addition to a surgical firm. However, there are a number of challenges regarding the
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successful widespread implementation of this role. This paper outlines a number of these concerns, and makes recommendations to aid the realisation of the non-medical practitioner as a normal part of the surgical team. In summary, the Association of Surgeons in Training welcomes the development of the non-medical workforce as part of the surgical
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team in order to promote enhanced patient care and improved surgical training opportunities. However, establishing a workforce of independent/semi-independent practitioners who compete for the same training opportunities as surgeons in training may
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threaten the UK surgical training system, and therefore the care of our future patients.
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ACCEPTED MANUSCRIPT 1. About ASiT The Association of Surgeons in Training (ASiT) is a professional body and registered charity working to promote excellence in surgical training for the benefit of junior doctors and patients alike. With a membership of over 2700 surgical trainees from all 10 surgical specialties, the Association provides support at both regional and national levels throughout
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the United Kingdom and Republic of Ireland. Originally founded in 1976, ASiT is independent of the National Health Service (NHS), Surgical Royal Colleges, and specialty associations. 2. Introduction
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Working hour restrictions and shift-patterns, reducing numbers of trainees, decreased hospitalisation times, enhanced recovery programmes, day-case surgery and changes to
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funding of healthcare have all contributed to the constantly evolving healthcare landscape. In the UK, the traditional firm structure of healthcare teams has seen little change theoretically: the Consultant is responsible for patient care and leads a team. Deputising to the Consultant are: a Specialty Trainee (StR; previously registrar), Core Trainee/Foundation Year 2 doctor (CT/FY2; previously Senior House Officer), and Foundation Year 1 doctor (FY1; previously House Officer). These individuals form the team of junior doctors who work to
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deliver patient care, whilst learning from each other. Each Consultant, however, no longer has three named junior doctors working in their team. Consultant Surgeons may find themselves supervising junior doctors whom they have never met before. To compound factors, members of the so-called team rotate every 4-6 months. With on-calls, night shifts,
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study leave, and annual leave, the time actually spent in a team can be extremely limited. For patients, this can be challenging: meeting a number of different people, all of whom are
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looking after them can become confusing, creating the potential for discontinuity of care and difficulty in forming a trusting relationship of trust. This can also impact on education and training: jeopardising both the continuity of training and the bond between trainer and trainee that facilitates development. Trainees can often find themselves tied to ward areas, performing administrative service tasks such as completing paperwork, re-writing drug charts, requesting and chasing investigations or spending significant time co-ordinating patients through hospital processes. This hinders attendance at formal teaching, operating theatres and outpatient clinics where training and education can take place.
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ACCEPTED MANUSCRIPT Much surgical work is based on day-case or enhanced recovery protocols, and in these cases trainees often provide a source of consistency. With changing rotas and shift patterns, stability in the healthcare team may not be apparent for medium term patients. The patient can expect regular consultations from professionals including Consultants, and the nonmedical workforce (NMW). The latter includes the nursing staff, pharmacists, and therapists.
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Increasingly, the NMW includes practitioners with healthcare training but no medical degree. The National Association of Assistants in Surgical Practice (NAASP) 2003 Surgical care practitioner core syllabus London defined the surgical care practitioner as ‘a nonmedical practitioner, working in clinical practice, as a member of the extended surgical team, who performs surgical intervention, pre-operative and post-operative care under the
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supervision of a consultant surgeon’1. This could be applied to a number of members of the NMW. The multiple pathways into the NMW have resulted in a number of titles for such
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practitioners including surgical care practitioners, surgical assistants, scrub practitioners, peri-operative practitioners, advanced nurse practitioners and physician (or surgeon) associates/assistants. As well as providing a constant presence on the wards, such a workforce can assist in the training of junior doctors by taking over a number of the service roles that prevent trainees from undertaking learning events. This system has been attempted in a number of surgical and non-surgical settings and although the benefits are
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clear, there are also potential pitfalls.
3. Current Experiences of the Non-Medical Workforce
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The Non-Surgical Field
The non-medical workforce is far from a novel concept: obstetric patients have benefitted
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from midwives for millennia. Currently midwives complement obstetric training by monitoring otherwise well, uncomplicated pregnant women, supporting ladies through labour and delivering babies, and performing venepuncture and cannulation, while documenting the progress of their patients. Patients requiring a higher level of care are highlighted to the medical team to allow an assessment and management plan to be made. The patient benefits from improved continuity of care and the trainee is afforded the opportunity to learn from both the midwife and, in the more challenging scenarios, the doctors. The Emergency Practitioner (also known as the Emergency Nurse Practitioner or Advanced Nurse Practitioner) is now commonly employed in the Emergency Department. The precise
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ACCEPTED MANUSCRIPT role of this professional varies but can include the assessment and triage of patients, management of minor ailments and injuries, requesting and interpreting investigations, and prescribing medications. Evidence suggests that this group of practitioners can be clinically equivalent to the senior house-officer grade in a number of specific tasks2-5.Again, they can facilitate training by managing the simpler cases, allowing junior doctors to focus on learning
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events, under the supervision of senior medical staff. Night Nurse Practitioners
With the advent of the ‘Hospital at Night’ Team6 (the skeletal workforce which manages
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night shifts in many hospitals) came the Night Nurse Practitioner. Typical duties include venepuncture, IV cannulation, assessment of unwell patients (escalating to medical staff if necessary), ordering investigations, and in some cases, prescribing analgesia and
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intravenous fluids. Removing such tasks from the junior doctors’ workload improves the educational quality of these often service-oriented shifts and augments the prompt assessment and early intervention of unwell patients improving patient safety. Anaesthetic Nurses/ Practitioners
A number of countries including the USA, the Netherlands and Sweden, employ the services
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of Anaesthetic Nurses (or Practitioners). This workforce comprises mainly individuals from a nursing background, who undergo 1-3 years of training, and monitor anaesthetics independently. Importantly, an anaesthetist or trained doctor is required to be present on
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induction and reversal of each anaesthetic7. To draw parallels with surgery is challenging: it is difficult to compare an operation with basic life-saving manoeuvres, implemented while
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senior support is sought if an untoward event occurs. The Surgical Field
The surgical field also benefits from a NMW and indeed the role can be much more versatile with the potential for diverse career pathways. Such opportunities vary from: assisting on the wards and in elective and emergency clinics, to independent emergency and elective operating8. Endoscopic procedures are commonly performed by non-medical practitioners.
Nurse
endoscopists and nurse cystoscopists have been shown to be as good as surgical trainees or Consultant Urologists in terms of pathology detection9. It has been shown that the use of a
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ACCEPTED MANUSCRIPT non-medical surgical assistant does not affect outcome in low-risk cardiac surgery10. The acute positive effects of the NMW are important but do not reflect the fact that this is not sustainable in the longterm. The training of junior doctors, in order to provide consultant surgeons of the future, is an investment. Models permitting both the NMW and trainees to work efficiently and effectively together do exist. Cardiothoracic surgery has employed
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cardiac non-medical practitioners who are trained to assist and independently harvest vein grafts. Although there is some crossover between the exact roles of such practitioners and surgical trainees, there may well be a middle-ground compromise whereby not only can the practitioner provide a service, they can also help to train junior doctors10. It is important, however, that such training is done under the supervision of a Consultant Surgeon who can
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take responsibility for the training and development of the junior doctor.
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4. Current Guidelines/Curricula
Training and development has been regulated by Universities, a number of which offer courses for the surgical-NMW, although there are guidelines for such training set out by various bodies11-12. The role is very much service driven, with professionals filling areas of perceived need, with potential for career progression from this starting point.
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Department of Health: The National Curriculum Framework for Surgical Care Practitioners A decade ago, England’s Department of Health published a document outlining the role of the NMW13. The role is somewhat indistinct from that of a surgeon in training, with the
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same competence and assessment standards being required. The document states that practitioners would act under the supervision of a consultant surgeon, within a defined scope of practice (which can be developed), to assess emergency and elective patients,
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assist with facilitating patient care in terms of organising and chasing tests, assist with surgical procedures, and also perform operations independently. The document seems aspirational, especially as it is clear that the NMW should not replace junior doctors, and should not compromise their training. RCSEng Wider Surgical Team publication The Royal College of Surgeons of England’s 2016 document, ‘A Question of Balance: The Extended Surgical Team’14 describes the fact that surgical trainees’ experience is hampered by a number of issues described above. The document calls for the development of the NMW in order to supplement the surgical team and ‘improve care and enhance training
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ACCEPTED MANUSCRIPT experience for junior doctors’. 5. Current Surgical Trainees’ Views The Association of Surgeons in Training has undertaken an anonymous survey, which aimed to explore current exposure and trainees’ attitudes and experiences towards NMW. The
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survey was distributed to all delegates who attended the 2015 ASiT Conference. A 20% response rate was received with 112 completed responses ranging from medical students to senior trainees, and encompassing all geographical regions within the UK.
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Over half (52%) of respondents had worked with non-medical practitioners, predominantly (49%) within a teaching hospital environment. A number of names for non-medical practitioners were used (Figure 1). Non-medical practitioners were observed in all surgical
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specialties except paediatric surgery and neurosurgery. A wide variety of skills and working practices were observed. Almost a quarter (24%) of non-medical practitioners were working in the theatre environment performing supervised surgical procedures. Sixteen percent of trainees reported observing practitioners performing surgical procedures independently. The NMW was seen to be independent prescribers in 21% of responses. Respondents
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generally had mixed attitudes towards the NMW (Figure 1).
In summary, trainees tended to agree that the NMW could improve service delivery (72%) and patient care (58%). There was a trend towards trainees feeling that the NMW took away training opportunities away from them (65%), although it was also felt that the NMW could
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support trainees on the wards (74%), in clinic (59%), and less so in the theatre setting (48%), or assessing acute admissions (47%). Just under half of respondents (46%) thought that
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non-medical practitioners could enhance surgical training. A similar proportion reported that they would be happy for non-medical practitioners to look after their relatives (47%), and suggested there should be more non-medical practitioner (46%). Over half (54%) of respondents stated that they would like to work with non-medical practitioners as consultants.
6. Current or Potential Challenges with the Non-Medical Workforce System There are a number of potential challenges to the introduction of the NMW, arguably related to the poorly defined remit of their role. Failure to clarify boundaries between the
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ACCEPTED MANUSCRIPT roles of the various professionals will likely result in delayed acceptance of the NMW and this must be a pre-requisite to further work. Patient perceptions Patient acceptability is central to the success of the surgical-NMW. There is currently a
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paucity of work examining patient perception of the surgical-NMW. However, as the specific roles develop and diversify, this may be become challenging. A high quality patient survey may help to delineate the potential role of such a practitioner.
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The End-Point
There is no current accepted job description for the NMW and indeed the number of titles is outnumbered by the variety of roles that the NMW fills. Current posts include solely pre-
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operative, intra-operative, or post-operative practice; and a combination of any or all of the above. Work is required to define the NMW scope of practice. Buch et al found that although trainees and surgical-NMW felt that the latter had a defined role, each group had different views as to what those were15. Trainees felt that the surgical-NMW acted at a junior trainee level, whereas the surgical-NMW felt that they functioned at a senior trainee level. This is probably unhelpful: there is little disagreement that the role of the midwife,
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Emergency Nurse Practitioner or Night Nurse Practitioner is different to that of the medical team. In the same way, the role of the surgical-NMW should not be likened to that of a junior doctor, but should be viewed as a complementary workstream. Drawing parallels
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between medical and non-medical professionals risks confusing patients. Taking Training Opportunities Away From Trainees
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The possibility of taking training opportunities away from junior doctors is a concern15. Specifically, operating experience may be threatened, however we may not have crossed the boundary into successfully training independent surgical-NMW. Kingsnorth reported his experience of attempting to formally introduce hernia surgery to the remit of the NMW. After providing 800 hours of supervised hernia-operating time, he concluded that ‘medical training teaches independence in decision making, and five years undergraduate study provides the platform for postgraduate training and the ability to quickly learn, master and deploy technical skills in operative surgery. The results of this pilot study suggest that for non-medically qualified practitioners the learning curve to acquire operative skills in inguinal hernia surgery and the associated clinical judgment is very long…and not cost-effective’16.
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ACCEPTED MANUSCRIPT Interestingly, he also clarified that the training of the non-medical practitioner did not negatively affect the training of junior doctors, as the practitioner would step aside when a junior doctor was available to take up a learning opportunity. There is an argument that the NMW enhances surgical training by removing elements of service-based work from trainees, allowing them to take advantage of training
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opportunities. Models such as that described by Martin et al, (2007), however, appear to offer the NMW the training opportunities that a junior trainee could benefit from. This paper showed that a series of 381 minor procedures was successfully undertaken by a nonmedical practitioner. The authors admit that the educational programme set out for the
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practitioner would have been beneficial for a junior doctor; which validates anecdotal reports that increasingly NMW can be preferentially given training opportunities over
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trainees by Consultant Trainers17. Training budgets
Medical training is a continuous process and professional development continues throughout practice. As stated in the RCSEng document, The Question of Balance: The Extended Surgical Team’14 training budgets are under heavy pressure. The document
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describes how funding streams intended for trainees’ development have been invested in the non-medical workforce. Facing increasing costs, junior doctors themselves are under immense financial pressure18-19, and cutting budgets that were originally indented to support the development of junior doctors through to consultancy, can only make surgery a less
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attractive career and as such ASiT would strongly oppose such proposals.
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Taking Trainer Time Away from Trainees It appears inevitable that if Consultant supervision is diverted away from surgical trainees to the NMW, the amount of training time available for the surgical trainee is reduced, leading to a need for increased quality of training to compensate. Competing for training, in a reducing working time pathway (length of training and also working day), will only serve to dilute training experiences and, therefore, the quality of surgeon produced. However with reasonable definition of roles, this could improve access to training. Taking Over the Role of the Doctor The role of the doctor may be difficult to define as many professionals make up part of the
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ACCEPTED MANUSCRIPT healthcare team. Within surgical training programmes, trainee surgeons develop their decision making skills, increasing their responsibility in a graduated fashion, under the overarching supervision their Consultant trainers. The signing off of competences by trainers includes active consideration of the need for a surgeon to be able to recognise and deal with the potential consequences of decisions and actions. This is as important outside the theatre
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as within it. Notably, it is not considered acceptable for a registrar to hold ultimate clinical responsibility in theatre in parallel with the consultant taking overall responsibility for the patient. To extend this privilege to a non-medical practitioner may undermine the responsibility and role of the doctor, potentially mislead patients, and represent a regressive
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step in terms of patient safety. A future solution to a current problem
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A number of universities and organisations offer pathways to train the NMW to the standard required by patients. Training is not complete following completion of such courses and delivery of the NMW is far from immediate. Post-graduate training in the form of diplomas, in-house training and completion of further short-courses is required. The NMW is not an immediate solution to the NHS’ recruitment problems.
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The Origin and Career Pathway of the NMW-Practitioner
Nursing and paramedical sectors are in a recruitment crisis20. To siphon from an already short workforce may further compromise patient safety, and simply shifts the problem from
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one area to another. Moreover, decanting the cohort which self-selecting cohort to undertake further training to join the NMW may remove the more motivated nursing staff from the nursing workforce. The current career pathway is also undetermined. The exact
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qualifications of a non-medical practitioner are variable, have no minimum baseline, and are not quality assured with no defined curricula. Unlike other healthcare professionals, patients are not afforded the benefit of non-medical practitioners being registered with a dedicated regulatory body such as the General Medical Council. 7. Recommendations Based on the survey undertaken by ASiT members in 2015 and discussions within the Council of the Association of Surgeons in Training, the following recommendations have been developed:
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ACCEPTED MANUSCRIPT 1. Work should be done to assimilate the opinions of patients and patient groups as to whether they would feel safe being treated by an increasing NMW. It must be clear to patients that, although these team members have had some training in healthcare, they are not medically qualified and are not doctors. 2. Following on from various inquiries, including but not limited to the Keogh Report21
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and Francis report22 all practitioners providing healthcare should be on an
authorised regulatory body’s register, undertake regular appraisals and be subject to appropriate assessment of outcome data where applicable.
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3. The NMW should not take training opportunities away from junior doctors as their learning objectives should be distinct and separate.
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4. The NMW and surgical trainees should not need to compete for trainer supervision. If this is unavoidable, adequate funding for supervisors should be made available prior to expansion of the NMW.
5. The development of the NMW should not result in a justification for any reduction in the numbers of junior doctors, with a continued minimum number of trainees in
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place to sustain a Consultant workforce.
6. The development of a NMW should not come at the cost of removing talented individuals from other, overstretched, healthcare professions such as nurses. Moreover any gaps left in these overstretched services, by the development of
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NMW, should not be filled by ‘nursing assistants’ or similar lesser experience or skills, with a resultant spiral of reducing expertise and subsequent patient safety
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concerns.
7. Funding for such a workforce should not jeopardise funding streams, or parts of funding streams, already allocated to surgeons in training. This includes existing training budgets: personal, regional and national, as well as funding for other continual professional development and salaries. Funding for training of the NMW must be completely separate and additional to existing regional training budgets
8. The introduction of the NMW should be piloted, with specific outcome measures examined. Outcome measures may include patient, trainee, nursing staff, consultant
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satisfaction;
complaints/litigation;
surgical
logbook
assessments; and work-placed based assessments undertaken. 9. The non-medical workforce should not be given responsibilities equivalent or greater than a post-MRCS level trainee.
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10. A national curriculum should be developed and finalized for the training of NMW, which incorporates work-based placed assessments, skills logbook and multi-source
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feedback.
8. Conclusions
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The aims of the non-medical workforce have been well described by the Department of Health National Practitioner Programme. The NMW will:
1. Enhance the capability of the surgical team and will evolve together within the team 2. Be the responsibility of a named Consultant Surgeon who has the time and
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resources to train them
3. Not compromise the training of future surgeons 4. Not replace Consultant Surgeons13
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The aims are laudable and in line with both current service requirements and those of trainees represented by The Association of Surgeons in Training. In agreement with the
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Royal College of Surgeons of England14, we would amend point 3 to read: ‘Improve the training of future surgeons’.
We would also add the primary objective: that the role of the NMW will ‘Be developed in such a way in which it is accepted by, understood by, and beneficial to patients’. In summary, the Association of Surgeons in Training welcomes the development of the nonmedical workforce as part of the surgical team, as an excellent opportunity to enhance patient care and surgical training, in parallel with desirable career prospects for the aspiring
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ACCEPTED MANUSCRIPT NMW practitioner. Existing models of such practice include midwives and anaesthetic nurse practitioners. However, the rapid development of the NMW, without clear role definition, allowing independent or semi-independent practice and leading to competition for the same training opportunities as consultant surgeons in training, may introduce increased risk to patients, be damaging to the surgical training system, and compromise patient
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understanding of the team’s roles and competences.
Conflict of interest
The authors are current surgical trainees and current elected members of the Council of the
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Association of Surgeons in Training and seek to improve patient care and surgical training in the UK. The authors have no other relevant financial or personal conflicts of interest to
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declare in relation to this paper.
Funding
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Nil
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ACCEPTED MANUSCRIPT References 1. National Association of Assistants in Surgical Practice (NAASP) in conjunction with The Royal College of Surgeons of England. Surgical Practitioner Core Syllabus 2003; London: NAASP/RCSE
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2. Sakr M, Angus J, Perrin J, Nixon C, Nicholl J, Wardrope J. Care of minor injuries by emergency nurse practitioners or junior doctors: a randomised controlled trial. Lancet 1999; 354: 1321-6.
3. Mann CJ, Grant I, Guly H, Hughes P. Use of Ottawa ankle rules by nurse practitioners. J
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Accid Emerg Med 1998; 15: 315-16.
4. Thurston, J, Field S. Should accident and emergency nurses request radiographs? Results
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of a multicentre evaluation. J Accid Emerg Med 1996; 13:86-89.
5. Freij RM, Duffy T, Hackett D, Cunningham D, Fothergill J. Radiographic interpretation by nurse practitioners in a minor injuries unit. J Accid Emerg Med 1996; 13:41-3 6. Hamilton-Fairley D, Coakley J, Moss F. Hospital at night: an organizational design that
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provides safer care at night. BMC Med Educ. 2014;14 Suppl 1:S17. doi: 10.1186/1472-692014-S1-S17. Epub 2014 Dec 1
7. Royal College of Anaesthetists. The Role of Non-medical Staff in the Delivery of Anaesthesia
Services.
2003.
https://www.rcoa.ac.uk/system/files/PUB-role_of_non-
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medical_staff.pdf (Last accessed 7th September 2016)
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8. Quick J. The role of the surgical care practitioner within the surgical team. B J Nurs 2013; (2) 759.
9. DiSario JA, Sanowski RA. Sigmoidoscopy training for nurses and resident physicians. Gastrointest Endosc. 1993; 39(1): 29-32. 10. Alex J, Rao VP, Cale AR, Griffin SC, Cowen ME, Guvendik L. Surgical nurse assistants in cardiac surgery: a UK trainee's perspective. Eur J Cardiothorac Surg. 2004;25(1):111-5 11.
Faculty
of
Physicians
Associates
at
the
Royal
College
of
Physicians.
http://www.fparcp.co.uk
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ACCEPTED MANUSCRIPT 12. Faculty of Perioperative Care at the Royal College of Surgeons of Edinburgh. https://fpc.rcsed.ac.uk 13. The Department of Health. The National Curriculum Framework for Surgical Care Practitioners. London: DoH, 2006.
Team.
2016.
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14. Royal College of Surgeons of England. A Question of Balance: The Extended Surgical https://www.rcseng.ac.uk/government-relations-and-
consultation/documents/a-question-of-balance-the-extended-surgical-team (Last accessed 7th September 2016)
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15. Buch KE, Genovese MY, Conigliaro JL, Nguyen SQ, Byrn JC, Novembre CL, Divino CM. Non-physician practitioners' overall enhancement to a surgical resident's experience. J Surg
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Educ. 2008; 65 (1): 50-3.
16. Kingsnorth AN. Training SCPs to perform inguinal hernia surgery: results of the Plymouth Action On programme. The Bulletin of the Royal College of Surgeons of England. 2005;87:242–3.
17. Martin S, Purkayastha S, Massey R, Paraskeva P, Tekkis P, Kneebone R, Darzi A. The
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surgical care practitioner: a feasible alternative. Results of a prospective 4-year audit at St Mary's Hospital Trust, London. Ann R Coll Surg Engl. 2007; 89(1): 30-5 18. Ercolani M, Vohra R, Carmichael F, Mangat K, Alderson D. The lifetime cost to English
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students of borrowing to invest in a medical degree: a gender comparison using data from the office of National Statistics. BMJ Open 2015;5:e007335 doi:10.1136/bmjopen-2014-
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007335
19. Stroman L, Weil S, Butler K, McDonald CR. Can you afford to become a surgeon? The bill, please. The Bulletin of the Royal College of Surgeons of England, 2015. DOI: 10.1308/147363515X14162390057944 20. https://www.nursingtimes.net/roles/nurse-managers/exclusive-nhs-nurse-staffing-crisisfuels-global-recruitment/5077670.article 21. Department of Health. The Keogh Review of the Regulation of Cosmetic Interventions. 2013.
http://www.gov.uk/government/publications/review-of-the-regulation-of-cosmetic-
interventions (Last accessed 7th September 2016)
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ACCEPTED MANUSCRIPT 22. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. 2013. http://webarchive.nationalarchives.gov.uk/20150407084003/http://www.midstaffspublicin
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quiry.com(Last accessed 7th September 2016)
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ACCEPTED MANUSCRIPT Abbreviations ASiT: Association of Surgeons in Training CCT: Certificate of Completion of Training
FY: Foundation Doctor ISCP: Intercollegiate Surgical Curriculum Programme
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NHS: National Health Service
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CT: Core Trainee
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NMW: Non-Medical Workforce
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Str: Specialist Trainee
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ACCEPTED MANUSCRIPT
S1743-9191(16)30939-6
DOI:
10.1016/j.ijsu.2016.09.090
Reference:
IJSU 3136
To appear in:
International Journal of Surgery
Received Date: 12 September 2016 Accepted Date: 27 September 2016
Please cite this article as: Gokani VJ, Peckham-Cooper A, Bunting D, Beamish AJ, Williams A, Harries RL, On behalf of the Council of the Association of Surgeons in Training, The Non-Medical Workforce and its Role in Surgical Training: Consensus recommendations by the Association of Surgeons in Training, International Journal of Surgery (2016), doi: 10.1016/j.ijsu.2016.09.090. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT The Non-Medical Workforce and its Role in Surgical Training: Consensus recommendations by the Association of Surgeons in Training Vimal J Gokani*, Adam Peckham-Cooper, David Bunting, Andrew J Beamish, Adam Williams, Rhiannon L Harries, On behalf of the Council of the Association of Surgeons in Training
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The Association of Surgeons in Training, 35-43 Lincoln’s Inn Fields, London, WC2A 3PE, UK www.asit.org
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*Corresponding author: [email protected]
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https://twitter.com/ASiTofficial @ASiTofficial.
The Non-Medical Workforce in Surgery
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Word count
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3509 (excluding abstract and references)
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Funding
Keywords: Non-medical work force; Surgical training; Surgery; Education; Surgical Care
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Practitioners
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ACCEPTED MANUSCRIPT Abstract: Changes in the delivery of the healthcare structure have led to the expansion of the nonmedical workforce (NMW). The non-medical practitioner in surgery (a healthcare professional without a medical degree who undertakes specialist training) is a valuable addition to a surgical firm. However, there are a number of challenges regarding the
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successful widespread implementation of this role. This paper outlines a number of these concerns, and makes recommendations to aid the realisation of the non-medical practitioner as a normal part of the surgical team. In summary, the Association of Surgeons in Training welcomes the development of the non-medical workforce as part of the surgical
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team in order to promote enhanced patient care and improved surgical training opportunities. However, establishing a workforce of independent/semi-independent practitioners who compete for the same training opportunities as surgeons in training may
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threaten the UK surgical training system, and therefore the care of our future patients.
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ACCEPTED MANUSCRIPT 1. About ASiT The Association of Surgeons in Training (ASiT) is a professional body and registered charity working to promote excellence in surgical training for the benefit of junior doctors and patients alike. With a membership of over 2700 surgical trainees from all 10 surgical specialties, the Association provides support at both regional and national levels throughout
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the United Kingdom and Republic of Ireland. Originally founded in 1976, ASiT is independent of the National Health Service (NHS), Surgical Royal Colleges, and specialty associations. 2. Introduction
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Working hour restrictions and shift-patterns, reducing numbers of trainees, decreased hospitalisation times, enhanced recovery programmes, day-case surgery and changes to
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funding of healthcare have all contributed to the constantly evolving healthcare landscape. In the UK, the traditional firm structure of healthcare teams has seen little change theoretically: the Consultant is responsible for patient care and leads a team. Deputising to the Consultant are: a Specialty Trainee (StR; previously registrar), Core Trainee/Foundation Year 2 doctor (CT/FY2; previously Senior House Officer), and Foundation Year 1 doctor (FY1; previously House Officer). These individuals form the team of junior doctors who work to
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deliver patient care, whilst learning from each other. Each Consultant, however, no longer has three named junior doctors working in their team. Consultant Surgeons may find themselves supervising junior doctors whom they have never met before. To compound factors, members of the so-called team rotate every 4-6 months. With on-calls, night shifts,
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study leave, and annual leave, the time actually spent in a team can be extremely limited. For patients, this can be challenging: meeting a number of different people, all of whom are
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looking after them can become confusing, creating the potential for discontinuity of care and difficulty in forming a trusting relationship of trust. This can also impact on education and training: jeopardising both the continuity of training and the bond between trainer and trainee that facilitates development. Trainees can often find themselves tied to ward areas, performing administrative service tasks such as completing paperwork, re-writing drug charts, requesting and chasing investigations or spending significant time co-ordinating patients through hospital processes. This hinders attendance at formal teaching, operating theatres and outpatient clinics where training and education can take place.
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ACCEPTED MANUSCRIPT Much surgical work is based on day-case or enhanced recovery protocols, and in these cases trainees often provide a source of consistency. With changing rotas and shift patterns, stability in the healthcare team may not be apparent for medium term patients. The patient can expect regular consultations from professionals including Consultants, and the nonmedical workforce (NMW). The latter includes the nursing staff, pharmacists, and therapists.
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Increasingly, the NMW includes practitioners with healthcare training but no medical degree. The National Association of Assistants in Surgical Practice (NAASP) 2003 Surgical care practitioner core syllabus London defined the surgical care practitioner as ‘a nonmedical practitioner, working in clinical practice, as a member of the extended surgical team, who performs surgical intervention, pre-operative and post-operative care under the
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supervision of a consultant surgeon’1. This could be applied to a number of members of the NMW. The multiple pathways into the NMW have resulted in a number of titles for such
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practitioners including surgical care practitioners, surgical assistants, scrub practitioners, peri-operative practitioners, advanced nurse practitioners and physician (or surgeon) associates/assistants. As well as providing a constant presence on the wards, such a workforce can assist in the training of junior doctors by taking over a number of the service roles that prevent trainees from undertaking learning events. This system has been attempted in a number of surgical and non-surgical settings and although the benefits are
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clear, there are also potential pitfalls.
3. Current Experiences of the Non-Medical Workforce
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The Non-Surgical Field
The non-medical workforce is far from a novel concept: obstetric patients have benefitted
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from midwives for millennia. Currently midwives complement obstetric training by monitoring otherwise well, uncomplicated pregnant women, supporting ladies through labour and delivering babies, and performing venepuncture and cannulation, while documenting the progress of their patients. Patients requiring a higher level of care are highlighted to the medical team to allow an assessment and management plan to be made. The patient benefits from improved continuity of care and the trainee is afforded the opportunity to learn from both the midwife and, in the more challenging scenarios, the doctors. The Emergency Practitioner (also known as the Emergency Nurse Practitioner or Advanced Nurse Practitioner) is now commonly employed in the Emergency Department. The precise
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ACCEPTED MANUSCRIPT role of this professional varies but can include the assessment and triage of patients, management of minor ailments and injuries, requesting and interpreting investigations, and prescribing medications. Evidence suggests that this group of practitioners can be clinically equivalent to the senior house-officer grade in a number of specific tasks2-5.Again, they can facilitate training by managing the simpler cases, allowing junior doctors to focus on learning
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events, under the supervision of senior medical staff. Night Nurse Practitioners
With the advent of the ‘Hospital at Night’ Team6 (the skeletal workforce which manages
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night shifts in many hospitals) came the Night Nurse Practitioner. Typical duties include venepuncture, IV cannulation, assessment of unwell patients (escalating to medical staff if necessary), ordering investigations, and in some cases, prescribing analgesia and
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intravenous fluids. Removing such tasks from the junior doctors’ workload improves the educational quality of these often service-oriented shifts and augments the prompt assessment and early intervention of unwell patients improving patient safety. Anaesthetic Nurses/ Practitioners
A number of countries including the USA, the Netherlands and Sweden, employ the services
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of Anaesthetic Nurses (or Practitioners). This workforce comprises mainly individuals from a nursing background, who undergo 1-3 years of training, and monitor anaesthetics independently. Importantly, an anaesthetist or trained doctor is required to be present on
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induction and reversal of each anaesthetic7. To draw parallels with surgery is challenging: it is difficult to compare an operation with basic life-saving manoeuvres, implemented while
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senior support is sought if an untoward event occurs. The Surgical Field
The surgical field also benefits from a NMW and indeed the role can be much more versatile with the potential for diverse career pathways. Such opportunities vary from: assisting on the wards and in elective and emergency clinics, to independent emergency and elective operating8. Endoscopic procedures are commonly performed by non-medical practitioners.
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endoscopists and nurse cystoscopists have been shown to be as good as surgical trainees or Consultant Urologists in terms of pathology detection9. It has been shown that the use of a
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ACCEPTED MANUSCRIPT non-medical surgical assistant does not affect outcome in low-risk cardiac surgery10. The acute positive effects of the NMW are important but do not reflect the fact that this is not sustainable in the longterm. The training of junior doctors, in order to provide consultant surgeons of the future, is an investment. Models permitting both the NMW and trainees to work efficiently and effectively together do exist. Cardiothoracic surgery has employed
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cardiac non-medical practitioners who are trained to assist and independently harvest vein grafts. Although there is some crossover between the exact roles of such practitioners and surgical trainees, there may well be a middle-ground compromise whereby not only can the practitioner provide a service, they can also help to train junior doctors10. It is important, however, that such training is done under the supervision of a Consultant Surgeon who can
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take responsibility for the training and development of the junior doctor.
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4. Current Guidelines/Curricula
Training and development has been regulated by Universities, a number of which offer courses for the surgical-NMW, although there are guidelines for such training set out by various bodies11-12. The role is very much service driven, with professionals filling areas of perceived need, with potential for career progression from this starting point.
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Department of Health: The National Curriculum Framework for Surgical Care Practitioners A decade ago, England’s Department of Health published a document outlining the role of the NMW13. The role is somewhat indistinct from that of a surgeon in training, with the
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same competence and assessment standards being required. The document states that practitioners would act under the supervision of a consultant surgeon, within a defined scope of practice (which can be developed), to assess emergency and elective patients,
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assist with facilitating patient care in terms of organising and chasing tests, assist with surgical procedures, and also perform operations independently. The document seems aspirational, especially as it is clear that the NMW should not replace junior doctors, and should not compromise their training. RCSEng Wider Surgical Team publication The Royal College of Surgeons of England’s 2016 document, ‘A Question of Balance: The Extended Surgical Team’14 describes the fact that surgical trainees’ experience is hampered by a number of issues described above. The document calls for the development of the NMW in order to supplement the surgical team and ‘improve care and enhance training
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ACCEPTED MANUSCRIPT experience for junior doctors’. 5. Current Surgical Trainees’ Views The Association of Surgeons in Training has undertaken an anonymous survey, which aimed to explore current exposure and trainees’ attitudes and experiences towards NMW. The
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survey was distributed to all delegates who attended the 2015 ASiT Conference. A 20% response rate was received with 112 completed responses ranging from medical students to senior trainees, and encompassing all geographical regions within the UK.
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Over half (52%) of respondents had worked with non-medical practitioners, predominantly (49%) within a teaching hospital environment. A number of names for non-medical practitioners were used (Figure 1). Non-medical practitioners were observed in all surgical
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specialties except paediatric surgery and neurosurgery. A wide variety of skills and working practices were observed. Almost a quarter (24%) of non-medical practitioners were working in the theatre environment performing supervised surgical procedures. Sixteen percent of trainees reported observing practitioners performing surgical procedures independently. The NMW was seen to be independent prescribers in 21% of responses. Respondents
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generally had mixed attitudes towards the NMW (Figure 1).
In summary, trainees tended to agree that the NMW could improve service delivery (72%) and patient care (58%). There was a trend towards trainees feeling that the NMW took away training opportunities away from them (65%), although it was also felt that the NMW could
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support trainees on the wards (74%), in clinic (59%), and less so in the theatre setting (48%), or assessing acute admissions (47%). Just under half of respondents (46%) thought that
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non-medical practitioners could enhance surgical training. A similar proportion reported that they would be happy for non-medical practitioners to look after their relatives (47%), and suggested there should be more non-medical practitioner (46%). Over half (54%) of respondents stated that they would like to work with non-medical practitioners as consultants.
6. Current or Potential Challenges with the Non-Medical Workforce System There are a number of potential challenges to the introduction of the NMW, arguably related to the poorly defined remit of their role. Failure to clarify boundaries between the
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ACCEPTED MANUSCRIPT roles of the various professionals will likely result in delayed acceptance of the NMW and this must be a pre-requisite to further work. Patient perceptions Patient acceptability is central to the success of the surgical-NMW. There is currently a
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paucity of work examining patient perception of the surgical-NMW. However, as the specific roles develop and diversify, this may be become challenging. A high quality patient survey may help to delineate the potential role of such a practitioner.
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The End-Point
There is no current accepted job description for the NMW and indeed the number of titles is outnumbered by the variety of roles that the NMW fills. Current posts include solely pre-
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operative, intra-operative, or post-operative practice; and a combination of any or all of the above. Work is required to define the NMW scope of practice. Buch et al found that although trainees and surgical-NMW felt that the latter had a defined role, each group had different views as to what those were15. Trainees felt that the surgical-NMW acted at a junior trainee level, whereas the surgical-NMW felt that they functioned at a senior trainee level. This is probably unhelpful: there is little disagreement that the role of the midwife,
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Emergency Nurse Practitioner or Night Nurse Practitioner is different to that of the medical team. In the same way, the role of the surgical-NMW should not be likened to that of a junior doctor, but should be viewed as a complementary workstream. Drawing parallels
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between medical and non-medical professionals risks confusing patients. Taking Training Opportunities Away From Trainees
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The possibility of taking training opportunities away from junior doctors is a concern15. Specifically, operating experience may be threatened, however we may not have crossed the boundary into successfully training independent surgical-NMW. Kingsnorth reported his experience of attempting to formally introduce hernia surgery to the remit of the NMW. After providing 800 hours of supervised hernia-operating time, he concluded that ‘medical training teaches independence in decision making, and five years undergraduate study provides the platform for postgraduate training and the ability to quickly learn, master and deploy technical skills in operative surgery. The results of this pilot study suggest that for non-medically qualified practitioners the learning curve to acquire operative skills in inguinal hernia surgery and the associated clinical judgment is very long…and not cost-effective’16.
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ACCEPTED MANUSCRIPT Interestingly, he also clarified that the training of the non-medical practitioner did not negatively affect the training of junior doctors, as the practitioner would step aside when a junior doctor was available to take up a learning opportunity. There is an argument that the NMW enhances surgical training by removing elements of service-based work from trainees, allowing them to take advantage of training
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opportunities. Models such as that described by Martin et al, (2007), however, appear to offer the NMW the training opportunities that a junior trainee could benefit from. This paper showed that a series of 381 minor procedures was successfully undertaken by a nonmedical practitioner. The authors admit that the educational programme set out for the
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practitioner would have been beneficial for a junior doctor; which validates anecdotal reports that increasingly NMW can be preferentially given training opportunities over
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trainees by Consultant Trainers17. Training budgets
Medical training is a continuous process and professional development continues throughout practice. As stated in the RCSEng document, The Question of Balance: The Extended Surgical Team’14 training budgets are under heavy pressure. The document
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describes how funding streams intended for trainees’ development have been invested in the non-medical workforce. Facing increasing costs, junior doctors themselves are under immense financial pressure18-19, and cutting budgets that were originally indented to support the development of junior doctors through to consultancy, can only make surgery a less
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attractive career and as such ASiT would strongly oppose such proposals.
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Taking Trainer Time Away from Trainees It appears inevitable that if Consultant supervision is diverted away from surgical trainees to the NMW, the amount of training time available for the surgical trainee is reduced, leading to a need for increased quality of training to compensate. Competing for training, in a reducing working time pathway (length of training and also working day), will only serve to dilute training experiences and, therefore, the quality of surgeon produced. However with reasonable definition of roles, this could improve access to training. Taking Over the Role of the Doctor The role of the doctor may be difficult to define as many professionals make up part of the
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ACCEPTED MANUSCRIPT healthcare team. Within surgical training programmes, trainee surgeons develop their decision making skills, increasing their responsibility in a graduated fashion, under the overarching supervision their Consultant trainers. The signing off of competences by trainers includes active consideration of the need for a surgeon to be able to recognise and deal with the potential consequences of decisions and actions. This is as important outside the theatre
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as within it. Notably, it is not considered acceptable for a registrar to hold ultimate clinical responsibility in theatre in parallel with the consultant taking overall responsibility for the patient. To extend this privilege to a non-medical practitioner may undermine the responsibility and role of the doctor, potentially mislead patients, and represent a regressive
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step in terms of patient safety. A future solution to a current problem
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A number of universities and organisations offer pathways to train the NMW to the standard required by patients. Training is not complete following completion of such courses and delivery of the NMW is far from immediate. Post-graduate training in the form of diplomas, in-house training and completion of further short-courses is required. The NMW is not an immediate solution to the NHS’ recruitment problems.
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The Origin and Career Pathway of the NMW-Practitioner
Nursing and paramedical sectors are in a recruitment crisis20. To siphon from an already short workforce may further compromise patient safety, and simply shifts the problem from
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one area to another. Moreover, decanting the cohort which self-selecting cohort to undertake further training to join the NMW may remove the more motivated nursing staff from the nursing workforce. The current career pathway is also undetermined. The exact
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qualifications of a non-medical practitioner are variable, have no minimum baseline, and are not quality assured with no defined curricula. Unlike other healthcare professionals, patients are not afforded the benefit of non-medical practitioners being registered with a dedicated regulatory body such as the General Medical Council. 7. Recommendations Based on the survey undertaken by ASiT members in 2015 and discussions within the Council of the Association of Surgeons in Training, the following recommendations have been developed:
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ACCEPTED MANUSCRIPT 1. Work should be done to assimilate the opinions of patients and patient groups as to whether they would feel safe being treated by an increasing NMW. It must be clear to patients that, although these team members have had some training in healthcare, they are not medically qualified and are not doctors. 2. Following on from various inquiries, including but not limited to the Keogh Report21
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and Francis report22 all practitioners providing healthcare should be on an
authorised regulatory body’s register, undertake regular appraisals and be subject to appropriate assessment of outcome data where applicable.
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3. The NMW should not take training opportunities away from junior doctors as their learning objectives should be distinct and separate.
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4. The NMW and surgical trainees should not need to compete for trainer supervision. If this is unavoidable, adequate funding for supervisors should be made available prior to expansion of the NMW.
5. The development of the NMW should not result in a justification for any reduction in the numbers of junior doctors, with a continued minimum number of trainees in
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place to sustain a Consultant workforce.
6. The development of a NMW should not come at the cost of removing talented individuals from other, overstretched, healthcare professions such as nurses. Moreover any gaps left in these overstretched services, by the development of
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NMW, should not be filled by ‘nursing assistants’ or similar lesser experience or skills, with a resultant spiral of reducing expertise and subsequent patient safety
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concerns.
7. Funding for such a workforce should not jeopardise funding streams, or parts of funding streams, already allocated to surgeons in training. This includes existing training budgets: personal, regional and national, as well as funding for other continual professional development and salaries. Funding for training of the NMW must be completely separate and additional to existing regional training budgets
8. The introduction of the NMW should be piloted, with specific outcome measures examined. Outcome measures may include patient, trainee, nursing staff, consultant
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satisfaction;
complaints/litigation;
surgical
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assessments; and work-placed based assessments undertaken. 9. The non-medical workforce should not be given responsibilities equivalent or greater than a post-MRCS level trainee.
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10. A national curriculum should be developed and finalized for the training of NMW, which incorporates work-based placed assessments, skills logbook and multi-source
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feedback.
8. Conclusions
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The aims of the non-medical workforce have been well described by the Department of Health National Practitioner Programme. The NMW will:
1. Enhance the capability of the surgical team and will evolve together within the team 2. Be the responsibility of a named Consultant Surgeon who has the time and
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resources to train them
3. Not compromise the training of future surgeons 4. Not replace Consultant Surgeons13
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The aims are laudable and in line with both current service requirements and those of trainees represented by The Association of Surgeons in Training. In agreement with the
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Royal College of Surgeons of England14, we would amend point 3 to read: ‘Improve the training of future surgeons’.
We would also add the primary objective: that the role of the NMW will ‘Be developed in such a way in which it is accepted by, understood by, and beneficial to patients’. In summary, the Association of Surgeons in Training welcomes the development of the nonmedical workforce as part of the surgical team, as an excellent opportunity to enhance patient care and surgical training, in parallel with desirable career prospects for the aspiring
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ACCEPTED MANUSCRIPT NMW practitioner. Existing models of such practice include midwives and anaesthetic nurse practitioners. However, the rapid development of the NMW, without clear role definition, allowing independent or semi-independent practice and leading to competition for the same training opportunities as consultant surgeons in training, may introduce increased risk to patients, be damaging to the surgical training system, and compromise patient
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understanding of the team’s roles and competences.
Conflict of interest
The authors are current surgical trainees and current elected members of the Council of the
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Association of Surgeons in Training and seek to improve patient care and surgical training in the UK. The authors have no other relevant financial or personal conflicts of interest to
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declare in relation to this paper.
Funding
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Nil
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ACCEPTED MANUSCRIPT References 1. National Association of Assistants in Surgical Practice (NAASP) in conjunction with The Royal College of Surgeons of England. Surgical Practitioner Core Syllabus 2003; London: NAASP/RCSE
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2. Sakr M, Angus J, Perrin J, Nixon C, Nicholl J, Wardrope J. Care of minor injuries by emergency nurse practitioners or junior doctors: a randomised controlled trial. Lancet 1999; 354: 1321-6.
3. Mann CJ, Grant I, Guly H, Hughes P. Use of Ottawa ankle rules by nurse practitioners. J
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Accid Emerg Med 1998; 15: 315-16.
4. Thurston, J, Field S. Should accident and emergency nurses request radiographs? Results
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of a multicentre evaluation. J Accid Emerg Med 1996; 13:86-89.
5. Freij RM, Duffy T, Hackett D, Cunningham D, Fothergill J. Radiographic interpretation by nurse practitioners in a minor injuries unit. J Accid Emerg Med 1996; 13:41-3 6. Hamilton-Fairley D, Coakley J, Moss F. Hospital at night: an organizational design that
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provides safer care at night. BMC Med Educ. 2014;14 Suppl 1:S17. doi: 10.1186/1472-692014-S1-S17. Epub 2014 Dec 1
7. Royal College of Anaesthetists. The Role of Non-medical Staff in the Delivery of Anaesthesia
Services.
2003.
https://www.rcoa.ac.uk/system/files/PUB-role_of_non-
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medical_staff.pdf (Last accessed 7th September 2016)
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8. Quick J. The role of the surgical care practitioner within the surgical team. B J Nurs 2013; (2) 759.
9. DiSario JA, Sanowski RA. Sigmoidoscopy training for nurses and resident physicians. Gastrointest Endosc. 1993; 39(1): 29-32. 10. Alex J, Rao VP, Cale AR, Griffin SC, Cowen ME, Guvendik L. Surgical nurse assistants in cardiac surgery: a UK trainee's perspective. Eur J Cardiothorac Surg. 2004;25(1):111-5 11.
Faculty
of
Physicians
Associates
at
the
Royal
College
of
Physicians.
http://www.fparcp.co.uk
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ACCEPTED MANUSCRIPT 12. Faculty of Perioperative Care at the Royal College of Surgeons of Edinburgh. https://fpc.rcsed.ac.uk 13. The Department of Health. The National Curriculum Framework for Surgical Care Practitioners. London: DoH, 2006.
Team.
2016.
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14. Royal College of Surgeons of England. A Question of Balance: The Extended Surgical https://www.rcseng.ac.uk/government-relations-and-
consultation/documents/a-question-of-balance-the-extended-surgical-team (Last accessed 7th September 2016)
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15. Buch KE, Genovese MY, Conigliaro JL, Nguyen SQ, Byrn JC, Novembre CL, Divino CM. Non-physician practitioners' overall enhancement to a surgical resident's experience. J Surg
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Educ. 2008; 65 (1): 50-3.
16. Kingsnorth AN. Training SCPs to perform inguinal hernia surgery: results of the Plymouth Action On programme. The Bulletin of the Royal College of Surgeons of England. 2005;87:242–3.
17. Martin S, Purkayastha S, Massey R, Paraskeva P, Tekkis P, Kneebone R, Darzi A. The
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surgical care practitioner: a feasible alternative. Results of a prospective 4-year audit at St Mary's Hospital Trust, London. Ann R Coll Surg Engl. 2007; 89(1): 30-5 18. Ercolani M, Vohra R, Carmichael F, Mangat K, Alderson D. The lifetime cost to English
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students of borrowing to invest in a medical degree: a gender comparison using data from the office of National Statistics. BMJ Open 2015;5:e007335 doi:10.1136/bmjopen-2014-
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007335
19. Stroman L, Weil S, Butler K, McDonald CR. Can you afford to become a surgeon? The bill, please. The Bulletin of the Royal College of Surgeons of England, 2015. DOI: 10.1308/147363515X14162390057944 20. https://www.nursingtimes.net/roles/nurse-managers/exclusive-nhs-nurse-staffing-crisisfuels-global-recruitment/5077670.article 21. Department of Health. The Keogh Review of the Regulation of Cosmetic Interventions. 2013.
http://www.gov.uk/government/publications/review-of-the-regulation-of-cosmetic-
interventions (Last accessed 7th September 2016)
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ACCEPTED MANUSCRIPT 22. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. 2013. http://webarchive.nationalarchives.gov.uk/20150407084003/http://www.midstaffspublicin
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quiry.com(Last accessed 7th September 2016)
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ACCEPTED MANUSCRIPT Abbreviations ASiT: Association of Surgeons in Training CCT: Certificate of Completion of Training
FY: Foundation Doctor ISCP: Intercollegiate Surgical Curriculum Programme
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NHS: National Health Service
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CT: Core Trainee
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NMW: Non-Medical Workforce
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Str: Specialist Trainee
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