Task transfer: the view of the Royal Australasian College of Surgeons

For several years, a gradual evolution has been taking place in the traditional roles played by different health professionals. Nurses have taken on some of the roles previously limited to doctors, and other health professionals now undertake tasks formerly carried out by nurses, radiographers, physiotherapists and technicians. Much of this task transfer has been driven by workforce shortages, particularly in non-metropolitan areas, but also by the recognition that a number of different health professionals can share a multitude of care competencies in addition to those unique to their own roles. This is most obvious in the skills exemplified by nurses working in intensive care departments, where they are often preferred to the frequently transient and, at times, inexperienced junior doctors.1 Nevertheless, these qualified nurses still report to the doctors who have primary responsibility for the individual patient’s management plan.

Surgeons work predominantly within multiskilled and multidisciplinary teams, and are dependent on the unique attributes and skills of team members such as theatre nurses. Surgeons are also the first to recognise and acclaim the skills of nurses and others involved in the perioperative care of surgical patients. Evolution of roles in a safe framework of defined knowledge and competencies should be discussed, and possibly supported, within a debate which has at its centre evidence, quality of care and safety of patients.2

In the Western world, some tasks in surgery previously considered the province of medical graduates are now shared by others. Nurse endoscopy clinics have been successfully implemented,3,4 and have become a vital component of screening and diagnostic services. Historically, surgeons have been assisted in theatre by nursing staff and by medical graduates, including trainees. The role of the nurses has evolved from a passive function to one of undertaking some degree of intervention under appropriate supervision, as exemplified by the roles of surgical physician assistants in the United States5 and surgical care practitioners in the United Kingdom.6 The success of a pilot project in Oxford, in which a non-medically qualified member of the surgical team harvested the long saphenous vein for coronary artery bypass grafting,6 led to the development of similar roles in some other surgical specialties. In the UK, the curricular framework for the surgical care practitioner has been developed by representatives of the Royal College of Surgeons of England and the National Association of Assistants in Surgical Practice.7 The program is aimed at non-medical practitioners who will not only manage the clinical care of patients but will also perform technical and operative interventions under defined levels of supervision by surgeons.8 Not surprisingly, these developments have not been supported unanimously.9

Considerations to be broached in any discussions of transfer of tasks within the surgical environment include the tasks being transferred; the possible impact on educating tomorrow’s surgeons; the recruitment, training and supervision of involved individuals; the importance of medical education in decision making; where responsibility will lie, particularly with respect to the judgement needed to outline a management plan; and, most importantly, how the public can be assured that their management remains the responsibility of surgeons. Some of these considerations are discussed below.

The RACS supports the evolution of new health care roles in surgery provided a clear need is identified, a proper curriculum and standards are developed, and provided these health professionals work under supervision as part of a surgical team and in situations where clinical outcomes are monitored continuously.