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Scope of Practice of Assistant Practitioners in Specific Areas of Practice

ASSISTANT PRACTITIONERS IN RADIOTHERAPY

The original Scope of Practice of assistant practitioners in radiotherapy was defined as performing limited treatment procedures which will vary in accordance with locally identified need and in consideration of the relative risk associated with the activity.
Scope of Practice related to specific radiotherapy procedures

Assistant practitioners must have a sound knowledge of the basic concepts of a defined area of practice as described in the Learning and Development Framework (2007).12

Within Radiotherapy Centres, assistant practitioners work as members of the team and in describing their scope of practice, it is important to recognise two distinct roles:

First, there are elements of the work traditionally performed by the radiographer which may be undertaken by the Assistant Practitioner who is trained and competent to carry out that element (ie the assistant practitioner takes responsibility for the tasks delegated to them).

Second, assistant practitioners may work alongside the radiographer helping with aspects of an episode of care under the direct supervision of the radiographer. This may include elements which would be outside the normal scope of practice for an assistant practitioner if working alone. The radiographer retains both professional and legal responsibility for the episode of care. The SCoR recommends that there should always be two Operators involved in each treatment activity. This means that a radiographer should not work alone with trainee assistant practitioners who are not yet entitled as Operators under IR(ME)R.

The assistant practitioner will work within a scope of practice under the supervision (direct or indirect depending upon the task) of a registered practitioner (radiographer) within relevant legislation and departmental protocols. Elements which may be delegated may include:

  • elements of pre-treatment processes such as imaging
  • elements of treatment delivery; those treatments defined by protocol and simple megavoltage treatments
  • elements of daily machine quality assurance tasks
  • elements of patient support and information within a clearly defined protocol.

All areas of practice of the assistant practitioner require robust training and education and an appropriate assessment of competence. It is the responsibility of the Radiotherapy Services Manager to define the details of the scope of practice for their assistant practitioners in response to their own service needs (and in line with guidance from this professional body) in agreement with the employer, who entitles the assistant practitioner to carry out the defined scope of practice.
However, the safety of the patient is always paramount and therefore the scope of practice is limited. Assistant practitioners can never replace a radiographer where a registered practitioner of this level is required.

Listed below are clinical situations where assistant practitioners can work but where they can only take responsibility for the core elements of set-up and for which they are assessed as competent. Assistant practitioners are able to contribute to the set-up of patients within the clinical situations listed below however they must be under the direct supervision (ie working alongside) of a registered radiographer and cannot take responsibility for the total treatment. This means that they cannot work alone and therefore must always be directly supervised for the more complex elements of the set up requirements.

These activities include:

  • complex and non-protocol defined radiotherapy including apposition techniques superficial, orthovoltage and electron techniques and, for example, multi-field/phase complex head and neck treatments.
  • patients with complex needs including children.

Practices outside the Scope of Assistant Practitioners

Listed below are a number of situations in which the responsibilities related to radiation protection, patient care and treatment planning and delivery are considered to be beyond the Scope of Practice and role of the assistant practitioner in radiotherapy:

  • obtaining consent for radiotherapy
  • decision making regarding treatment complications
  • on-treatment patient review/patient follow up
  • administration and supply of medicines under Patient Group Directions - NB assistant practitioners are not permitted, by law, to use Patient Group Directions (PGDs).

ASSISTANT PRACTITIONERS IN CLINICAL IMAGING

(i) Radiographic imaging

The Department of Health project that examined skill mix in clinical imaging 13 concluded that the activity of the assistant practitioner would be restricted to undertaking plain film radiography (standard radiographic imaging) under the supervision of a registered health care practitioner (radiographer). There was also the possibility that other activities that would provide support for radiographers where assistant practitioners would be working under direct supervision could be explored.

The Scope of Practice in standard radiographic imaging includes:

  • appendicular skeleton
  • axial skeleton excluding skull and cervical spine (see below)
  • chest and thorax
  • abdomen and pelvis.

The skull and cervical spine are excluded if they are to be imaged as a result of trauma. Best practice suggests that computed tomography is the most appropriate modality and technique to be employed. Imaging of the cervical spine in trauma poses a specific risk and therefore should be carried out by experienced radiographers.

Imaging of the orbits prior to magnetic resonance imaging (MRI) to exclude the presence of metal foreign bodies is acceptable provided that additional training has been given. Similarly, following additional acceptable training, assistant practitioners can be accredited for undertaking dental radiography in adults.
Dual energy x-ray absorptiometry (DEXA) imaging

The use of DEXA equipment by assistant practitioners is growing, however this should be under the supervision of a registered radiographer. We are aware that some nurse practitioners supervise DEXA services and in those circumstances we expect the nurse practitioner to be entitled as an Operator under IR(ME)R. Standard operating procedures must identify how to obtain  advice regarding radiographic practice or radiation protection issues.  The scope of practice of the assistant practitioner is limited to image and data acquisition. The assistant practitioner must not interpret the data or convey an interpretation of that data to the patient or another healthcare practitioner.

Supplementary projections, repeat imaging and discharge

A qualified and accredited assistant practitioner can assess their images for their technical acceptability. Any repeat imaging must be agreed by the supervising radiographer. If supplementary projections are required, the assistant practitioner must have been additionally trained in these techniques and only then authorised to undertake them by the supervising radiographer and in accordance with local protocols.

When the examination is deemed to have been completed, then the supervising radiographer will view the images and discharge the patient. Local schemes of work have been developed where, if the patient is returning to another department in the hospital such as an outpatient clinic and the images will be immediately reviewed by the referring clinician, the supervising radiographer can make the decision not to review the images. However the supervising radiographer still remains responsible for the act of delegation and the episode of care. In no circumstances should a patient be discharged from the department to return home or leave the hospital unless the images have been reviewed by a radiographer, radiologist or referring clinician. Further information pertinent to breast screening can be found in the relevant section.

Practices outside the scope of assistant practitioners in radiographic imaging

There are a number of situations in which the responsibilities related to radiation protection and
patient care are considered to be beyond the Scope of Practice and role of the assistant practitioner.

The examination of patients with major trauma

The scope of practice is limited to the “adult, ambulant patient” who is “conscious, co-operative and communicative”. For the severely injured, it likely that modifications to projections or techniques may be required. This requires that an experienced radiographer undertakes these examinations. The role of the assistant practitioner is restricted to working under the direct supervision of the radiographer undertaking the examination. This applies equally to working within the main department or within the accident and emergency department.

Mobile x-ray units in areas remote from the main department

The primary concern of all involved in an imaging procedure is that the patient is treated effectively, within ALARA principles and following best practice. There have been suggestions that assistant practitioners undertake imaging procedures on wards and remote locations and without the direct supervision of a radiographer.  There are a number of reasons why this is unacceptable and outside  the recognised scope of practice of assistant practitioners:

  • As best practice and to achieve dose limitation to both the patient being imaged and other patients, staff and visitors, patients should be examined within the main imaging department wherever possible. If the patient’s condition precludes this then, by definition, the patient’s condition is complex and likely to require adaptation of standard technique. Justification of the individual exposure will also be required, given the needs of the patient and the requirement to adapt technique and, under IR(ME)R, this cannot be undertaken by the assistant practitioner. It is also inappropriate and not in the patient’s best interests that imaging should be delayed while the assistant practitioner finds a radiographer to provide supervision. It is unacceptable, in these circumstances, for advice to be given by telephone.

 

  • The application of radiation protection measures to limit dose to other patients, staff and visitors is the subject of the Ionising Radiations Regulations 1999. The Society and College of Radiographers states unequivocally that this level of responsibility to monitor the environment and exposure of staff is beyond that of an assistant practitioner.

 

  • The supervising radiographer who has delegated the task and is responsible for the episode of care would be placed in a difficult position if she/he is held responsible for the activities of another person or situation over which they have no direct knowledge or control. It is unacceptable to the SCoR to expect a radiographer to accept this liability.

(ii) Mammography

Assistant practitioners have become a well established element of the workforce in the NHS Breast Screening Programme. The focus of their activity is with non- symptomatic well women. It is becoming evident that, as breast care services are re-aligned, there may be the opportunity for them to expand their Scope of Practice to include symptomatic patients. However, this must be on the understanding that they have undertaken the additional education and training necessary for them to fulfil this role and that they continue to work under protocol and the supervision of a radiographer. In addition, the employing authority must be advised of their additional duties and expanded Scope of Practice and the justification for projections additional to the standard cranio-caudal and medio-lateral projections must be made by a registered health care practitioner.

Assistant practitioners have been employed to work alongside radiographers on mobile breast screening units. This is considered acceptable as the radiographer remains responsible for the episode of care. In no circumstances does the Society and College of Radiographers accept that the mobile screening service can be delivered entirely by assistant practitioners working without the supervision of a radiographer who is also available to act as a Practitioner under IR(ME)R if required. Before working on a mobile unit, the assistant practitioner must have been assessed as fully competent in the use of mammography equipment in a breast screening centre.

In the event that a woman presenting for screening can only have a “partial examination”, this is deemed to be a variation from protocol and must be justified by a Practitioner (under IRMER). The assistant practitioner cannot act as a Practitioner and the examination requires justification by the supervising radiographer.

With the implementation of digital imaging equipment on mobile units, it is now possible for the images to be viewed at acquisition. Therefore the same procedures regarding repeat imaging and discharge in respect to standard radiographic imaging are acceptable. Repeat imaging should be agreed with the supervising radiographer. However these arrangements are for local agreement and implementation. The rationale for discharge remains the same as for analogue equipment. The care pathway for breast screening dictates that images are reviewed and technical recall instigated if appropriate. Supplementary projections would not be undertaken in mobile units and therefore the technical acceptability of the images can be judged by an experienced assistant practitioner and the woman informed that the examination is complete. 

Additionally, the same considerations must be given to the assistant practitioner in respect of health and safety matters as to radiographers undertaking mammography, ie there must be proper attention to rest periods and rotation of duties to minimise the risk of work related musculo-skeletal disorders.

Practices outside the scope of assistant practitioners in mammography

The role of the assistant practitioner is primarily to acquire the standard images for screening. Some centres may wish to involve assistant practitioners in the imaging of symptomatic women or of biopsy samples. The accreditation of an assistant practitioner to undertake the imaging of symptomatic women requires evidence of additional education and training to support this activity. Additional training can be given for the imaging of biopsy specimens if this is a locally agreed procedure.

Advice from the NHS Breast Screening Programme considers that the imaging of the augmented breast (women with implants) is not a routine procedure. These women often have concerns about the appearance or feel of the implant that need to be discussed in detail possibly through referral back to their surgeon. To adequately image the augmented breast may require adaptation of technique. The SCoR therefore supports the view expressed by the NHSBSP and advises that these examinations are undertaken by the radiographer.

It is not within the scope of practice for assistants to assess images for the purpose of technical recall or recall to assessment. We do not accept that assistant practitioners can extend their practice to the examination of the breast by ultrasound.

(iii) Assisting in fluoroscopy

The role of the assistant practitioner during investigations involving fluoroscopy is to support the registered health care practitioner. Therefore, in these situations, the provisions of direct supervision prevail. The assistant practitioner having been adequately trained in fluoroscopy may assist a radiographer or radiologist in undertaking fluoroscopic examinations. To fulfil the condition of direct supervision for fluoroscopic procedures, the radiographer or radiologist will be present in the examination room and leading the procedure.
Practices outside the scope of assistant practitioners in fluoroscopy

Fluoroscopy in operating departments and locations remote from the clinical imaging department

The requirement for fluoroscopy in operating departments and similar locations remote from the main department poses particular challenges. It may involve the use of mobile equipment and thus require the establishment of a temporary controlled area or it may be in a purpose built facility such as a cardiology suite. The examination may be complex and the patient may be unconscious requiring the Operator (under IR(ME)R) to continuously monitor the radiation exposure in order to determine and communicate that prolonged or continued exposure may not be justified. Justification is the responsibility of an entitled Practitioner under IR(ME)R 2000 and the assistant practitioner cannot undertake this role .

The education and training prescribed by the Society and College of Radiographers and the non-registered status of assistant practitioners does not equip them for this activity and level of responsibility. Additionally, it is considered that to prolong the patient’s exposure to anaesthesia while advice or assistance is sought from the supervising radiographer may compromise the patient’s wellbeing. Therefore it is the view of the SCoR that the responsibility for undertaking imaging in these situations is that of a registered radiographer.

Some centres may hold the view that the medical practitioner leading the operation or investigation is the Practitioner under IR(ME)R 2000 and can therefore fulfil the requirements for justification as well as maintain a safe radiation environment for staff. This view is not supported by SCoR in that it believes that the medical practitioner’s role should be focussed on the clinical procedure being undertaken. Where the medical practitioner is undertaking the role of Practitioner under IR(ME)R 2000, it is imperative that the employer has carried out and documented a thorough risk assessment including the radiation safety aspects for both patients and staff relative to the anticipated episodes of care. This includes ensuring that the Practitioner has been adequately trained to act in that capacity as required by IR(ME)R 2000, specifically Regulations 4 (4) and 11.

Both the Practitioner and the Operator have a duty to adhere to the ALARP (as low as reasonably practicable) principles of dose reduction and the maintenance of a safe radiation environment.

SCoR has considered and supported individual cases where the examination is non complex and is undertaken with radiographer support immediately available. Advice must be sought from SCoR by departments and individual accredited assistant practitioners before such an extension to the scope of practice can be accepted. However it remains that, for many operations, procedures and investigations the potential for significant dose accumulation is high. The individual responsible for monitoring dose accumulation, the radiation environment and for challenging prolonged exposure has a responsibility beyond that of an assistant practitioner. In these situations it must be the responsibility of a registered radiographer.
As in the case of using mobile imaging equipment on wards, the radiographer who is nominally responsible for supervision is placed in a difficult position if an adverse incident or 'exposure that is greater than intended' results from the examination.

Children

As discussed in the recent Society and College of Radiographers’ publication ‘The Child and the Law: The Roles and Responsibilities of the Radiographer’, 14 the responsibilities of the radiography workforce to children are both critically important and complex. They include such issues as:

  • child protection
  • confidentiality and consent
  • non-accidental injury and skeletal survey
  • co-operation, distraction and immobilisation.

The radiographer has a clear duty of care to safeguard and promote the welfare of children including responsibility for child protection. The Society and College of Radiographers believes that because of the complexity of issues and the possible serious consequences of any mistakes, the interests of children are best served by radiographers taking the responsibility for the imaging procedure. Any actions taken by assistant practitioners with regard to children should be under the direct supervision of the radiographer.

The imaging of children frequently requires adaptation of technique and therefore this would preclude the assistant practitioner from independently undertaking the examination.

Where no modification of technique is required and where children may be deemed to be ‘Gillick competent’, (a term used to describe when a minor may be able to consent to his or her own medical treatment despite their young age), it may be possible for an experienced and accredited assistant practitioner to undertake some standard examinations provided that the welfare interests of the child are being overseen by a registered healthcare practitioner who is trained in this aspect of care.

(iv) Computed Tomography and Magnetic Resonance Imaging

The initial Scope of Practice of the assistant practitioner was limited to the acquisition of standard radiographic images. The role of an assistant practitioner in computed tomography (CT) and magnetic resonance imaging (MRI) is related to providing support for other registered healthcare practitioners, eg radiographers and radiologists, and for aspects of patient care. Therefore, in these situations, the provisions of direct supervision prevail. Accredited assistant practitioners should apply for an extension to their individual scope of practice stating the additional education and training they have undertaken to support this role.

(v) Nuclear Medicine and Radionuclide Imaging

Assistant practitioners can be involved in these procedures as Operators provided that they have undergone adequate education and training as required by IR(ME)R 2000. In this role they may position equipment and select image acquisition parameters. At all times they should be working under the direct supervision of a registered radiographer, healthcare scientist or qualified nuclear medicine technologist.
 
As non-registered healthcare practitioners, they may not administer radiopharmaceuticals under Patient Group Directions. However they may be entitled by their employer to administer radiopharmaceuticals under Patient Specific Directions. In these instances, the SCoR recommends that this be for oral administration only and not intravenous administration. In all cases, the dose to be administered must be checked by a second Operator before it is given to the patient.

Practices outside the scope of assistant practitioners in nuclear medicine/radionuclide imaging 

The preparation of any radiopharmaceutical prior to administration, including dose calculations, is beyond the scope of practice of an assistant practitioner.

ASSISTANT PRACTITIONERS IN ULTRASOUND

Ultrasound services are multidisciplinary and multi professional in nature and include a range of examinations which play an essential part in the screening, diagnosis and management of patients in primary, secondary and tertiary care settings. The demand for ultrasound imaging is increasing and due to the versatility of the technique, its application in various fields of medicine is also expanding.

The purpose of this section is to indicate where an assistant practitioner, appropriately supervised by a registered healthcare practitioner* (henceforth referred to as a ‘’sonographer’’), can contribute to service delivery by being educated and trained to undertake routine, non-complex ultrasound examinations and to recognise when the expertise of a more experienced sonographer is required.

The term ‘’sonographer’’ in the context of this document does not imply any specific professional background but does imply registration with a statutory regulator (eg the Health Professions Council, the Nursing and Midwifery Council or the General Medical Council), or equivalent*, and education and training at postgraduate level to undertake ultrasound examinations. The SCoR believes that sonographers must be registered with one of the statutory regulators of medical or non-medical practitioners or, where this is not possible, with the Public Voluntary Register of Sonographers. This upholds best practice in terms of protection of the public and patient safety.

* Some sonographers, usually those trained overseas, are not currently eligible for registration with one of the statutory regulators. These should seek entry to the Public Voluntary Register of Sonographers maintained by the College of Radiographers.

All patients/clients presenting to the ultrasound department are entitled to receive the highest standard of care, therefore the responsibility for ensuring the quality and standard of the episode of care remains with the designated supervising sonographer. The episode of care begins with the referral for an ultrasound scan. All referrals for an ultrasound examination must be confirmed as appropriate by a sonographer before delegating to an assistant practitioner.

The activity of the assistant practitioner in ultrasound should be restricted to undertaking limited, single condition and simple screening ultrasound examinations performed to an agreed protocol and under the supervision of a registered sonographer. The assistant practitioner may undertake other duties such as supporting other sonographers, undertaking examinations and the routine quality control of equipment. Any limitations of the role of the assistant practitioner must be made absolutely clear. It is not appropriate for assistant practitioners to discuss clinical matters with patients or clients and, if unexpected findings arise during any examinations the assistant practitioner is authorised to carry out, they must seek immediate advice from the sonographer supervising their practice.

The Scope of Practice related to specific ultrasound procedures

There are elements of the work traditionally performed by the sonographer that may be undertaken by the assistant practitioner who ‘is trained and competent to carry out that element’ (ie the assistant practitioner takes responsibility for the tasks delegated to them).
The assistant practitioner will comply with relevant legislation and departmental protocols and work within their competence, recognising their limitations and when to seek advice.

Assistant practitioners may also work alongside a sonographer helping with aspects of an episode of care, for example, providing chaperoning services or providing support to patients.

The sonographer retains both professional and legal responsibility for the episode of care.

Elements of ultrasound practice which may be delegated to assistant practitioners include:

  • single measurements, single conditions or routine screening examinations; for example
    • obstetric dating scans where the task is limited to making a single measurement followed by recording the associated gestational age that has been automatically calculated by the machine software from standard data charts/tables. N.B. Nuchal translucency measurements are not permitted.
    • Abdominal aortic aneurysm (AAA) screening where a single organ is scanned and measurements taken and recorded.
  • calculating bladder volumes and ankle brachial pressure indices using dedicated or specialised single purpose equipment and automatic calculation software.
  • routine surveillance examinations to monitor anatomical dimensions where a baseline scan has been performed by a registered healthcare practitioner.
  • routine quality control of imaging equipment.
     

Practices outside the scope of assistant practitioners in ultrasound
Listed below are a number of situations in which the responsibilities related to the practice of ultrasound, patient care and patient management are considered to be beyond the scope of an assistant practitioner.

 

  • Ultrasound examinations on patients with complex needs including children, and hospital in-patients.
  • Ultrasound examinations which investigate multiple organs and conditions and may reveal complex pathology.
  • Ultrasound examinations which require a differential diagnosis.
  • Ultrasound examinations which require specialised image acquisition and interpretational skills, including fetal anomaly screening and nuchal translucency measurements.
  • Ultrasound examinations which require high levels of communication skills, for example breaking bad news.
  • Ultrasound examinations which require decision making regarding patient management and referral.
  • Ultrasound examinations which require decisions for patient review/patient follow up.
     

Supervision

Where the assistant practitioner is supervised by a radiographer/sonographer, SCoR considers that the supervising practitioner should have completed a CoR/CASE accredited postgraduate training programme such as a Postgraduate Certificate/Diploma/MSc in Medical Ultrasound and have at least two years of clinical experience in this speciality. They should also be able to demonstrate the level of knowledge and skills necessary to supervise others effectively as outlined in the SCoR Practice Educator scheme.

Additionally, it is the responsibility of the manager/employer to ensure that individuals carry out examinations according to current British Medical Ultrasound Society safety guidelines and are ‘‘adequately educated and trained for their role’’. The assistant practitioner must not undertake tasks for which they have not been trained or entitled to carry out.

Ultrasound service managers and employers are advised to seek advice and clarification with regard to the scope of practice of assistant practitioners in circumstances that they consider may not be covered by this guidance document. Enquiries should be directed, in the first instance, to the Professional and Educational department at SCoR.

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