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Supervision, Accountability and Delegation

It must be remembered that the underlying role of the assistant practitioner is to perform protocol limited clinical tasks under the direction and supervision of a registered practitioner, usually a radiographer.  The assistant practitioner is not a registered healthcare professional (a situation that is unlikely to change for the foreseeable future) and therefore cannot take overall responsibility for the “episode of care”. The person in overall charge of the radiographic, radiotherapy or ultrasound procedure is usually a registered radiographer or other registered healthcare professional. Within a framework of supervision they may be able to delegate appropriate tasks to the assistant practitioner.

Radiographers who themselves are undergoing considerable professional development or preceptorship should not be expected to undertake the additional burden of supervision of assistant practitioners. It is expected that those radiographers providing supervision are themselves employed within roles for which the job description includes responsibilities for teaching and assessing in the workplace.

The SCoR has published a Statement 7 and a Framework 8 related to clinical supervision. It should be recognised that clinical supervision is a quality assurance framework and not a quality control process. Clinical supervision is a two-way process between an individual and his/her mentors, supervisors and peers and is intended to ensure that safe, effective practice is carried out at all times.

The principle of supervision means that there must be a designated supervisor and the assistant practitioner will know clearly who is supervising them for all tasks that they undertake and that their supervisor will be working with them in the imaging or treatment room, or will be immediately accessible for support and advice. Legal opinion has advised that ‘’adequate supervision’’ for assistant practitioners cannot be provided by telephone and therefore the Society and College of Radiographers does not support this practice.

It must be agreed by both the assistant practitioner and the supervising radiographer that the assistant practitioner is competent to undertake the task required, whether they are working under direct supervision or under indirect supervision. If they carry out the task under direct supervision ie working alongside a registered radiographer or other registered practitioner, legal responsibility for the task remains with the supervising radiographer as the autonomous, regulated practitioner. Indirect supervision occurs when the supervising radiographer, having ascertained that the examination for a particular patient is appropriate, delegates the task to the assistant. The radiographer may not actually oversee the procedure being undertaken, however they retain the responsibility for the act of delegation.

Where a supervising radiographer judges that the assistant practitioner being supervised is not able to undertake the allocated task, the supervising radiographer is directly responsible and accountable for ensuring that the task is re-allocated, or for carrying out the task personally. It is also the responsibility of the assistant practitioner to alert the supervising radiographer to situations where they do not have the competence or confidence to undertake the allocated task.

The Law and the Assistant Practitioner

All healthcare practitioners have a duty of care and therefore a legal liability with regard to the patient. They must be able to perform competently and to inform their supervisors when they are unable to perform competently. In order for anyone to be accountable they must:

  • have the ability to perform the task
  • accept the responsibility for the task
  • have the authority to perform the task within their job description and the policies and protocols of the organisation

For the assistant practitioner to act as an Operator under IR(ME)R 2000  9 they must be entitled by their employer and be able to evidence “adequate education and training” for that role.

The radiographer has a duty of care and a legal liability with regard to the patient. If they have delegated a task, they must ensure that the task has been “appropriately delegated”.

Appropriate delegation means that:

  • the task is necessary and delegation is in the patient’s best interest. This comes within the elements of consent and justification. Justification cannot be undertaken by the assistant  practitioner as they are not registered healthcare practitioners
  • the assistant practitioner understands the task and how it is to be performed
  • the assistant  practitioner has the skills and abilities to perform the task
  • the assistant practitioner accepts the responsibility to perform the task competently.

NHS Wales have published the following statement:

“Delegation is the process by which you (the delegator) allocate clinical or non-clinical treatment or care to a competent person (the delegate). You (the delegator) will remain responsible for the overall management of the service user and accountable for your decision to delegate. You will not be accountable for the decisions and actions of the delegate”

This principle is upheld by the SCoR in that assistant practitioners must not be working in areas remote from the supervising radiographer as the radiographer may not be in a position to intervene or provide advice to prevent an adverse incident. The process of delegation will help to establish the circumstances in which advice should be sought from the supervisor and confirm the availability of the supervisor should they be required for advice and support.

Principles of delegation

  • Delegation must always be in the best interest of the patient and not performed simply in an effort to save time or money.
  • The assistant practitioner must have been suitably trained to perform the task.
  • The assistant practitioner should always keep full records of training received, including dates. In roles requiring them to act as an Operator under IR(ME)R, such record keeping is a legal requirement.
  • There should be clear guidelines and protocols in place so that the assistant practitioner is not required to make a clinical judgement that they are not competent or authorised to make.
  • The role should be within the job description.
  • The person who delegates the task must ensure that an appropriate level of supervision is available. The level of supervision must be appropriate to the task being delegated. In complex examinations or treatment or with patients who are severely injured, ill or incapacitated, this will require the assistant practitioner to work alongside the radiographer (direct supervision). 
  • The whole process must be assessed for the degree of risk.

Professional responsibilities of the supervising radiographer
 
The ‘’Episode of Care’’
When a patient/client presents for imaging or treatment they are entitled to receive the highest standards of care. The responsibility for ensuring the quality and standards of the episode of care therefore remains with the registered practitioner (radiographer). The ‘’episode of care’' begins with the referral for imaging or treatment using ionising (or non-ionising) radiation. All exposures involving ionising radiation must be justified before they are made and the justification  must be undertaken by someone recognised and entitled by the employer as a ‘Practitioner’ under IR(ME)R 2000. Following the publication of The Ionising Radiation (Medical Exposure) (Amendment) Regulations 2006 10, the ‘Practitioner’ must be a registered health care professional whose profession is regulated by a body as detailed within Section 25 (3) of the National Health Service Reform and Health Care Professions Act 2002. 11 For this reason, an assistant practitioner is legally not allowed to take on the role of ‘Practitioner’. The assistant practitioner as an IR(ME)R ‘Operator’ is, however, legally responsible for the tasks they are entitled by the employer to undertake in relation to ionising radiation medical exposure.

Each episode of care ends when the patient/client is discharged from the imaging or radiotherapy department either back into the primary care environment or onwards to another hospital department. The satisfactory discharge of patients is the responsibility of the supervising radiographer.

Adverse Incidents

In the event of an adverse incident arising from the actions of the assistant practitioner, the act and appropriateness of delegation may be challenged. If the delegation was deemed inappropriate then it is the radiographer who may have this aspect of their professional conduct investigated and may risk losing their registered status with the Health Professions Council (HPC). The HPC cannot take action against the assistant practitioner as they are not a registered healthcare practitioner.

Even if the employer offers vicarious liability for actions undertaken outside the Scope of Practice or an individual’s competence, the supervising radiographer is not protected from any action that may be taken against them by the HPC. Put simply, even if the employer indemnifies the radiographer against litigation by a patient, the radiographer can still lose their registration to work as a radiographer.

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