Task transfer: A survey of Australian surgeons on the role of the Task transfer: A survey of Australian surgeons on the role of the non-medical surgical assistant non-medical surgical assistant

Background: A non-medical surgical assistant is a clinician who provides perioperative care in the role of surgical assistant but does not possess a medical degree. This role has been practiced in Australia for more than 20 years. Aim: This survey investigates Australian surgeons’ attitudes and current practice regarding the role of the non-medical surgical assistant. Design/method: Distribution of the survey was online in December 2015 by the Royal Australasian College of Surgeons (RACS). Data analysis was descriptive using online survey methodology and convenience sampling. Results: In the private sector in Australia 105 respondents (35 per cent) use a non-medical surgical assistant. In the private sector in Australia, 188 respondents (64 per cent) were ‘very supportive’ or ‘supportive to some degree’ of the role, with 60 (20 per cent) ‘undecided’ and 48 (16 per cent) ‘not supportive’. Conclusion: The results illustrate there is support in the Australian surgical community for the role. The majority of respondents advocated contribution to governance of the role and curricula oversight by the RACS.


Introduction
The lines of demarcation between health care professionals were once clear. Gender, education and the ability to prescribe have historically differentiated doctors and nurses 1 . Privileges of medical practice protected by legislation and insurance reimbursement are no longer the sole domain of the medical doctor 2 . A need for 'non-physician practitioners' to meet changes in the health care environment has contributed to less defined lines of demarcation between health care professionals' roles [3][4][5][6] . In the light of alterations to the context of health care and availability of resources, registered nurses (RNs) and allied health professionals are acknowledged as an under-used asset for safe and cost effective health care delivery [7][8][9][10] . Task transfer does not dilute medical care but does strengthen health care 11 .

Background
The role of the non-medical surgical assistant (NMSA) is well established in the international setting with clinicians who are not medical doctors providing perioperative care 12 . An example of international support for the NMSA role is well illustrated in the United Kingdom (UK). The Royal College of Surgeons England (RCSE) has been proactive Peer-reviewed article in undertaking a comprehensive review of the curriculum of the NMSA 13 . The objective was to improve performance of the entire surgical team. This work culminated with the updated curriculum framework for the surgical care practitioner (SCP) in 2014 14 . The RCSE also requested streamlining of titles of NMSA within the UK to standardise parameters for the roles 13,15 .
By comparison, the Royal Australasian College of Surgeons (RACS) has had little input into curriculum or training of the NMSA in Australia. The most recent position statement (2015) from the RACS on the surgical assistant does not outline what specific qualifications a surgical assistant should hold and suggests the level of knowledge and skill is at the discretion of the surgeon 16 . This is in contrast to the Medicare Benefits Scheme which will only remunerate doctors for intraoperative 'assisting at operation' in the private sector 17 .
The majority of clinicians performing this role in Australia are RNs 18 . The nursing labels in Australia for NMSAs are perioperative nurse surgeon's assistant (PNSA) or nurse practitioner (NP) 19,20 .
At the inception of the NMSA role in Australia in 1999, the RACS president indicated that the RACS would support an intraoperative component of the role 21 . There is a paucity of evidence of early RACS support in the Australian literature. A surgical workforce census report in 2011 outlined that RACS members were supportive of the roles of NP and physician assistant (PA) as surgical assistants 22 . A 2006 paper by RACS members on the topic of the NMSA highlighted recruitment, training and supervision of the NMSA as potential issues. The emphasis of this paper was that evolution of roles should be within a framework of 'defined knowledge and competencies' based in evidence, supporting a high level of care and patient safety 23 .

Aim
The survey aimed to clarify:

surgeons' opinions
• Do surgeons support the role in Australia?
• Which qualifications were appropriate?
• What governance structure was required?
• What input should the RACS have in curriculum development and training?

surgeons' practice
• Quantify the experience of surgeons.
• Determine who in Australia was using NMSAs.

Participants/ethics
The survey had ethics approval from The University of Queensland (#2015000084).
While this paper refers to Australian surgeons, RACS' membership also includes New Zealand (NZ) surgeons, who constituted only 1 per cent of respondents. Surgeons, both active and retired, and trainees were eligible for the survey.

Survey/sampling
The survey was advertised as per RACS's policy for 'external' surveys via their online newsletter, Fax mentis, in December 2015 and January 2016. Due to a low response rate, second round contact was established with individual surgical specialty associations and societies. Once the survey was distributed beyond the affiliation with the RACS, membership of the RACS was not necessary to participate.
When specialty surgical groups were approached, how they chose to circulate the survey to members influenced how many members responded. Some specialty groups such as General Surgeons Australia and the Australia and New Zealand Society of Vascular Surgeons emailed the survey link directly to members; the Australian Orthopaedic Association Limited (AOA) placed a link to the survey on their website. For this reason specialty response rates were not reflective of the membership of these surgical specialty organisations. Low response does expose the survey to non-responder bias 33 .
In a recent practice audit of the NMSA role in Australia, the surgical specialty with the highest uptake of NMSA use was orthopaedic surgery, followed by general surgery and then gynaecology 18 . Gynaecologists and obstetricians were not well represented in the membership of the RACS and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists declined the request to circulate the survey to members.

Data analysis
Collected data were predominately of quantitative character. Descriptive data analysis was undertaken within Qualtrics (Qualtrics, Provo, UT) software 34 .

Results
In total 445 surveys were submitted, however, not all respondents answered all of the questions. The majority of respondents (227 or 68 per cent) practiced in the metropolitan area and the largest number of respondents were from Queensland (103 or 31 per cent). Demographics of respondents are presented in Table 1.
General surgery was the most common specialty with 187 (56 per cent) respondents. This influenced the highest uptake of NMSA in general surgery (see Table 2, on the next page). In regard to support of the role of the NMSA in the private sector in Australia, 188 respondents (69 per cent) were 'very supportive' or 'supportive to some degree', with 60 (22 per cent) 'undecided' and 48 (16 per cent) were 'not supportive'. Surgeons were less supportive of the NMSA in the public sector (refer Figure 1)

Discussion
Scrutinising the trends of support between the public and private sectors, a similar number of surgeons were 'very supportive' of the NMSA in the private sector as 'not supportive' in the public sector. This may be attributed to a concern that the NMSA will negatively impact junior doctor training; however, this is not supported in the literature 20 There was support amongst respondents for a wide range of qualifications to perform the role of the NMSA. In this survey 36 per cent of respondents thought an NP qualification was appropriate and 32 per cent thought a PA was appropriate. This percentage of support is less than reported in a surgical workforce census report published by the RACS in 2011 22    There was no financial assistance for this project. * Participants were able to select more than one option