5. Clinical supervision
5.1 Clinical supervision
Every trainee must, at all times, be responsible to a nominated consultant, whether undertaking routine lists without direct consultant supervision, or emergency duties. The consultant must be available to advise and assist the trainee as appropriate. Sometimes this will require the consultant’s immediate presence but on many occasions less direct involvement will be needed. Supervision is a professional function of consultants and they must be able to decide what is appropriate for each circumstance in consultation with the trainee. The safety of an individual hospital’s supervision arrangements is the concern of the local department; it is necessary for them to agree local standards and protocols that take account of their particular circumstances. This section details the definitions of the different levels of supervision that local departments must consider; and have been developed from a consideration of the professional responsibilities of medical practitioners to patient safety.
5.1.1 Educational supervision
Every trainee must have a nominated educational supervisor to oversee their individual learning. The College recommends that an educational supervisor is responsible for a maximum of four trainees.
5.2 Clinical supervision: the obligation to patients
Every patient requiring anaesthesia, pain management, or perioperative medical or intensive care must be cared for under the direction of an appropriate named consultant. When appropriate, trainees or Specialty Doctors19 may, provided they have the appropriate competencies provide direct care, without direct consultant supervision. To ensure the safety of patients, a trainee must be responsible to, and subject to clinical supervision by a designated consultant at all times. This includes those occasions when the trainee, as part of their training, is deemed competent to make decisions without immediate reference to a more senior clinician.
Trainees must be encouraged to seek advice and/or assistance as early as possible whenever they are concerned about patient management; both in and out of hours. At all stages of training, a supervisor must respond with appropriate support to a request for assistance from a trainee. Patient safety must never be compromised.
Every doctor should be prepared to oversee the work of less experienced colleagues and must make sure that medical students and doctors in training are properly supervised.20 Thus, there is an expectation that more senior trainees will provide appropriate levels of supervision to their more junior colleagues at times.
5.3 Grades of clinical supervision
Clinical supervision of daytime and out of hours duties for trainees falls into two categories: direct and indirect:
Direct supervision: This means the trainee is working directly with a supervisor who is actually with the trainee or can be present within seconds. This proximity maintains patient safety but, when appropriate, allows a trainee to work with a degree of independence that allows them to develop confidence.
Indirect supervision: Indirect supervision falls into three categories: local, distant and remote sites:
- Local supervision: The supervisor is usually within the theatre suite e.g. the ‘starred consultant’ system, is immediately available for advice and is able to be with the trainee within minutes of being called. The actual permitted time and/or ‘distance separation’ of the supervisor from the trainee should be determined locally to maintain acceptable levels of patient safety; this will depend on the combination of the trainee’s grade, the nature of the clinical work and the layout of the hospital.
- Distant supervision: This means the supervisor is available rapidly for advice but is off the hospital site and/or separated from the trainee by over 10 minutes. The maximum time or ‘distance separation’ permitted will be determined by local clinical governance arrangements. Support for trainees during distant supervision is one of the factors that must be considered by the Deanery/LETB and the GMC when determining the grade and number of trainees who can be trained at any given hospital. Distant supervision requires that:
- The trainee and supervisor agree that it is appropriate for the trainee
- The trainee knows the limitations within which he/she can work
- The trainee is capable of managing the possible complications of any procedure he/she might reasonably be expected to undertake until help arrives
- Supervision in remote sites: The RCoA defines a remote site as any location where general or regional anaesthesia is administered away from the main theatre suite and/or anaesthetic department and in which it cannot be guaranteed that the help of another anaesthetist will be available. This may be either within or away from the base hospital. Supervision in a remote site is a special example of distant supervision. Trainees should only be permitted to work in remote sites under distant supervision if:
- The trainee is judged by the Clinical Director in conjunction with the College Tutor/Educational Supervisor to possess the knowledge, skills, professional judgement and experience which is required to undertake such duties
- A consultant is available to provide advice for the trainee throughout the period that the trainee is anaesthetising in a remote site
- Skilled assistance for the trainee anaesthetist is available in the remote site at all times
- The anaesthetic equipment and monitoring complies with the current recommended guidelines and standards appropriate to the work being performed in the remote site
- The trainee has the confidence to work at the proposed level of supervision
5.4 Clinical supervision by Specialty Doctors
When clinical supervision of a trainee is being provided by a Specialty Doctor, the trainee must always have access to an identified Consultant.
5.5 Clinical supervision of one trainee by another
Clinical supervision of one trainee by another occurs out of necessity and is also an essential part of their training; senior trainees must gain the knowledge, skills and professional judgement to do this safely and effectively. So, a junior trainee may refer to a more senior trainee as their first line of advice and assistance however both must be subject to consultant supervision.
There will be some occasions during highly specialised training when it will be inappropriate for senior trainees to act as supervisors because they themselves may require direct supervision from a consultant.
5.6 Clinical teaching and supervision
The placement of a trainee with a consultant is always a teaching opportunity. The time spent by trainees with consultants allows both teaching and assessment of the trainee, and both aspects form part of clinical teaching. There will be times when direct supervision may be a prime requirement for patient safety and equally, there will need to be times when supervision is more ‘hands-off’ to allow trainees to develop their skills running clinical sessions themselves.
Areas for assessment should be identified prior to starting a list, and the trainee should ask the trainer in advance to perform an assessment .The trainer should observe the performance of the trainee, and give immediate verbal feedback as well as suggestions for future development, further reading etc. Trainers should comment on clinical and non-clinical aspects of performance, such as professionalism and team-working.