Recommendations for assessing competency in advanced trainees

Each facility is responsible for accrediting advanced trainees for pleural/chest drain management in line with their scope of practice.

Each facility is responsible for ensuring patients undergoing any pleural procedure are managed in a safe clinical environment where medical officers and specialist nurses deemed competent to insert and manage pleural drains are available at all times.

The competency recommendations aim to ensure that all NSW facilities follow a consistent process for educating and training advanced trainees and demonstrating that they have attained competency.

Advanced trainee pleural drain competency

The essential elements in the process of demonstrating pleural procedural competency are:

• the trainee gaining  theoretical knowledge and becoming familiar with the equipment in use
• the trainee learning  the physical skills and techniques required  to complete the specific procedure
• the supervisor assessing the trainee’s competency in pleural procedures
• the trainee participating in quality assurance processes.

Gaining theoretical knowledge and familiarisation with equipment

The advanced trainee should demonstrate satisfactory theoretical knowledge of, and be familiar with, the specific equipment in use before progressing to the practical aspects of procedural training.
This may be achieved by a combination of:

• the supervisor quizzing the advanced trainee to assess their knowledge of anatomy, physiology and pleural disease
• the advanced trainee completing one or more pleural procedure training courses, which include an assessment component (such as those provided by the Thoracic Society of Australia and New Zealand (TSANZ) and the Clinical Training and Evaluation Centre, University of Western Australia)
• the supervisor directing the advanced trainee to access recommended online resources (see section E-learning resources).

Learning the procedural technique

Procedural training should occur via incremental experience, beginning with simulation, progressing to practise using models and eventually to performing procedures on patients under supervision.

Competency in less invasive procedures (such as thoracocentesis) should be gained before more complex procedures (such as pleural catheter insertion) are attempted. At each stage, the advanced trainee should demonstrate proficiency before progressing to a subsequent stage.

The emphasis should be on safe and effective technique, rather than on the absolute number of procedures performed. For all procedures, more than one supervised attempt is recommended.

It is expected that, with the variety and increasing complexity of procedures practised and the variable rate of skill acquisition by individual advanced trainees, multiple supervised attempts will be required  before proficiency is achieved.

Assessing procedural competency in an advanced trainee

Proficiency and/or competency are not rigidly  defined but depend on the supervisor’s judgement as to whether the advanced trainee is capable of performing the specific pleural procedure independently.

This judgement will entail specific consideration of all aspects of the pleural procedure, including:

• the decision to perform the procedure
• choice of an appropriate location and timing for the procedure
• obtaining consent for the procedure
• appropriate administration of sedation, topical anaesthesia and analgesia
• completion of Clinical Procedure Level 2 Safety Checklist
• interpretation of contemporaneous imaging
• use of bedside ultrasound to assist a pleural procedure
• maintenance of aseptic technique throughout the procedure
• the procedural technique, including hand-eye coordination
• adherence to local policies and guidelines
• leadership skills and respectful interaction with the assisting staff
• accurate and appropriate documentation
• management of pleural drain complications and emergencies
• use of an appropriate procedure for removal of the pleural drain.

Quality assurance

The advanced trainee requires insight into their own skill mix and limitations to ensure they know when to seek help and/or abandon a procedure to ensure a safe outcome for the patient. Recording evidence of participation in quality assurance processes, including self-reflection, completion a Pleural Procedure Training log, quality audit and critical incident monitoring is recommended  throughout the training process.

Once deemed competent to perform a specific procedure, the advanced trainee will be formally credentialed for the specific pleural procedure in line with local facility processes.

Maintenance of procedural skills

Given insufficient evidence on which to base recommendations as to the number and frequency of procedures required each year to maintain clinical competency, this document relies on consensus expert opinion ( ACI Pleural Procedures Working Group). The working group recommends that each year the advanced trainee performs at least one supervised procedure and one procedure performed independently without adverse events.
Involvement in quality assurance processes is also recommended.

Supervisor roles and responsibilities

The supervisor is a medical officer deemed competent by the healthcare organisation governance bodies to perform pleural procedures.

The role of the supervisor is to:

• ensure that the advanced trainee has acquired appropriate theoretical knowledge
• ensure physical procedural skills are adequate and the advanced trainee is able to demonstrate procedural technique as required
• supervise and observe each procedural attempt until procedural competence is attained, which includes provision of timely and constructive feedback as required
• oversee quality assurance processes and monitor logbook entries
• maintain their own pleural procedural performance skills by periodically updating via peer review, pleural courses or similar means, sufficient to intervene (when necessary) while undertaking a supervisory role.

Advanced trainee roles and responsibilities

The advanced trainee is responsible for:

• attaining background theoretical knowledge prior to attempting any procedural techniques
• acquiring incremental procedural experience, starting with simulation, models and simple procedures before progressing to complex procedural techniques or applying procedures to patients
• practising pleural procedural techniques with the goal of achieving procedural competence and developing appropriate quality assurance processes
• completing procedures under direct supervision / observation following the Royal Australasian College of Physicians’ training requirements
• documenting procedures and keeping a procedural log book
• accepting and using supervisor feedback to achieve continuous improvement in performance
• maintaining procedural performance skills once credentialed via supervised procedures, independent procedures and assuming the supervisor role for other advanced trainees.

Inability to achieve competency

Some advanced trainees may not achieve procedural competency by the completion of their training period. Should such a trainee wish to undertake pleural procedures, further supervised training is required. This scenario may increase in frequency as pleural procedures become more specialised and complex.

At present, all NSW respiratory advanced trainees are required to achieve competency in specific procedural techniques and will fail to satisfy training requirements if they do not.

The Guide for assessing competency in pleural procedures for advanced trainees and specialist nurses aligns with:

• Clinical Excellence Commission. Clinical Procedure Safety
• NSW Ministry of Health. Clinical Procedure Safety (PD 2017_32)
• Royal Australian College of Physicians. Adult Respiratory Medicine & Sleep Medicine Advanced Training Curriculum. Physician Readiness for Expert Practice (PREP) Training Program.