Scenario: appropriate delegation
During a weekday's surgical session, the ward registered veterinary nurse (RVN) on duty gets called into theatre to assist with an orthopaedic procedure. There are several inpatients that require monitoring and administration of a range of medications. The RVN requests that his assisting student veterinary nurse (SVN), currently in the first year of training, administer potassium to a patient, as requested by the veterinary surgeon (VS) on the treatment plan, for severe hypokalaemia. The SVN completes the task, administering the medication via the patient's indwelling intravenous catheter. On examination some time later, the patient is discovered deceased in the kennel. On investigation by the VS it is apparent that the infusion was delivered rapidly and probably caused, or contributed to, the patient's death.
The key issues that will be explored in this article focus on the delegation of Schedule 3 tasks, in particular the intravenous injection of medications where there may not be clear guidance as to the speed of administration or complications that may arise. The legal, professional and ethical issues will be addressed to gain an insight into where failings have been made in the critical incident and how these may apply to practice.
Frameworks for consideration
It is necessary to first consider which frameworks we must abide by as citizens of the UK, registered professionals, and individuals with our own moral codes before embarking on an examination of this case.
Legal frameworks include our need to abide by criminal and civil laws within the country of residence.
Professional frameworks are necessary to ensure that individuals working within a profession do so with appropriate guidance as to what is acceptable, what is not, and with the ability to gain support and direction if required.
Ethical frameworks allow individuals to assess a scenario using appropriate ethical perspectives and with consideration of their own moral codes.
Legal framework
It is appropriate to consider the legal framework we, as citizens of the UK as well as veterinary professionals, must abide by. Registered veterinary nurses (RVNs) and student veterinary nurses (SVNs) are accountable from a legal perspective, as discussed by Pullen et al (2011), to abide by relevant legislation.
Criminal law
Criminal law considers offences against the country's set of laws, this is not just encompassed within Statute, or Acts of Parliament, but these give us a clear set of rules that must be abided by (Gray and Wilson, 2006). Common law, or unwritten laws where there is no defined set of rules, should be considered if there are relevant examples, e.g. another RVN has been prosecuted under similar circumstances. In the critical incident the investigation of any breached Acts of Parliament is sufficient.
First, it is key to examine if there has been any breach of The Veterinary Surgeons Act (VSA) 1966, specifically in relation to the Schedule 3 amendment. Under the VSA (1966) medical treatment can be administered by a SVN under direction of the veterinary surgeon (VS) and under the supervision of the VS or RVN (RCVS, 2017a). Supervision is defined by the RCVS (2017a) as ‘the veterinary surgeon is present on the premises and able to respond to a request for assistance if needed’. This criterion was met in the incident as the need for ‘direct, continuous and personal supervision’ is only required in the case of minor surgery (RCVS 2017a).
In the scenario the patient was under the care of the VS, the treatment was prescribed by the VS and delegated appropriately, and directed for completion, to the RVN. Therefore, it is relevant to highlight that the delegation of a prescribed dose of a POM-V medication to an RVN by the VS was appropriate in this case. The RVN in turn delegated the task to the SVN; however, it could be argued that appropriate supervision has not occurred despite the definition in the VSA (1966). If a medication required slow infusion via an intravenous line it could be assumed that this information would be passed to the RVN on delegation. However, it is not clear whether the same guidance was given to the SVN.
What is a clear issue here is the delegation of a task which was outside the remit of the role of the RVN. As identified previously, under the VSA (1966) medical treatment can be administered by a SVN however guidelines must be adhered to. These include that ‘the animal is, for the time being, under the care of a registered veterinary surgeon or veterinary practitioner and the medical treatment… is carried out by the student veterinary nurse at his direction’. If appropriate, the task should only have been delegated by the VS using his/her knowledge of the competency of the SVN to carry out the task safely (RCVS, 2017a).
Civil law
Civil law is concerned with the rights of individuals to not suffer harm or loss at the hands of another, or an organisation. These may include negligence or breach of contract in this critical incident (Gray and Wilson, 2006).
In order to determine whether negligence has occurred three criteria must be met:
- Is there a duty of care? There is a clear duty of care here, the duty to provide the medication correctly and to follow professional, and legal, frameworks in relation to delegation of tasks.
- Has there been a breach of this duty of care? It is clear that The Veterinary Surgeons Act (1966), Schedule 3 amendment was not adhered to in terms of the delegation of the medical treatment. This will be investigated further in terms of the professional implications, however the delegation of a skilled task to an inexperienced member of staff, without appropriate supervision, could definitely be classed as a breach of duty of care.
- Has this led to harm or loss which could have been reasonably foreseen? Logically it would be reasonable to assume that the delegation of a skilled task to an unqualified member of staff, without appropriate supervision and guidance could lead to harm to the patient. Intravenous injections should be carried out slowly to avoid any serious complications to the brain or heart (Argyle et al, 2011). A study carried out by Hoehne et al (2015) highlighted this risk by detailing the dangers of hyperkalaemia following rapid administration of potassium. It is also not clear what monitoring, if any, was carried out following the administration of the intravenous medication and if there was any request for this. Following the administration of any intravenous medication it would be assumed that basic parameters should be observed to highlight any potential adverse reactions. Whether this happened is unclear and would be investigated should there be any potential civil case instigated by the client.
Negligence can only be proven if a breach of duty of care has led to harm or loss for the owner of the patient. The client has lost their pet therefore negligence could be proven but may be difficult to pursue in a monetary sense (Earle, 2006). From a civil law perspective pets count as property, however harm or loss of the pet cannot be dealt with in terms of emotional trauma to a client, only a monetary value one.
It is also necessary to address whether a breach of contract has occurred in this scenario. Considering the contract made between the practice and the owner it is important to examine consent. Although the scenario has not stated it, we can assume appropriate consent has been gained from the owner/s via the discussion and signing of a consent form. It is worth considering whether informed consent was gained in terms of the delegation of tasks to nursing staff, but is unlikely to be an issue for this particular incident.
It can be assumed that all the relevant individuals' employment contracts would refer to appropriate professionalism and adhering to legislation as well as the RCVS Code of Professional Conduct for Veterinary Surgeons or Veterinary Nurses (RCVS, 2017b). Therefore, in relation to assessing whether a breach of employment contract has occurred it is relevant to assess whether there is any clear breach of these Codes.
Professional framework
Professionally RVNs should work within the guidance of the RCVS Code of Professional Conduct for Veterinary Nurses (RCVS, 2017b). Although SVNs should be encouraged to access and work within the Code the registered professional in the scenario would be held accountable for any deviations from their professional duties. RVNs are answerable to the RCVS, must justify their professional decisions and can be liable to disciplinary action should this be deemed a case of disgraceful conduct in a professional sense (RCVS, 2014).
According to the RCVS (2017b), detailed in the Code of Professional Conduct for Veterinary Nurses, animal health and welfare should be a RVN's first consideration. With regards to the scenario the RVN must consider the welfare of the ward patients as well as the anaesthetised patient undergoing a surgical procedure. In these circumstances it would be appropriate to consider whose needs come first and which tasks would be appropriate to delegate. The SVN could have assisted with the surgical procedure to free up the RVN to deal with the demands of his ward patients. In this case having the VS on hand to personally supervise the SVN during their surgical nursing duties, any issues with the administration of medications, or the carrying out of any technical tasks, would have been addressed.
The RCVS Code of Professional Conduct for VNs discusses the need for RVNs to delegate to those only with appropriate experience and competence (RCVS, 2017b). It would appear in the scenario that this was not the case as the SVN clearly did not carry out the infusion in a safe manner considering the medication prescribed. As it is the RVN's professional responsibility to assess the competence of the SVN, it would be sensible to assume it should be the RVN who is held accountable for the resulting outcome.
Rowlinson (2016) discussed the issues surrounding lone working for SVNs. Although the SVN in the scenario was not working alone in practice, the VS and RVN were available for assistance if required, comparisons can be made as the task was completed without personal supervision. Rowlinson (2016) concluded that as SVNs do not have the skills, knowledge and expertise of a RVN they should not be expected to partake in activities that require this. This is supported by Branscombe (2012) who also confirmed the fact that RVNs can delegate the giving of minor treatments to a patient for an SVN to complete. However, Branscombe (2012) ultimately highlighted that this must come under the direction of the VS.
It is clear through the discussion of the RVN's professional responsibilities that this could be deemed a case of inappropriate delegation. It could then be considered whether this could amount to a case which required reporting.
Whistle-blowing
Welsh and Bayliss (2012) discussed the incidences that may potentially require blowing the whistle on practices which could have a negative effect on patient wellbeing. It is important to establish whether this is a one-off mistake or a series of issues that may further affect the welfare of patients (Welsh and Bayliss, 2012). It is not clear in the scenario whether this is a one-off issue, but it is relevant to consider the appropriate whistle-blowing procedure. According to the RCVS (2016), seeking to find an internal solution would be the most appropriate course of action. This could involve approaching a senior member of staff in order to change practice protocols and to acknowledge there is a need to identify those tasks that would or would not be appropriate to delegate depending on the experience, skills and qualification of a member of staff. If the delegation of skilled tasks that require the knowledge and expertise of a RVN continued to occur, then this would need to be reviewed. The RCVS (2016) suggested gaining advice from the RCVS Professional Conduct Department where a formal complaint would be reviewed should the issue not be resolved internally.
Complaint procedure
It is clear there is a breach of the legal and professional frameworks and this may have implications to the RVN, as the registered professional within the scenario who can be seen to be at fault. As the professional regulatory body it would be the role of the RCVS to investigate any complaint brought against the RVN, whether this were to come from the client or from a member of the veterinary practice.
Any complaint made to the RCVS regarding the conduct of the RVN would be assessed and investigated to decide whether there is a case against the RVN and whether it should be referred to the RVN Preliminary Investigation Committee (RVNPIC) (RCVS, 2017c). Due to the deviation from the Code of Professional Conduct for Veterinary Nurses, it is likely that the case would be referred to the RVNPIC for consideration. The case may then be referred to the RVN Disciplinary Committee (RVNDC) for a formal hearing should the RVNPIC consider that the RVN's conduct has fallen short of what is reasonably acceptable for a competent RVN (RCVS, 2017c).
Any criminal conviction as a result of the RVN's actions would require disclosing directly to the RCVS in order for the RVNDC to make a judgement as to whether ‘disgraceful conduct in a professional sense’ has occurred (RCVS, 2014). A decision could then be made relating to any potential suspension or removal from the register of veterinary nurses, regardless of the avenue taken.
Ethical frameworks
There are several factors to consider when attempting to make an ethical decision and ethical principles can be used as a guide. However, it is important to consider that, as established by Abbitt (2011), we should assess the legal implications of an action over and above our own set of beliefs and values. Welsh (2003) supports the theory that an understanding of ethics and ethical principles can help RVNs address their options.
Utilitarianism is a consequentialist theory which looks at the outcome of an action (Mullan, 2006). We would strive to reach an outcome with the greatest good for the highest number of individuals. In the scenario the needs of the patient in theatre must also be considered alongside of those in the kennelling area. The SVN's need for support should also be recognised as the outcome of the scenario would certainly impact on the SVN's confidence in carrying out these duties in the future. The greatest good could be achieved through the support of the SVN throughout their duties, potentially by the SVN supporting the VS in theatre. Therefore, the ward patients would receive the skilled care from the RVN.
Deontology assesses the following of rules or boundaries to a role (Mullan, 2006). It is not the consequences of the action that is of issue here, although, as highlighted by Wood (2011), ignoring these would not be the most appropriate thing to do. It would be useful to refer back to Schedule 3 of the VSA (1966) and the RCVS Code of Professional Conduct for Veterinary Nurses (RCVS, 2017b) in terms of what support the SVN should receive. Appropriate advice, guidance and potential personal supervision of the task would be preferable here, as identified earlier.
Virtue ethics addresses an individual's own moral code, according to Mullan (2006), and their need to strive to be a virtuous person by achieving certain qualities. This could include: justice which involves treating all fairly; fidelity which is concerned with treating those close with special care; self-care such as looking after one's own needs such as mental, physical and spiritual health; and prudence which is the acquiring of virtues. The best course of action in the scenario would depend on the reasons behind the actions of the RVN. The RVN would need to consider the needs of the patient in theatre and whether they felt that the task was of an appropriate level to delegate. No clear answer can be gained here, but utilising a virtue ethics perspective can help to justify one's actions as those best suited to the scenario from all aspects.
Conclusion
There is a wealth of information regarding the delegation of acts of veterinary surgery, for example dentistry, anaesthesia and the giving of POM-V medications, by RVNs or SVNs without VS involvement. However, this article helps to highlight key concerns in relation to delegating a legal task which may not have been appropriate due to the professional and ethical implications identified.
When delegating a task both the VS and RVN must be sure that the task is suitable for delegation and that the SVN in question is competent to complete the task safely and without affecting patient welfare. This ultimately would be related to the level of training the SVN has received and the level of supervision within practice.
A more appropriate course of action in the scenario would have been the SVN supporting the VS in theatre, therefore accessing the direct supervision of a registered professional as and when required. The RVN would then be free to assess, medicate and monitor his patients within the ward. Should a SVN be asked to carry out a task that they feel they are not competent to complete it would be appropriate to voice their concerns or ask for further clarification and/or support.
With RVNs, and SVNs, being accountable for their own actions it is important to consider which task is most appropriate to delegate. In this critical incident it is clear that the RVN involved breached the legal, professional and ethical frameworks discussed, therefore the task was not appropriate to delegate.
Key Points
- Delegation of a Schedule 3 task to an student veterinary nurse (SVN) should come from the registered veterinary surgeon using their knowledge of the competency of the individual to carry out the task.
- Under Schedule 3 a supervised task delegated to a SVN, involving the administration of medical treatment, should be carried out under the guidance of the delegating VS, but not necessarily under direct and personal supervision.
- Under the Royal Charter (2015) registered veterinary nurses (RVNs) are accountable and responsible for any decision they make, including in relation to delegation.
- There has been a breach of all three areas of interest — legal, professional and ethical frameworks — therefore, the task was inappropriate to delegate.
- It is important to recognise the significance of inappropriate delegation in veterinary practice, as any complaint made against the RVN could, potentially, affect their professional status.