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COMMENTARY

Advanced Practice in Physiotherapy Me1 Stewart

Key Words Advanced practice in physiotherapy, advanced physiotherapy practice/specialist practice.

Introduction Advanced practice in physiotherapy has devel- oped with scant acknowledgment of its meaning, and hence little understanding of the standards by which it is measured. This is not surprising given the short history of the profession and the difficulty many physiotherapists find in making explicit their levels of skill. Additionally, physio- therapy attempts t o assess and quantify the interplay between perceptual, cognitive, and motor systems of the body, apply the appropriate assessment tools to them, and measure changes which occur. I t then seeks to use the subsequent findings to guide treatment. It soon becomes apparent that is an intricate challenge to try to explicate the standards of the physiotherapy skills which are practised.

The Chartered Society of Physiotherapy (CSP) defines physiotherapy as ‘a health care profession which emphasises the use of physical approaches in the promotion, maintenance and restoration of an individual’s physical, psychological and social well-being encompassing variations in health status’ (CSP, 1996). This statement defines practice and includes no acknowledgment of the standards of outcome the recipient might expect. These are offered by the Standards of Physio- therapy documents which, however, give no indication of the standard of physiotherapy skill required in order for the outcomes to be achieved. The assumption is that the outcomes will relate directly to the input of physiotherapy. While this may be true, natural healing and deterioration occur within in the body, and the stated outcomes may be so general that they could be achieved irrespective of the intervention. Thus, the extent to which the administration of recognised levels of physiotherapy skill correlates with the achieve- ment of outcomes is unknown.

Advanced practice assumes that better outcomes are achieved by its administration. If it is to be used as a standard measure of skill within the profession then attention to its definition is required. In isolation, it is a very general term which conveys little indication of the context in

which it is being used. The terms ‘advanced prac- tice in physiotherapy’ or ‘advanced physiotherapy practice’ are often used but different meanings may be construed from them. Whereas the former could suggest that there is scope, the latter clearly refers to the skills which are deemed to constitute the practice of physiotherapy. If this distinction is recognised, it has implications for how we might recognise the different levels of practice within the profession and for the scope of professional development for physiotherapists.

The main aims of this paper are to explore the extent to which the concept of advanced practice in physiotherapy compares to that of advanced physiotherapy practice; attempt to identify the features of ‘advanced practice in physiotherapy’; and explore the implications of advanced practice in physiotherapy for the development of the profession. Further consideration of the concept of advanced physiotherapy practice will be dealt with in a separate paper.

A Concept of Advanced Practice in Physiotherapy Advanced practice in physiotherapy allows contemplation of the view that it reaches beyond the mainstream of practice. It recognises that the physiotherapists who are doing it may not be carrying out physiotherapy as defined by the CSP. In line with the CSP’s view of specialist practice (CSP, 1995), members may identify their own standard of practice at advanced level. It also encompasses the notion that physiotherapists may be expanding and deepening the growth of the profession indirectly by virtue of their involve- ment in allied disciplines, for example research, education, and management. It is dynamic, with its evolution informed by research.

The onus for the dissemination of information regarding advanced practice lies with the practi- tioners. The importance of access to this information stands as a feature which serves t o inform, and t o help in the evaluation and improvement of physiotherapy practice for the benefit of all stakeholders. Alternatively, the concept of advanced physiotherapy practice in the sense of specialist practice recognises methods guided by the scope of practice, rules of profess- ional conduct, and guidelines to specialisms as laid down by the CSP (CSP, 1995). It has the potential to contribute to the body of know- ledge of recognised physiotherapy practice.

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Levels of Skill within Physiotherapy The notion of advanced practice in physiotherapy with the inclusion of skills other than those which fall within the scope of practice as defined by the CSP may be controversial, but at present we have few formal structures by which to investigate this level of practice. The most common and perhaps the most outdated of scales which attempt t o address levels of skill are the Whitley Council pay scales. Physiotherapists in posts which fall outside this structure adopt the pay structure of their host institution or remain outside any formal framework. Thus the skills, and hence job status and career development of physio- therapists working in these areas, may go unrecognised. The continuing restructuring of the NHS has led to an increase in the number of physiotherapists who fall within this category (CSP, 1996). The Whitley Council scales include physiotherapist, and various grades of senior, superintendent, district, teacher, and principal titles. The scales and titles for lecturers in phys- iotherapy, lecturer-practitioners, physiotherapists in research, physiotherapists in private practice, and specialist practitioners and many others are excluded. Since it is almost impossible to iden- tify all the capacities in which physiotherapists work, this list is difficult to complete.

The recently published Pay Review Body recom- mendations (CSP, 1998) have introduced three discretionary increments above the existing Senior 11, I, and Chief/Head/Superintendent IV and ChiefEIeadSuperintendent I11 titles in reco- nition of those who ‘have extended their roles in response t o a number of developments’. These discretionary increments have gone some way in recognising developing practices, but are targeted from a Senior I1 level, limited to the existing grading structure, and continue to fall short in addressing the issues of advanced practice as outlined in this article.

Although the CSP recognises the clinical specialist as ‘a physiotherapist who possesses a body of knowledge and skill above that expected of an average practitioner’ (CSP, 19951, it soon becomes obvious that despite this, the existing categori- sation is very limited. The present and future development in the diversity of skills of physio- therapists could conceivably complement or conflict with the scope of physiotherapy practice as defined by the CSP. At present, all physiother- apists who have been successful in completing a course in physiotherapy which has been jointly validated by the CSP, the Council for Professions Supplementary to Medicine (CPSM) and the teachiig institution, regardless of their current posts, are (on payment of a fee) entitled to hold

chartered and/or State registered status, a stan- dard of competence to practise. Many chartered physiotherapists may be carrying out work which does not fall within the scope of physiotherapy practice but have developed advanced levels of skill in the work they do.

In considering all the levels of practice of char- tered physiotherapists, questions arise regarding the nature of their work and how much of it constitutes physiotherapy practice and whether the requirement to be State-registered still applies. The continuing acceleration in the variation of practice and with it the scope for professional development demands that these changes are recognised if the profession, the clients and other stakeholders are to receive improved benefits from them. Issues of levels of practice vis-a-vis standards of practice will also need to be addressed.

Developing Advanced Practice in Physiotherapy It is a requirement for the majority of physio- therapists that where posts fall outside the Whitley Scale, they still have to be registered with the CPSM. Despite this, it should be recognised that many State-registered physiotherapists have changed their practice from direct, ‘hands-on’, face-to-face contact with clients to pursue the development of other allied skills. These skills may or may not have a direct relevance to the profession but they may have the potential to contribute significantly to its growth, for example, the contribution of physiotherapists in research.

The emphasis on the development of research skills may have no immediate or direct impact on the users of physiotherapy. However, the need to develop improved research skills has long been acknowledged by the profession as vital to its growth and credibility. While physiotherapists in research may or may not be on the fringes of the scope of physiotherapy practice, or indeed be far removed from it, they may be on the cutting edge of its advancement. A career structure which fails to give due recognition to its researchers is limited and inflexible and does little to advance the notion of professional development. Likewise, lecturers in physiotherapy may or may not be current ‘hands-on’ physiotherapy practitioners but they too may be viewed as important contrib- utors to the advancement of physiotherapy practice where one of the main contributions is to teaching and learning from an academic base. Should it be a requirement that the lecturers involved in the core teaching of physiotherapy be registered with the CPSM and the CSP? Where and when in the teaching of physiotherapy does

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State or CSP registration cease to matter? There are no simple answers to these questions but they highlight areas of growth of the profession where academic, professional and clinical boundaries are becoming increasingly blurred. There are no formal requirements from the CSP or CPSM for practitioners t o demonstrate maintenance of or improvement in standards of practice in order to remain chartered or to retain State registration.

There is a clear overlap between that which is viewed as advanced practice in physiotherapy and advanced physiotherapy practice; the latter could be subsumed under the former. Advanced physio- therapy practice/specialist practice falls within the scope of practice or sits on the fringe of devel- oping practice with a level of skill over and above the mainstream and demands that the practi- tioner is State registered. In advanced practice in physiotherapy I suggest that this may not be necessary.

In summary, the features of advanced practice in physiotherapy are that: 0 I t is on the cutting edge of physiotherapy practice.

Individuals may or may not be State registered. It should bring about improved change in

practice that is in line with the changing needs of the NHS and/or the clients with respect to physiotherapy.

It uses research to inform practice. Practitioners originate from chartered status

and are now experts in a recognised field (not necessarily physiotherapy).

Dissemination of knowledge to peers and others occurs as a regular feature of practice.

Rethinking Professional Development A career structure which recognises the diversity of features of physiotherapy practice is urgently needed. This urgency stems from a lack of aware- ness of managers within and outside the NHS and the public regarding the scope of practice of phys- iotherapists. A comparison of the employment profile of nurses at all levels within the NHS stands in marked contrast to that of physiother- apists. It is evident that nurses have been targeted and encouraged through Regional funding to take on the role of advanced practi- tioners and to extend their traditional roles in order to accommodate some of the changes within the health service. However the general lack of reference to the professions allied to medicine

(PAMs) and the possibility that they too could fulfill the requirements for these roles has largely been ignored. The PAMs have seen advances in nursing practice blur the distinctions in certain areas and they have viewed this as a threat to their professions. Although it is argued that this blurring should be viewed in a positive light (Potts, 19961, the slower recognition by manage- ment of the advancing practices of the PAMs may have fuelled some of these resentments.

The Future The production of physiotherapists who can operate as independent practitioners with a commitment to evidence-based practice, evaluate and reflect upon their practice, initiate and respond to change is reflected in the Chartered Society of Physiotherapy Curriculum Framework for undergraduates (CSP, 1996). At a postgrad- uate level, this initial facilitation of competencies provides the foundation for the development of an advanced practitioner with abilities to respond to changing service needs.

The potential to harness and advance the prac- tices of the PAMs should not be allowed to go unexplored. The identification and recognition of advanced practices in physiotherapists and other PAMs could serve as a mechanism to explore the common problems associated with their career development, grading structure, and pay. The employment profile of chartered physiotherapists suggests that there is a need to rethink the career structure and to provide a framework of profes- sional development in which the contribution of physiotherapy in health care is recognised, assessed, apd given its true value.

Author and Address for Correspondence Me/ Stewart Mfd MCSP DipTP is a lecturer in physiotherapy in the School of Health Sciences, University of Birmingham, Morris House, Edgbaston, Birmingham 81.5 2TT.

This article was received on December 12, 1996, and accepted on December 15,1997.

References Chartered Society of Physiotherapy (1 995). ‘Specialisms and Specialists’, Information Paper No PA 23, CSP, London, page 1.

Chartered Society of Physiotherapy (1 996). ‘Annual Report’, CSP, London, page 11.

Chartered Society of Physiotherapy and Council for Professions Supplementary to Medicine (1 996). ’The Curriculum Framework‘, CSP, London, page 6. Chartered Society of Physiotherapy (1 998). ‘Stewards News’, CSP, London, page 1.

Potts, J (1996). ‘Physiotherapy in the next century: Opportunity and challenges’, Pbysiotberapy, 82, 3, 150-1 55.

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