Allied health: integral to transforming health

"Why is it not bringing me meaning and purpose?" Former occupational therapists' narratives of leaving the profession

INTRODUCTION

The demand for occupational therapy services in Australia has experienced considerable growth in the last decade. Despite an increase in occupational therapy numbers, there remains a substantial workforce shortage. One reason for this shortage is difficulty with the retention of occupational therapists and subsequent workforce attrition. The literature attributes planning to leave as being influenced by high workloads, insufficient time, a negative workplace culture, and stress impacting well-being. However, much of this research is specific to a practice area, such as mental health, and does not explore the experiences of those who have already left. Knowing why people leave occupational therapy will inform our understanding of how to support and retain our occupational therapy workforce.

METHODS

A qualitative study was undertaken using narrative inquiry in an Australian context. In 2022, stories were gathered from six former occupational therapists who left within the previous 5 years. Data were collected via semi-structured in-depth interviews using Zoom. Interviews were recorded and transcribed verbatim. The data were analysed using narrative and thematic analysis.

FINDINGS

Four themes were developed: "I just want to help this person"; "there was no real understanding"; "Trying to find where occupational therapy fits for me"; and "I'm not able to continue … anymore." Participants experienced dissonance between enacting their occupational therapy values and the expectations of their management. They were challenged by unsupportive workplace cultures and leadership styles that undermined their autonomy. They responded with resilience, and trying new ways to continue being occupational therapists, but became increasingly uncomfortable and stressed until they reached a tipping point where they decided to leave.

CONCLUSION

Increasing leadership development within the profession is essential, along with creative strategies for meeting funding requirements and fulfilling occupational therapy values. Workplaces that provide autonomy and respect the occupational therapy role are likely to support retention.

Unraveling attrition and retention: A qualitative study with rehabilitation professionals

BACKGROUND

Health human resources are scarce worldwide. In occupational therapy (OT), physical therapy (PT), and speech-language pathology (S-LP), attrition and retention issues amplify this situation and contribute to the precarity of health systems.

OBJECTIVE

To investigate the phenomena of attrition and retention with OTs, PTs and S-LPs who stayed in, or left their profession.

METHODS

Cultural-historical activity theory provided the theoretical scaffolding for this interpretive description study. We used purposeful sampling (maximum variation approach) to recruit OTs, PTs, and S-LPs from Quebec, Canada. Individual interviews were conducted with 51 OTs, PTs, and S-LPs from Quebec, Canada, in English or French (2019-2020). Inductive and deductive approaches, and constant comparative techniques were used for data analysis.

RESULTS

Six themes were developed: 1) characteristics of work that made it meaningful; 2) aspects of work that practitioners appreciate; 3) factors of daily work that weigh on a practitioner; 4) factors that contribute to managing work; 5) relationships with different stakeholders that shape daily work; and 6) perceptions of the profession. Meaningfulness was tied to participants' sense that their values were reflected in their work. Factors outside work shaped participants' work experiences. Recurrent negative experiences led some to leave their profession.

CONCLUSION

Findings underscore a critical need to address contributing factors to attrition and retention which are essential to ensuring the availability of OTs, PTs and SLPs for present and future rehabilitation needs.

Creating a framework for change: transitioning to value-based healthcare in Queensland

Value-based healthcare has been described as the sustainable, equitable and transparent use of healthcare resources to achieve improved experiences and outcomes for people and communities. It is supported by all levels of government in Australia, with recent initiatives championing a shift away from traditional, clinician-centric care delivery to a more contemporary, value-based approach. To date, however, efforts in Queensland have focused on smaller scale siloed models of care and have not extended to the transformational change required to create equitable and sustainable healthcare delivery. The Queensland Health Allied Health Framework for Value-Based Health Care (the Framework) builds on contemporary frameworks with reference to the local context in Queensland and provides a structure and starting point for clinicians and managers to work together with consumers to transform services to focus on preventative health and wellbeing, shifting the focus of care to the community and sustainably improving the quality of care delivered. The Framework outlines key considerations for the design and implementation of new services, including understanding the care pathway, supporting an outcome driven workplace culture, measuring what matters and designing for outcomes. Several key lessons were learnt during the development of the Framework, including the importance of early and sustained consumer partnerships, of establishing a shared definition of value-based healthcare that enables integration across the care pathway and the need for leadership at all levels to actively support the change management process. While developed for Queensland public allied health services, the Framework is intended to be a system-wide tool relevant to all health professionals and services.

Consumer perspectives of allied health involvement in a public hospital setting: cross-sectional survey and electronic health record review

Objective Consumer-centred care is fundamental to high-quality health care, with allied health professionals playing a pivotal role in hospital settings. Allied health typically operates within standard weekday working-hours. Consumer preferences for receiving allied health services are largely unexplored but could inform whether weekend and/or out-of-hours services are required. This study aims to understand consumer preferences for hospital-based inpatient and outpatient allied health services. Methods Using a cross-sectional survey and convenience sampling approach, consumers of a public health service in Melbourne, Australia were surveyed about preferences for allied health service delivery. Electronic health record reviews compared the accuracy of self-reported service delivery times. Descriptive statistics, concordance and predictive values were calculated. Responses to free-text survey items were analysed using content analysis. Results Of 120 participants (79% response rate), most (69%) received allied health services, however, almost half of inpatient responders (44%) were unsure of the specific allied health professional involved. Audit results found moderate-high concordance overall (range, 77-96%) between self-reported and audit-identified allied health services by profession. Most inpatient responders had no strong day of week preference, equally selecting weekdays and weekend days, with most preferring services between 8 am and 4 pm. Outpatient responders (81%) preferred a weekday appointment between 8 am and 12 pm or before 8 am (29%) to complete scheduled activities early in the day. Conclusion While provision of allied health services during standard working-hours was preferred by most consumers, some inpatient and outpatient consumers are receptive to receiving weekend and out-of-hours services, respectively. Decisions about offering these services should consider operational capacity and research evidence.

Attrition and Retention of Rehabilitation Professionals: A Scoping Review

INTRODUCTION

Attrition is defined as a permanent departure from one's profession or the workforce. Existing literature on retention strategies, contributing factors to the attrition of rehabilitation professionals and how different environments influence professionals' decision-making to stay in/leave their profession, is limited in scope and specificity. The objective of our review was to map the depth and breadth of the literature on attrition and retention of rehabilitation professionals.

METHODS

We used Arksey and O'Malley's methodological framework. A search was conducted on MEDLINE (Ovid), Embase (Ovid), AMED, CINAHL, Scopus, and ProQuest Dissertations and Theses from 2010 to April 2021 for concepts of attrition and retention in occupational therapy, physical therapy, and speech-language pathology.

RESULTS

Of the 6031 retrieved records, 59 papers were selected for data extraction. Data were organized into three themes: (1) descriptions of attrition and retention, (2) experiences of being a professional, and (3) experiences in institutions where rehabilitation professionals work. Seven factors across three levels (individual, work, and environment) were found to influence attrition.

DISCUSSION

Our review showcases a vast, yet superficial array of literature on attrition and retention of rehabilitation professionals. Differences exist between occupational therapy, physical therapy, and speech-language pathology with respect to the focus of the literature. Push , pull , and stay factors would benefit from further empirical investigation to develop targeted retention strategies. These findings may help to inform health care institutions, professional regulatory bodies, and associations, as well as professional education programs, to develop resources to support retention of rehabilitation professionals.

Understanding How Newly Implemented Rehabilitation Best Practices Are Sustained: A Realist Review

OBJECTIVE

We conducted a realist review to understand how (mechanism) and in what circumstances (context) evidence-based practices are sustained in rehabilitation (outcome).

DATA SOURCES

MEDLINE, Embase, reference lists, and targeted websites.

STUDY SELECTION

Two independent reviewers calibrated study selection; then 1 reviewer screened all titles and abstracts, while the second reviewer screened a random 20%. We repeated this process for full texts. We included 115 documents representing 61 implementation projects (8.9% of identified documents). Included documents described implementation projects in which physical therapists, occupational therapists, and/or speech-language pathologists were the target users of an evidence-based practice.

DATA EXTRACTION

Two reviewers repeated the independent process described in study selection to extract basic study and sustainability characteristics as well as context, mechanism, outcome, and strategy text.

DATA SYNTHESIS

Using basic numerical analyses, we found that only 54% of evidence-based practices in rehabilitation are sustained. Furthermore, while authors who reported sustainability planning sustained the practice 94% of the time, sustainability planning in rehabilitation is rare (only reported 26% of the time). Extracted text was synthesized using the realist technique of inductive and deductive retroduction in which context, mechanism, outcome, and strategy text are combined into narrative explanations of how sustainability works. To inform these explanations, we applied normalization process theory and the theory of planned behavior. Collectively, the 52 identified narratives provide evidence for 3 patterns: (1) implementation and sustainability phases are interconnected, (2) continued use of the evidence-based practice can be interpreted as the ultimate sustainability outcome, and (3) intermediate sustainability outcomes (ie, fit/alignment, financial support, benefits, expertise) can become contextual features influencing other sustainability outcomes.

CONCLUSIONS

Implementation teams can use the narrative explanations generated in this review to optimize sustainability planning. This can sustain practice changes and improve quality of care and patient outcomes. Future research should seek to iteratively refine the proposed narrative explanations.

Exploring professional identity in rehabilitation professions: a scoping review

Professional identity is believed to foster self-confidence and resilience in health care professionals. While literature exists describing professional identity in medicine, the relevance of this evidence to rehabilitation professionals (occupational therapy (OT), physical therapy (PT) and speech-language pathology (S-LP)) is limited due to differences between professions in decision-making authority (patient care), professional autonomy and understanding of their scope of practice. The objective was to determine the extent, range and nature of the literature on professional identity/professional identity formation in rehabilitation professionals. Findings from the scoping review based on Arksey and O'Malley's methodological framework are presented. A search was conducted on MEDLINE (Ovid), Embase (Ovid), AMED, CINAHL, and ProQuest Dissertations and Theses from 1996 to October 2020 for empirical and conceptual studies on OT, PT, and S-LP clinicians or students. Of 4983 retrieved records, 53 papers were selected for data extraction. Data were organised into themes for professional identity/professional identity formation: conceptual descriptors (dynamic state, multiple identities); influences (person, professional education/environments, profession-at-large). Findings are consistent with the professional identity literature in medicine. However, they point to gaps for further empirical inquiry in the role of symbols and rituals in the professional identity/professional identity formation of rehabilitation professionals, profession-specific differences between OT, PT and S-LP, and influences related to the profession-at-large on the professional identity/professional identity formation of rehabilitation professionals. These findings may help to inform professional education programs and health care and professional systems in developing resources to support professional identity formation of rehabilitation professionals.

How can the healthcare system deliver sustainable performance? A scoping review

BACKGROUND

Increasing health costs, demand and patient multimorbidity challenge the sustainability of healthcare systems. These challenges persist and have been amplified by the global pandemic.

OBJECTIVES

We aimed to develop an understanding of how the sustainable performance of healthcare systems (SPHS) has been conceptualised, defined and measured.

DESIGN

Scoping review of peer-reviewed articles and editorials published from database inception to February 2021.

DATA SOURCES

PubMed and Ovid Medline, and snowballing techniques.

ELIGIBILITY CRITERIA

We included articles that discussed key focus concepts of SPHS: (1) definitions, (2) measurement, (3) identified challenges, (4) identified solutions for improvement and (5) scaling successful solutions to maintain SPHS.

DATA EXTRACTION AND SYNTHESIS

After title/abstract screening, full-text articles were reviewed, and relevant information extracted and synthesised under the five focus concepts.

RESULTS

Of 142 included articles, 38 (27%) provided a definition of SPHS. Definitions were based mainly on financial sustainability, however, SPHS was also more broadly conceptualised and included acceptability to patients and workforce, resilience through adaptation, and rapid absorption of evidence and innovations. Measures of SPHS were also predominantly financial, but recent articles proposed composite measures that accounted for financial, social and health outcomes. Challenges to achieving SPHS included the increasingly complex patient populations, limited integration because of entrenched fragmented systems and siloed professional groups, and the ongoing translational gaps in evidence-to-practice and policy-to-practice. Improvement strategies for SPHS included developing appropriate workplace cultures, direct community and consumer involvement, and adoption of evidence-based practice and technologies. There was also a strong identified need for long-term monitoring and evaluations to support adaptation of healthcare systems and to anticipate changing needs where possible.

CONCLUSIONS

To implement lasting change and to respond to new challenges, we need context-relevant definitions and frameworks, and robust, flexible, and feasible measures to support the long-term sustainability and performance of healthcare systems.

Is interprofessional education a valued contributor to interprofessional practice and collaboration within allied health in Australia and New Zealand: A scoping review

Research on the value of interprofessional education (IPE), collaboration and practice in the health sector at both a pre- and post-registration level has increased in recent years. A scoping review of Australian and New Zealand studies was conducted on the value of IPE to interprofessional practice in allied health professionals from 2013 to 2019. A scoping review framework was used to identify 109 studies. Twenty-one articles met the eligibility criteria. The studies were grouped into undergraduate students in academic and WIL settings, allied health professionals and clinical educators. Results suggest that IPE is necessary for the maintenance of interprofessional practice and that it is strongly connected to the development of successful communication within the interprofessional environment. Authentic IPE experience and socialization opportunities appear to be major facilitators of interprofessional practice but no consensus regarding the ideal length of time or timing of IPE was found. The studies also provided an insight into facilitators and barriers to successful implementation of IPE and interprofessional practice in rural environments. As IPE has been shown to contribute to improved interprofessional practice and patient outcomes, future research should explore how to create IPE opportunities for implementation within rural communities where adequate resourcing is most challenged.

Evaluation of occupational therapy-led advanced practice hand therapy clinics for patients on surgical outpatient waiting lists at eight Australian public hospitals

STUDY DESIGN

This is a prospective cohort study.

INTRODUCTION

Evidence is emerging that advanced practice hand therapy clinics improve patient outcomes.

PURPOSE OF THE STUDY

The aim of this study was to evaluate an advanced practice hand therapy model of care for patients with chronic hand conditions on surgical outpatient waiting lists at eight Australian public hospitals.

METHODS

Nonurgent and semiurgent patients were screened and treated, as required, by an advanced practice hand therapist and then discharged from the surgical outpatient waiting list as appropriate. Outcomes included patient safety, impact on the waiting list, patient satisfaction, and patients' perception of change as measured by Global Rating of Change (GROC). The GROC score was also compared across diagnoses. The relationship between the waiting time and need for surgical review during hand therapy treatment was also assessed. As appropriate, T-tests and analysis of variance were used for statistical analyses.

RESULTS

A total of 37.2% of patients who commenced hand therapy were removed or discharged from the surgical outpatient waiting lists. Of the subset of patients who completed hand therapy (n = 1116), 28.4% were discharged without requiring surgical follow-up. A further 7.53% requested return to the waiting list despite discharge being recommended. The model of care was safe, and patient satisfaction was above 90%. The mean GROC score was +2.09 (±3.58) but varied across diagnoses with trigger finger or trigger thumb showing the greatest improvement (+4.21 ± 2.92, P < .01). Patients who did not require surgical consultation during hand therapy had a shorter wait time for their initial hand therapy appointment (P < .001).

CONCLUSIONS

The advanced practice hand therapy model of care was safe and effective in reducing hospital surgical outpatient waiting lists. Patients reported high satisfaction.

Substitution, delegation or addition? Implications of workforce skill mix on efficiency and interruptions in computed tomography

Objectives This study evaluated multiple computed tomography (CT) workforce models to identify any implications on efficiency (length of stay, scan frequency and workforce cost) and scanning radiographer interruptions through substituting or supplementing with a trained CT assistant. Methods The study was conducted in a CT unit of a tertiary Queensland hospital and prospectively compared four workforce models, including usual practice: Model 1 used an administrative assistant (AA) and one radiographer; Model 2 substituted a medical imaging assistant (MIA) for the AA; Model 3 was usual practice, consisting of two radiographers; and Model 4 included two radiographers, with a supplemented MIA. Observational data were collected over 7 days per model and were cross-checked against electronic records. Data for interruption type and frequency, as well as scan type and duration, were collected. Annual workforce costs were calculated as measures of efficiency. Results Similar scan frequency and parameters (complexity) occurred across all models, averaging 164 scans (interquartile range 160-172 scans) each. The median times from patient arrival to examination completion in Models 1-4 were 47, 35, 46 and 33min respectively. There were between 34 and 104 interruptions per day across all models, with the 'assistant role' fielding the largest proportion. Model 4 demonstrated the highest workforce cost, and Model 2 the lowest. Conclusion This study demonstrated that assistant models offer similar patient throughput to usual practice at a reduced cost. Model 2 was the most efficient of all two-staff models (Models 1-3), offering the cheapest workforce, slightly higher throughput and faster examination times. Not surprisingly, the additional staff model (Model 4) offered greater overall examination times and throughput, with fewer interruptions, although workforce cost and possible role ambiguity were both limitations of this model. These findings may assist decision makers in selecting the optimal workforce design for their own individual contexts. What is known about the topic? Innovative solutions are required to address ongoing health workforce sustainability concerns. Workforce substitution models using trained assistants have demonstrated numerous benefits internationally, with translation to the Australian allied health setting showing promise. What does this paper add? Building on existing research, this study provides clinical workforce alternatives that maintain patient throughput while offering cost efficiencies. This study also quantified the many daily interruptions that occur within the CT setting, highlighting a potential clinical risk. To the best of our knowledge, this study is the first to empirically test the use of allied health assistants within CT. What are the implications for practitioners? Role substitution in CT may offer solutions to skills shortages, increasing expenditure and service demand. Incorporating appropriate assistant workforce models can maintain throughput while demonstrating implications for efficiency and interruptions, potentially affecting staff stress and burnout. In addition, the assistant's scope and accepted level of interruptions should be considerations when choosing the most appropriate model.

Allied health professionals' perceptions of interprofessional collaboration in primary health care: an integrative review

This integrative review synthesizes research studies in order to explore the perceptions of allied health professionals regarding interprofessional collaboration in primary health care. A comprehensive literature search was conducted using three electronic databases and a manual search of the Journal of Interprofessional Care. The Crowe Critical Appraisal Tool was used to assess the quality of included papers. Study findings were extracted, critically examined and grouped into themes. Twelve studies conducted in six different countries met the inclusion criteria. Thematic analysis revealed five themes: (1) shared philosophy; (2) communication and clinical interaction; (3) physical environment; (4) power and hierarchy; and (5) financial considerations. This review has identified diverse key elements related to interprofessional collaboration in primary health care, as perceived by allied health professionals. Opportunity for frequent, informal communication appeared essential for interprofessional collaboration to occur. Allied health professionals working in close proximity to health practitioners from other professions had more regular interprofessional interactions than those who were geographically separated. Co-location of multiple primary health care services within the same physical space may offer increased opportunities for interprofessional collaboration. Future research should avoid reporting on allied health professionals in primary health care collectively, and isolate data to the individual professions. Direct observational methods are warranted to investigate whether allied health professionals' perceptions of interprofessional collaboration align with their actual clinical interactions in primary health care settings.

How Much Allied Health Therapy Care Is Enough? An Evidence Scan

Purpose: Pressure to eliminate low-value health care is increasing internationally. This pressure has produced an urgent need to identify evidence-based methods to determine the value of allied health (AH) care, particularly to recognize when additional AH care adds no further benefits. This article reports on the published methods of determining the value of AH care. Method: We systematically scanned PubMed, MEDLINE, AMED, CINAHL, PsycINFO, and the Grey Literature Review database from inception until July 2018 for peer-reviewed English-language literature. Hierarchy of evidence and information on study design and the methods or measures used to determine the value of AH care were extracted. Results: Of 189 articles, 30 were potentially relevant; after the full text was read, all were included. Of these, 24 reported on ways of determining the value of AH care, and 6 described the optimal provision of AH episodes of care. No methods were reported that could be applied to establish when enough AH therapy had been provided. Conclusion: This review found a variety of attributes of value in AH care, but no standard value measure or methods to determine what constituted enough AH care. Repeated measurement of the standard attributes of value and costs is required throughout episodes of AH care to better understand the impact of AH care from the different stakeholders' perspectives.

Workplace injuries in the Australian allied health workforce

Objective This study aims to identify the number, costs and reported injury mechanisms of serious injury claims for allied health professionals. Methods Using Australian Workers' Compensation injury data, the number, mechanism, and costs of injury claims were calculated for eight groups of allied health professions (chiropractors and osteopaths, speech pathologists and audiologists, occupational therapists, physiotherapists, psychologists, podiatrists, social workers and prosthetists/orthotists) between the 2000-01 and 2013-14 financial years. Workforce injury rates were calculated using the 2011 Australian Census Workforce data (denominator) and 2011 Workers' Compensation Statistics claims data (numerator). Results Across the allied health professions, 7023 serious injuries (minimum 5 days absence from work) were recorded with an associated total compensation cost of A$201970000. Fewer than 1.5% of each allied health professional group had an injury claim, with the exception of prosthetists/orthotists who had a rate of 25.9% serious injury claims (95% confidence interval 21.9-30.4). The average cost per claim varied across the allied health professions, from the lowest cost of A$19091 per injury for occupational therapists to the highest of A$48466 per claim in chiropractic and osteopathy. Body stressing followed by mental stress were the most common mechanisms of injury. Conclusions Mechanism of injury, both physical and psychosocial, were identified. Prosthetists/orthotists are at the highest risk of workplace injury of all allied health professions. This suggests the need for further investigation and development of appropriately targeted injury prevention programs for each allied health profession. What is known about this topic? Retention of allied health professionals is a significant issue, with workplace injuries identified as one contributing factor to this problem. Healthcare workers are potentially at high risk of injury as they are exposed to a range of physical and psychosocial hazards in their workplace. What does this paper add? This paper is the first to report on serious injuries, minimum 5 days absence from work, from Australian Workers' Compensation data, across a range of allied health professions. Various allied health professions were examined to identify the number, mechanism and cost of serious workplace injuries finding there is an average of 500 serious claims per year at a cost of A$14million. Prosthetists/orthotists were identified as having the highest proportion of claims per workforce population. What are the implications for practitioners? These results suggest highly varied injury rates across allied health professions. Compensation data does not enable accurate identification of causal factors. Further work is required to identify relevant causal factors so that targeted risk reduction strategies can be developed to reduce workforce injuries.

Advanced Physiotherapy Practice: A qualitative study on the potential challenges and barriers to implementation in Ghana

Objective: To identify the potential challenges and barriers to the implementation of Advanced Physiotherapy Practice (APP) in Ghana. Methods: A basic interpretive qualitative study design was conducted, with a semi-structured focus group comprising eight physiotherapists and a one-to-one interview with the director of orthopedic surgery in the second largest hospital in Ghana. Participants were sampled purposefully to ensure they had a clear understanding of APP. Discussions were audio recorded, transcribed, coded and thematic analysis was performed. Findings: Four key themes were identified as potential challenges to the implementation of APP in Ghana. Theme 1 Jurisdictional Disputes: Physiotherapists believed doctors will not accept the practice, while the doctor interviewed was willing to accept the practice. Theme 2: Management Support: Support from management was identified as a potential barrier to APP implementation due to workplace culture and liability. Theme 3 Change in Law and Policy: APP could be hindered if there is no legislative support and policies in place. Theme 4 Postgraduate Training: This was identified as key to the implementation of APP since there is no such level of training in Ghana. Conclusion: Barriers to health-care programs are often not identified and addressed prior to their implementation in developing countries, leading to program failure. Addressing these four barriers and challenges could ensure the successful implementation of APP in Ghana. APP has the potential to improve access to rural health-care delivery and augment the shortage of health professionals in developing countries.

Work-related musculoskeletal injuries in prosthetists and orthotists in Australia

Objective. This study aims to determine the prevalence of work-related musculoskeletal disorders in prosthetists/orthotists working in Australia. Secondary to this, the relationship between work-related hazards and work-related musculoskeletal disorders will be examined. Methods. In 2012, a self-report survey was conducted with the prosthetist/orthotist workforce in Australia (N = 139, 56% response rate). Data on workplace physical and psychosocial hazards, job satisfaction, work-life balance and musculoskeletal discomfort were collected. Predictors of work-related musculoskeletal disorders were assessed using logistic regression analysis. Results. Prevalence of work-related musculoskeletal disorders was 80%. Gender (β = 1.31, p = 0.030), total weekly hours (β = 0.9, p < 0.010) and physical (β = 1.91, p < 0.010) and psychosocial (β = 1.28, p < 0.010) hazards were all associated with reporting of work-related musculoskeletal disorders. Females reported higher levels of work-related musculoskeletal disorder discomfort than males in all body areas. Conclusions. Work-related musculoskeletal disorders prevalence is high in prosthetists/orthotists. This suggests that focus on workplace injury prevention is required. Targeted prevention requires systematic identification and then control of all relevant workplace hazards.

How physiotherapists supervise to enhance practical skills in dedicated aides of toddlers with cerebral palsy: A qualitative observational study

BACKGROUND

Physiotherapy from an early age is considered important for children with cerebral palsy (CP). In preschool, dedicated aides are responsible for the daily follow-up and training under the supervision of a physiotherapist (PT). Knowledge is sparse regarding what is created and achieved in clinical practice involving triads (i.e. the PT, aide, and child) with respect to the enhancement of practical skills in dedicated aides. The study purpose was to explore form and content in supervision.

METHODS

Nonparticipating observations were performed on a purposive sample of seven triads, including seven PTs, seven dedicated aides, and seven preschool toddlers with CP with function level III-IV of the Gross Motor Function Classification System. Each triad was video-recorded once. Data consisted of 371 minutes of video recordings analyzed using content analysis and enactive theory on participatory sense-making.

RESULTS

From the analysis, three supervision approaches emerged: (1) the Cognitive Supervision approach; (2) the Joint Action Supervision approach; and (3) the Embodied Supervision approach. Each approach gives rise to different types of sense-making processes, ranging from merely reflective ways of knowing through verbal and visual conveyance to mutual embodied ways of knowing through joint actions and physical interplay. To make use of all approaches, PTs require incorporated handling skills and action competence.

CONCLUSION

Supervision is an emergent process where knowledge is transformed through interactions and shared sense-making processes.

IMPLICATIONS

Clinicians should be aware of the context-dependent and interactional factors that drive the supervision process.

South African primary health care allied health clinical practice guidelines: the big picture

BACKGROUND

Good quality clinical practice guidelines (CPGs) are a vehicle to implementing evidence into allied health (AH) care. This paper reports on the current 'state of play' of CPGs in a lower-to-middle-income country (South Africa), where primary healthcare (PHC) AH activities face significant challenges in terms of ensuring quality service delivery in the face of huge PHC need.

METHODS

A qualitative study was conducted, using semi-structured interviews with purposively-sampled individuals involved in AH PHC CPGs in South Africa. They included national and state government policy-makers, academics and educators, service managers, clinicians, representatives of professional associations, technical writers, and members of informal professional networks. The interview data was transcribed and de-identified, and analysed descriptively by hand-coding. The COREQ statement guided study conduct and reporting. A framework to guide research in other countries into perspectives of AH PHC CPG activities was established.

RESULTS

Of the 32 invited, 29 people participated: of these 25 were interviewed and four provided meeting notes. Most participants had multiple professional roles, being engaged concurrently in clinical practice, academia, professional associations and / or government. Key themes comprised Players (sub-themes of sampling frame, participants, advice, role players and collaboration); Guidance (sub-themes of nomenclature, drivers, purpose, evidence sources) and Role of AH in PHC (sub-themes of discipline groupings, disability and rehabilitation, AH recognition).

CONCLUSION

There was consistently-expressed desire for quality guidance to support better quality AH PHC activities around the country. However no international CPGs were used, and there were no South African CPGs specific to local PHC AH practice. The guidance gap was filled by non-evidence-based documents produced often without training, to deal with specific clinical situations. This led to frustration, duplication and fragmentation of effort, confusing nomenclature, and an urgent need for standardised and agreed guidance. We provided a standardised framework to capture perspectives on CPGs activities in other AH PHC settings.

Shape of allied health: an environmental scan of 27 allied health professions in Victoria

Objective In 2015, the Victorian Department of Health and Human Services commissioned the Victorian Allied Health Workforce Research Program to provide data on allied health professions in the Victorian public, private and not-for-profit sectors. Herein we present a snapshot of the demographic profiles and distribution of these professions in Victoria and discuss the workforce implications. Methods The program commenced with an environmental scan of 27 allied health professions in Victoria. This substantial scoping exercise identified existing data, resources and contexts for each profession to guide future data collection and research. Each environmental scan reviewed existing data relating to the 27 professions, augmented by an online questionnaire sent to the professional bodies representing each discipline. Results Workforce data were patchy but, based on the evidence available, the allied health professions in Victoria vary greatly in size (ranging from just 17 child life therapists to 6288 psychologists), are predominantly female (83% of professions are more than 50% female) and half the professions report that 30% of their workforce is aged under 30 years. New training programs have increased workforce inflows to many professions, but there is little understanding of attrition rates. Professions reported a lack of senior positions in the public sector and a concomitant lack of senior specialised staff available to support more junior staff. Increasing numbers of allied health graduates are being employed directly in private practice because of a lack of growth in new positions in the public sector and changing funding models. Smaller professions reported that their members are more likely to be professionally isolated within an allied health team or larger organisations. Uneven rural–urban workforce distribution was evident across most professions. Conclusions Workforce planning for allied health is extremely complex because of the lack of data, fragmented funding and regulatory frameworks and diverse employment contexts. What is known about this topic? There is a lack of good-quality workforce data on the allied health professions generally. The allied health workforce is highly feminised and unevenly distributed geographically, but there is little analysis of these issues across professions. What does this paper add? The juxtaposition of the health workforce demographics and distribution of 27 allied health professions in Victoria illustrates some clear trends and identifies several common themes across professions. What are the implications for practitioners? There are opportunities for the allied health professions to collectively address several of the common issues to achieve economies of scale, given the large number of professions and small size of many.

Mapping South African allied health primary care clinical guideline activity: establishing a stakeholder reference sample

BACKGROUND

Little is known about allied health (AH) clinical practice guideline (CPG) activity in South Africa, and particularly in relation to primary health care (PHC). This paper reports on a scoping study undertaken to establish a reference framework, from which a comprehensive maximum variation sample could be selected. This was required to underpin robust sampling for a qualitative study aimed at understanding South African primary care AH therapy CPG activities. This paper builds on findings from the South African Guidelines Evaluation (Project SAGE) Flagship grant.

METHODS

South African government websites were searched for structures of departments and portfolios, and available CPGs. Professional AH association websites were searched for CPGs, purposively-identified key informants were interviewed, and CPGs previously identified for priority South African primary care conditions were critiqued for AH therapy involvement.

RESULTS

Key informants described potentially complex relationships between players who may be engaged in South African AH CPGs, in both public and private sectors. There were disability/rehabilitation portfolios at national and provincial governments, but no uniformity in provincial government organisation of, or support for, PHC AH services. There were no AH primary care therapy CPGs on government websites, although there was 'clinical guidance' in various forms on professional association websites. Only two CPGs of priority South African PHC conditions included mention of any AH therapy (physiotherapy for adult asthma and chronic obstructive pulmonary disease).

CONCLUSION

A comprehensive and wide-reaching stakeholder reference framework would be required in order to capture the heterogeneity of AH primary care CPG activity in South Africa. This should involve the voices of national and purposively-selected provincial governments, academic institutions, consultants, public sector managers and clinicians, private practitioners, professional associations, and private sector insurers. Provincial governments should be selected to reflect heterogeneity in local economics, population demographics and availability of university AH training programs. This investigation should aim to determine the areas of PHC in which AH are engaged.