Physiotherapists should be proactive in preparing themselves to participate in innovative models of health care, which are emerging from healthcare workforce reforms in Australia. A targeted literature review was undertaken through EBSCO Host, cochrane, Medline, sportsdiscus, cinahl, Healthsource and Google.com. Themes included the need for standard National action in relation to legislative and regulatory / registration issues, appropriate education, credentialing and supervisory requirements for physiotherapy prescrib
Physiotherapists should be proactive in preparing themselves to participate in innovative models of health care, which are emerging from healthcare workforce reforms in Australia. A targeted literature review was undertaken through EBSCO Host, cochrane, Medline, sportsdiscus, cinahl, Healthsource and Google.com. Themes included the need for standard National action in relation to legislative and regulatory / registration issues, appropriate education, credentialing and supervisory requirements for physiotherapy prescrib
Physiotherapists should be proactive in preparing themselves to participate in innovative models of health care, which are emerging from healthcare workforce reforms in Australia. A targeted literature review was undertaken through EBSCO Host, cochrane, Medline, sportsdiscus, cinahl, Healthsource and Google.com. Themes included the need for standard National action in relation to legislative and regulatory / registration issues, appropriate education, credentialing and supervisory requirements for physiotherapy prescrib
Non-medical prescribing by physiotherapists: Issues reported in the
current evidence Joanne H. Morris a, * , Karen Grimmer b a ACT Health Directorate, Canberra 2605, Australia b International Centre for Allied Health Evidence, (iCAHE), University of South Australia, Australia a r t i c l e i n f o Article history: Received 8 March 2013 Received in revised form 6 April 2013 Accepted 8 April 2013 MeSH keywords: Physical therapy modalities Physical therapy specialty Drug prescriptions Drug therapy Primary health care Medicine Extended scope physiotherapy a b s t r a c t Physiotherapists should be proactive in preparing themselves to participate in innovative models of health care, which are emerging from the healthcare workforce reforms in Australia. One challenging outcome of workforce change is physiotherapy (non-medical) prescribing (NMP), which is part of the extension of scope of physiotherapy practice. This paper summarises the current evidence base for Australian physiotherapists seeking to obtain prescribing rights. A targeted literature review was un- dertaken through EBSCO Host, Cochrane, Medline, SportsDiscus, Cinahl, Healthsource and Google.com using broad search terms to identify peer-reviewed and grey literature pertaining to NMP by physio- therapists, nationally and internationally. No critical appraisal was undertaken however literature was structured into the NHMRC hierarchy of evidence. Themes raised in the included literature were reported descriptively. There were six relevant peer-reviewed articles, of hierarchy levels III_3 and IV. There was however, comprehensive and recent grey literature to inform Australian physiotherapy NMP initiatives. Themes included the need for standard National action in relation to legislative and regulatory/regis- tration issues, appropriate education, credentialing and supervisory requirements for physiotherapy prescribing. Many lessons can be learnt from the literature, including the importance of planned, uniform National action (rather than piecemeal state-by-state initiatives). Essential elements include appropriate training and skills-based recognition within the discipline and the broader health team, and the need to overtly demonstrate effectiveness and safety. Regularly-evaluated service-delivery models which support NMP by physiotherapists arefurther required, todemonstrate efciency, timeliness, patient centredness andequity. Crown Copyright 2013 Published by Elsevier Ltd. All rights reserved. 1. Introduction The last decade has seen rapid international changes to healthcare environments and workforce (Kersten et al., 2007; McClellan, et al., 2010; Stanhope et al., 2012). Drivers of change include increasing prevalence of chronic disease, ageing pop- ulations, and increasing community expectations of responsiveness (eg shorter waiting times, quicker assessments). This has led to innovative models of care described internationally as workforce redesign (Robertson et al., 2003; Stanhope et al., 2012). Expansion of scope of practice is one workforce redesign initiative which in- volves physiotherapists (Robertson et al., 2003). Increased prevalence of chronic disease brings an increased demand for medicines. Within an environment promoting healthcare responsiveness to consumer demand, this can be addressed by increasing the number of prescribers via Non-Medical Prescribing (NMP). This paper considers medicolegal, professional and educational as well as workforce redesign issues relevant to prescribing by physiotherapists. 2. Issues surrounding extended scope practice in physiotherapy Extended Scope Physiotherapy Practice (ESP) is dened as: A role that is outside the currently recognised scope of practice and requires legislative change. Extended scope of practice requires some method of credentialing following additional training, com- petency development and signicant clinical experience. Examples * Corresponding author. Tel.: 61 02 6244 2154; fax: 61 02 6244 3692. E-mail addresses: jo.morris@act.gov.au (J.H. Morris), Karen.grimmer@ unisa.edu.au (K. Grimmer). Contents lists available at SciVerse ScienceDirect Manual Therapy j ournal homepage: www. el sevi er. com/ mat h 1356-689X/$ e see front matter Crown Copyright 2013 Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.math.2013.04.003 Manual Therapy 19 (2014) 82e86 include prescribing, injecting and surgery. This role describes the breadth of practice. Australian Health Workforce Advisory Committee, 2006. 2.1. Background of NMP NMP has been in existence in the UK since 1989 (Drug and Therapeutic Bulletin, 2006). This largely reects pressures brought to bear on the UK health workforce, to increase service responsive- ness. Specically relating to physiotherapy-prescribing in the UK, activities have occurred under direct instruction from Medical Practitioners since early1990s, andinjectionpractices since1995via patient-group directives (PGDs). In 2009, there were approximately 3000 physiotherapy-injectors (Department of Health (UK) 2009). There is general international support for ESP physiotherapy roles as a way of making specialist healthcare services more available to those who need it (Kersten et al., 2007; McClellan et al., 2010; Lebec, 2010). Kersten et al. (2007) systematically reviewed literature about ESP physiotherapy roles in the UK, their accept- ability and effectiveness. This review included 23 data sources that reported at least one component of ESP physiotherapy roles being invasive (eg prescribing and injecting). Holdsworth et al. (2008) specically mentioned prescribing NSAIDs as a component of extended-scope physiotherapy roles. However, there is a lack of published evidence relating to the role and effectiveness of physiotherapists when prescribing or adminis- tering medication, or injecting. There is more literature relating to other ESP physiotherapy roles in undertaking traditional medical tasks egorthopaedic triage or listing for surgery (Kerstenet al., 2007). A study by Birchall et al. (2008) discussed the efcacy of injecting hyaluronic acid for the treatment of OA knee pain, with the injections being provided by physiotherapists, however the paper did not discuss the ability of the physiotherapists to provide this treatment more the efcacy of the treatment itself. For the purposes of this paper, prescribing is dened as: The information gathering, clinical decision making and commu- nication steps involved in the initiation, continuation or cessation of a medication, remedy or treatment for a specic patient Nissen et al., 2010. 3. Methods 3.1. Aim This review aimed to identify issues reported in the current literature (published and unpublished) which should be consid- ered, before NMP by physiotherapists is introduced in Australia as part of any workforce reform. The current evidence-base was established in three ways a) a targeted literature reviewof electronic databases EBSCOHost, Cochrane, Medline, SportsDiscus, Cinahl, Healthsource, using broad search terms of: Prescr# Physiother#* b) identifying grey literature via Google.com and government internet sites c) Hand searching reference lists of included peer-reviewed and grey literature to identify articles not retrieved via primary database searching. Included articles were limited to full text, peer-reviewed, and comprehensive government documents, published between 2002 and 2012. Included articles were classied in the NHMRC hierarchy (Merlin, et al., 2009), although critical appraisal of methodology was not undertaken. Literature was extracted on NMP activities undertaken by physiotherapists, and service delivery issues (i.e. legislation, registration, training, competencies). Data synthesis was reported descriptively. 4. Results Of 237 potentially relevant peer-reviewed articles, six directly addressed NMP for physiotherapists. Three relevant government reports were also sourced, and no additional references were identied by hand-searching (see Fig. 1). 4.1. Overview Six relevant peer-reviewed articles were found (hierarchy levels III_3, IV). Three comprehensive, recent grey literature sources were identied. The evidence suggests that the UK approach to physio- therapy ESP (including NMP) has lacked a consistent, robust and National direction (Nissen et al., 2010; McCormick and Downer, 2012; Stanhope et al., 2012). However Nissen et al. (2010) and the Department of Health (UK) (2009) concur that NMP has the po- tential to: Improve patient care without compromising safety Make it simpler and more efcient for patients to get the medicines they need Increase patient choice in safely accessing medications e including access to care closer to home Make better use of the skills of health professionals and in- crease value for money Contribute to introduction of a more exible team working Facilitate early discharge from hospital Prevention of admission to hospital 4.2. Safety The UK Department of Health (2009) demonstrated in an adverse events report (January 2005eJune 2006) detailing 60,000 medication incidents in the UK, that none related to Allied Health Professional (AHP) prescribers. The reports investigating NMP (Department of Health (UK) 2009; Nissen et al., 2010) highlighted key requirements to safely introduce NMP: Credentialing processes A competency framework A licensed accrediting body/organisation to regulate registra- tion processes It is therefore essential to consider these components in the context of introducing NMP by Australian physiotherapists. 4.3. Models of prescribing The UK has trialled several NMP models. Nissen et al. (2010) completed a scoping report for National Health Workforce Australia on NMP, based on UK learnings. They presented ideas for developing a nationally-consistent approach to prescribing by non- medical health professionals in Australia. Four cumulative tiers were recommended to underpin introduction of NMP in Australia: 1. Administration: tight model for immediate prescription only 2. Protocol model: allowing scope for supply of a course of medication (e.g. antibiotics) J.H. Morris, K. Grimmer / Manual Therapy 19 (2014) 82e86 83 3. Supplementary/collaborative: delegated prescribing author- ity model with controls on disease state(s) treated and range of medications available 4. Independent: delegated prescribing authority where a prac- titioner operates within a collaborative environment without direct supervision constraints The cumulative approach described by Nissen et al. (2010) could be adapted to accommodate the variety of clinical areas and con- texts within which Australian physiotherapists operate, as well as individuals prescribing interests. For instance, for the rst tier, basic formulary could be developed for individual clinical areas, using clinical experts, which are then adapted to individual situations. 4.4. Current legislation There are Australian state-by-state variations in the Medicines, Poisons and Therapeutics Goods Regulations/Acts, relative to physiotherapists. In some Australian states, there is capacity within current legislation to trial limited physiotherapy-prescribing (un- der standing order or permit arrangements), whilst other states require legislative changes. Information about state and territory Medicines and Poisons Acts needs to be accessed by individual state websites (Appendix 1). The Australian Health Practitioner Regula- tion Agency (AHPRA) is currently developing a document to collate this information, thus providing a central resource for physiother- apists to review the legislation as it applies to them. 4.5. Grey areas of physiotherapy-prescribing There are continuing legislative grey areas of physiotherapist involvement with medicines in Australia (Sullivan & Lansbury, 1999; Grimmer et al., 2002; Kumar & Grimmer, 2005). This in- cludes physiotherapists providing patients with variable advice regarding NSAIDs and pain medication, or administering NSAIDs during treatment. In light of NMP initiatives, it is timely to consider the differences in medicines training in Australian undergraduate and postgraduate physiotherapy programs, to ensure minimum educational standards (Sullivan & Lansbury, 1999; Grimmer et al., 2002; Kumar & Grimmer, 2005; Braund & Haxby Abbott, 2011) 5. Discussion Proactivity is required to ensure that NMP by Australian phys- iotherapists has appropriate medicolegal support, formal training and credentialing, and formal recognition by the health workforce. Whenever a physiotherapist receives NMP rights, standard evalu- ations should regularly occur to ensure consistent quality care. The Institute of Medicine model (Kohn, et al., 2000) denes quality care in terms of effectiveness, efciency, timeliness, safety, patient centredness and equity. NMP by physiotherapists should be eval- uated in these terms to ensure that it is a recognised and sustain- able element of the future health workforce. 5.1. Regulation There is a new National registration body for physiotherapists (Australian Health Practitioner Regulation Agency (AHPRA e http:// www.ahpra.gov.au/)). This may be the most appropriate Australian body to provide regulatory authority to Australian physiotherapy- prescribing. This approach would be consistent with the UK experi- ence, where the regulatory body (the Health Professions Council), is responsible for the regulatory function of physiotherapist- prescribers, by a notation in the clinicians registration. It is there- fore suggestedthat a caveat be includedinthe Australianregistration processes to accommodate credentialed physiotherapy-prescribers. 5.2. Education and training Coupled with variable training in undergraduate pharmacology (Sullivan &Lansbury, 1999; Grimmer et al., 2002; Kumar &Grimmer, 2005; Braund & Haxby Abbott, 2011), currently there are limited training programs in post-graduate pharmacology available to Fig. 1. Literature review ow chart. J.H. Morris, K. Grimmer / Manual Therapy 19 (2014) 82e86 84 physiotherapists wishing to work inESP roles. Adecade-old study by Sullivan and Lansbury (1999) suggested that inadequate training in medications potentially resulted in lax practice, particularly related to obtaining and keeping comprehensive records about patients medication. These ndings were supported by Grimmer et al. (2002) who undertook a survey of approximately half of the registered physiotherapists in South Australia. This survey found notable dif- ferences in engagement with medicines in day-to-day clinical practice, as well as variable understanding of dosage, and action of oral and topical NSAIDs. More recently, Braund and Haxby Abbott (2011) undertook a study of New Zealand physiotherapists under- standing of contraindications to recommending NSAIDs, nding that whilst 70% could demonstrate knowledge relating to gastro- Intestinal issues, ulcers or bleeding, only 30% had demon- strated knowledge of respiratory, renal or allergic risks. This literature highlights that an essential component for introducing physiotherapy-prescribing is a nationally-recognised and accredited training program for undergraduate physiotherapists, and formal avenues for continuing professional development, credentialing and skill maintenance for physiotherapists working in-scope as well as in extended scope roles. 5.3. Credentialing The credentialing and education process must translate to the clinical environment and model of care within which the physiotherapy-prescriber works. A credentialing model that in- cludes supervision from a registered prescriber within an appro- priate clinical context is essential to ensure that a safe and effective level of prescribing practice is achieved and recognised. However, in the current context, where there are no registered physiotherapy prescribers, there has to be engagement with other registered prescribers to provide supervision. McCormick and Downer (2012) identied that a key component for supervision of NMP students is ensuring that the education and supervision process and scope of practice of the NMP student is well under- stood by the medical supervisor. A key consideration to intro- ducing physiotherapy-prescribing will be education and consultation with other health professionals to ensure local sup- port and engagement. 5.4. Use of protocols and guidelines Atkins (2003) identied through interviews with 11 UK phys- iotherapists with recognised injecting skills that a more formalised approach to physiotherapy-prescribing and ESP roles will produce a more consistent, transferable and recognised workforce. 5.5. Competency A competency framework that is specic to Australian physio- therapy knowledge and practice is urgently required, to underpin roll-out of extended scope of practice. Australian physiotherapists have the skills and training to assess, diagnose and provide treat- ment to patients in broad clinical areas, including, but not limited to, musculoskeletal, cardio-respiratory, neurology, paediatrics, obstet- rics and gynaecology and aged-care practices. There are credible workforce, patient access and health outcome drivers to extend physiotherapy scope of practice in all of these clinical areas, thus consideration of prescribing needs across these clinical elds is required. Moreover, many of the urgent drivers for change come from rural and remote areas, where access to medical practitioners may be a signicant issue. The practicalities of introducing physiotherapy-prescribing in metropolitan, regional, rural and remote settings need to be carefullyconsidered, as the ways inwhich NMP is introduced and supported may be signicantly different. 6. Conclusion NMP is an essential component of physiotherapy ESP. With the right training and supports, it has been shown to be safe overseas, and it could be practiced similarly by Australian physiotherapists. However, for this to be a successful and acceptable workforce re- form initiative in Australia, it requires policy and legislation changes, promotion of alternative NMP models to suit different situations, context-relevant training and credentialing, and informed support from the medical profession. Comprehensive evaluation criteria should be developed and widely implemented, to ensure that safe practices and prescribing principles are demonstrated by physiotherapy-prescribers. Acknowledgements Jessica Stanhope, iCAHE, for assisting with searching. Appendix 1. State and Territory Legislation documents relating to medicines Victorian Drugs, Poisons and Controlled Substances Act 1981: http://www.legislation.vic.gov.au/Domino/Web_Notes/LDMS/ LTObject_Store/LTObjSt7.nsf/DDE300B846EED9C7CA25761600 0A3571/3E94BBFB45B6850ACA257A700000A6DF/$FILE/81-97 19aa099%20authorised.pdf Controlled Substances Act 1984 e South Australia: http://www. legislation.sa.gov.au/LZ/C/A/CONTROLLED%20SUBSTANCES%20 ACT%201984/2004.09.29/1984.52.PDF Health (Drugs and Poisons) Regulation 1996 e Queensland: http:// www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HealDrAPoR 96.pdf Poisons Act 1971 e Tasmania: http://www.thelaw.tas.gov.au/ tocview/index.w3p;condall;doc_id81%2B%2B1971 %2BAT% 40EN%2B20100214000000;histon;prompt;rec;termpois ons%20act Poisons and Therapeutic Drugs Act 1966 e New South Wales: http://www.legislation.nsw.gov.au/maintop/view/inforce/act 311966cd0N Poisons and Therapeutic Goods Regulation 2002 http://www. legislation.nsw.gov.au/fullhtml/inforce/subordleg6392002 FIRST0N Northern Territory Poisons & Dangerous Drugs Act: http://www. austlii.edu.au/au/legis/nt/consol_act/padda296/ Western Australia Poisons Act 1964: http://www.austlii.edu.au/ au/legis/wa/consol_act/pa1964121/ Poisons Regulations 1965 http://www.austlii.edu.au/au/legis/wa/consol_reg/pr1965230/ s40.html Australian Capital Territory e Medicines, Poisons and Therapeutic Goods Act 2008: http://www.legislation.act.gov.au/a/2008-26/ current/pdf/2008-26.pdf Source of support None. 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