Table Of ContentWe dedicate this book to our students. Manyfrom the past are already advanced
practitioners, and those with whom we work currently,carrythe seedsof future
advanced practice.
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Foreword
'Thegreatthinginthisworldisnotsomuchwherewe One of the challenges of skills utilization has
are but in what direction we are moving' (Oliver been finding ways to use, define and regulate
WendellHolmes) 'advanced' practice. There are several reasons
Ithas beenenlighteningto write the foreword why this is so: it is difficult to functionally
forthisvisionarybookwhichtakes the readeron define the exact level of practice which stops
ajourney alongthe pathto advancedpracticein, being 'ordinary' andbecomes advanced: educa
explaining, en route, what advanced practice is tion may not have kept up with the needs of
and why, in today's challenging health care practice, so that practitioners learn from experi
world,itisimportant. ence and in-service professional development,
Theauthorsaredrawnfrom differentrehabilita and none of this is regulated: or there may be
tiontherapy areas, bringing a fresh perspective to turf wars, over who 'owns' particular pieces of
theissuesofadvancedpracticeandstartby reflect practice. These are difficultissues,butthisbook
ingonthe driversfor changein the currenthealth tackles themall in apracticalway, usingworked
carearena.Theeconomicimperativeinmostcoun examples to show different routes to advanced
tries is to keep costs down while continuing to practice, likely obstacles and ways of overcom
meetgrowing demand, often resulting in changes ing them. The book acknowledges that in many
tothe structure of the health system. Because of waysthetitle ofadvancedpractitionercannotbe
this,thereisa needfor professionalswho are able given, it has to be taken, and this readiness for
toworkwithinever-changinghealthcare systems practice is acquired not only through formal
aswellas a growing interest in the links between learning. The reflective practitioner is one who
education, provider performance and quality of can look at their own quality of practice, and
care. These challenges provide an apt backdrop consider to what extent it is evidence based,
againstwhich to consider the potential contribu how theory can be applied to it, and whether
tionsofadvancedhealthcare practitioners. theycanteachothers.
Human resources in health care are central to Havinga level of self-awarenesswhichresults
delivering health services, and yet the World in increased motivation to improve knowledge
Health Report 2000 noted that determining and andskills, andputtheseintopracticeto improve
achievingthe 'right' mix ofhealth personnel is a quality of care, is the cornerstone of empower
major challenge for most health systems. The ment as a practitioner. With self-efficacy comes
knowledge and skills that staff have, and the inner power to make decisions comfortably, to
waysin whichtheyare managedsothattheycan take calculated risks and to tackle the unex
use them effectively and efficiently, affects not pected in everyday practice. This is the sustain
onlythe satisfaction of health care practitioners, able professional development for which all
buteven morecrucially,determinesthe qualityof those involved in humanresources development
carethey provide. are seeking. It is not easily taught, but it is
encouragingtofind itdiscussedin this bookinall work for describing and measuring health, to
its dimensions. define activity and participation. Hocking notes
Over the past few years, there has been a that in using this framework practitioners will
growing debate about the role of health in the have tohave the skills and knowledge to measure
development of societies. Work done by WHO healthoutcomesinanindividualisedway,over the
has shown that a healthy population is a pre long term - skills she identifies with advanced
requisite for growth, rather than an expensive practice.Toachievethisgoal,shesuggeststhatpro
optionfor developingcountries. Healthypeople, fessionals must increasingly work together, each
supported by a functioning health sector, can withauniquecontribution.
ensure that their societies develop, and sustain This is the new world of health care. Such an
theirdevelopment. For this reason, loss ofhealth approach- teamwork using the skills of a range
isalossnotonlytothe personbutalso tofamilies of professionals, and measuring health and not
and societies. only illness in a population - is vital both to
Improving the health of an individual, or the developing countries struggling to improve
populationas awhole,does notmeanonly reduc health conditions despite severe financial and
ing prematuredeathduetodiseaseandinjury,but human resources limitations, and to industrial
also aboutmaximizingthe capacityofindividuals countriesworkingto providefair andresponsive
to live a full lifein society.Healthis the ability to healthservicesin atimeofchangingexpectations
live life to its full potential, and to realise this amongtheirpopulations,andwithlimitedfinan
potential,rehabilitationtherapistshaveakey role. cial resources.
In Chapter 8 of this book, Clare Hocking dis The journey is only beginning, but this book
cusses the advanced occupational practice skills providesanessentialmaptoallserioustravellers.
neededby healthcarepractitionersinordertohelp I commendittoallthoselookingto advancetheir
people follow their occupations, and thus lead a practice.
fulfilling and productivelife.Sheuses the WHO's
International Classification of Functioning Disability OrvillAdams
andHealth,whichisacommoninternationalframe- WHO,C;eneva,2003
Preface
The impetus for writing this text came firstly give you several ways in which you could
fromnumerous recent government publications, examine the needs of your own place of work
particularly in theUKandthe USA.These papers whileat thesametimeputtingyourserviceinto
emphasizethe needfor healthprofessionalstobe a wider context. These are skills that an
collaborative, innovative, evidence-based and advanced practitioner needs to acquire and to
creative in developing new, integrated areas of be sensitive about.
practice. The concept of a highly qualified, Our own professional development has gone
advanced practitionerandspecialist,whocan act through many stages, becoming honed often
as,and is, officially recognized as a consultant is through trial and error but also through deliber
an important feature of the government direc ate planningand further study. Now, in different
tives,especiallyin the UK.Webecamechallenged ways, we have reached a stage where we can
and inspired by the notion of developing a map operateon expertknowledge,supportedthrough
thatcould guide an early-career healthcare prac lifelong learning, until we hit the nextbig learn
titionertobecomean advancedpractitioner,who ingcurve. Given the fast rate at whichall aspects
couldeffectivelyfillaconsultantpositionatsome of health-care are changing, we believed that it
latertime. wouldbe helpful to provide you with a guide as
Our second source of inspiration came from an early-careerpractitionerso thatyoucan accel
ourownexperienceas clinicians, managersand erate the process ofbecoming an advanced prac
educators of undergraduate and postgraduate titioner. This notion follows the same line of
students. Betweenus, we have worked as clini thinkingthatisadvocatedin teachingclinical rea
cians and/or educators in seven countries, soningin orderto enhancethe processofmoving
where we had to adapt to different concepts of from novice to expert. Processes like these take a
health and culture, in the delivery of services considerable amount of time-often many
(public and private) and the education of years-sothe sooneryou are awareofyourcareer
healthcare professionals.Also, we have worked paththebetteryou can planandfollow yourown
with students who have come to our programs map.
from many countries and cultures. Each one We also bring our own perspective on, and
had a different slant on healthcare. These per beliefabout,healthcareprofessionals.Deliberately,
spectives stemmed from each country having we have not referred to themas allied despite the
other priorities and needs. Furthermore, each factthatmanydocumentsdo. Webelievethatthe
profession had developed slightly differently, term allied suggests dependency, and this is not
so there were many diverse ways of working compatible with the notionof autonomy thatwe
and interpretingpractice. There are few univer are advocating. However, we accept that in
saltruths and yet there are some commonprin some contexts, the term allied refers to the
ciples and processes. The chapters in this text operational relationship of the allied health
professional groups to each other and to that of relatetomanyotherhealthprofessionals,suchas
medicine. dieticians, dental hygienists, nurses, medical
All the chapters in this text were written by technologists, psychologists, physicians, and
experiencedandadvancedhealthcareprofession pharmacists.
als. These authors come from Australia, Canada, Figure1.1is ourmap.Itrepresents thecontext
New Zealand, the UK and the USA. They repre ofhealthcarepracticefrom the perspectiveof the
sent a rich diversity of experiences from cultural practitioner.Itisrepeatedas akey for eachchap
andprofessionalperspectivesthatincludehealth ter. We invite you to use the figure and the text
promotion,medicaleducation,occupationalther reflectively, as a guide for developing your own
apy and physiotherapy and speech-language careerplan, and adding your ownquestions and
therapy/pathology. As this text is published in ideas. Weseethis text asaworkingmaptowhich
the UK, we have used UK spelling, with some you can constantly return at different stages in
modifications. However, we have used both UK your career as.well as using it for different pur
and North American terms to describe profes poses suchas workingwithand supervisingstu
sionals, depending on their country of origin dents or for developing your role as a mentor. It
and/or the literature being cited. Thus, North can also be used as a plan for a department to
American physical therapists and their publica progress to becoming more scholarly and
tionshavenotbeenturnedintophysiotherapists, research-focused. Wehope that youwillfind the
or vice versa. We have also kept references to text valuable, and that collectively we have
speech and language therapists or pathologists, inspired you to learnmore and to add your own
depending on their countries of origin. The insights and scholarship as you move along in
majority of the references we have cited, and yourcareer.
examples we have used are about occupational
therapists, physio/physical therapists, and GillianBrown,SusanA. Esdaile,SusanE.Ryan
speech-languagepathologists, therapists. But we 2003
have also included examples and references that
Contributors
AuldeenAlsop, MPhil, BA,DipCOT,SROT, HelenM. Madill,PhD,
Discipline Leader for Occupational Therapy Professor and Graduate Programs Coordinator
Sheffield Hallam University, School of Health Centre for Health Promotion Studies, University
andSocialCare, Sheffield, England,UK ofAlberta,Edmonton,Canada
Gillian Brown,MSc,DipCOT,SROT, Maralynne D. Mitcham, PhD, DipCOT, OTR/L
HeadOccupational Therapist, Barking Havering FAOTA,
and Redbridge NHS Trust, and Senior Lecturer, Professor and Director, Occupational Therapy
UniversityofEastLondon,London,England,UK Educational Program, Department of
Rehabilitation Sciences, College of Health
SusanA.Esdaile,PhD, MAPS,AccOT,OTR,SROT, Professions, Medical University of South
Professor, Department of Occupational Therapy, Carolina,Charleston,SC,USA
Eugene Applebaum College of Pharmacy and
HealthSciences,Wayne State University, Detroit, Gwilym Wyn Roberts, MA DipCOT SROTAMICPD,
Michigan,USA Head of Department, Department of Occupa
tional TherapyEducation, School of HealthCare
JoyHiggs, PhD,MPHEd,GradDipPhty,BSc,Professor, Studies,UniversityofWalesCollegeofMedicine,
School of Physiotherapy, Director, Centre for
Cardiff,Wales,UK
ProfessionalEducationAdvancement, Faculty of
Health Sciences, University of Sydney, NSW,
LindaM. Roth, PhD,
Australia
Associate Professor and Education Coordinator,
Department of Family Medicine, Faculty of
ClareHocking,MHSc(OT), Medicine, Wayne State University, Detroit,
Principal Lecturer, School of Occupational
Michigan, USA
Therapy Auckland University of Technology,
Auckland,NewZealand
Susan E. Ryan, MS, BAppSc, OTR, SROT, AccOT,
Professor, School of Occupational Therapy,
VivienHollis,PhD, MSc,TDip,COT,OT(C),
UniversityCollege,Cork, Ireland
ProfessorandChair, DepartmentofOccupational
Therapy, Faculty of Rehabilitation Medicine,
M. Clare Taylor, PhD, DipCOT, SROT,BA(Hans), MA
UniversityofAlberta,Edmonton,Alberta, Canada
(Dist),
PrincipalLecturer, OccupationalTherapySubject
LindyMcAllister, PhD,MABSpThy,
Group, School of Health and Social Sciences
CourseCoordinator Speech Pathology, School of
CoventryUniversity,England,UK
Community Health, Charles Sturt University,
Albury,NSW,Australia
Acknowledgements
Wewouldliketo expressourgratitudeto thecol We are pleasedthatwewere able to includesug
leagueslistedbelowfor reviewingearlierchapter gestions from people representing several health
drafts and providing us with valuable feedback. professionsandfrom early-careerpractitioners.
Barbara HooperMS, OTRjL MaryE.WilcoxBSc(Pharm),BA, DipJ
DianeHamiltonOTR NiallFitzpatrickDip COT, SROT
IdaCaniniOTR PetraJ. Klompenhouwer-MeijerMS, OTR,SROT
c.
Jennie AriailPhD StephanieFadeBSc(Hons),SRD
KarenFronMPT ToddWolneyMT(ASCP)
1 Appreciating the big picture: you
are part of it!
The socio-political influences on health
practice in the public and private
sphere
Susan E. Ryan, Susan A. Esdaile and Gillian Brown
Figure1.1 Thepractitioner's perspectiveofthecontextofhealthcarepractice:
individualqualities neededandkeyaspectsofprofessionaldevelopment tobecome
anadvancedpractitioner
Chapter outline Wehaveseparated this chapterintotwopartsthat examinethe major
influenceson healthcarein thepublicand the privatesphere. The first
partlooks atthe presentchallengestohealthcareprofessionals,includ
ing, in particular, the definitions and role requirements of the newly
createdpositionof the advanced practitioner. The reasons for the cre
ation of this role are outlined in subsequent sections that look at the
factors drivinghealthcare changes, the changinghealthcare scenarios
2 Becoming an advanced healthcarepractitioner
and the consequentneedfor differentways of working. Thesefactors
are coupled with the recognition that other forms of knowledge and
different capabilities are required. Ways of maintaining professional
standardsthatwillsupportthesechangeswithvariousregulationsare
contrasted between professions and between countries. International
and globalissuesthatimpacton practicein the various countries rep
resented in this book are discussed and implications are suggested.
The factors shapingthe privatesphereoftheindividualandhoweach
practitionerworksin thischangingclimateare featured in threeways:
howtoshapeideas,howtomanagepower,andhowtoorganizetimeto avoid
stress. The chapter concludeswitha summary.
Keywords Advanced practice,vision, leadership, power structures
Anticipated As a result of reading this chapterwe anticipate that you willbe able
outcomes to:
• appreciate the complex breadth of factors that impact on national
and local healthcare services
• understand theneedfor visionand leadership from advancedprac
titioners
• realize the implications for altered service structures that the pro
posedchangeswill generate
• formulate strategiesto progressyourcareer-pathtowardsbecoming
an advanced practitioner.
Perspectives on the Healthcare practitioners are being challenged on several different
big picture fronts. Manygovernmentsin developedcountriesare demandingfun
damental re-organizations of all aspects of their healthcare. This
includes all levels ofeducation, the diversification and distributionof
healthprograms,otherwaysofworkingwithpatients/clients and the
promotion of particular forms of research. Various commissions have
been set up in different countries to examine national requirements
and many of these reports are referenced in this book. At the same
time, evolutionary changes are being generated from within health
professions as anatural resultofthe developingmaturityofsome rel
atively young professions. Research capabilities and study findings
are also contributingto practice changes.
Some challenges often seem contradictory. Certain changes appear
tosuggestthathealthcarepractitionersshouldworkat lowertechnical
levels to formulated patterns of practice. At the opposite end of this
continuumisthe advancedpractitioner,anewcareerrole thatisbeing
carved out that has a different combination of skills and knowledge.
This role is thefocus of thisbook.
Called variously by other titles such as consultant therapist and
nurse specialist, the definition of an advanced practitioner remains
cloudy and is developing. You can become part of this development
andthisbookwillgiveyouways to follow andideasto use. Figure1.1
illustrates multiple and overlapping layers that we believe constitute
thecrucialpartsthatwilldevelop this role. Centredbypersonalqual-
