Advanced practice physiotherapists in primary health care: stakeholders’ views of a new scope of practice
Gill Stotter 1 3 , Eileen McKinlay
2 , Ben Darlow 1 *
1
2
3 Present address:
Abstract
Advanced and extended primary health care practice roles have been developed in Aotearoa New Zealand (NZ) for dietetics, nursing, pharmacy, and physiotherapy professions. Advanced musculoskeletal physiotherapy roles in primary health care could address escalating health care costs, challenges to workforce sustainability and inefficient primary/secondary care interfaces. Little is known about how stakeholders perceive the recently introduced Advanced Practice Physiotherapist (APP) scope of practice.
This study aimed to explore health professionals’ perceptions of the APP scope of practice in NZ and how APPs could influence physiotherapy service delivery for people with musculoskeletal conditions in primary health care.
Qualitative, face-to-face, semi-structured interviews were conducted with 15 participants including physiotherapists, general practitioners, medical specialists and Accident Compensation Corporation case managers. Inductive interpretive analysis was undertaken.
Five themes were identified: perceptions of current musculoskeletal management in primary health care; lack of a career pathway; ways in which APPs might facilitate change and what their role would be; characteristics of an APP; and the implementation of the APP role into practice.
Stakeholders were supportive of the APP scope of practice and thought it has the potential to improve patient pathways, health care delivery and health outcomes for those with musculoskeletal conditions. Stakeholders also thought it would fill an important gap in the physiotherapy clinical career pathway. Successful implementation will require assessment of applicants’ personal attributes as well as clinical experience and academic qualifications to ensure all stakeholders have confidence to engage with the service, clear communication, active promotion and specific funding.
Keywords: advanced practice, career mobility, health pathways, health workforce, musculoskeletal, physiotherapy, primary health care, scope of practice.
| WHAT GAP THIS FILLS |
| What is already known: The Physiotherapy Board has recently introduced an Advanced Practice Physiotherapist scope of practice. Little is known about how stakeholders perceive this scope of practice. |
| What this study adds: Primary health care stakeholders are broadly supportive of the Advanced Practice Physiotherapist scope of practice. It may improve patient pathways, health care delivery and health outcomes for those with musculoskeletal conditions, and the clinical career pathway for physiotherapists. |
Introduction
Advanced practice is a level of practice where health professionals have developed their professional expertise, skills and behaviours to a higher level, practising in more complex situations with greater autonomy and responsibility than standard clinical practice.1 In Aotearoa New Zealand (NZ), increasing numbers of disciplines including dietetics, nursing, pharmacy and physiotherapy have advanced or extended practice roles with physiotherapy and nursing having regulated scopes of advanced practice. The Physiotherapy Board of New Zealand, which prescribes physiotherapy scopes, qualifications and competencies in accordance with the Health Practitioners Competence Assurance Act (HPCA) 2003,2 gazetted the Physiotherapy Specialist scope in 2012 and the Advanced Practice Physiotherapist (APP) scope in 2021 (in addition to the existing general Physiotherapist scope). Little is known about how physiotherapists and the wider health professional community have responded to the APP scope.
In the United Kingdom and elsewhere, advanced practice roles for physiotherapists have been established in secondary care (where most physiotherapists work) for more than 20 years.3–5 More recently, advanced practitioner roles have developed in UK primary care, where general practitioners (GPs) have traditionally held a gatekeeper role.6–9 These roles have included advanced practice (such as triage of complex cases) and extended practice (such as referring for high-tech imaging, administering injections or limited prescribing rights).10 Internationally, advanced roles have not been regulated within scopes of practice, in contrast to the APP scope in NZ. Overall, it has been shown that models of service delivery that include physiotherapists practising at a higher level (advanced practice) improve health care access, reduce waiting times, improve onward referral for physiotherapy treatment or medical specialist assessment, enhance self-management strategies, improve patient outcomes and boost patient satisfaction.6,10–13
In NZ, the public have been able to self-refer to physiotherapists since the 1970s and in 1989 physiotherapists were formally recognised as a first-contact profession. This often occurs in primary care in owner-operated private physiotherapy practices. In 2018, 68% of NZ registered physiotherapists worked in private practices and 20% worked within (at the time) District Health Boards (DHBs).14 The majority of private physiotherapy practices focus on providing management for musculoskeletal conditions, commonly part-funded by the Accident Compensation Corporation (ACC).
The burden of musculoskeletal disease is increasing with the aging population, increasing obesity and the rising prevalence of multi-morbidity. In NZ, one in four adults are affected by a musculoskeletal disorder.15 The number and associated costs of new musculoskeletal claims for personal injury lodged with ACC has increased annually over the last 4 years.16 To address the escalating health care costs, challenges to workforce sustainability (particularly the burden on a limited number of orthopaedic surgeons) and inefficient primary/secondary care interfaces, the then Ministry of Health recommended development of a musculoskeletal conditions pathway17 including referrals from primary care to orthopaedic clinics to be triaged by either a GP with special musculoskeletal interest or a physiotherapist with advanced skills. The New Zealand Health and Disability Review (2020) also recommended development of advanced practice physiotherapy roles in primary health care to improve the health outcomes for those currently most disadvantaged (Māori, Pacific Peoples and those on low incomes).18
Given there are large differences in health care systems and advanced practice internationally, it is important to understand the context for the APP scope in NZ. This research aimed to:
Explore the perceptions and attitudes of health professionals to the introduction of a new regulated scope for APP in relation to the management of musculoskeletal conditions in primary health care in NZ.
Explore health professionals’ views of potential barriers and enablers to implementation of APP roles for musculoskeletal management in primary health care in NZ.
Method
Ethical approval was gained from the University of Otago Human Ethics Committee (D18/316), and Māori consultation undertaken with the Ngāi Tahu Research Consultation Committee. All participants provided written informed consent.
Design
This qualitative study used the approach of Interpretive Description to collect and analyse data, identifying thematic patterns and relationships between data, and to explore meanings and explanations.19,20 Interpretive Description is a constructivist methodology that aims to understand participants’ experiences and ‘what is going on’ directly from the data rather than using a perceived prior theoretical understanding.
The study design followed the Consolidated Criteria for Reporting Qualitative Research (COREQ)21 (Supplementary File S1).
Participants
Face to face, semi-structured, audio-recorded interviews were sought with those who met the inclusion criteria and were recruited using maximal variation sampling in two NZ sites.22,23 Three groups of stakeholders were eligible to participate: NZ registered physiotherapists in primary health care who provided care for those with musculoskeletal problems; NZ registered GPs and medical specialists who provide care for those with musculoskeletal problems; and ACC case managers with 5 years’ experience of managing those with complex musculoskeletal problems. The sampling frame sought variation on practice location (rural/urban) among physiotherapists and among the group of other professionals. In addition, variation was sought among physiotherapy participants in relation to years of experience (<10 years or ≥10 years), previous qualification as a New Zealand College of Physiotherapy Advanced Practitioner (yes or no) and practice size (<5 people or ≥5 people). Recruitment continued until sampling frame requirements were met and no new themes or important variation in themes emerged during subsequent interviews. It was anticipated that 14 interviews would be sufficient. An additional medical specialist with wider health system roles was purposively recruited to seek new themes or important variation. Potential participants who met the inclusion criteria and helped fulfil sampling framework requirements were emailed information about the study and invited to contact the research team if they were interested in taking part. Two orthopaedic surgeons declined to participate, and one physiotherapist declined to participate due to their negative opinion about the APP concept.
Fifteen interviews were conducted. Six participants were physiotherapists with a range of career and workplace site experience. Nine other health and other professionals took part: four GPs; three medical specialists (orthopaedic surgeon, sports and exercise physician, rheumatologist); and two ACC case managers (Table 1).
| Code | Age (years) | Gender | Experience | Location | Size of practice | Nature of professional interactions A | Interview duration (min) | |
|---|---|---|---|---|---|---|---|---|
| Physio 1 | 30–39 | Male | 16–20 years | Small town/Rural | >5 HP | Unidisciplinary | 69 | |
| Physio 2 | 40–49 | Male | 20+ years | Suburb | >5 HP | Unidisciplinary | 57 | |
| Physio 3 | 50–59 | Female | 20+ years | City | >5 HP | Interprofessional (sports physician) | 51 | |
| Physio 4 | 40–49 | Female | 6–10 years | Suburb | <5 HP | Unidisciplinary | 60 | |
| Physio 5 | 40–49 | Female | 20+ years | Large town | <5 HP | Interprofessional (orthopaedic) | 64 | |
| Physio 6 | 20–29 | Male | 1–5 years | City | >5 HP | Interprofessional (orthopaedics) | 68 | |
| GP 1 | 50–59 | Male | 20+ years | Small town/Rural | >5 HP | Interprofessional (general practice) | 64 | |
| GP 2 | 30–39 | Female | 6–10 years | Suburb | >5 HP | Interprofessional (general practice) | 39 | |
| GP 3 | 50–59 | Male | 16–20 years | City | >5 HP | Interprofessional (general practice) | 37 | |
| GP 4 | 50–59 | Female | 20+ years | Suburb | <5 HP | Interprofessional (general practice) | 55 | |
| Orthopaedic surgeon | 40–49 | Male | 11–15 years | City | >5 HP | Interprofessional (orthopaedics) | 49 | |
| Sports & exercise physician | 40–49 | Male | 11–15 years | City | >5 HP | Interprofessional (physio) | 31 | |
| Rheumatologist | 60–69 | Male | 20+ years | Large town | >5 HP | Interprofessional | 56 | |
| ACC case manager 1 | 60–69 | Female | 16–20 years | Small town/Rural | <5 HP | Unidisciplinary | 43 | |
| ACC case manager 2 | 30–39 | Female | 6–10 years | City | >5 HP | Unidisciplinary | 50 |
HP, Health Professional; GP, General Practitioner; ACC, Accident Compensation Corporation. Ethnicity collected but not reported as identifiable.
Process
Prior to their interview, participants were sent an introduction to the concept and context of APP and a definition of APP in NZ developed by the research team (Box 1). These documents facilitated a shared understanding of APP. Interviews were conducted by GS, an experienced physiotherapy clinician and former New Zealand College of Physiotherapy (dissolved 2014) Advanced Practitioner known to some interviewees (because of a professional role previously held). GS was completing a Master of Primary Health Care degree, with close support from experienced qualitative researchers BD and EM. Interviews were guided by a schedule of questions (Supplementary File S2). Interview schedules tailored to each stakeholder group were developed by the full research team to ensure balanced and open questions; schedules were piloted prior to use. Interviews were undertaken at a time and location convenient to the participants and ranged from 31 to 69 min in duration (median 55 min). At the conclusion of the interview, participants completed a demographic questionnaire (professional discipline, age, gender, ethnicity, years of experience, workplace location and size of workplace) and field notes were recorded. Interview transcripts were reviewed by the whole research team to assure the quality of the research process.
| Box 1.Definition for advanced physiotherapy practice in NZ |
| Advanced practice physiotherapists (APPs) have developed their skills and knowledge in an area of practice through clinical experience and post-graduate study and demonstrated achievement of specific competencies. APPs apply in-depth research informed knowledge and skills to physiotherapy assessment and care, understanding the person, their context and the influences on their health to inform diagnosis, management, and prognosis. |
| APPs work in primary and secondary care settings. Physiotherapists and other health care professionals can refer clients to APPs when they require a clinical case review or advanced assessment and management. A key role for APPs is to triage cases referred to specialist clinics to ensure active rehabilitation options are appropriately and optimally explored prior to, or in conjunction with, consideration of surgical approaches. Consumers who perceive that they require an advanced assessment and management can choose to consult an APP. |
| APPs work collaboratively with a wide range of health professionals and are involved with student supervision, peer mentoring and leading improvements in care delivery. |
Analysis
Interviews were transcribed and imported into NVivo 12 (QSR International, Melbourne, AUS) computer software to organise, manage and explore the data. In accordance with Interpretive Description, a process was developed by GS to code, classify and create links, ensuring that reflexivity was maintained at all stages through journalling and team discussion.23 GS disclosed experiences, roles and biases prior to commencing interviews so that other team members could identify influences on analysis. Initially patterns were established between datum and used to test assumptions with BD and EM. Rigour was maintained by the constant review of data and exploration using brainstorming, mind mapping, whiteboard exercises and reflections to rigorously deconstruct and construct emerging relationships, looking for similar and different meanings. A draft thematic framework informed ongoing recruitment of participants to provide further and varied insights to the research question.
Results
Five themes were identified from the interviews: perceptions of current musculoskeletal management in primary health care; lack of a career pathway; ways in which APPs might facilitate change and what their role would be; characteristics of an APP; and the implementation of the APP role into practice.
Theme one: perceptions of current musculoskeletal management in primary health care
All participants discussed their experiences of current practice with musculoskeletal management of complex conditions in primary health care (see Table 2 for exemplar quotations).
| Theme one: perceptions of current musculoskeletal management in primary health care | |
|---|---|
| Variability in diagnostic accuracy and inappropriate use of investigations | |
| I think that one of the main problems is the lack of capability of primary care to diagnose musculoskeletal problems and formulate management plans. (Rheumatologist) | |
| They’ve been unsure how to make a reasonable clinical diagnosis, they’ve referred for imaging in the hope that that might give them a diagnosis. They find something on imaging that becomes the diagnosis whether or not it’s the cause of the symptoms and that’s the treatment path that is followed. (Physio 5) | |
| Lack of clear clinical pathways and access to secondary services | |
| I see that there’s a lot of people kind of languishing between primary and secondary care, not necessarily sitting they’re on waiting lists to be seen, but actually just sitting there suffering because there’s no pathway at the moment. (GP 2) | |
| You’re much more likely to send off an earlier referral (to secondary care) if you’re not quite confident in what you’re doing or you don’t have the resource to fall back on for a second opinion or reassurance. (Physio 6) | |
| Fragmentation, poor communication and lack of interprofessional collaboration | |
| I kind of like to direct people towards the appropriate service that I think is going to have the best outcome and I just simply don’t know who those people are. (Rheumatologist) | |
| I’m certainly aware that physios have expertise in other areas, and it would be good to know those people who they are. (GP 3) | |
| I think it is across specialities so whether it be nursing or whether it be GPs or whether it be physio’s I don’t think we impart enough information between each other, neither what we think’s going on, how we’re prepared to see them, or how many times we see them, and what we do with them. We have a point of entry information giving, we have a point of exit information giving, there’s very little in between … communication I think ain’t the best. (GP 1) |
Participants described a wide variation in GPs’ and physiotherapists’ musculoskeletal skills and knowledge and believed this was related to their areas of expertise and training as well as individual strengths and weaknesses. Patient complexity, lack of specific clinician expertise or lack of review of clinical reasoning could result in an unclear diagnosis and/or a non-specific management plan. Inability to establish a clinical diagnosis could lead to the inappropriate use of investigations, such as ultrasound scans and X-rays and/or symptomatic treatment that did not address the cause of the patient’s issue.
Participants spoke of the lack of a clear musculoskeletal clinical pathway to access clinicians with the appropriate clinical reasoning and diagnostic skills for people who do not improve with first line management. This led to inappropriate or prolonged treatment and increased financial and wellbeing costs to the patient. The combination of inability to make an appropriate diagnosis, ineffective physiotherapy or other allied health treatment and lack of support for a second opinion or reassurance was thought to result in unnecessary referrals to medical and surgical specialists. Musculoskeletal specialist referrals were often made because patients were not making progress and GPs and physiotherapists did not know what to do next rather than because the GP or the physiotherapist thought the patient required specialist treatment.
Participants talked about fragmentation of service delivery, with primary health care professionals working in isolated silos and not communicating between disciplines, primarily due to insufficient time, resourcing and opportunity or a communication mechanism to discuss cases. They stressed the importance of good communication and collaboration between disciplines to deliver consistent messages to patients, reduce misinformation and to set common goals. However, the current process led to frustration for patients and health professionals alike. Non-physiotherapy participants described not knowing where or to whom to refer for specific areas of physiotherapy expertise. They were unsure where or how to identify these physiotherapists other than through ‘word of mouth’ or ‘feedback’.
Theme two: lack of a career pathway
Physiotherapy participants discussed the lack of a career pathway in physiotherapy and how the role of the APP might facilitate career progression (see Table 3 for exemplar quotations).
| Theme two: lack of a career pathway | |
|---|---|
| Lack of career pathway | |
| My overall concern for the profession firstly is the number of young people who are leaving the profession early and within the first five years, and I know there are a number of drivers behind that, but my impression is that one of them is the lack of supervision in their early years and certainly the inability to see a clear career path. (Physio 5) | |
| Not being able to retain staff beyond that seven to ten-year mark because that’s where people are quite often hitting a peak in terms of their capabilities but also their pay scale. (Physio 1) | |
| If there’s no road ahead clinically, people do start to take sideways ones within the profession, of into management or into research … but there are also the ones that if they don’t see that clinical road going forward and they’re not interested in those sideways movements, they are starting to leave the profession which is an enormous problem. (Physio 6) | |
| APP offers a career step | |
| It [the APP role] gives physiotherapists a bit of a career pathway, a bit of structure which currently is probably a little lacking … that’s a challenge for the profession because it’s hard to retain your experienced people. (Rheumatologist) | |
| I do wonder the effect that another tier [APP role] would have in terms of career progression, because I think some of the views perhaps by physios at that five to seven year mark is what does the road look for me from here. (Physio 6) | |
| To have this recognition and this ability within the profession [APP] I think is fantastic, and it’s something that we’ve got to look at as opposed to just a specialist role because to achieve this is out of the question for a lot of people who are in private practice or in clinical setting. So, it gives the profession the ability to have this tiered level that I think is important for the profession to grow. (Physio 2) |
Physiotherapy participants thought the lack of a career pathway and retention of physiotherapists were key concerns for the profession. They noted many graduates were leaving the profession within the first 5–7 years of practice. This was influenced by a lack of support and supervision to develop clinical skills, lack of recognition and remuneration for different levels of clinical experience and not being able to see a clear clinical career pathway.
Participants thought that a clear career structure that promoted ongoing learning and provided a framework to develop and recognise clinical skills and competencies would encourage physiotherapists to remain within the profession. Some felt the APP scope would offer physiotherapists a needed step in the career structure that was more achievable than the existing physiotherapy specialist scope. They thought this would help to keep experienced, skilled physiotherapists in the clinical workforce rather than moving into management or ownership roles, research or leaving the profession altogether.
Theme three: ways in which APPs might facilitate change and what their role would be
Participants identified how the introduction of APPs might facilitate change within the profession (see Table 4 for exemplar quotations).
| Theme three: ways in which APPs might facilitate change and what their role would be | |
|---|---|
| Improved patient journeys | |
| There needs to be acknowledgement of [APP] people’s skill levels based around clinical practice, professionals’ practice where third-party people can access them for opinions. I think that’s where the advanced practice comes into it both in terms of external to the profession but also within the profession. (Physio 2) | |
| I see the advanced physiotherapist as somebody who may be able to give us a hand with these complex patients. (GP 3) | |
| She’s been having a lot of physiotherapy and things aren’t really improving and to get a specialist opinion … She had a three to four month wait … so having [an APP] who I knew had expertise in shoulders would have been amazing and probably much more useful than the orthopaedic surgeon because I don’t think it’s something that’s going to be operated on. (GP 2) | |
| You get the appropriate person [APP] to administer the treatment and you don’t have someone who’s overqualified who provides the treatment. (Orthopaedic Surgeon) | |
| It would be nice to get a second [physiotherapy] review with that, like if we’re not seeing any progress is … what we’re doing physio wise … actually working or not … probably more like the medical review but like physiotherapy review. (ACC case manager 2) | |
| [APPs] would be able to take them forward in their recovery much sooner than waiting to see a specialist doctor. (Sports and Exercise Physician) | |
| Peer support and mentoring | |
| My thoughts on experienced clinicians is that a big part of their role is responsibility to the juniors and less experienced physios coming through that we are able to mentor them and bring the whole profession up to a good level in terms of teaching them directly. (Physio 3) | |
| … being there to help their peers … absolutely, but not overloaded by it [other responsibilities] because otherwise we’re losing them out of the clinical field. (ACC case manager 1) |
Participants described how APPs could address some of the failings of the current system of musculoskeletal management in primary health care, particularly for those who fail to respond to initial physiotherapy management, are not recovering as expected or for whom primary practitioners do not know ‘what to do next’. Having a formally recognised APP (with clear guidelines and processes for referral) would enable professionals and primary care practitioners (GPs, nurse practitioners, physiotherapists, ACC case managers) to identify someone with the expertise needed by the patient and seek a clinical case review or a second opinion.
It was suggested that APPs could provide peer support, mentoring and clinical supervision particularly for less experienced and new graduate physiotherapists, but this was balanced by concerns that this risked overloading APPs. Participants also thought that APPs needed to demonstrate clinical leadership and offer advanced clinical guidance.
Theme four: characteristics of an APP
‘Characteristics of an APP’ included discussion of the qualifications, competencies and assessment criteria that the Physiotherapy Board had set (at the time) for registration under the APP scope of practice (https://www.physioboard.org.nz/app) (see Table 5 for exemplar quotations).
| Theme four: characteristics of an APP | |
|---|---|
| Qualifications, competencies and skills required | |
| Masters means that you’re doing something you’re actually questioning, looking because you’re doing some literature review, you’re looking at a little bit of original work as well. So, it seems a sensible way to set a bar to allow other practitioners in different groups to look at letters after a name. (GP 1) | |
| Understanding the person, I see is the real key. Their context and influences and on their health to inform diagnosis, management and prognosis but their context that’s really important. So, the person how they’re seeing the world, how they see their injury is so important. (ACC Case Manager 1) | |
| I think that my success as a clinician more recently is less and less almost within what I do but how I communicate. It’s how I listen and respect the person as a whole and how their injury fits into their life. (Physio 3) | |
| … the things that drive better results are better listening, better communication, better collaboration, understanding what it is that you can offer, understanding what you can’t but also understanding the people around you and what they can offer. (Physio 1) | |
| How APPs will be assessed and recognised | |
| I support regulation … it can be perceived as tiresome but you have to have a standard which someone has to pass and maintain … you have to demonstrate that you are keeping up to a level of standard which your peers have accepted. (GP 3) | |
| If you’re looking at ACC and potentially down the track other health insurers, having a regulated scope I think makes that pathway a lot easier, because clearly there’s got to be a very robust process for it to be a regulated scope and that probably provides the third party insurers and ACC with a level of confidence that the standard has been met. (Physio 5) | |
| Cost is a major barrier for most people but … you’d want a cross section of physiotherapists embarking on this to be able to provide the service to a cross section of people … the population’s heterogenous and the providers need to be heterogenous. (GP 3) |
Participants agreed APPs needed post-graduate qualifications but were unsure if a Master’s qualification was necessary with some placing greater importance on the individual practitioner, their clinical experience and results, rather than the level of formal qualification. It was agreed that 5 years clinical experience should be a minimum requirement and that clinical competencies were key within the limitations of their scope of practice. Many highlighted the diverse skill set needed by APPs, particularly their personal qualities such as being a trusted, nurturing, supportive, empathetic and non-critical role model. It was considered that they must demonstrate understanding of the referring physiotherapist’s context as well as that of the patient. APPs must also role model collaborative interprofessional practice, know if and when to refer to other health professionals and understand what is best for the patient.
All participants emphasised that for APPs to be recognised and accepted both within and external to the profession, there must be a robust and transparent process of qualification and competency assessment. This needed to include assessment of clinical skills and their commitment to continued learning. Regulation by the Physiotherapy Board and recognition by leaders within the physiotherapy profession would provide the assurance to physiotherapists, health professionals and potential funders of the assessment process and credibility of the APP role. Some participants talked about potential barriers to becoming an APP. Cost, time and accessibility in achieving academic requirements and competencies may reduce the chances of having a culturally diverse group of APPs, which was considered essential if APPs were to meet the equity needs of the NZ population.
Theme five: the implementation of the APP role into practice
Participants discussed their views on the potential opportunities, risks and barriers for implementation of the APP role into practice (see Table 6 for exemplar quotations).
| Theme five: the implementation of the APP role into practice | |
|---|---|
| Opportunities and risks | |
| It gives the profession the ability to have this tiered level that I think is important for the profession to grow. (Physio 2) | |
| I think that attitudes from doctors and patients would take time to adjust on average. And I think it would require for the APPs to demonstrate their value and also to ACC, which you can only do when you’re given the opportunity. (Sports and Exercise Physician) | |
| Barriers to acceptance of the APP role | |
| I don’t look upon it as threatening I think it’s adding to the value that we deliver to a patient and that’s what it should be about not about you know maybe feeling aggrieved that an advanced physio [APP] can order a scan or you know might be taking patients away from the practice, I think those days should be gone. But I imagine there might be some GP’s who might feel that way. (GP 3) | |
| I think it needs to be carefully managed. The last thing we would want would be for the previous physio to feel as though they’ve been undermined, and so it’s managing the patient so that they don’t have the perception that they’ve had wasted treatment, wasted care in what they’ve had previously because I think that would only undermine the profession, and not be good for the patient themselves. (Physio 2) | |
| The important part is that if they do access into the service that the APP then doesn’t take that case within their service. It should be essentially supported care, that the APP’s there to support the primary practitioner. (Physio 6) |
Participants expressed widespread support for the APP role and the opportunities it provided for physiotherapists, health professionals and patients. Physiotherapy participants felt having the recognition of an advanced scope between the general scope physiotherapist and the specialist physiotherapist would provide a middle tier to assist with professional growth and an improved career pathway. Risks to implementation included the practicalities of how the APP role would be integrated into practice including making a clear distinction between the three physiotherapy scopes. APPs would also have to demonstrate their value not only to the funders but also to other health professionals through demonstrating the difference APPs made to patient care. Lack of funding for APP roles was seen as a major risk and challenge. If health professionals and health funders did not see value in the APP role with evidence of improved patient pathways and outcomes, it would not be accepted and appropriately funded. If so, physiotherapists may not see the value of undertaking further study to achieve the requirements and competencies.
Barriers to the APP role were also noted, with some feeling that GPs or physiotherapists might feel threatened by the new scope. Participants suggested that integrating sessional APP clinics within GP practices could develop relationships, and that allowing the referring physiotherapists to be present at review appointments could develop a collaborative opportunity. Participants thought it would be important to ensure separation from the APP’s regular practice or workplace. Barriers to APPs providing a clinical case review were suggested at patient and referrer levels. Patients may not be comfortable requesting further assessment as it could imply criticism and lack of trust in their regular physiotherapist. Patients may also be frustrated at having to see different health professionals and retelling their story, feeling they were not heard or had wasted their time or money with previous treatment. Health professionals may be reluctant to seek a clinical case review from an APP because they feel uncomfortable and defensive about their own patient management. Physiotherapists who do not meet the APP academic requirements but feel they have the requisite clinical experience may also have difficulty seeking or accepting clinical opinions from APP colleagues. Participants thought that APPs would need to undertake their assessments in a non-judgemental but objective manner, reinforcing the importance of their professional supportive role and emphasising the goal of the best outcomes for patients to break down the barriers and build trust in the process.
Discussion
This qualitative study explored the views of key stakeholders about the introduction of a regulated scope of advanced physiotherapy practice in relation to the management of musculoskeletal conditions in NZ primary health care. Physiotherapists, GPs, medical specialists and ACC case managers were broadly supportive. Participants identified several problems within existing primary health care management of musculoskeletal conditions and with the physiotherapy career structure that they considered an APP role could positively influence. Participants discussed the attributes that would contribute to the success of the APP scope as well as risks and potential barriers.
Current primary health care management of musculoskeletal conditions was thought to be variable, inefficient and characterised by fragmentation, poor communication and lack of intra- and interprofessional collaboration. Physiotherapists and GPs lack clear and appropriate clinical pathways for managing complex or slow to resolve cases. APPs could improve the status quo by being recognisable and accessible as a physiotherapist with higher level skills who can review diagnoses and rehabilitation options, diverting cases away from unnecessary imaging or medical specialist referral. This is consistent with the impact of advanced physiotherapy roles observed internationally.10
Participants agreed a formal post-graduate qualification was necessary to qualify as an APP but were uncertain about whether this needed to be a Master’s degree. Subsequent to the conduct of this research, the Physiotherapy Board has changed the requirement from a Master’s to a post-graduate diploma. Participants emphasised the personal qualities and relationships that an APP would need to undertake the role and ensure its success. Physiotherapists have expressed concern that an aversion to scrutiny and concerns about losing patients to another practice limits referral for peer review and second opinions.24 To overcome these concerns, participants considered that APPs would need to be professional, nurturing, supportive and empathetic toward peers. They would need to have excellent communication skills that enable them to relate to patients and intra- and interprofessional colleagues.11 They would also need to demonstrate that patients are referred back to their source with recommendations, rather than being retained within their own business. Integration of APPs as a role within the primary care practice team may ensure a perception of neutrality and assist the development of interprofessional relationships.
Participants considered that successful implementation of the APP scope would require explicit integration of APP roles into funded clinical pathways and clear communication and promotion of the differences between the three scopes of practice (general, APP, specialist) to the physiotherapy profession, the primary care community and to patients.25 The advanced nurse practitioner scope of practice was introduced in NZ in 2001, but uptake was slow with limited numbers seeking the scope.26 Review of this process highlighted the importance of policy and practice engagement in planning and integrating new scopes, the need to establish advanced roles as part of a well-defined career path with clear and accessible training opportunities and the importance of widespread championing of the role.26 Uptake of the physiotherapy specialist scope of practice (introduced in 2014) was also slow, but increased after achievement of specific funding from the ACC in 2019. This demonstrates the potential to implement advanced physiotherapy scopes into the NZ health system.
An important opportunity for the APP scope identified by participants was to provide a career step that helps to retain physiotherapists in clinical practice. Consistent with previous research,27 participants were concerned that physiotherapists were leaving the profession due to a lack of opportunity to progress within what has traditionally been a very horizontal profession. Participants felt that the APP scope could provide both an opportunity that may help physiotherapists to structure their professional development and an attractive option for those who wish to progress their clinical careers within physiotherapy. The net effect of these opportunities would be to improve professional development and retain greater numbers of physiotherapists within the profession.28
Strengths and limitations
Caution is needed when generalising qualitative research findings beyond the participants involved. This study included a diverse range of stakeholders in management of musculoskeletal conditions. This allowed collection of a broad range of views and identification of areas of commonality. This approach did not allow saturation of views from within each group of stakeholders. As such, it is likely that additional nuance would emerge if further interviews were conducted with individuals from within each stakeholder group, however, this is unlikely to change the overall conclusions. The median interview length was 55 min, enabling participants to express themselves in depth. Primary analysis was undertaken by a single researcher, but quality and rigour were maintained through frequent and active involvement of the entire research team.
Implications
Based on participants’ views, the APP scope of practice is likely to enhance management of musculoskeletal conditions in NZ primary health care. There are several risks to successful implementation, including lack of knowledge of the APP role, health system structure and funding barriers and potential referrers’ concern that they will lose reputation or patients through seeking second opinions from APPs. It is important that the health system, profession and APPs are cognisant of these risks and actively take steps to manage these. To ensure all stakeholders have confidence to engage with the service, applicants’ personal attributes should be assessed in addition to academic qualifications, clinical experience and clinical competence. Policy and practice engagement in planning and integrating the APP scope, embedding the APP scope as part of the physiotherapy career pathway with accessible training opportunities, creating specific funding for APP practice, clear communication and widespread active promotion could support successful implementation of the APP role.
Data availability
Qualitative interview data are not available for sharing due to the risk of identifying participants.
Conflicts of interest
Ben Darlow and Gill Stotter were both members of the Physiotherapy Board Scopes of Practice and Advanced Practitioner working groups. All authors declare no other competing interests.
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