The responsibilities of being a physiotherapist

Introduction

This chapter provides an insight into what it means to be a physiotherapist and a member of the physiotherapy profession in the UK.

The chapter explores the development of the profession and how physiotherapy acquired the privileges and responsibilities of autonomous practice, and explores the consequences of that for contemporary professional practice.

Finally, the chapter considers how the changing shape of health services in the UK and society’s increasing expectations of health professionals to deliver safe, high-quality health services within finite resources and which patients can trust are shaping physiotherapy practice. The ways in which physiotherapists can demonstrate the quality of both, practice and service delivery, through clinical governance, play vital role and this is also discussed.

The term patient has been used throughout this chapter to describe the individual to whom physiotherapy is being delivered. It is recognised that at times the term service user is more acceptable for some groups to whom physiotherapists provide intervention, e.g. in illness prevention. The term physiotherapist has been used throughout the chapter, but it is recognised that the chapter will also be of relevance to students and support workers, and others involved in delivering physiotherapy services.

Background to the chapter

Tidy’s Physiotherapy has been a key text for physiotherapists over the years. Earlier editions have provided prescriptive descriptions of what physiotherapists should do in particular situations or for specific conditions. This prescriptive approach has become less relevant to the delivery of contemporary healthcare and recent editions of this chapter have demanded critical thinking from the reader. This reflects the development of the profession and the diversity of roles and settings physiotherapists deliver services within, both alone and within teams, providing healthcare for a diverse range of conditions. This change has been reflected in the education of physiotherapists focussing on developing analytical and clinical reasoning skills individualised to the patient. Recent editions of this chapter have, therefore, demanded critical thinking from the reader.

No two patients, clinical situations or professional roles are the same; each requires the physiotherapist to use their skills and knowledge to determine the most appropriate action. In a clinical situation, physiotherapists must use their skills and knowledge to carry out a full and accurate assessment and, using clinical reasoning skills and considering the individual patient, offer appropriate options for management. Throughout the decision-making process the patient should be educated and informed of the options available, and be given the opportunity to participate fully in their management. This includes consideration of the indication for managing the patient in physiotherapy, discharging them or referring them on. The responsibility for this decision-making process lies with the physiotherapist and the physiotherapist is accountable for this decision, hence the dichotomy of autonomy as both a privilege, i.e. the ability to act independently, and a responsibility, i.e. having accountability for the decisions made.

Accepting the responsibility requires maturity and an understanding of the implications of this responsibility. The individual physiotherapist must also understand the concept of scope of practice, competence, and the individual nature of scope (CSP 2008). An individual’s scope will change throughout their career and competence must be maintained through career-long learning, through self-evaluation of both the physiotherapist’s learning needs and the service required, for example, maintaining currency with the most effective interventions. This commitment will maintain the trust of the patient and the public in both the individual and the profession.

History of the physiotherapy profession

This section provides an overview of the development of the physiotherapy profession with a particular focus on the development of autonomy and regulation of physiotherapy. An overview of the early days of the profession can be found in the book In Good Hands (Barclay 1994). Further references may be found in The History of the Physiotherapy Profession (CSP 2010), which provides an insight into the development of autonomy and, subsequently, scope of practice.

The Chartered Society of Physiotherapy (CSP) was founded in the UK in 1894, under the name of the Society of Trained Masseuses. It was established as a means of regulating the practice of ‘medical rubbers’. For many years, doctors governed the profession and one of the first rules of professional conduct stated ‘no massage to be undertaken except under medical direction’ (Barclay 1994). The Society used the opportunities created by developments in medicine and technology, and the demands of war to extend its manual therapy skills, and to add exercise and movement, electrophysical modalities and other physical approaches to its repertoire during the early years of the twentieth century (Barclay 1994). This scope of practice, which was legitimised by a Royal Charter in 1920, remains the hallmark of contemporary physiotherapy practice (CSP 2008).

Physiotherapy continued to evolve and consolidate its position during the 1930s and 1940s. This was achieved through ongoing patronage of the medical profession and recognition of physiotherapy’s contribution to society’s health and well-being. The development of the Welfare State during the 1940s created opportunities for physiotherapy to apply and develop its practice across a growing range of medical specialisms (Barclay 1994). Physiotherapy training moved into hospital-based schools during 1948, which effectively meant that newly qualified physiotherapists were prepared for practice in National Health Service (NHS) hospitals. Over time, the NHS became the primary employer of physiotherapists.

Physiotherapy’s quest for self-regulation during the 1950s was quashed by the medics who had effectively established control of its practice through sustained involvement in the CSP’s governance structures and ongoing patronage. Following intense lobbying by physiotherapy and other healthcare professions, the Council of Professions Supplementary to Medicine (CPSM) opened a physiotherapy register in 1962 which represented a shift in the power of medicine over physiotherapy. Despite the introduction of state regulation, doctors continued to assert full responsibility for patients in their charge, arguing that ‘professional and technical staff have no right to challenge his views; only he is equipped to decide how best to get the patients fit again’ (Barclay 1994).

It took more than 80 years for the physiotherapy profession to progress from the paternalism of doctors, on whom physiotherapists were dependent for referrals. The first breakthrough came in the early 1970s, when a report by the Remedial Professions Committee, chaired by Professor Sir Ronald Tunbridge, included a statement that, while the doctor should retain responsibility for prescribing treatment, more scope in application and duration should be given to therapists. The McMillan report (DHSS 1973) went further, by recommending that therapists should be allowed to decide the nature and duration of treatment, although doctors would remain responsible for the patient’s welfare. This recognised that doctors who referred patients would not be skilled in the detailed application of particular techniques, and that the therapist would therefore be able to operate more effectively if given greater responsibility and freedom.

Eventually, in the 1970s, a ‘Health Circular, Relationship between the Medical and Remedial Professions’ was issued (DHSS 1977). This acknowledged the therapist’s competence and responsibility for deciding the nature of the treatment to be given. It recognised the ability of the physiotherapist to determine the most appropriate intervention for a patient, based on knowledge over and above that which it would be reasonable to expect a doctor to possess. It also recognised the close relationship between therapist and patient, and the importance of the therapist interpreting and adjusting treatment according to immediate patient responses, thus securing professional autonomy. This autonomy brought responsibilities and the ongoing need for physiotherapists to demonstrate competence in decision-making, building up the trust of doctors and those paying for physiotherapy services. This was reflected in the inclusion of skills of assessment and analysis as a key component of the qualifying curriculum introduced in 1974.

Two years after gaining professional autonomy in 1977, and supported by the shifts in physiotherapy education towards polytechnics, the CSP opened the debate on all-graduate entry – an identity traditionally associated with professions (Tidswell 1991). All-graduate entry was finally achieved in 1994 following considerable debate about how degree status would benefit patients and ensure the ongoing development of physiotherapy practice (Tidswell 2009).

In 1996 delegation of activities to healthcare practitioners, including some medical tasks, was facilitated by the document ‘Central Consultants and Specialists Committee: Towards tomorrow – The future role of the consultant’ (Marriott 1996). The content of this report, together with the political drivers to contain healthcare service costs and maximise productivity, created new opportunities for physiotherapists to develop new skill-sets to undertake tasks that were previously the domain of medicine. These ‘extended’ roles were typically found in musculoskeletal medicine: physiotherapists working alongside doctors triaging patients on the waiting list or providing ongoing medical management of people with long-term conditions. Over time, these roles shifted into other medical specialisms, such as neurology, respiratory care and women’s health – evidence of the clinical- and cost-effectiveness of this model of practice.

Towards the end of the 1990s, concerns about the quality of patient care, professional power and the need to contain the spiralling medico-legal costs, led to an overhaul of the regulatory frameworks in healthcare. Clinical governance was introduced as a system of quality control in 1997. Discussions about the need to review the regulation of professional groups like physiotherapy who worked alongside medicine, led to a change in terminology in 1999, from ‘professions supplementary to medicine’ to ‘health professions’. Legal protection of the title ‘physiotherapy’ and ‘physical therapist’ followed under the Health Professions Order (DH 2002, HCPC 2001) – an outcome that the Chartered Society had been seeking for over 30 years. Alongside protection of title came a whole raft of changes designed to strengthen and modernise the regulation of healthcare professions, including physiotherapy. The CPSM was replaced by the Health Professions Council (HPC) in 2002 and subsequently renamed the Health and Care Professions Council (HCPC) in 2012. One of the most significant changes for registrants was the introduction of a process to audit their ongoing competence to practise and requiring engagement with continuing professional development (CPD) (HCPC 2011).

Once the physiotherapy profession had acquired all-graduate entry, physiotherapy continued its pursuit of professional traits by shifting the debate from examination of skills and techniques to attempting to identify the underpinning knowledge that makes it unique (Roberts 2001). This change is reflected in both the Physiotherapy Framework (CSP 2011c) and the Learning and Development Principles (CSP 2011b).

In 2007 the CSP Council agreed a fresh interpretation of the Royal Charter:

… the scope of practice is defined as any activity undertaken by an individual physiotherapist that may be situated within the four pillars of physiotherapy practice where the individual is educated, trained and competent to perform that activity. Such activities should be linked to existing or emerging occupational and/or practice frameworks acknowledged by the profession, and be supported by a body of evidence…

(CSP 2008)

Most recently, the CSP Council agreed to a new Code of Professional Values and Behaviour (CSP 2011a) that brings to the fore CSP member responsibilities relating to scope of practice, including the responsibility to consult with the CSP if a member is aware that a new area of practice challenges the boundaries of recognised scope of practice.

Physiotherapy has used the opportunities created by changes in society, developments in science and technology, and transformations in the design and delivery of education and healthcare, to evolve into what the profession is today.

Responsibilities of being A professional

Since its inception in 1894, physiotherapy practice has been governed by a set of legal, regulatory and ethical frameworks and these are explored here. As described earlier, physiotherapists, as part of a profession, have certain rights or privileges together with a responsibility to themselves, the patient, the profession and the organisation within which they undertake their professional role. These responsibilities sit within legal, organisational and regulatory frameworks.

Characteristics of a profession

There are various theories on how to describe a profession in the literature. One way reflects work undertaken during the 1950s and 1960s which explored professions by identifying common traits and considering the qualities that distinguished a profession from an occupational group (Koehn 1994; Richardson 1999). A profession is described as:

• licensed by the state;

• a professional organisation which has developed and maintains a code of conduct or standards of practice based on acknowledged ethical principles;

• able to discipline members who contravene the code/standards;

• having exclusive knowledge and a technical base which is protected by the law;

• autonomous in its members’ work;

• having members undertaking professional activity which requires them to have responsibilities or duties to those who need assistance;

• having responsibilities which are not incumbent on others.

By creating evidence of these traits, professions have been able to justify their ability to exercise power within society. As illustrated above, physiotherapy has sought to acquire the traits associated with a profession over time. From its inception in 1894 as an occupational group trained and examined in medical massage, physiotherapy has established a distinctive knowledge and skill-base that was first recognised by a charter in 1920, and more recently by achieving all-graduate entry – which also serves to ensure the maintenance and development of its unique knowledge and skills-base. The responsibilities of professional practice are expressed and regulated through standards which are regulated by the state.

Professionalism defines what is expected of a professional. Becoming an autonomous professional requires an acceptance, often implied, of certain responsibilities, in return for certain privileges. These responsibilities require behaviours and attitudes of individuals in whom professional trust is placed. Professionalism is widely understood to require these attributes (Medical Professionalism Project 2005 (cited in CSP 2005b); CSP 2011a):

• a motivation to deliver a service to others;

• adherence to a moral and ethical code of practice;

• striving for excellence;

• maintaining an awareness of limitations and scope of practice, and a commitment to empowering others (rather than seeking to protect professional knowledge and skills).

However, defining and providing evidence of professionalism is often more complex. A recent research report by the HCPC (2011) considered the concept of professionalism as many fitness to practise cases referred to regulators include professionalism. The report summarised that:

… professionalism has a basis in individual characteristics and values, but is also largely defined by context. Its definition varies with a number of factors, including organisational support, the workplace, the expectations of others, and the specifics of each service user/patient encounter. Regulations provide basic guidance and signposting on what is appropriate and what is unacceptable, but act as a baseline for behaviour, more than a specification…

A profession that fulfils these expectations establishes and maintains credibility with the public and demonstrates its capacity to carry the privileges of professional practice – autonomy and self-regulation. In turn, fulfilment of these expectations demonstrates a profession’s ability to fulfil the parallel responsibilities of professional practice – accountability, transparency and openness.

A key element of physiotherapy students’ preparation for practice on qualification is their being supported in developing their understanding of, and engagement with, the responsibilities and privileges that professionalism encapsulates. The concept of professionalism also relates strongly to the role of physiotherapy support workers.

Possessing knowledge and skills not shared by others

Any profession possesses a range of specific knowledge and skills that are either unique or more significantly developed than in other professions. For physiotherapy, the roots of the profession can be found in massage. Physiotherapists continue to use massage therapeutically, as well as employing a wide range of other manual techniques, such as manipulation and reflex therapy. Therapeutic handling underpins many aspects of rehabilitation, requiring the touching of patients to facilitate movement, and the significance of therapeutic touching of patients still sets physiotherapy aside from other professions.

The World Congress for Physical Therapy (WCPT) states that:

Physical therapy provides services to individuals and populations to develop, maintain and restore maximum movement and functional ability throughout the lifespan. This includes providing services in circumstances where movement and function are threatened by ageing, injury, diseases, disorders, conditions or environmental factors. Functional movement is central to what it means to be healthy…

(WCPT 2011)

Cott et al. (1995) proposed an overarching framework for the profession: the movement continuum theory of physical therapy, arguing that the way in which physiotherapists conceptualise movement is what differentiates the profession from others. They suggest that physiotherapists conceive movement on a continuum from a micro- (molecular, cellular) to a macro- (the person in their environment or in society) level. The authors argue that the theory is a unique approach to movement rehabilitation because it incorporates knowledge of pathology with a holistic view of movement, which includes the influence of physical, social and psychological factors into an assessment of a person’s maximum achievable movement potential. They argue that the role of physiotherapy is to minimise the difference between a person’s current movement capability and his/her preferred movement capability.

In the UK, one approach to conceptualising physiotherapy is to consider physiotherapy, as defined by the Royal Charter, as the four pillars of practice of:

• massage;

• exercise and movement;

• electrotherapy;

• kindred methods of treatment (CSP 2008).

The acquisition of these knowledge, skills and attributes from qualifying programmes, and subsequently on qualification through a range of learning activities, may be used by physiotherapists to benefit people in a range of specialties or patient groups, for example elite athletes, older people, people with developmental or acquired conditions, or people with mental health problems. A recent definition of the Physiotherapy Framework states that:

Physiotherapy is a healthcare profession that works with people to identify and maximise their ability to move and function. Functional movement is a key part of what it means to be healthy. This means that physiotherapy plays a key role in enabling people to improve their health, wellbeing and quality of life.

(CSP 2011c)

More generally, Koehn (1994) suggests professionals are perceived to have moral authority, or trustworthiness if they:

• use their skills in the context of the client’s best interests and ‘doing good’;

• are willing to act for as long as it takes to achieve what was set out to be achieved or for a decision to be made that nothing more can be done to help the client;

• have a highly developed internalised sense of responsibility to monitor personal behaviour, for example by not taking advantage of vulnerable patients;

• demand from the client the responsibility to provide, for example, sufficient information to allow decisions to be made (compliance);

• are allowed to exercise discretion (judgement) to do the best for the client, within limits.

Principle 1 of the Code (CSP 2011a) requires that members demonstrate appropriate professional autonomy and accountability. In doing so members are expected to:

1.1.1. Use their professional autonomy to benefit others;

1.1.2. Understand and accept the significant responsibility that professional autonomy brings;

1.1.3. Accept and uphold their duty of care to individuals;

1.1.4. Are responsible and accountable for their decisions and actions, including the delegation of activity to others;

1.1.5. Justify and account for their decisions and actions;

1.1.6. Ensure that their activity is covered by appropriate insurance.

Scope of practice

As a professional body, the CSP defines the scope of practice for physiotherapy in the UK. In doing so it recognises that UK physiotherapy is diverse, and ‘requires a dynamic, evolving approach to scope to ensure the profession is responsive to changing patient and population needs and that its practice is shaped by developments in the evidence base’. In taking this approach it ‘enables the profession to initiate, lead and respond to changes in service design and delivery, and to optimise opportunities for professional and career development, while being sensitive to the roles and activities of other professions and occupational groups’ (CSP 2011c). Scope of practice relates strongly to competence and professionalism.

This concept of scope recognises that:

• the profession’s scope of practice is evolving, and needs to evolve, in line with changing patient and population needs, developments in the evidence base, changes in service design and delivery, and changing opportunities for professional and career development;

• practice includes a diversity of activity that is shaped by the collective, shared principles and thinking of the profession;

• individuals have a responsibility to limit their activity to those areas in which they have established and maintained their competence;

• individuals need to evaluate and reflect on their personal activity, taking account of the profession’s evolving evidence base, and respond appropriately to their learning and development needs;

• individual competence changes and shifts as they progress through their physiotherapy career;

• individuals have a responsibility to be aware of how their practice may challenge the boundaries of the scope of practice of UK physiotherapy and to take appropriate action (CSP 2011d).

Every physiotherapist has her or his own personal ‘scope of practice’ (CSP 2011c) – that is, a range (or scope) of professional knowledge and skills that can be applied competently within specific practice settings or populations. When a person is newly qualified, this scope will be based on the content of the pre-qualifying course, but will also be informed by the individual’s experience in clinical placements and the amount of teaching and reflective learning that has been possible as part of those placements. As a career progresses, and as a result of CPD and personal interest, these skills and knowledge evolve with a physiotherapist developing some skills, adding new skills and possibly losing competence in some areas. It is the responsibility of the professional to understand his or her personal scope of practice as it changes and evolves throughout their career. To practise in areas in which a physiotherapist is not competent puts patients at risk and is a breach of the HCPC standards (HCPC 2007, HCPC 2008).

For example, some physiotherapists will become competent in highly skilled areas such as intensive care procedures or splinting for children with cerebral palsy, which are unlikely to have been taught prior to qualification. Others will extend their skills in areas in which they already had some experience, for example in the management of neurological conditions. Others will extend their scope to become experts in a specific clinical area and advance their skills of clinical reasoning by participating in research, teaching or management of complex conditions, or undertaking clinical specialist, advanced practice or consultant roles (CSP 2002d).

Competence

Competence is the synthesis of knowledge, skills, values, behaviours and attributes that enable physiotherapists to work safely, effectively and legally within their particular scope of practice at any point in time (CSP 2011a).

Competence changes as a physiotherapist progresses through their career and relates to an individual’s professional and life experiences, learning from reading, from evaluating practice and from reflecting on practice, or through more formal ways of learning. Competence in some areas will increase while competence in others will decrease or be lost. To maintain competence a physiotherapist must engage in structured, career-long learning and development to meet their identified learning needs.

Physiotherapists have a duty to keep up to date with new information generated by research, with what their peers are thinking and doing, and by formally evaluating the outcome of their practice. The responsibility for this is dictated by the HCPC (2008) and reflected in the Quality Assurance Standards for Physiotherapy Service Delivery (CSP 2012). For example, Section 3 Learning and Development includes a number of Standards including Standard 3.1 Members actively engage with and reflect on the continuing professional development (CPD) process to maintain and develop their competence to practise.

Responsibility to patients

This chapter has already discussed the importance of the individual physiotherapist, as well as the profession as a whole in maintaining the attributes of professionals. Koehn (1994) argues that trustworthiness is what stands out as a particularly unique characteristic of being a professional – to do good, to have the patient’s best interests at heart and to have high ethical standards.

Trust is, perhaps, the most essential characteristic with which to develop a sense of partnership with patients that, in turn, will optimise the benefits of intervention. For physiotherapy, many of the other hallmarks for building and securing trust are set out in the QA standards (CSP 2012).

Responsibility to those who pay for services

Physiotherapists have an ethical responsibility to payers of services, whether these are commissioners of healthcare, purchasers of services, taxpayers or individual patients, to provide efficiently delivered, clinically- and cost-effective interventions and services in order to provide value in an era when resources for healthcare are limited.

Responsibility to colleagues and the profession

A profession has legitimate expectations of its members to conduct themselves in a way that does not bring the profession into disrepute, but rather enhances public perception of it. Physiotherapists have a duty to inform themselves of what is expected of them. Indeed, the expectation of the CSP is that members adhere to the Code (CSP 2011a), and this commitment forms part of the contract of membership of the CSP. Similarly, the CSP expects that all members should meet the Quality Assurance Standards for Physiotherapy Service Delivery (CSP 2012). Where they do not, programmes of professional development should be put in place to facilitate full compliance, as part of the individual’s professional responsibility.

Physiotherapists are encouraged to be proactive in supporting each other’s professional development and in promoting the value of the profession in local workplace settings, in policy-making forums and in the media. Physiotherapists should not be critical of each other except in extreme circumstances. However, they do have a duty to report circumstances that could put patients at risk. In the NHS there are procedures and a nominated officer within each trust from whom advice can be sought. Outside the NHS, advice can be sought from the CSP.

Belonging to A profession

Regulation: The Health and Care Professions Council (HCPC)

The Health Professions Council (HPC) was created by the Health Professions Order 2001 (HCPC 2001) as the statutory regulator of 13 professions, including physiotherapy. The regulatory process is a government measure to protect patients and the public from unqualified or inadequately skilled healthcare providers. As the number of professions increased to 17, it was renamed the Health and Care Professions Council (HCPC) in 2012 to reflect the diversity of the professions regulated.

In the UK, the titles ‘physiotherapist’ and ‘physical therapist’ are protected and only physiotherapists registered (registrants) with the HCPC may call themselves a physiotherapist or physical therapist. As the title is protected, a physiotherapist listed does not, therefore, need to place HCPC after their name as this is implicit within the title.

The HCPC sets standards of professional training, performance and conduct for the 17 regulated professions and maintains a public register of health professionals that meet its standards. The HCPC publishes generic standards for HCPC registrants, standards of conduct, performance and ethics (HCPC 2008) and profession-specific standards (Standards of Proficiency Physiotherapists, HCPC 2007), which members are required to and agree to meet. Registrants are required to keep up to date with the processes and requirements decreed by the HCPC. The HCPC only regulates the practice relating to humans and does not include regulation of physiotherapists practising on animals.

In 2006, the HCPC put in place a system requiring re-registration at intervals of two years (HCPC 2011). Re-registration was introduced partly in response to a lessening of public confidence in the NHS following, for example, the report into children’s heart surgery in Bristol (Bristol Royal Infirmary Inquiry 2001). Equally disturbing were the revelations about the murders of so many patients by Harold Shipman, a man who had previously been a trusted general practitioner (GP), where health systems failed to detect an unusually high number of deaths (DH 2004).

These measures demonstrate a commitment to protecting the public through more explicit and independent processes (DH 2002). The re-registration process is linked to an individual’s commitment to continuous professional development (CPD), whereby individuals must undertake and maintain a record of their CPD activities and, if required, submit evidence of this and its outcomes to their practice, service users and service. The process of re-registration aims to identify poor performers who may be putting the public at risk, as well as providing an incentive for professionals to keep up to date, maintaining and further developing their scope of practise and competence to practise.

The HCPC takes action when complaints are received and if registered health professionals, including physiotherapists, do not meet these standards (HCPC 2005). The process of registration and the accessible public register provide assurance to the public that a physiotherapist is legally allowed to practise. Disciplinary processes are in place to ultimately remove an individual from the register (HCPC 2005) where necessary.

While the principles of professionalism should be aspired to by physiotherapists anywhere in the world, the existence and/or role of regulators and professional bodies in the locations of practice when outside the UK may vary depending on political, social and financial factors.