1 The professional profile of the physical therapist Royal Dutch Society for Physical Therapy
3 The professional profile of the physical therapist 3
4 Address: Stadsring 159b, Amersfoort, The Netherlands Address for correspondence: P.O. box 248, 3800 AE Amersfoort, The Netherlands Internet Design and print: Drukkerij De Gans, Amersfoort 2006 Koninklijk Nederlands Genootschap voor Fysiotherapie (KNGF) All rights reserved. The KNGF s objective is to create conditions due to which high-quality physiotherapeutic care is realised, which is accessible to the entire Dutch population, with recognition of the physical therapist s professional expertise. The KNGF looks after the interests of over 20,000 associated physical therapists with regard to the content of the profession, social and economic aspects. 4
5 Foreword This is the professional profile of the physical therapist in This professional profile describes the curre nt state of affairs of the professional domain and the necessary competencies of the physical therapist, so that the academies can prepare their students for the present professional field. The professional profile of 2005 replaces the first version of the professional profile from The professional domain of physical therapy is developing enormously. As a specialist in movement, the physical therapist experienced a coup of professionalism. Scientific research now unmistakeably proves the positive effects of physical therapy. The demand for physiotherapeutic expertise is increasing and the physical therapist plays an important role in changing health care. The experiment with free tariffs, the introduction of Diagnosis Treatment Combinations (DTC) and the direct accessibility of physical therapy as of 1 January 2006 are explicit examples of that. Other kinds of global developments require room, such as that of competency management. In order to guarantee the coherence of the professional domain in all of these rapid changes, it is important that the description of the profession of physical therapy is adequate, so that we have a joint starting point for positioning physical therapy in health care. The professional profile forms the basis for many outlines. It positions physical therapy in health care and forms the key to the connection between training and the professional sphere of action. The professional profile is important to the KNGF in order to have consensus in the professional group about the core of its professional domain and to be able to compare the Dutch situation to international developments. For the academies, the professional profile is not only important for designing the training to become a physical therapist, but also for designing continued and extra training. With regard to the associations of professional content in the KNGF, the professional profile forms the basis for developing and describing their specialisations in professional competency profiles. For the practitioner of the profession and managers, the professional profile offers support for formulating personal development plans, for filling in the need for training and for executing the personnel policy. The professional profile does justice to the scope of the professional field and offers room for developments. The professional profile is also relevant to external parties in order to place the position of the physical therapist in health care. In this document physical therapy is used as an equivalent for physio therapy. Work method The same as in the first version, the professional profile was developed in cooperation between the Royal Dutch Association for Physical Therapy (Dutch abbreviation: KNGF) and the Dutch association of Physical Therapy education (Dutch abbreviation: SROF), in which the academies for physical therapy are represented. Two work groups were developed for the development of this professional profile. The first work group was for the development of the competence profile. Before this work group set out on its task, there were three academies that had their own competence profiles. Three authors of these profiles were in the competence profile work group. The second work group was occupied with recording all of the other parts of the professional profile. This professional profile work group was composed in such a way that an as wide as possible range of expertise from the daily practice of physical therapy was represented. The work groups focused on writing a legible professional profile. The starting point in this was to record everything on the basis of the professional group s independence by focusing on what the physical therapist does. The physical therapists products and services are guaranteed on the basis of the scientific development of the profession. Apart from the fact that developments with regard to content were given a position, a differentiation in the competence level was also made, namely, starting level and advanced level. A further differentiation between the bachelor and master level was also explored, which can be filled in further in the future. The work group is aware of the fact that the description is a momentary recording of the situation in the year 2005 with a look ahead to the future and to the restrictions that this entails. During the recording process, the competence profile and professional profile were carefully attuned to one another. Finally, a summary of the competence profile was included in the professional profile (chapter 4). The complete competence profile was established by the SROF in June There were representatives from the KNGF board, the KNGF policy committees, science, education, from the intramural and extramural work setting and the authors of the professional profile from 1998 in the project s supervising committee. During the developmental process, the concept texts were submitted to and discussed with 60 physical therapists and the representatives from the various sections in and around physical therapy during two internal validation meetings. The concept was submitted to the Scientific Board twice, and twice to the KNGF s policy committee and at least once to each policy committee of the KNGF. Finally, the concept was submitted to 15 organisations involved in physical therapy, including the Inspectorate for Health Care and the Ministry of Public Health, Welfare and Sports, but also to the Order of Medical Specialists and the National Association of General Practitioners for an external validation round. Book marks The professional profile starts with a description of the domain of physical therapy in chapter 1 as a brief summary of the several parts of the professional profile. Chapter 2 provides a picture of the position of physical therapy in health care. Chapter 3 describes the physical therapist s expertise and everything that a physical therapist factually does. Chapter 4 is a summary of the competence profile of the physical therapist. It describes the different roles that the physical therapist has in practising his profession and the competencies necessary for this. Chapter 5 describes the organisation of the KNGF, the safeguard of quality in physical therapy and the education continuum. Chapter 6 is a summary of relevant legislation and regulations for physical therapy. Chapter 7 casts a view to the history of physical therapy and to the developments in the future. Chapter 8 is an outline of the 5
6 consulted literature. Finally, Chapter 9 provides a survey of the people involved in this project, which resulted in this actualised professional profile. For the sake of the text s legibility, we only indicate the male form, without meaning to exclude the female physical therapist. This also applies to the patient: the text uses the term he, but naturally, we also mean the female patient. By the way, the term patient is used throughout this text, but we also mean the client and legal representative. This distinction was emitted for reasons of legibility. Royal Dutch Society for Physical Therapy 6
7 Contents Foreword 1 1 The domain of physical therapy The position in health care The physical therapist: a specialist with regard to human movement Objectives in physiotherapeutic care The physical therapist s work methods Professional and scientific attitude and ethics 6 2 Physical therapy in health care Health and human movement Health care Physiotherapeutic care provision Attuning and cooperation 8 3 The development of expertise Expertise Methodical work methods Phases in methodical action Clinical reasoning Interventions Anamnesis Testing, measuring and analysing Guiding and informing Directing and exercising Physical therapy in a narrower sense Manual interventions From practice to theory Forming of theory Physical therapy science 11 4 The Competence profile of the physical therapist The main lines of the competence profile Range of the profile Professional roles Professionalism Levels Survey of roles and competencies Roles 13 Care provider 13 Manager 13 Developer of the profession Competencies Norms of professionalism Dealing with work and tasks Dealing with others Dealing with one s own functioning 21 5 Organisation, guaranteeing quality and education continuum The KNGF The structure Professional associations Views Guaranteeing quality Academies Reforms in education BaMa structure 24 7
8 6 Legal context BIG Act BIG register Act on Quality for care institutions Act on tariffs in health care The right of complaint Disciplinary jurisdiction The Act on the Medical Treatment Agreement (Dutch abbreviation: WGBO) The Act on the Protection of Personal Information (Privacy) (Dutch abbreviation: WBP) Professional ethics 26 7 History, development and future History Developments and future Demand for physical therapy Market functioning Movement and health Direct accessibility Work-related physical therapy New professions and shifting of tasks Transparency and benchmarking 28 Consulted literature 29 Parties involved in the actualisation of the professional profile 30 8
9 The Professional Profile of the Physical therapist 1 The domain of physical therapy 1.1 Position in health care Physical therapists are active in both extramural (first-line) and intramural health care. In extramural (first-line) care, physio-therapists work as solo performers, in a partnership or in employment. In intramural care, physical therapists mainly work in hospitals, rehabilitation centres and nursing homes. Physical therapists also work in businesses, education, scientific research, care for psychiatric patients and the mentally ill. Out of over eighteen thousand practising physical therapists in The Netherlands, approximately thirteen thousand works extramurally and five thousand intramurally. They work together multiprofessionally in transmural chains and networks. Physiotherapeutic care is classified as curative somatic care. Physical therapists also develop activities in other areas. For example, the attention for prevention in care has increased in recent years due to the interest of healthy and sound exercise. Different developments and changes are taking place in health care. For example, the physical therapist has been directly accessible since 1 January 2006; this means that no referral is necessary anymore. Direct accessibility fits in with the ideas regarding the shifting of tasks and an efficient organisation of health care. 1.2 The physical therapist: specialist of human movement Physical Therapy is the professional field of human movement: the physical therapist is occupied with the human movement apparatus in their daily environment and social participation. Physiotherapeutic care focuses on the causes of health problems and the consequences of diseases, disorders and syndromes, aimed at stimulating health with regard to movement in relation to participation in society. Following on from the search for causes, the physical therapist pays a great deal of attention to prevention. The physical therapist establishes the patient s (im) possibilities for movement. He evaluates in what way movement takes place in order to analyse why the patient moves in this way exactly. In the analysis, the physical therapist looks for the causal factors and factors that can be influenced, on the basis of which he formulates the objectives and a treatment plan in consultation with the patient. The objective of treatment is the optimisation of the patient s movement based on his capacities and the existing possibilities. 1.3 The objectives of physiotherapeutic care The patient s interests form the centre of the choice for the treatment objectives. Health problems and requests for help with regard to movement have strong coherence with the individual patient s world of experience. The physical therapist strives to attune physiotherapeutic care to the request for help. The specific objectives of physical therapy include: creating possibilities for the improvement or maintenance of the patient s participation level preventing requests for help, health problems and a recurrence of health problems in the field of movement relieves health problems (described in functions, activities and participation), reduces these or helps to compensate for them offers guidance and support during the patient s suffering influences the attitude, behaviour and lifestyle of the person requesting help in so far as they are related to the request for help and/or health problem influences the life and work circumstances in so far as they are related to the request for help and/or health problem 1.4 The physical therapist s work methods The physical therapist s work methods are characterised by a conscious, process-like, systematic and effective approach. This approach is described as methodical physiotherapeutic work method. Due to these work method, the physical therapist is able to provide tailor-made care, which is transparent and can be tested. The introduction of direct accessibility makes consulting the physical therapist possible without a doctor s referral. That is why the screening process was added to methodical intervention. This screening process means: recognising symptoms within or outside of the physiotherapeutic domain. After the evaluation, the physical therapist formulates the health problem in a physiotherapeutic diagnosis. This is based on the generally accepted and appropriate and motivated diagnostic skills. The patient s functioning problem is described on the basis of the ICF (International Classification of human Functioning). The term human functioning in the ICF refers to functions, anatomical characteristics, activities and participation. The term functioning problem refers to disorders, impairments and participation problems. Additionally, the ICF contains a reference to external factors that can influence the health problem (WHO-FIC CC Netherlands 2002). In the treatment, the physical therapist applies a variety of interventions. He makes his choice of interventions on the basis of clinical expertise and the patient s preferences, wishes and expectations. Additionally, he bases his choice on the best available and scientifically motivated evidence (including guidelines). In physical therapy, the terms movement therapy or exercise therapy or physiotechnic modalities were always used as the key of physiotherapeutic intervention, combined with massage therapy in some cases. The interim Classification of Interventions in Medically-related Professions (Dutch abbreviation: CVPB) uses the following list of interventions: guiding/informing/directing/exercising/physical therapy in a narrower sense and manual interventions. 1.5 Professional and scientific attitude and ethics The physical therapist is expected to put the patient s health problems in the perspective of movement and movement problems. An essential development is taking place of evidencebased practice. Physiotherapeutic expertise is characterised by the ability to apply professional knowledge to complex and concrete situations. The physical therapist integrates patient-specific information, epidemiological information and a number of additional conditions. It is expected of the physical therapist that he methodically weighs, organises and integrates this heterogenic information as a professional in the motivation of his clinical decisions. If available, proven insights are helpful, which have been recorded in the form of guidelines. The physical therapist often uses clinical expertise as a source of information. 9
10 2 Physical Therapy in health care 2.1 Health and human movement Health is an abstract, ambiguous term that is coloured by ideas from a historic, social and cultural perspective. The World Health Organisation (WHO) defined health in 1947 as: a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The value of this definition is that health is regarded as something personal of the individual involved. Hagenaars and Verduin (2001) phrased it as follows: a person is healthy if he as a free and responsible person has a useful and meaningful life in his opinion in the circumstances that form his existence. Physical Therapy is occupied with stimulating health and healthy behaviour in relation to movement. Health is in this case interpreted as a process of humanisation that is supported by a harmonious relation between the person and his human situation (Kuiper 1975). Following on from the formulation by Hagenaars and Verduin, the degree of health can be regarded from a biological, psychological, social and personal perspective as an interaction between the person s load and load capacity. Functioning problems are expressed in terms of disorders, impairments and participation problems (WHO-FICCC Netherlands 2002). For the development of the formation of physiotherapeutic theory and the body of knowledge, two points of view regarding health are important: a biological understanding of health, whereby health is merely defined as the proper functioning of the organism in a physical sense. a broad and positive description (as defined by the WHO), whereby health is associated with the appreciation of functioning, which depends, among other things, on the circumstances the individual is in and the purposes the individual sets himself. In the narrow description, no disease, disorder or syndrome can be involved without a medical diagnosis. After all, only scientific insights justify the use of the term disease, disorder or syndrome. For example, muscle tissue is defined as a sub-system that converts chemical energy into mechanical energy for the movement of (parts of) the organism. Scientific research provides insight into pathophysiology and pathogenesis. This is why disorders that become manifest in impairments can be traced more easily. Based on the narrow description, disease is undesired in a reasoned way. In the description with a broad formulation, indicating the limits is difficult. Every human activity comes under the term health. Each distinction between political, moral or cultural problems on the one hand and health problems on the other is eliminated. This means that health is not the same for everyone, but differs per initial situation and the objectives set. People move within their abilities and skills, with an objective and in interaction with their environment. The movement observed can be described in terms of strength, speed, flexibility, endurance and coordination if movement is regarded as a moving of the body or of the parts of the body. Human movement also expresses how people feel in their world of experience. The physical therapist uses movement as a starting point for solving an (imminent) health problem. 2.2 Health care Health care comprises the whole of organisations, professional groups, measures and means aimed at influencing public health in a positive way. Health care is subdivided into several, partly overlapping, domains of care, such as curative somatic care, nursing care, mental health care, care for the handicapped, care for the elderly, child and youth care, home care and preventive care. Physiotherapeutic care is classified as curative somatic care with a great deal of attention to prevention. Curative care is described after the place where the care is offered: intramural and extramural care. Intramural care comprises among other things - the care for patients in hospitals, nursing homes and rehabilitation centres. Extramural or first-line care comprises the care that is provided outside of institutions. This care is largely provided by free practitioners. This division that grew in history is supplemented by chain care and transmural care. The intentions of these developments are evident: we pursue realising coherence and continuum in care, so that the patient receives the best care at the right place, at the right time and at the lowest possible expense. Not the location where the care is provided forms the centre, but the patient s interests and request for help. The care is provided on the basis of arrangements regarding cooperation, attuning and management between generalist and specialist care providers. This involves a common objective and a born responsibility with explicit sub-responsibilities. 2.3 Physiotherapeutic care The physical therapist focuses on human movement, placed in the context of healthy functioning. The physiotherapeutic domain is supported and carried by the medical sciences and behavioural sciences. The physical therapist s care process focuses, among other things, on human movement (deviations) and intends to increase or maintain the quality of life by stimulating functions, activities and participation and by exerting influence on personal factors and environmental factors. For this purpose, the physical therapist works together with the patient on his recovery and on learning to deal with his health in daily situations. Physiotherapeutic care is occupied with the functional aspects of health, which usually requires imbedding in multi-professional care. Movement problems with back, neck, shoulder and knee form the majority of all referrals in the first line (NIVEL/Prismant 2003). The people, who are treated by physical therapists in hospitals, are mainly referred by the neurologist, neurosurgeon, cardiologist, intensive care specialist, general surgeons and orthopaedic specialist. In nursing homes and rehabilitation centres, it mainly concerns people with the consequences of neurological disorders (stroke, Parkinson s disease and Multiple Sclerosis), lack of movement and orthopaedic disorders (mainly of the hip and knee). Physical Therapy is a specific profession with a wide range. Its application concerns people of different ages, phases of life, needs for help and intensity of care and takes social develop- 10
11 ments, such as lack of movement and overweight into account. In this way, physical therapy wants to contribute to people continuing to participate in the work process. Physical therapists also focus on children with developmental disorders, so that they can (continue to) function in their group of contemporaries. Additionally, physical therapists make it possible that (elderly) people can continue to live at home longer and they reduce the suffering of patients with pain. The epidemic of the lack of movement and overweight has a great influence on the development and course of (chronic) diseases, disorders and syndromes. Moreover, there is an increase in work-related disorders and psychological problems, all with consequences on the quality of movement. The demand for physiotherapeutic care increases due to this. Additionally, another domain is increasing in size due to the aging of society: movement problems in elderly people. Finally, the physical therapist guides and advises care providers and nursing staff in how the intensity of care can be reduced. In this way, physical therapy makes an important contribution to public health, the transfer from an intramural residence to the home situation, to the quality of life of great groups of (chronically ill) people and keeping the expenses controllable. Physio-therapy also contributes inside and outside of health care to limiting the costs of absenteeism and incapacity for work. 2.4 Attuning and cooperation The physical therapist s work requires cooperation with both fellow-physical therapists and other practitioners. Optimal care to the patient implies that care is provided in mutual coherence, as well as the means which are available to a limited extent. In specific diagnosis groups, the physical therapist cooperates in transmural chains and networks. The formal work relation between the medical specialist and physical therapist was arranged by the legally stipulated referral relation for decades. Changed legislation made it possible as of 1 January 2006 that the physical therapist is also directly accessible. The necessity for cooperation certainly continues to exist; the awareness of the value of good cooperation increases rather than decreases. In the provision of care, medical specialists and physical therapists each have their own starting points and roles. Differences in starting points imply that physiotherapeutic care and medical care mutually supplement one another. 11
12 3 The development of expertise The development of expertise in physical therapy takes place with regard to two dimensions: the dimension of the profession and the dimension of the individual professional. With regard to the dimension of the profession, it refers to the process of professional development with specific characteristics such as the start and formation of a body of knowledge. Additionally, it refers to consciousness and recognition of one s domain of expertise. With regard to the dimension of the individual professional, it refers to the process in which the individual physical therapist further develops his knowledge, expertise and professional assessment and integrates new insights in his professional action. The two processes are connected inseparably, but focus on different objectives. The processes are joined in the professional profile, which applies to every physical therapist. Expertise is no longer supposed to be the sum of knowledge, skills and attitudes, but as integrated entities, the term that is now used is competencies. 3.1 Expertise Physiotherapeutic care relates to the areas of cure and care: it concerns an approach that focuses on reducing problems in movement and on the consequences of diseases, disorders and syndromes. The physical therapist evaluates the patient s health problem on the basis of the terms formulated in the ICF. The ICF offers a structure for organising and presenting information about human functioning in a broader perspective in a useful way and in mutual coherence. In this way, problems can be distinguished with regard to nature and range (characteristics, functions, participation in social traffic, etc.) but also with regard to factors (external, personal) which influence functioning. Human functioning and any problems with that are then regarded as the outcome of a dynamic interaction between a person s health problems, (diseases, disorders, accidents, trauma s, etc.) and the context in which those problems occur (WHO-FIC CC Netherlands 2002). In the past decades, the physical therapist has familiarised himself with thinking in the terms of the ICF. In addition to this, evidence-based practice (EBP) was introduced in physical therapy, which becomes manifest, among other things, in the use of guidelines to support physiotherapeutic intervention at clinical level. EBP is a way of working that results in the integration of the best evidence from scientific research with the therapist s clinical expertise and the patient s values. This requires a critical-constructive attitude from the physical therapist, whereby the most effective treatment is pursued (Offringa et al. 2003). EBP concerns the application of scientific information taking into account what the professional puts in with regard to meaningful considerations from clinical experience in relation to the patient s preferences, wishes and expectations. Good communication is necessary for attuning the patient s preferences, wishes and expectations and the physical therapist s professional responsibility. The physical therapist arrives at the content of his professional intervention in consultation with the patient. From this view, the physical therapist uses the patient s health problem as the starting point, realising that both the manifestation of a health problem and the interpretation of an anamnesis takes place in an interaction of biological (condition and constitution), psychological and social (environmental) factors. The physical therapist asks himself whether the patient s ideas influence the health problem. The physical therapist evaluates the meaning of the problem to the patient with regard to movement and in which tasks, abilities and activities the patient s intention can be expressed insufficiently. Taking this information into account yields therapeutic varying factors. The physical therapist uses accepted theories and insights with regard to aetiology, diagnostics and therapy, common sense and general human communicative capacities. The physical therapist takes responsibility for his interpretations and submits these to the patient. He points out any risks to the patient. They decide how the health problem is approached together. 3.2 Methodical work methods The physical therapist s professional approach is characterised by working methodically. Due to these work methods, the physical therapist is able to provide care to fit the nature of the problem. In doing so, the patient remains informed of the considerations, reasoning and arguments that form the basis of the physical therapist s decisions Phases in methodical intervention The following phases are distinguished in physiotherapeutic methodical intervention: 1 registration, orientation on the request for help, screening and information to the patient 2 anamnesis 3 physiotherapeutic evaluation 4 formulation of the physiotherapeutic diagnosis and indication 5 treatment plan 6 execution of treatment 7 evaluation 8 conclusion These phases have a cyclic character. Linking back takes place between the different phases based on decision moments: After each phase, the physical therapist decides whether he continues to the following phase or that he has to return to a previous phase. The physical therapist starts the factual treatment after he has formulated a treatment plan. After the evaluation of treatment, he decides whether the treatment period can be concluded on the basis of the results realised. In methodical intervention, the interaction between the physical therapist and patient plays an important role. Also thanks to methodical intervention, the physical therapist s care provision can be tested internally as well as externally. Linking back to the referring doctor is also important in this process Clinical reasoning Clinical reasoning comprises the mental processes of collecting, interpreting and structuring information, which enables the physical therapist to clarify and solve a problem based on his biomedical, behavioural-scientific and physiotherapeutic knowledge. In making decisions, the physical therapist will have to consider social and financial-economic aspects in coherence in addition to many professional considerations. In the followed line of reasoning, two phases are distinguished 12
13 (Hagenaars et al. 2003): one phase of orientation and analysis, which results in the analysis of the patient s health problem one phase of synthesis and design, which results in the formulation of a treatment plan in consultation with the patient in order to solve the health problem The directing questions in the orientation and analysis of the problem include: What are the nature and possible consequences of the disease, disorder or syndrome for the patient s movement? Which factors were decisive for its development and the possible consequences for the patient s movement? Which factors are decisive for the patient s health problem? Is the development of (the consequences of) the disease, disorder or syndrome normal or deviant? What does any deviation in the development consist of and which factors have influenced this? Directing questions in the phase of synthesis and design include: Is the referral to/request for physical therapy justified? Which physiotherapeutic objectives apply to the patient? By means of which strategy can these objectives be realised? Which physiotherapeutic interventions are applied? Who will be the treating physical therapist? Physiotherapeutic care is problem-solving. The physical therapist bases his strategy on the foundations of knowledge of physio-therapy and transforms this insight to clinically applicable knowledge. Brouwer and colleagues (1995) regard this transformation as the basis of clinical reasoning). They define it as follows: Clinical reasoning can be described as the application of relevant knowledge (facts, procedures, concepts and principles or rules) and skills in order to give a (profession-specific) assessment of the patient s problem, to diagnose and treat this. 3.3 Interventions In the evaluation and treatment, the physical therapist applies various interventions. The choice he makes is based on scientific insights, knowledge from experience and the guidelines and protocols of the professional group. The whole of diagnostic and therapeutic interventions is described in the Classification of Interventions of Medically-related Professions (CVPB). In case of physical therapy, this mainly concerns: questioning (anamnesis) testing, measuring and analysing guiding and informing directing and exercising physical therapy in a narrower sense manual interventions The characteristic interventions for physical therapy are mainly: Guiding and informing, directing and exercising, physical therapy in a narrower sense and manual interventions. The interventions can be applied in combination. The evaluation and treatment in physical therapy are characterised especially by this combination of interventions for patients with health problems concerning movement. Guidance always forms part of the physical therapist s activities. The physical therapist combines guidance with one or more interventions from the other three groups in a treatment series Questioning (anamnesis) The physical therapist forms a basis for his physiotherapeutic diagnosis and treatment plan by asking the patient about the development and course of his disease/disorder and the consequences/meaning for his functioning Testing, measuring and analysing In determining his physiotherapeutic diagnosis and treatment plan and in the evaluation of the treatment objectives, the physical therapist uses developed and validated measuring instruments as much as possible. These measuring instruments fit in with the disease/disorder found and are suitable for evaluating the results of physiotherapeutic intervention Guiding and informing When the physical therapist guides the patient, he informs and advises and supports the patient. We define informing and advising as teaching factual and relevant information to the patient or to persons who are relevant for the patient. This more or less binding, personal advice focuses on the optimisation of the patient s state of health and his environment. The advice is provided on the basis of factual and relevant information. We can describe offering support as the process-like assistance to the patient and relevant persons during the instruction of, acquiring and application of activities, using the possibilities of health care and accepting and emotional processing of the health problem. This support also comprises checking and stimulating the patient in his process of learning and acceptance Directing and exercising When we use the terms directing/exercising as an intervention of the physical therapist, we mean the direct or indirect influencing of a function or ability that the patient carries out as a means to improve that function or ability Physical therapy in a narrower sense The application of physical stimuli via equipment that is used in physiotherapeutic practice belongs to physical therapy in a narrower sense. The forms of energy applied are of an electric, electromagnetic, thermal or mechanical nature and combinations of these forms of stimuli Manual interventions In manual interventions, the CVPB differentiates between realising an articular movement and massage. An articular movement is the manual changing of the position of the body or the parts of the body of the patient. This is not the same as massage. According to the CVPB, massage is the application of mechanical stimuli to the patient s body by means of the therapist s hands, if necessary, supported by an aid that does not change the nature of the stimulus. 3.4 From practice to theory The adequate solution of health problems requires a flexible basic attitude from the physical therapist in his thinking. He has to navigate between different heterogenic domains and sources 13
14 of knowledge. On the one hand, the physical therapist has to analyse disorders, diseases and syndromes, on the other hand he has to be able to recognise psychological and social factors. All of these factors have to be weighed in the formulation of a treatment plan. In order to simplify this weighing, physiotherapeutic guidelines were developed. These guidelines describe the best available approach in a certain health problem. The heterogenic sources of knowledge are represented in the structure of the guidelines. The streamlining of the different sources is the essence of EBP and is aimed at optimising the success of treatment. The physical therapist developed assessment capacity in practice which enables him to test the aspects of the individual patient to the guideline. This assessment capacity is a normative, nonscientific competency, which comprises, among other things: the ability to determine which information is useful, valuable, relevant, suitable, adjusted, reliable and adequate in a certain situation. Practical physiotherapeutic intervention requires a value assessment from the physical therapist with regard to the suitability, relevance, adequacy and practicability of the scientific supply of knowledge; in that case, science application is involved The formation of theory In clinical practice, therapeutic choices were solely based on biomedical (pathophysiological and anatomical) insights for a long time. Physical Therapy developed in the slipstream of existing medical practice and biomedical insights. Insight into pathophysiological mechanisms resulted in therapeutic expectations regarding the effects on so-called physiological and anatomical final goals. In the formation of physiotherapeutic theory, the emphasis was mainly on the possibility of influencing pathophysiological mechanisms. Physiological and anatomical parameters functioned as indicators for sickness and recovery. Disorders were supposed to be established rapidly and adequately and they were supposed to be influenced by therapy. Therapy was supposed to result in the normalisation of the disturbed physiological/anatomical disorder and in a reduction of the activity of the sickness process. The effectiveness of commonly used diagnostic tests and interventions applied can now be indicated. It has become clear that the recovery of a physiological/anatomical dysregulation is not simply the reverse of the causes. This does not automatically mean that the patient becomes better. After all, there are other clinically relevant parameters in the field of human functioning, participation and the quality of life Physiotherapeutic science Medical science primarily focuses on the scientific research of diseases, disorders and syndromes. Physiotherapeutic science focuses on: the research of the treatable consequences of disorders, diseases and syndromes on movement in the patient s daily life and his role fulfilment in his environment the effectiveness of physiotherapeutic interventions the research regarding the legitimisation and innovation of physiotherapeutic care from the perspective of the patient s preservation of movement and autonomy the (scientific audit of) implementation of physiotherapeutic care innovations The body of knowledge of physical therapy is fed by knowledge and insights from: the beta and gamma sciences (also called: Life Sciences, Movement Sciences and Health Sciences) mainly from the medical-biological, behavioural-scientific, knowledgetheoretical and epidemiological domains (Spreeuwenberg Committee 2001) the developing body of knowledge of physical therapy as an authentic independent profession within health care (RGO 2003) the innovation sciences 14
15 4 The competence profile of the physical therapist 4.1 The main lines of the competence profile A competence profile describes all of the competencies a professional has to be able to carry out the tasks and activities of his profession. A competence profile serves two purposes: it forms a basis for the description of the function with tasks and responsibilities in an organisation it gives direction to academies with regard to the minimum final objectives to be realised (with regard to content and level) The term competency refers to the capacity of performing certain tasks and of solving the questions or problems occurring in the process. The term forms a bridge between the tasks and activities on the one hand and the necessary expertise on the other hand The range of the profile The competence profile of the physical therapist describes the whole of competencies the physical therapist possesses to perform the tasks and activities connected to practising the profession in the year The competence profile is based on the greatest common divider of tasks of physical therapists regardless of the specific circumstances and work settings. In reality, these circumstances and work settings have great influence on the physical therapist s work. Furthermore, every physical therapist will have acquired competencies at a higher level and in other fields by experience and further training to what is described in the profile. The profile can therefore mainly be regarded as a common basis and as such does not cover the great variety of the competencies of every physical therapist in The Netherlands in his specific work setting. Per competency domain, the competencies and all directly related aspects are described first. Subsequently, the level of the physical therapist s competencies at the end of his initial training/start of the profession is described per domain. These competencies are also called the starting competencies. Finally, the indicators for the advanced level are described. The competencies of physical therapists active in a special field (with specific target groups or therapeutic means) are described in the supplement of the function and competence profiles of the different specialisations in the professional group Professional roles The competencies have been organised on the basis of the three roles that the physical therapist fulfils and combines in his work: care provider, manager and developer of the profession. The role of care provider relates to the primary process. The roles of manager and developer of the profession are at the service of the primary process; They are not separate roles: they are complimentary and in daily practice, they sometimes overlap in such a way that the most that can be said is that the roles and competencies can be distinguished. They make a high-quality service possible. At individual level, the extent to which each of the roles is fulfilled and the accompanying competencies are addressed differs per work situation. In each role, a distinction was made in the competencies, which have the character of orientation, assessing, deciding and planning and in competencies whereby executing, realising and evaluating are in the foreground. The combination of roles and categories of competencies provides the following competency domains: the physical therapist as a care provider: - screening, diagnosing, planning - therapeutic intervention - preventive intervention the physical therapist as a manager: - organising - enterprising the physical therapist as a developer of the profession: - research - innovation Screening Diagnosing Planning Therapeutic intervention Preventive intervention organising enterprinsing Research Innovation Fig. 1. Coherent competency domains. The exact relation between the roles can differ per work situation. Although preventive and therapeutic interventions are of a comparable order, a distinction is made between the two in the profile. The distinction does justice to the differences in the nature of the two types of tasks, activities and contexts. If disorders, diseases and syndromes and the consequences of these are involved, the competencies were placed in the domain of therapeutic intervention. When competencies are meant in the field of service, consultation and advice aimed at the prevention of health problems and disorders, they were placed in the domain of preventive intervention Professionalism Professionalism in the physical therapist s intervention is not only embedded in what he does, but also in how he does this. A professional performance is characterised by, among other things, the efficiency of the intervention, the time span within which the tasks can be fulfilled, the constant search for attuning with the patient and reliability in meeting agreements and promises. For the sake of the clarity of the profile, the characteristic aspects of professional intervention at are not pointed out every time for each competency. They are solely mentioned if extra attention is required Levels With regard to the competencies, a distinction was made every time in the level of the beginning physical therapist ( qualified to start practising as the final level of the initial training) and that of an advanced physical therapist. No differentiation was given in terms that indicate on which basis the advanced level 15
16 was reached. Some physical therapists will reach an advanced level by practical experience and additional training. Others will mainly derive this from specific, longer term training, for example in the form of training at Master s level. Regardless of the route that physical therapists follow individually, competent intervention at an advanced level expects a combination of both experience and specific training. Although the competencies at starting level are relevant to the initial training in the first place, they are also relevant to the perspective in the longer term (the advanced level). After all, an adequate preparation for practising the professions is not strictly limited to reaching that starting level, but extends to the development of the capacity to be able to continue to function in the profession in the longer term and add on to competencies. 4.2 A survey of roles and competencies This survey provides a further specification of the required competencies per role. In practice, the roles and competencies are no isolated entities, but they are connected with each other and form an integral part of practising the profession. Together, the different roles and competencies give an indication of the range of the profession; the necessary depth is expressed in the described level of the competencies. In this way, competencies are demarcated by a combination of contents and level Roles Care provider In the roll of care provider, the physical therapist offers professional help in the form of treatment and guidance. He also provides services in the form of advice, information, education, training and coaching. Prior to this, he gives a professional assessment of the situation in a broader sense and discusses and considers the (im) possibilities for physiotherapeutic care with the patient (and any other people directly involved. What is characteristic for this care provision is: methodical work methods acting in correspondence with the principles of EBP focused on increasing or preserving the patient s independence Manager The role of manager relates to the organisation of his activities, whereby the physical therapist contributes to the functioning of the organisation internally and in relation to the environment. The gauging points in that are: effectiveness and efficiency of the organisation and work processes continuity of care and the coordination with third parties, such as colleagues and other care providers attuning of supply and demand positioning of the organisation responsible enterprising in relation to high-quality care and service provision Developer of the profession The role of developer of the profession concerns the responsibility with regard to the preservation and/or improvement and guarantee of the quality of one s provision of care and service and making contributions to the further development of the profession. Characteristic details for this include: relating practice to study and relating study to practice systematic monitoring/registration of one s work and transparency focusing on guaranteeing and improving quality development and dissemination of new insights by means of research, education and information Competencies Competencies are specific to content and context to an important extent. Whether a person is competent in a specific situation depends on the degree to which he has the expertise and experience relevant to solving problems in the context in which these problems occur. That is why the description contains an explanation of typical and critical professional situations and results in addition to a brief, compact formulation of the competencies. These professional situations are mainly intended as an illustration; the whole of problems and contexts is so varied that giving a description that does justice to all situations that occur in practice is not feasible. 16
17 Professional role The physical therapist as a care provider: screening, diagnosing, planning Competency(ies) The physical therapist outlines the (threatening) health problems based on the request for help in a methodical way and relates these to movement and moving participation. Depending on the results of the first screening and the findings from the physiotherapeutic evaluation, the physical therapist makes decision in consultation with the patient with regard to the treatment to be started, advice or referral. Explanation Screening, diagnosing and planning comprise an orientation on the request for help, a physiotherapeutic exploration and assessment of (threatening) health problems in relation to movement, determining the physiotherapeutic diagnosis and formulating a treatment or prevention plan in consultation with the patient and in a methodical way (effective, systematic, according to a process and conscious). Where necessary, the physical therapist asks or uses additional information from other professionals involved in the provision of care. In direct access, the physical therapist determines in the first screening whether further physiotherapeutic analysis is useful. Depending on the outcomes, diagnostic physiotherapeutic evaluation is subsequently done or the patient is referred. The treatment or prevention plan at minimum describes: cause, diagnosis, objectives, strategy, physiotherapeutic interventions agreed on and time planning. Directives are: the request for help, possibilities for physiotherapeutic help, expectations and experiences regarding the results (evidence-based) and existing guidelines for the approach to be followed. Critical/typical professional situations Patients who consult the physical therapist directly without a referral (in direct access). Other disorders are not eliminated beforehand. In that case, the physical therapist has to screen first to what extent there is an indication for further physiotherapeutic evaluation. Patients in whom complex health problems are involved (multiple pathologies, recurring or persistent health problems) and a long-term period of recovery. In relation to work or sports, the physiotherapeutic assessment of the situation can also comprise a thorough analysis of work circumstances, (physical) environment and/or sports specific activities and a clarification of the patient s expectations and values in relation to movement. Results Physiotherapeutic diagnosis, advice, referral, treatment plan, registration, correspondence to third parties. Level indicators Starting level Masters all aspects of the role of care provider integrally In a variety of patients Carries out tasks fluently at a work pace that fits in with practising the profession Can account for choices made Advanced level Fulfils the role of care provider in a characteristic way Carries out the tasks in complex problems fluently in different types of patients Is (very) experienced with one professional context or experienced with various professional contexts Functions as a vade mecum for colleagues and other professionals involved in the provision of care 17
18 Professional role The physical therapist as a care provider: therapeutic interventions Competency(ies) The physical therapist executes the treatment plan methodically and in cooperation with the patient. He evaluates the effects of the interventions on the patient s movement and state of health periodically, and adjusts the plan, if necessary, in order to realise optimal results. Explanation Therapeutic intervention comprises the execution of physiotherapeutic interventions, guidance/support of the patient, (interim) evaluation, informing the patient and reporting (to third parties), in close cooperation with the patient and in a methodical way (effective, systematic, in accordance with a process and conscious). Therapeutic intervention is often aimed at an individual, but can also take place in groups. The cooperation with the patient intends to guide, coach and activate him with regard to the health problem. The physical therapist constantly attunes and regularly checks how the patient experiences the problem and treatment and adjusts his interventions accordingly on that basis. The effectiveness and efficiency of the treatment plan are assessed in an evaluative way: have the objectives and quality been realised optimally, compared to an acceptable motivation, (material and immaterial) costs and period of time? Optimal results can vary from the full recovery of health problems up to and including adjustment to and adequate dealing with a permanent loss in function(s), to acceptance and satisfaction of the patient. The approach chosen is attuned to the therapeutic objectives, both curative and with regard to secondary and tertiary prevention. Critical/typical professional situations First-line care can require a broad range of capacities from the physical therapist in order to meet the variety in requests for help. Clinical care whereby patients are treated intramurally in a limited time span based on treatment protocols. Situations involving long-term and often multi-professional care process, which require mutual attuning or whereby other professionals have to be instructed, for example with regard to transfers, mobility and ADL-oriented actions. Results Executed treatment plan, treatment objectives realised, information, education, advice, reporting and accounting to third parties Level indicators Starting level Masters all aspects of the role of care provider integrally. in a variety of patients. Carries out tasks fluently at a work pace fitting in with practising the profession Can account for made choices. Advanced level Fulfils the role of care provider in a characteristic way Carries out the tasks in complex problems fluently in different types of patients Is (very) experienced with one professional context or experienced with various professional contexts Functions as a vade mecum for colleagues and other professionals involved in the provision of care 18
19 Professional role The physical therapist as a care provider: preventive intervention Competency(ies) aimed The physical therapist gives information and advice with regard to health stimulating behaviour and measures at the prevention of health problems. He provides forms of training and coaching, individually and in groups aimed at health stimulating behaviour in daily life, work and leisure time. Explanation Preventive intervention comprises a variety of forms for both individual clients and groups: informing, advising, giving consultations, executing training programmes and courses, guiding or coaching of (a) client(s), giving information and presentations. If desired, the physical therapist works together with other professionals. Preventive interventions mainly relate to primary and secondary prevention aimed at: the protection of health (reducing risk factors), health stimulation (healthy behaviour and lifestyle), early observation or tracing and treatment of (threatening) health problems in relation to movement and pain. The emphasis of physiotherapeutic care can be on: advising on measures and adjustments for the reduction of risks, for example, in case of unilateral forms of load offering the opportunity for and support to clients in learning/training health stimulating activities and behaviour offering clients insight into the relation between their health and the factors that lead to health problems making clients aware of their own possibilities for preventing, solving or stabilising health problems and stimulating an active attitude in this In cooperation with the client(s), preventive activities and programmes are evaluated (in the meantime) and adjusted, where necessary. Critical/typical professional situations A single consultation with a client who wants a second opinion about certain activities or risks Developing and executing exercise programmes for (specific target) groups Planning and executing individual coaching routes Making reliable information about health problems and the possibilities or limitations of physiotherapeutic care accessible, for example via an informative and interactive website. Results Advice, consultation, prevention plan, executed training sessions, presentations, objectives realised, reporting, and accounting to third parties Level indicators Starting level Masters all aspects of the role of care provider integrally In a variety of clients Carries out the tasks fluently at a work pace that fits in with the practising of the profession Can account for made choices Advanced level Fulfils the role of care provider in a characteristic way Carries out the tasks in complex problems fluently in different types of patients Is (very) experienced with one professional context or experienced with various professional contexts Functions as a vade mecum for colleagues and other professionals involved in the provision of care 19
20 Professional role The physical therapist as a manager: organising Competency(ies) The physical therapist organises his work effectively and efficiently, and works together with colleagues and other professionals in care. He contributes to the management and optimalisation of work processes with regard to the maintenance and improvement of the organisation s functioning. Explanation Organising comprises planning and organising one s activities, attuning one s work to that of colleagues, maintaining a systematic patient administration and financial administration, providing information to third parties involved, constructively contributing to the design, realisation and improvement of work processes and work climate, care for the availability and management of the necessary facilities and means and periodical evaluative meetings regarding the realisation of the practice s objectives. The physical therapist gathers, processes, and keeps all relevant information with regard to the financial and patient administration. He takes the applicable professional ethics, legislation and regulations, needs from patient populations and health insurers requirements into account. Critical/typical professional situations Within the organisation: making arrangements with regard to the divisions of work, attuning activities In institutions, such as hospitals and rehabilitation centres: holding multi-professional meetings regarding the attuning of care tasks and responsibilities Organising or participating in decision-making regarding the provisions in the organisation. Results Systematic patient administration and financial administration, pleasant and constructive work and treatment climate, efficient work methods and adequately organised chain care Level indicators Starting level Organises his activities and carries these out independently in conformity with the arrangements and planning Independently maintains the administration of patients and the practice Realises a division and attuning of task in cooperation with colleagues Contributes to a good execution of policy and plans of activities Advanced level Gives direction to colleagues/personnel at starting level based on knowledge and experience Can take partial responsibility for parts of the management of the practice Develops policy and plans for activities with regard to service, facilities, HRM, and finances 20
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