Report and Background Discussion on Advanced Practice in Occupational Therapy

Transcription

1 Report and Background Discussion on Advanced Practice in Occupational Therapy Prepared by: Marcia Finlayson and Janet Craik in consultation with Patricia Dickson, Sandra Bressler and Francoise Rollin, Input for this report was generated through participation of individuals attending the Advanced Practice Professional Issues Forum CAOT Conference Ottawa, Ontario, June 4 th, 2009

2 Facilitator: Marcia Finlayson, PhD, OT (C), OTR/L, Dr. Marcia Finlayson is a tenured Associate Professor in the Department of Occupational Therapy at the University of Illinois at Chicago and the Managing Editor of the Canadian Journal of Occupational Therapy. Over the course of her 22 year career, she has worked in hospital-based practice in Canada, developed and supervised occupational therapy service delivery in role-emerging settings in Canada and the US, and participated in the development of clinical doctoral degrees in occupational therapy (OTD) at two US universities. As a consequence of her experiences, Dr. Finlayson has become increasingly interested in the notion of advanced practice, how this term is used in the profession of occupational therapy, and what its implications are for postprofessional education and the profession as a whole. Panelists: Patricia Dickson, Advanced Practice Occupational Therapist, Holland Orthopaedic & Arthritic Centre, Sunnybrook Health Sciences Centre Tricia graduated from the University of Western Ontario s Occupational Therapy program in 1997 and is currently pursuing a Master s in Rehabilitation Science at McMaster University. She has been employed as an occupational therapist at Sunnybrook s Holland Orthopaedic and Arthritic Centre in Toronto since 2001 and in 2008 received Sunnybrook s Schulich Award for Clinical Excellence. Tricia currently enjoys a unique role as the Advanced Practice OT in the Holland Centre s Hip & Knee Arthroplasty Program. Her role encompasses an extended scope clinical caseload, committee involvement, practice-based research and clinical staff mentoring. She is also the Chair of the Ontario Society of Occupational Therapists Advanced Practice Task Force. Sandra Bressler, Clinical Assistant Professor, Dept. of Occupational Therapy and Occupational Science, University of British Columbia, Senior Consultant, Corpus Sanchez Consultancy Inc. Sandra earned a Bachelor of Occupational Therapy from McGill University and a Master of Arts in Leadership and Training from Royal Roads University. In 2004, she received the award of Fellow of the Canadian Association of Occupational Therapists. Sandra has worked in healthcare for over 30 years as a clinician, supervisor and administrator. Previously she was the Director of Therapy Services at Children s and Women s Health Centre of British Columbia, in Vancouver. Sandra is a licensed occupational therapist, a Clinical Assistant Professor in the Department of Occupational Therapy and Occupational Science, University of British Columbia and has joined Corpus Sanchez International Consultancy as a senior consultant. Françoise Rollin, President Ordre des ergothérapeutes du Québec Françoise Rollin holds a bachelor s degree in occupational therapy and a master s degree in public administration. She is the current president of the Ordre des

3 ergothérapeutes du Québec. After having worked as a clinician and a rehabilitation service manager for more than twenty years, she chose to orient her career towards the development of the profession and the protection of the public. She was first elected president of the Ordre des ergothérapeutes du Québec in 1990 and has since devoted herself to the development of occupational therapy, the regulation of the profession and Quebec s professional system. All her work has been accomplished with the constant preoccupation of gaining a higher recognition for the services provided by the occupational therapists and making sure the population gets the best services it is entitled to.

4 Introduction For 2009, the Canadian Association of Occupational Therapists (CAOT) identified the need to explore the concept of advanced practice for the profession of occupational therapy in Canada as a strategic action. This Professional Issue Forum (PIF) provided CAOT members with an opportunity to explore advanced practice in occupational therapy within the current health care context. Panelists presented the environmental influences that are driving advanced practice, and the clinical, educational, and research implications. The specific objectives of the forum were to: Explore the meanings & key issues related to advanced practice, Exchange information & perspectives about the factors influencing advanced practice, and Develop recommendations for CAOT about the next steps the organization should consider in terms of addressing advanced practice in the profession. The forum was held at the Crowne Plaza Hotel, Ottawa, Ontario on June 4 th, 2009 from 8:30AM-11:30AM. There were 68 participants before the break and 43 participants returned after the break. The format started with introductory remarks from the facilitator (Finlayson), followed by presentations from the panelists (Dickson, Bressler, Rollin). Following the panel, participants divided into four small groups to discuss a series of questions related to advanced practice in occupational therapy. Groups reported back, large group discussion was held, and a series of recommendations for CAOT were identified. A survey on advanced practice and an evaluation form were distributed to participants. The purposes of this report are to: 1. Summarize the background materials reviewed by the members of the Advance Practice panel prior to the forum, 2. Highlight the key issues identified by the members of the panel through their respective presentations at the forum, 3. Present the issues that were identified through round table discussions held as part of the forum, and 4. Make recommendations to CAOT about next steps. Background The information in this section of the report was presented at the forum by Marcia Finlayson in her introductory remarks. The term advanced practice is being used increasingly by occupational therapists, employers, educators and regulators across Canada and around the world. The term is used in occupational therapy job advertisements, educational program advertising (e.g., pos-professional degree foci, continuing education courses, specialty certification descriptions), entry-level occupational therapy course descriptions, occupational therapy

5 job descriptions, and in some practice legislation in the US. Table 1 provides a few examples of the use of the term to date. Table 1: Observed Uses of the term Advanced Practice in Occupational Therapy Source Transition to Practice course descriptions (718, 728, 738), McMaster Occupational Therapy Program MScOT/CourseListing/tabid/1574/Default.aspx Advanced Practice Issues Course, Post-professional MS degree website, Elizabethtown College, PA +Courses&area=OT OTD program description, University of Illinois at Chicago California Board of Occupational Therapy, Dept of Consumer Affairs Punwar & Peloquin (2000). Occupational Therapy Principles and Practice. Lippincott (p. 100) Use of Term This practically-based half course will provide students with the opportunity to develop advanced practice skills within laboratory and real world situations Students will develop advanced knowledge in specialty areas of occupational therapy practice [the OTD]...focuses on developing advanced practitioners with special expertise, advanced knowledge and skills, and the ability to take on leadership and educational roles in the field. Definition of advanced practices: Hand therapy, use of physical agent modalities, and swallowing assessment, evaluation, or intervention [advanced practice] high levels of competence in specialized practice areas.leads to a specialty certification In preparing for the PIF, the panel members concluded that the term advanced practice : Is commonly used in occupational therapy, Has no definition in occupational therapy, and Has no common understanding in occupational therapy. Consequently, key materials from two other organizations were reviewed to gain a greater understanding of what advanced practice could potentially mean and what

6 characteristics and competencies might be associated with such a role. We reviewed materials from the Canadian Nurses Association and the Ontario Physical Therapy Association. Nursing Perspective on Advanced Practice The Canadian Nurses Association produced a position statement on advanced nursing practice (CNA, 2008, p. ii). In this statement, CNA states that: Advanced Nursing Practice (ANP) describes an advanced level of nursing practice that maximizes the use of in-depth nursing knowledge and skill to meet the health needs of clients ANP extends the boundaries of nursing s scope of practice and contributes to nursing knowledge as well as the development and advancement of the profession The statement also identifies characteristics that are consistently associated with advanced nursing practice. These characteristics are summarized briefly below: Demonstrates expert and specialized practice Has the ability to explain and use theory, experience & research to meet complex client needs Has breadth and depth of knowledge Is involved in research, use of research findings, and changing nursing practice based on research Is involved in intersectoral collaboration to meet client needs Is able to analyze and influence health policy Exhibits substantial autonomy and independence Has a high level of accountability. Physiotherapy Perspective on Advanced Practice In 2006, the Ontario Physiotherapy Association struck a task force to examine the issue of advanced practice in that profession. The task force, headed by Linda Woodhouse, prepared a discussion paper for the Association (available at: In this paper, Woodhouse and colleagues differentiate advanced practice physiotherapists from extended class physiotherapists from clinical specialists. The definitions and descriptions of these three types of physiotherapists are summarized below: Advanced practice physiotherapist: denotes not only advanced clinical skill set, but also education, program development, critical appraisal, analytical, research and leadership skills that contribute to the knowledge, development, and advancement of the physiotherapy profession (Woodhouse, 2006, p.6) Extended class physiotherapist: This is a proposed protected title for physiotherapists with advanced clinical expertise working beyond traditional boundaries in advanced practice roles.

7 Clinical specialist: Is an individual with an advanced level of clinical reasoning, professional judgment and clinical skills, which fall in legislated scope of practice. The physiotherapy discussion paper continues and presents eight characteristics of an advanced practice physiotherapist. These characteristics include: Has extensive clinical experience, sound clinical judgment Has an understanding of the broader health care context Is an effective communicator Is a collaborator who consults with clients, families, others Is a self-directed, life-long learner Is a critical thinker who analyzes knowledge, translates to practice, and contributes to development of new knowledge Is professional provides high quality care and is ethical, honest, and demonstrates integrity. Based on these documents, professional experience, and preparatory discussions of the panel members, several common issues were identified with respect to understanding advanced practice. These issues are as follows: Differentiating within scope versus expanded scope Differentiating advanced versus specialty practice The panelists also observed that there appear to be several core characteristics of advanced practitioners, which include: Using theory and evidence deliberately to improve the quality of care provided to clients Engaging actively in knowledge translation to change and improve how practice is carried out Contributing to / being involved in research activities Being a leader Having breath of knowledge (health care environment, policy) Collaborating, communicating, partnering across sectors The panelists also acknowledged that the issue of AP has many stakeholders, all of whom have their own agenda, concerns and needs. Key stakeholders include: Practitioners who are looking for career advancement/ladder opportunities, Employers who are looking to improve the quality and efficiency of their organizations, Regulators who are legally obligated to protect the public and ensure that therapists are competent to perform the functions they are assigned to do, Educators who must be prepared to participate in the training of individuals who are moving into advanced practice roles, and The public, which wants the best possible care and to receive that care in a timely and satisfactory manner that leads to positive outcomes.

8 With this background, the panel members outlined their core assumptions about advanced practice. These assumptions were shared at the forum to frame the panel presentations, round table discussions, and large group discussions. 1. We assume that practice occurs across several descriptive continuums. For example, some key continua are: a. Poor practice to best practice b. Entry level to proficient c. Generalist to specialist. 2. We assume that best practice is what all occupational therapists should be striving to achieve, regardless of position on other continuums. Best practice is theory-driven, occupation and evidence-based, and outcomes-oriented. 3. We assume that advanced practice: a. Is different than best practice b. Is more than specialist practice and more than lots of experience c. Is something that only a small proportion of the profession will achieve d. Is of interest to and being driven by many different players who have different interests and agendas e. Must take into account competencies and scope of practice f. Occurs within a legal and regulatory context, and therefore may not be uniform across the country Key Issues Raised During Panel Presentations Patricia Dickson Clinician s perspective: Environmental pressures have driven organizations to develop advanced practice & extended scope roles. Currently, advanced practice Occupational therapists are experienced OTs whose skillsets are leveraged with additional training to fill clients and systems needs within an organization, especially where there are areas of high demand, such as mental health, arthritis, etc. Examples of these roles are currently found in Ontario in the areas of orthopaedics and rheumatology (Dickson & Bain 2008). These clinicians may receive advanced education and skills training that is facilitybased (e.g. Holland Orthopaedic & Arthritic Centre s advanced practice training), university-based (e.g. McMaster full time MSc Rehabilitation Science). Advanced skillset training currently may also include university affiliated certificate programs (e.g.the Advanced Care Practitioner in Arthritis Care, hosted by St. Michael s Hospital affiliated with the University of Toronto ) Sandra Bressler Employer s perspective:

9 1. Senior management must identify that the position is a priority to be funded 2. Institutes access to funding sources for advanced education 3. Unions (provincial) 4. Universities need to play active role in providing and developing this level of education 5. Regulators provide opportunities for career laddering; increased job satisfaction; financial incentive; increased knowledge translation Challenges include a program management system and the sustainability of advanced practice. Françoise Rollin Regulator s perspective: Throughout Canada, although there are similar competencies gained through university programs and similar practices across the nation, but there is differing provincial legislation. The challenges in advocating advanced practice include the generalist vs. specialist dichotomy; no one definition of advanced practice; concepts have already been defined by law in some provinces. The role and responsibility of a regulator is to ensure that occupational therapy practice will be on a continuum of professional activity and that it includes evidence-based practice and advanced practice. It is recommended that regulator s Adopt a framework to analyze professional activities in occupational therapy, Adopt common definitions supporting the categorization of activities, and Make sure to consider contextual factors and include other stakeholders. Issues Identified in Round Table Discussions After the panel presentations, forum participants divided into four discussion groups. They were provided with a set of questions to consider as a group and provided one hour to go through them. At the end of the hour, groups were asked to report back on their discussions. It quickly became clear that groups had become engrossed in important discussions related to advanced practice, but had not gone through the specific questions. Therefore, Marcia Finlayson asked each group to present the key points of its discussion. From these reports, several common themes emerged from the groups: It is not clear what advanced practice actually is. During the discussion, several possible ways of framing it were identified: o Identifying protected acts versus restricted acts versus a set of particular skills, o Fulfilling our full scope of practice, o Fulfilling a leadership role with a specialist skill-set, o Being an innovator by linking research and leadership in new areas of practice.

10 There was consensus that advanced practice should not be taking on physician roles (i.e., being mini doctors ). There is a desire to have a commonly understood, national definition that can be used consistently within the profession. It may be that advanced practice is not the right term for Canadian occupational therapists, and consideration should be given to whether or not another term might be more appropriate. Occupational therapists want career ladders and advanced practice roles might be a way of addressing this desire. As a consequence, advanced practice is an important workforce planning issue. Regulation and regulators must play a critical role in any discussions about advanced practice. In addition to these core themes, many other important points were raised during the discussion: Occupational therapists are well positioned for advanced practice roles (however they may be defined), as they have a broad skill set. Nevertheless, it is necessary for the profession to be better able to articulate these skills to others. There are many potential areas of opportunity for occupational therapists who might desire an advanced practice role. Two key examples include primary health care and promoting interprofessional coordination to improve care provision. Advanced practice roles will require additional education and therefore there seems to be accreditation issues that must be considered once these roles have a clear definition in the field, and the educational needs related to fulfilling these roles are identified. Questions were raised about who would pay for this additional education therapists or employers. If advanced practice roles are defined and pursued by occupational therapists, the typical/regular duties of occupational therapists must still be fulfilled. Therefore, addressing the roles and responsibilities of support workers needs to be a part of any discussion related to advanced practice occupational therapy. Several key questions were also raised during the discussion, these include: Is advanced practice simply a matter of better integration of our existing skills? Is it simply fulfilling our full scope of practice or does it mean that we must expand the current CAOT Occupational Therapy Profile document? In defining and delimiting advanced practice in occupational therapy, what are we trying to achieve as a profession? How can we defend these goals? How would we evaluate competency in advanced practice roles? What would the impact of advanced practice occupational therapy be on the public? What are the implications of advanced practice roles, particularly if they have extended scope responsibilities, for professional malpractice insurance? Would tasks defined as expanded scope be covered under occupational therapists insurance? How do advanced practice roles fit into the union context?

11 Throughout the discussions, it was apparent that many tensions existed regarding advanced practice and the implications for the profession. For example, if advanced practice roles require involvement in research, this may reduce time to spend in clinical practice. Making this choice could create tensions in workplaces and among coworkers. Strategies to address these types of tensions would have to be addressed during the definition and development of advanced practice roles. Despite the challenges, questions and tensions identified during the discussion, there did appear to be consensus that Canadian occupational therapists needed a national vision of what advanced practice should and could be in Canada. This vision needs to be portable across provinces, span the skill level continuum (entry to proficient), address all of the pillars of practice (clinical, research, education, leadership), and incorporate all types of clients. There also appeared to be consensus that national guidelines and criteria that employers could use to prepare for and support advanced practice occupational therapy would be needed. Recommendations for CAOT 1. Develop a task force, with the following responsibilities/mandate: a. Conduct an environmental scan (SWOT analysis) specific to advanced practice in occupational therapy. b. Conduct a needs assessment to determine what the following stakeholder groups want and could offer in relation to advanced practice occupational therapy: i. Clients ii. Policy makers iii. Occupational therapists iv. Support workers v. Educational programs c. Use findings from the environmental scan and needs assessment to: i. Define the difference between full scope of practice and advanced practice ii. Identify the barriers to full scope at a master s entry level iii. Identify potential career laddering options for occupational therapists d. Develop a national definition of advanced practice occupational therapy in Canada that is not institutionally or provincially based OR select and define an different term that permit a national perspective e. Determine the educational requirements required for advanced practice occupational therapy. 2. Potential members and/or representatives of the task force should include: a. Representatives from the Occupational Therapy Council (e.g, ACOTUP, ACROTRO, CAOT, Foundation) b. Representative from the Federal Ministry of Health c. Representative from the provincial governments (health ministries)

12 d. Representation from other organizations that have been addressing issues related to advanced practice, possibilities include: i. Canadian Nurses Association ii. British College of Occupational Therapists iii. Unions iv. Academic health centres organization (e.g. Association of Canadian Academic Health Care Organizations) Summary There is a pressing need to explore and create a national vision for advanced practice in occupational therapy in Canada. We are not yet ready to write a position statement on advanced practice, yet there is a sense of urgency to move forward with the discussions. The first step will be to set up a task force that can develop the definition of advanced practice within the context of Canadian occupational therapy. Claudia von Zweck, Executive Director at CAOT agreed that CAOT begin to work on this issue and present it to the CAOT Board of Directors at their meeting in November, References California Board of Occupational Therapy, Department of Consumer Affairs. (2009). Retrieved July 9, 2009, from Canadian Nurses Association. (2008). Advanced nursing practice: A national framework. Retrieved July 9, 2009, from ANP_National_Framework_e.pdf Elizabethtown College. (n.d.).occupational therapy department courses. Retrieved July 9, 2009 from McMaster University, School of Rehabilitation Science. (2008). Curriculum design (MScOT). Retrieved July 9, 2009, from Punwar, A. J., & Peloquin, S. M. (2000). Occupational therapy principles and practice (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. University of Illinois at Chicago. (n.d.). Doctor of occupational therapy (OTD). Retrieved July 9, 2009 from Woodhouse, L., & The Advanced Practice Physiotherapy Task Force, Ontario Physiotherapy Association. (2006). Discussion paper: Advanced practice physiotherapy in Ontario. Retrieved July 9, 2009, from Comments: contact Janet Craik (jcraik@caot.ca) or Marcia Finlayson (marciaf@uic.edu)