C ∗ álgebra de un grupo abeliano localmente compacto

This section provides an overview of the strategy used to search for literature relating to MSK ESP practice, both in the UK and abroad. The purpose of the literature review was to look for evidence relating to the following:

1. the exact nature of ESP roles in MSK medicine

2. the clinical effectiveness and cost-effectiveness of ESP roles 3. training, education, and competency frameworks for ESPs

4. the use of Delphi methodology in defining competencies or competency frameworks in health care

20 Reach a consensus opinion regarding

the core clinical competencies (skills, knowledge, and attributes) for MSK ESP practice in primary care.

Seek the views of MSK medical consultants and MSK ESPs regarding the competencies required for MSK ESP practice in primary care.

 MSK ESPs now expected to deal with a wide variety of MSK presentations.

 Access to specialist medical support is now variable and often limited.

MSK ESP roles move into primary care.

 Skills and knowledge for the role have not been defined.

 Medico-legal aspect of extended practice is a grey area.

 Training and education rarely identified.  The role involves substitution for doctors.  Some roles are highly specialized, in a

narrow field of practice, e.g., working with a shoulder surgeon.

 Practice continues to extend.  No regulation of ESP practice.

 No competency and curriculum framework underpinning the role.

 Poor quality research in the field.  A wide variety of titles and roles exist.  Posts are set up in an ad hoc fashion to

meet local demand.

 The patient perspective is poorly understood.

 Doctors’ views rarely sought.

 Competitive health-care market (other non- medical practitioner roles).

 The role is supported by the medical consultant and the wider multidisciplinary team. MSK ESP roles established in a variety of settings in secondary care. Table 1.1 The Conceptual Framework

21 A librarian specializing in health sciences was consulted to ensure that the literature search was thorough and that terms were adequately defined. The terms, truncation, and wildcards used in the search are detailed in Table 1.2. Boolean operators ‘AND’, ‘OR’ and ‘ADJ’ were used and the resources accessed can be found in Table 1.3. The search included ‘grey’ literature as well as published evidence, and included health-care systems other than the NHS. Monthly alerts were set up for AMED, CINAHL, Ovid MEDLINE and Google Giga, and a final search was conducted for work published in 2011/12. There were no limits on the type of study design or the year of publication. Studies relating to paediatric medicine were included if they concerned MSK extended-practice physiotherapy. The search was limited to the English language. Literature relating to advanced-practice roles in other professions was not included, but its inclusion was allowed where it also discussed extended-scope physiotherapy roles. Literature relating to routine physiotherapy was sometimes included, but only where the exact nature and scope of the role was uncertain.

Results were screened using the title and abstract and all full-text articles were retrieved electronically or via inter-library loans; in some instances, the authors were contacted directly. The reference lists in full-text articles were checked manually for additional papers. Studies representing levels I, II and III evidence (CEBM, 2010) were appraised for quality using worksheets from the Critical Appraisal Skills Programme and BestBETs websites, which also provided guidelines for appraising qualitative research (BestBETs, 2010; CASP, 2010). Studies with inadequate qualitative or quantitative data and studies representing levels IV and V evidence were excluded from this formal appraisal process, but they were included for their descriptive content.

Papers relating to extended-practice or advanced-practice roles in physiotherapy totalled over 235, of which only three were randomized controlled trials (Daker- White et al., 1999; Richardson et al., 2005; Jesudason et al., 2011). A fourth publication, an unpublished PhD thesis (McClellan, 2009) described a randomized controlled trial, and this led to the subsequant publication of an abstract in a peer-

22 reviewed journal (McClellan et al., 2009). One systematic review was found relating specifically to MSK ESP roles (Kersten et al., 2007) and one review focused on the ESP role in emergency care (Kilner, 2011). A further three systematic reviews incorporated MSK ESPs as part of a review of nursing and other AHP extended-practice or advanced practice roles: McPherson et al. (2006), Lowe & Prior (2008), and Laurant et al. (2010). The review by Lowe & Prior (2008) was later updated (Stanhope et al., 2012a; 2012b); a fourth review was identified but it focused solely on consultant-practitioner roles (Humphreys et al., 2001). Out of 415 hits, 196 papers where a Delphi study had been used to establish either clinical competencies or education curricula in health care were evaluated; only one of these, an observational study (Ellis, Kersten, & Sibley, 2005), concerned MSK ESP (physiotherapists and occupational therapists) competencies in hand therapy.

Table 1.2 Search Terms

Concept 1 Concept 2 Concept 3 Concept 4

physiotherap$ allied health professional$ extended scope extended practice extended role advanced scope advanced practice advanced role enhanced scope enhanced practice enhanced role practitioner$ MSK musculoskeletal orthop?edics orthop?edic rheumatology competenc$ skills Concept 5 Concept 6 email internet online web based web-based Delphi technique Delphi survey$ questionnaire$ Table 1.3 Resources Electronic databases

CINAHL (Allied Health and Nursing), 1982-02/2011 PEDro (Physiotherapy Evidence)

MEDLINE (1950-02/2011)

AMED, Allied and Complementary Medicine (1985-02/2011) EMBASE (1980-02/2011)

23 OpenSIGLE

Fade library Others

ProQuest Dissertations & Theses database The National Research Register Archive The British Library EThOS online theses The British Library Integrated Catalogue The British Library Conference Collections

Google scholar/Google Giga alerts/advanced Google search The CSP website/ interactive CSP website/ extended-scope physiotherapy website

DH website

National Institute for Health Research Service Delivery and Organization Programme

1.9 Summary

In the UK, the MSK ESP role is well established and the role remains widely accepted by doctors, patients, and other professions allied to medicine. However, there is no competency and curriculum framework for MSK ESP practice, despite the fact that newer non-medical health-care practitioner roles working alongside ESPs already have competency and curriculum frameworks, produced with help from the medical Royal Colleges. SfH has produced the Advanced Practitioner Orthopaedic Physiotherapy Musculoskeletal NTR template, which brings together generic competencies designed to be replicable across different locations but it does not focus on clinical competencies or the MSK ESP role in primary care. The focus of this current study is the ESP role in community-based MSK interface clinics, which is becoming more prevalent as a result of government reforms proposing the transfer of services from hospital-based services to services based in the community settings (DH, 2006a; DH 2006d; DH, 2007a), and this will be discussed in more detail in chapter three. The next chapter reviews the literature surrounding MSK ESP roles in the UK and abroad, but similarly fails to uncover an existing competency framework for MSK ESPs.

24 Chapter 2

MSK Extended-Scope Physiotherapy Practice in the UK and Abroad