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Module CHLD0026- Research Project

Essay title Literature review

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Introduction

Professional autonomy, as stated by the World confederation for physical therapy, means the responsibility of the professional to make decisions

regarding the management of a patient or client based on one’s own professional knowledge and expertise to manage his/her practice

independently and to act according to the rules of ethics and the code of professional conduct within the framework of health legislation.

Physiotherapy is rapidly evolving as an autonomous profession, with distinct identify and evidence-based practice. Gaining professional

autonomy is a privilege for any profession (Sandstorm 2007).

The pioneers for a change in physiotherapy practice were Australian physiotherapists (Galley, 1977), and since 1978 physiotherapists have been

autonomous practitioners on qualification . Similar establishment of a new professional status has occurred in developed countries like the UK,

united states of America, Canada. The progression of physiotherapy in these countries has been achieved through added responsibilities

undertaken by physiotherapists such as extended scope practitioners, clinical specialists, therapists acting as first contact practitioners and

acquiring additional skills such as drug prescription, injection therapy and diagnostic imagining prescription along with evidence -based practice

(WCPT, 2012; CSP, 2013). The evolving evidence-based practice underpinning research, has changed our view of acting as first contact

practitioners in a professional capacity within certain self-imposed limitations.

Professional autonomy is usually regulated by defined standards of practice, licensure, and accreditation of a professional entity (Sandstorm,

2007). Despite the professional autonomy granted, the development of autonomous status differs in different health systems internationally,

based on the legislations and organizations which govern the profession. Sandstorm (2007) has described various factors which threaten

autonomy and professional development, such as medical dominance, rationalization which involves bureaucracies controlling the organization

of the profession, deprofessionalization which involves deskilling of the profession. Internal disposition which is social isolation of a profession

has been identified as a potential threat to autonomy. According to the APTA vision 2020, there are three key concepts to autonomous practice:

excellence, communication and collaboration, and advocacy and caring. Differential diagnosis and clinical decision making reflect an excellence

in practice is a key concept of autonomous profession. A commitment to lifelong learning and professional development are important to achieve

excellence in practice as well. Autonomous practice involves practice that is in collaboration with other practitioners and the patient and family

members without a supervisory relationship. Accepting responsibility of one’s practice and advocacy for the patients are important for optimal

outcomes.

The term direct access means that physical therapists have direct access to assess and treat patients without a medical referral for example in

the intensive care unit, determining which patients need physiotherapy interventions (WCPT). Although direct access earlier identified as one of

the major goals towards achieving professional autonomy (sandstorm 2007), the vision APTA 2020 has states these two terms to be distinct to

each other and autonomy is not dependent on the mode of referral. Direct access is a benefit to the consumer, whereas autonomous practice is

a characteristic of the practitioner. If the distinction between a referral for consultation rather than an order for what is to be performed is

understood, then autonomous practice is possible irrespective of the mode of access .Moreover, autonomous practice is not setting specific.

(Cormack et al., 2010)

To summarise the vision 2020 is for achieving autonomous practice with the physiotherapist’s practices to the fullest potential of his /her

education and scope of practice and not as a technician or relying on the orders of another provider, exercising continuous self-evaluation to

determine effectiveness of treatments and using evidence based practice based on latest research.

The current practice in Oman lacks a standardized job description and follows a pattern of medical dominance, wherein physiotherapy treatment

is initiated after a referral from physician is obtained with investigations and diagnosis done. Considering the multi-ethnicity of medical doctors

working in hospitals in Oman, there is a variation in the perception of the medical doctors towards the scope of physiotherapy and independent

status of physiotherapists. This also raises the doubt, due to this lack of awareness of the role and scope of our practice by the referring

physicians could there be patients who are good candidates for physiotherapy and might benefit from treatment going unmissed. The lack of

education about the scope of physical therapy intervention in critical care, leads to inappropriate referrals which are often misleading and out of

scope of physiotherapy. As a result, there seems to arise frequent role expectation conflicts and considering being a limited staffed department

managing a 300 bed hospital, it often leads to inability to provide quality treatment, undertake self-evaluation using outcome measures and

regular monitoring of patient progress and efficient following up. In gaining autonomy along with reducing inter-professional conflicts,

physiotherapists can conduct regular screening of the patients, initiate pre-operative rehabilitation and help in prevention of complications, be an

active part of the MDT team and decide treatment strategies through collaborative work, and early intervention will be possible. To my

knowledge, no research has been undertaken to explore the autonomous status of physiotherapists in Oman, in a hospital setting and the

perceptions of physiotherapists and medical professionals towards it. This study aims to explore the perceptions of physiotherapists and doctors

in Oman towards autonomous practice, to find the gap in knowledge which is essential to make collaborative practice to be autonomous and

provide the best health care, as well as to identify the barriers and facilitators to autonomous practice.

Literature review

Introduction

This review explores the factors perceived by physiotherapists as obstacles towards practising autonomously and the development of the

physiotherapy profession. The perceptions of patients, physicians and other stakeholders towards physiotherapists being the first contact

practitioner was also reviewed.

Literature search methods

The following databases were searched: Scopus, Pubmed, Embase, Science Direct. The MeSH terms used were “physiotherapy’ OR ‘physical

therapy AND professional autonomy OR autonomy. Keywords used were professional autonomy in physiotherapy. Some articles were found

from reference list of relevant articles. Limited studies on perceptions of physiotherapists to professional autonomy were found. Since direct

access and patient self-referral are aspects of professional autonomy and recognition of clinical competence (Ganiyu 2008), further search was

carried out using terms; direct access or open access or self-referral AND physical therapy OR physiotherapy first contact practitioner. No

articles in specifically in-patient settings were found, hence general practice settings are included in this review.

Inclusion Exclusion

- Full articles in English

- General settings, hospital, outpatient,

home and welfare institutions.

-

- Articles in which full text was not available.

- Other languages.

Relevant studies

n= 19

PUBMED

n= 501

EMBASE

n= 361

SCOPUS

n= 283

Excluded duplicates, non English articles, full articles not available

Relevant studies

n= 9

SCIENCE DIRECT

n=426

Studies found in reference lists

n=2

Figure 1: Flowchart of literature search

Table 1:Summary of studies on perceptions of physiotherapists towards their professional role and autonomy.

Study Design Practice setting population aim method results(Crout et al., 1998)United states

Qualitative OPD- orthopedic Licensed physiotherapists n= 471

-investigate difference in opinions and practices between physiotherapists practicing in a state with direct access (Massachusetts) and those practicing in a state that does not permit full access (Connecticut). -To examine the practice of physical therapists practicing in direct access

Self-made questionnaire2 forms284 returned Massachusetts n=176Connecticut n=108

Data combined both groups-96.4% satisfied with career.-87% felt challenged in current job position.-75% supported DA.-73.6% believed DA important for professional development.-less than 20% believed entry level education prepared new graduates for DA practice.

(Ogiwara and Kurokawa, 2008)Japan

Cross-sectional Medical institutionWelfareResearchPublic adminother

229 practising physiotherapistsSystematic sampling method.

To investigate professional role and autonomy of Japanese physiotherapists.

Self-administered postal survey Validated questionnaire (Bergman, 1990)RR 45.8%

-the respondents regarded physiotherapy as specific in its objectives but ill-defined in its role-47.3% believed the physician expected them to be active members of healthcare team. 40.1% believed they were expected to receive patients on referral. -Majority were independent in their work but felt restricted in selection of patients and planning discharge.-Little role conflicts in working environment.-52.7% reported carrying out systemic evaluation of treatment. -Regarded their professional status lower than nurses.

(Groth, 2008)United states

Cross-sectional Hospital basedCorporate ownedTherapist ownedPhysician ownedOther

754 CHT (OT) 32.5%CHT (PT)/ PT 17.3%OT 32.5%Convenience sampling

To examine therapists autonomy in clinical decision making, to describe therapists clinical reasoning strategies, the influence of autonomy on actual clinical practice. (within the context of flexor tendon rehabilitation)

52-item self developed questionnaireRR = 25.3%

-autonomy in CDM was perceived to be low by majority.-greatest autonomy in deciding frequency of rehab sessions and least autonomy in choosing the timing of initiation of rehab and choosing the protocol.-Shared decision making occurred but CDM was rarely collaborative.-Clinical reasoning strategies used frequently, had a novice approach.

-The perceived lack of autonomy negatively affected therapists’ compliance with surgeons’ preferences.

(Chanou and Sellars, 2010)Greece

Qualitative phenomological approach

Private practice 10 physiotherapists Cluster sampling method.

To investigate Athenian physiotherapists experiences of the referral system in Greece and its impact on professional autonomy.

Semi-structured interview

-Physiotherapists were frustrated by the current referral system in Greece.-Confusion in role of practice-They revealed their practice was restricted by medical dominance, bureaucratic process and the public perception of the profession-Internal constraint amongst the physiotherapists

(Chidozie Emmanuel et al., 2015)Nigeria

Cross sectional study Out-patient settings 100 physiotherapists Simple random sampling

To assess the perception of DA and PSR among physiotherapists in south-west Nigeria.

Validated questionnaire for WCPT (Bury and Stokes, 2013)RR 75%

-high awareness on legislation regulating practice and scope of practice-health service funding and reimbursement policies negatively impact DA.-40% reported that entry level education inadequate for DA and PSR-52% recommended a post professional residency programme.-medical views (71%) and political views (65%), reported to be major barriers. -medical and political support reported to be major facilitators.

(Rotor and Capio, 2018)Philippines

Qualitative studyPhenomenological approach

Hospital Out-patientHome health care

10 physiotherapistsPurposive sampling

To explore the clinical reasoning experiences of Filipino physiotherapists across three practice settings.

Semi structured interviews

-prescription based referral system limited CR-procedural reasoning commonly used-diagnostic and predictive reasoning limited.-limiting factors for CR included practice settings and professional relationship with physician.- responses suggest lack of autonomy in practice.

Key: OPD=out patient department , DA=direct access, CHT= certified hand therapist, OT= occupational therapist, PT= physiotherapist, RR= response rate , CDM= clinical decision making, CR= clinical reasoning, WCPT= world confederation of physical therapy, PSR= patient self-referral.

Table 2: Summary of studies exploring perceptions of GP’s, patients and other stake holders towards PFCP .

Study Design Setting Population Aim Method Results

(Desjardins-Charbonneau et al., 2016)

Cross sectional Members of Laval university (52,000 potential participants)Convenience sampling

n= 513Students, professors, teaching assistants, researchers, support staff, administration, direction members.exclusion: member or student of dept of rehabilitation

assess the perceptions of a university community sample in quebec about physiotherapists as primary care practitioners and advanced practice physiotherapists for MSK disorders.

Web survey RR 1%CR 87%

90% believed physiotherapists were competent and skilled 93% trusted physio management in MSK conditions-12% believed it was mandatory to obtain medical referral before physiotherapy.-11% not aware physiotherapists are allowed DA.-58% believed not mandatory to have physician’s diagnosis before physiotherapy.

(Moffatt et al., 2018)United kingdom

Qualitative Two GP practices PFCP in MSK

GP’s , physiotherapists, administrative/reception staff, one practice nursen= 14

aimed to explore how the professionals and practice staff involvedin the delivery of an in-practice physiotherapy self-referral scheme understoodthe service, with a focus on perceptions of value, barriers and impact

Individual and focus group interviews

-it was acknowledged the imperative to change the preconception of GP being the legitimate choice.-reconceptualization of inter-professional hierarchies.-changing perception of primary care as being driven by a multidisciplinary approach. -PFPCS influenced working practice in terms of redistribution of labour and critical role of admin staff- health staff reassurance of physio expertise MSK

(Goodwin et al.)2020Nottingham , UK

Qualitative FPCP service in Nottingham

Patients, physiotherapists, GP’s, administrative staff, commissioners.Convenience sampling10 pts

To explore factors that affect public awareness and understanding of FPCP

Semi structured interviews and focus groups

-There is general public awareness of physiotherapy as a profession.-There is a lack of awareness and patient understanding of FPCP-Traditional methods of advertising FPCP are ineffective andpoorly plannedIt was acknowledged signposting by administrative staff was fundamental in ensuring access to FPCP

Key : RR=response rate, CR= completion rate, MSK= musculoskeletal, DA= direct access, GP= general practitioner, FPCP= first primary contact practitioner, PFPCS= primary first practitioner contact service.

Summary of themes which emerged from the studies based on perceptions of physiotherapists/patients/GP’s/public to their role and professional autonomy.

1.1 Perceptions of role of physiotherapy and scope of practice

An uncertainty in role and scope of practice was observed amongst physiotherapists in the studies undertaken in Japan (Ogiwara and Kurokawa,

2008)and Greece(Chanou and Sellars, 2010). The participants in Chanou et al.’s (2010) study seemed to be uncertain in how they perceived

their role and what was expected of them from other professionals, as a result leading them to adopt working practices which were not

individualised to the patient , indicating an absence of clinical reasoning and decision making. The majority in Ogiwara and Kurokawa et al.’s

(2008) study perceived their practice to be well defined in its objectives but ill-defined in its role. When their perception on their confidence in

practice was assessed, all participants estimated their professional competency to be low. Participants with a diploma degree estimated their

competency to be high, as compared to the baccalaureate and associate degree holders (mean ±SD 3.0±2.0 vs 2.3±1.7). A reason for this was

attributed to the unstandardized education and different types of physiotherapy training schools. It seems like a bachelor curriculum would

involve more theoretical knowledge and evidence-based research; hence the students would have higher academic potential and expectations

from the course as compared to the diploma courses which would focus on practical applications without in depth theoretical knowledge base.

Moreover, in both the studies (Chanou and Sellars, 2010, Ogiwara and Kurokawa, 2008) it was observed that the percentage of Master degree

holders was less, this is attributed to unavailability of higher degrees offered in the countries and lack of standardization in the education

institutions.

Although the majority in (Ogiwara and Kurokawa, 2008) study believed that physiotherapy treatment was necessary to the patient’s overall

health, there was a variation on how they believed physicians perceived their practice. Almost half of the participants (47.3%) believed that they

were expected to be autonomous and active members of the healthcare team by the physicians, however 40.1% believed they were expected to

treat only the patients referred by the doctor, once again displaying an uncertainty of professional role. Moreover, it was reported that a very

small percentage 7.7% assessed patients received on referral from physician, exercising lack of diagnostic reasoning. The participants reported

having rarely experienced conflicting role expectations from other healthcare workers in their working environment which seems to indicate that

the physiotherapists do not challenge medical authority by voicing their own opinions and treatment strategies based on scientific evidence. The

absence of role conflicts in practice indicates lack of assertiveness and an absence of self-direction, which is vital for role definition and

professional development. Similar reports of some physiotherapists comfortable in accepting the referring doctor advised treatment strategies

and reluctance in assuming responsibilities was highlighted in Chanou et al.’s (2010) study as well. This demonstrates an internal constraint

amongst the physiotherapists, confusion in the scope of their practice and as a result establishing routine practices.

Physiotherapists in (Chanou and Sellars, 2010) study , reported facing restrictions to practice to their full potential due to lack of awareness of the

physicians about their autonomous status and the medical dominance. The legislation regulating the physiotherapy profession in Greece dictates

that physiotherapists can choose the treatment or modality after being given a diagnosis by doctors or follow particular instructions by doctors.

These places the physiotherapists in a subordinate role expected to follow instructions from sources outside the profession and not exercise their

own clinical decision making and professional judgement. These illustrate professional domination and rationalization which are identified as

threats to professional autonomy (Sandstorm 2007). As a result, the respondents reported feeling less creative and restricted in their practice. It

indicates the possibility of lack of job satisfaction amongst physiotherapists due to these obstacles which prevent them from practicing to the full

potential of their knowledge and skills. However, due to the small sample size of only 10 participants and all in private settings, it is difficult to

generalise the results to all Greek physiotherapists. Thus, there is a lack of awareness of professional role and lack of uniformity in practice

(Ogiwara and Kurokawa, 2008, Chanou and Sellars, 2010).

In contrast in the study done by Crout K. et al (1998), the physiotherapists practising in both the states (Massachusetts and Connecticut) were

satisfied and challenged in their practice, indicating confidence in professional role.

1.2 perceived obstacles to clinical decision making

Autonomy in clinical decision making implies a defined scope of practice, a distinct knowledge base and expertise (Schutzenhofer KK 1987). The

participants in (Ogiwara and Kurokawa, 2008)study exercised autonomy in deciding the treatment plans and strategies and initiating treatment

with patients as deemed appropriate. However, they lacked autonomy in selection of patients to treat and in planning discharges, treatment is

generally continued until the patient was discharged from the hospital. There seems to be a lack of authority, decision making and predictive

reasoning in their practice. Moreover, only 52.7% reported to self-evaluate the effectiveness of their treatment using outcomes measures, which

is vital to gain expertise and professional recognition. In order to establish a clear definition of role and development of professionalism self-

evaluation by means of using outcome measures is critical. The therapists in Groth’s (2008) study reported having less freedom in initiating

treatment as well as deciding the treatment plans. The practice in united states for hand rehabilitation is physician prescribed, although shared

decision making was reported frequently, the therapists perceived a reliance on the surgeon in collaborative work. The surgeons decided key

elements of rehabilitation. It was reported that this lack in autonomy influenced their practice and led to delayed initiation of rehabilitation which

the therapists predicted can lead to unfavourable patient outcomes. However, the results need to be interpreted with caution due to the low

response rate 25.3% in this study, and the authors provided no details on the therapists who failed to respond to the questionnaire. Moreover,

the study used convenience sampling to recruit participants who may not have been representative of flexor tendon rehabilitation therapists. In-

depth interviews would have given better an in-depth insight of the issues. It’s important to point out that the participants in this study included

occupational hand therapists as well, so results cannot be generalised to physiotherapists autonomy alone. However, it enables one to

understand the medical dominance and struggle for autonomy faced by other allied health professionals as well.

Similarly physiotherapists in (Rotor and Capio, 2018) study found that the strict prescription based manner of referrals limited their clinical

decision making as they were expected to follow the PT prescription without even conducting an evaluation. Evaluation and diagnosis is

important to direct the PT treatment, which seemed to be ignored by the participants in this study attributing it to the prescription based referrals.

It is uncertain however if the physiotherapists felt restricted due to the referrals or negligence to exercise clinical reasoning and decision making,

as seen in Chanou et al.’s 2010 study. However, in Rotor and Capio.’s (2018) study this appeared to differ on the practice settings and the

relationship of the physiotherapist with the referring doctor, which shows a lack of uniformity in the guidelines for professional practice.

Participants from non-hospital settings exercised liberty in making their own clinical judgements and try new intervention strategies as deemed

appropriate based on their clinical reasoning. Similar findings were observed in Chanoue et al.’s (2010) study , participants in this study as well

highlighted the hierarchical relationship with the referring doctors to be a limitation to their autonomous practice. Majority viewed their relationship

with the referring doctors to be restrictive. Some participants (Rotor and Capio, 2018) reported that they could modify or discontinue a patients

treatment, only after informing the referring doctor first , this gives an impression of the need to argue or seek approval for a recommended

programme rather than voicing ones professional opinion. This raises the issue of lack of knowledge regarding physiotherapy scope of practice

and independent practitioner status amongst medical doctors and a professional dominance. This led to physiotherapists in this study being

dissatisfied with their clinical practice and led to a feeling of resignation due to this lack of autonomy. This feelings of frustration and

dissatisfaction were observed by participants in (Chanou and Sellars, 2010) study as well due to restrictions imposed by the legislation and

public funds. However, both the studies (Chanou and Sellars, 2010, Rotor and Capio, 2018) had a small sample size, a larger sample size would

provide a better picture of the inequalities in the healthcare system experienced by physiotherapists.

1.3 perceived threats to autonomy by adopting clinical reasoning strategies

The importance of interactive and collaborative reasoning between the physiotherapist and patient in achieving therapy goals is highlighted by

(Rotor and Capio, 2018). As reported the physiotherapists in out-patient settings exercised good clinical reasoning as opposed to those in

hospital-based settings who adapted a more novice approach with limited diagnostic and predictive reasoning since the patients referred come

with a prescribed plan of treatment. Only a few reported to do an evaluation of the patient already with a diagnosis from the referring physician. In

Groth’s, (2008) study it was found that majority of the therapists frequently used established protocols to make clinical decisions like initiation of

ROM exercises, number of days post op ,as most flexor tendon rehabilitation protocols are described chronologically. Hence, little clinical

reasoning is practiced which reflects a novice and unprofessional approach to treating patients. It indicates that individualized care is not

provided as per the patient’s needs rather following a set protocol for all patients. A reason for this could be that the therapists were asked to

respond according to how they would treat a typical or routine patient. An atypical presentation could possible produce advanced clinical

reasoning strategies. Following the surgeon’s orders as reported by respondents, shows lack of applying clinical reasoning in practice. This leads

to deprofessionalization or deskilling of the profession which is a threat to autonomy. One could assume that, these observations are similar to

the physiotherapists in Chanou et al.’s (2010) study, who adopted a behaviour of reluctance in assuming responsibility for their actions and

preferred being in a subordinate role to medical dominance. However, larger sample sizes would be required to obtain conclusive results.

1.4 Impact of external public perceptions of physiotherapy on autonomous practice

The degree of autonomy held by a profession is a reflection of how the society grades that profession (Kusakari J 1995).The

physiotherapists in (Chanou and Sellars, 2010, Ogiwara and Kurokawa, 2008) reported the public to have a low perception of physiotherapy ,

a lack of professional recognition by the patients was observed by participants in Chanou et al.’s study, they lacked trust in the

physiotherapists knowledge and skills in providing quality care. They attributed this to medical dominance and believed that if the medical

doctors acknowledged the scope of physiotherapy it would influence the patient’s perception of the profession too. In (Goodwin et al.) and

(Moffatt et al., 2018) study they explored the perceptions of various stakeholders towards physiotherapists acting as first contact

practitioners. They recognized the imperative for a cultural change which was based on the preconception amongst the patients that the GP

is the ultimate choice of care. It was acknowledged in these studies that, it is important to reconceptualize the role of physiotherapy and

redefine primary care as a multidisciplinary approach rather than a GP care only. Similarly, it has also been recognized by Goodwin et al.

lack of awareness of scope of physiotherapy practice amongst patients and medical professionals is a significant barrier to its

implementation. The study on a university community sample (Desjardins-Charbonneau et al., 2016) showed that the participants were

satisfied and had confidence in physiotherapists in their roles for the primary care management of musculoskeletal disorders. However, the

results should be interpreted with caution since the sample were members from a university, hence more health literate that the general

public. Moreover, this study only focused on MSK disorders, studies on role of physiotherapists in other settings are required.

1.5 Factors perceived to be obstacles and facilitators to autonomous practice

Medical dominance has been perceived as an obstacle to CDM and reasoning in various settings, more prevalent in hospital settings (Rotor and

Capio, 2018). The participants in Chidozie Emmanuel et al.’s (2015) and Chanou and Sellars et al.’s (2010) study emphasized that in order to

facilitate role recognition of physiotherapy amongst the public, it is essential to gain support from medical professionals through dialogue.so that

physiotherapy should not be subservient to other professions.

Rationalization and de-professionalization

In Nigeria (Chidozie Emmanuel et al., 2015), majority of physiotherapists reported non-reimbursement from insurance companies to

physiotherapy services without a physician’s referral. Similar findings were reported by participants in (Chanou and Sellars, 2010) study.

Restrictions imposed by reimbursement policies and public funds were recognised as the most limiting factor to their practice by Greek

physiotherapists, it was reported that public funds declare that the physician’s referral should be followed precisely, which would impact the

therapist’s clinical decisions. The patient would receive number of sessions/ modalities based on the funds they are registered with. A referral

system should be guided by the health-care benefit rather than the cost of the intervention (Brown and Fitzner, 1999). Posing a threat to

professional autonomy through rationalization and domination (Sandstrom, 2007).

Lack of legislative support: Physiotherapy professional bodies and associations have a dominant role in promoting physiotherapy as

practitioners of choice and professional autonomy (Chidozie Emmanuel et al., 2015). There was no legislative support for direct access in Nigeria

, however majority seemed to find strategies to overcome these restrictions. A majority of physiotherapists were practising direct access without

legal support, and some were unaware of the lack of support for DA from the legislative body.

Similar strategies were seen in (Chanou and Sellars, 2010) study strategies like refusing to carry out prescribed interventions if deemed

inappropriate , communicating and discussing treatment strategies with referring doctors and some reported altering the treatment without

informing the referring doctor or the patient. Although these strategies are adopted by the professionals committed to protect their patients from

potential harm and provide effective treatment, there is are ethical issues regarding patient consent and autonomy. However, covert strategies

adopted by physiotherapists should not become the norm .(Chanou and Sellars, 2010) acknowledged that in order to achieve an effective health

care system which supports professional autonomy, legitimate systems need to be put in place. According to (Ogiwara and Kurokawa, 2008) in

japan the law allows physiotherapy practice to anyone who wishes to practice it, which is a barrier in defining the role of physiotherapists

professionally and socially . As a result, physiotherapy cannot be firmly established as a professional body, which explains the uncertainty of role

perception and lack of uniformity amongst the physiotherapists in the study.

Deficiencies in education curriculum and non- standardized education for physiotherapists has been identified as a significant barrier towards

establishing autonomy. 40% of physiotherapist in (Chidozie Emmanuel et al., 2015) study reported the entry level education to be deficient in

preparing new graduates for direct access. An unstandardized and inadequate educational programme in Japan was also attributed to the

perception of physiotherapists having low competency, and an obstacle to autonomous practice. There is an acknowledgement of a universal

introduction of an objective structured clinical examination (Ogiwara and Kurokawa, 2008).

This led to participants in most studies to introduce set stipulations to practice independently. Participants in Chidozie Emmanuel et al.’s (2015)

study recommended that a post-professional residency programme should be undertaken to facilitate physiotherapists as first contact

practitioners. The importance of continuous professional development training and lifelong learning in establishing professional development and

autonomy has been highlighted by (Chidozie Emmanuel et al., 2015, Chanou and Sellars, 2010). In a comparison between opinions and

practices towards direct access in a state with DA practice versus without, the therapists practising in a state without DA (Crout et al., 1998),

recommended stipulation’s to be put in place to initiate DA, such as treatment plans being periodically reviewed by physicians, therapists having

minimum one year post graduate experience and the requirement to attend standard number of continuous professional development courses

(CPD) , which somehow reflects their perceived inadequacy in scope of practice. It was recognized that the importance of lifelong learning is

fundamental to the development of autonomous practice. The retention of state registration in the UK is based on evidence of continuing

competence to practice (HPC, 2005). Continuing education and engaging in CPD should be a professional obligation to achieve standardization

of practice. (Rotor and Capio, 2018) have recognized the need to advance and evolve physiotherapy practice with the use of evidence-based

practice in decision making, disability prevention and wellness promotion which are areas of PT practice which aren’t subject to physicians’

prescription.

The researchers in (Rotor and Capio, 2018) study attributed the actions of the physiotherapists in Philippines to their intent to stay within the

perceived cultural norms while interacting with their colleagues in the health profession. They acknowledged the importance of teaching future

PT professionals to comfortably communicate and voice their professional role in patient care.

Implications for the current study

The studies reviewed explored the perceptions of physiotherapists on their role and autonomy, as well as barriers to autonomous practice. Due

to limited literature on physiotherapy professional autonomy alone, studies which explored the perceptions of physiotherapists and other

stakeholders (GP’s, patients, administrative staff, community members) on physiotherapists acting as first contact practitioners were reviewed.

Since achieving direct patient access and being the practitioner of choice is attributed to professional autonomy (Sandstorm 2007). Six studies

focused on opinions on autonomy and practices of physiotherapists, however most of the studies surveyed physiotherapists practising in out-

patient settings and private practice mostly managing musculoskeletal/orthopaedic cases. In the studies undertaken by Ogiwara et al. (2008) and

Rotor et al. (2018) included physiotherapists from hospital, home, medical institutions and other welfare services, although it was not clear if they

included physiotherapists practising in the in-patient settings. The results from the studies cannot be generalised to physiotherapists in all

settings. Further due to small sample sizes (Chanou et al , Rotor et al ), low response rate (Groth 2008), and sample not being representative of

the population (Groth 2008, (Chidozie Emmanuel et al., 2015) the results should be interpreted with caution.

In Crout K et al.’s (1998) study, the comparison between the therapists in the two states seemed biased. Since all the physiotherapists included

in the survey were members of American physical therapy association (APTA), knowing that APTA is in favour of direct access raises the risk of

biased results. Moreover, more physiotherapists in the direct access practicing state (Massachusetts) had a master’s degree and only one third

were practising under direct access. A better comparison would be between physiotherapists completely practicing in direct mode of access

versus physiotherapists in a state that does not permit neither evaluation or treatment without a referral. Three studies explored perceptions of

other stakeholders to physiotherapy first contact practitioner service, again all included physiotherapists in OPD orthopaedic settings. Moreover

Goodwin et al.’s (2020) study had only 10 participants , and a selection bias was seen in (Desjardins-Charbonneau et al., 2016) study since 64%

of participants had previously undertaken physiotherapy treatment hence were aware of role of physiotherapy. The sample was from a university

setting where participants are likely to be more health literate than the average population.

The perceptions of physiotherapists to their role and professional autonomy in Oman and other middle east countries is still not known.

Understanding their awareness and opinions on autonomy and the barriers and facilitators to autonomous practice in the in-patient settings, will

help in developing role definition , better collaborative inter-professional relationships and implementing new strategies for effective health care.

Aims

A survey to explore the perceptions of physiotherapists in doctors and Oman towards autonomous physiotherapy practice in in-patient settings.

Objectives

1. To explore the perceptions of physiotherapists and doctors towards physiotherapy professional autonomy.

2. To identify the potential barriers and facilitators perceived towards practising autonomously in the in-patient settings.

3. To create awareness on the autonomous status of physiotherapists.

Appendix :

Research protocol

PROPOSED PROJECT TITLE: A survey of the perception of physiotherapists and doctors in

Oman to physiotherapy autonomy and direct access practice.

BACKGROUND

Although physiotherapy autonomy is recognized by the World confederation of physical

therapy (WCPT,2007a), the level of autonomy differs in many countries. (Massey,2001)

The current physiotherapy referral system in Oman is dependent on physicians. A medical

referral is required for physiotherapists to operate in both private and public sectors, with

physiotherapists acting as a secondary point of contact. Resulting in the physiotherapist

having limited liberty in practice, especially in the management of patients in the in-

patient setup. Due to a lack of standardized guidelines regulating the job description of

physiotherapists, often there is a variation in the scenarios encountered in the process of

referring a patient to physiotherapy. It is not unusual to receive prescription-based

referrals, frequency and duration of treatment desired and in some instances, patients

deemed unfit for physiotherapy.

Studies show that direct access to physiotherapy in outpatient settings and as primary

contact practitioners is associated with equal or better patient outcomes, decreased

health care costs and improved access as well as patient satisfaction and positive reviews

from other stakeholders. There are no studies which explore physiotherapy perceived

autonomy and first contact practice in the in-patient settings.

RESEARCH QUESTION

A survey questionnaire of the perceptions of physiotherapists and doctors in Oman to

physiotherapy autonomy and direct access practice in the in-patient settings.

AIMS

To explore the current role and scope of practice in Oman and views of

physiotherapists and physicians on professional autonomy .

To evaluate the awareness of physiotherapists and doctors towards the

autonomous status of the profession, as stated by WCPT (2007)

To create awareness regarding the benefits of this approach on patient outcomes,

health costs and ease of access.

To determine potential facilitators and barriers towards physiotherapists acting

autonomously and as primary contact practitioners in an in-patient setting.

Undertaking this study will help to educate other team members on the scope of

physiotherapy and bridge the gap between physiotherapists and other

professionals in the multidisciplinary team, to work in collaboration and provide

effective treatment and rehabilitation strategies benefiting the patient.

OBJECTIVES

Conducting an online survey directed to physiotherapists, including questions

about their entry level qualification/years of experience/speciality/area of

expertise and awareness of physiotherapy autonomy.

Their experience working with a multidisciplinary team and their perception

towards the concept of self-referring patients based on their own assessment

and planning an effective management.

A questionnaire directed to doctors to know their perceptions on the concept of

physiotherapists practicing independently and decision making. Their views on

the potential pitfalls to this approach.

METHODS

1.ETHICS AND R&D CONSIDERATIONS –

Permissions from the Commanding Officer Armed Forces Hospital Oman, the Head of

Physiotherapy and rehabilitation department. Awaiting approval.

Permission from the research committee at the Ministry of Health, Oman. Awaiting

approval.

2.STUDY DESIGN – A questionnaire-based online survey.

a) The study will be conducted at the Armed forces hospital, government sector

hospital in Muscat Oman and the Royal hospital Muscat Oman.

b) Target population: physiotherapists and doctors in government sector hospitals in

Oman.

c) Inclusion criteria- Qualification: B.Sc., M.Sc., Ph.D. PT with> 2 years work

experience, PT with in-patient and critical care work experience. Doctors

(anaesthetists, ICU intensivists, general physicians, orthopaedics, neurosurgeons)

d) Exclusion criteria- Qualifications: Diploma, PT<2 years’ experience, PT with only

out-patient exposure, non-clinical PT. Doctors outside Oman, private sector.

e) Sample size – approximately 25-30.

3.PROCEDURE

Convenience sampling technique to recruit participants.

Self-made questionnaire, approximately 30-35 questions divided into sections.

Close-ended questions with multiple choice answers and/or Likert scale response.

Text box provided to write comments on each section.

Open-ended questions where required.

Participant anonymity maintained.

Descriptive analysis will be done.

PLANNED PILOT and/or RELIABILITY STUDY

Piloting the questionnaire to assess the clarity and precision of the content. Receiving feedback from Senior Physiotherapists > 10 years’ experience, UCL

professors. Getting approval for the questionnaire.

DATA COLLECTION

Surveymonkey.com, wen platform will be used. Link will be sent through email to the

participants.

STATISTICAL ANALYSIS: Descriptive statistics.

DESCRIBE HOW THE RESEARCH FINDINGS WILL BE USED

Positive findings from this survey will help raise awareness about physiotherapy

autonomy in Oman along with its benefits.

The study will add to professional development of physiotherapists.

It will aid in efficient time management, to focus on the areas where PT can provide

quality treatment and benefit the patients.

Timely management of patients.

Avoiding waste of resources.

REFERENCES :

CATHARINE DUNCAN, L. M. A. C. H. 2015. Impact of using physiotherapy self-referral in the medical-surgical neurological intensive care unit. Physiotherapy Canada, 67, 39-45.

Ojha, Heidi A, Rachel S Snyder, and Todd E Davenport. "Direct Access Compared with Referred Physical Therapy Episodes of Care: A Systematic Review." Physical Therapy 94.1 (2014): 14-30. Web.

Crout, K. L., Jennifer, H. T., & Miller, D. J. (1998). Physical therapists' opinions and practices regarding direct access. Physical Therapy, 78(1), 52-61.

doi:http://dx.doi.org.libproxy.ucl.ac.uk/10.1093/ptj/78.1.52

WCPT. Declarations of Principle. London: World Confederationfor Physical Therapy, 2007a.

CHIDOZIE EMMANUEL, M., KAYODE, D. O., RUFUS ADESOJI, A., UDOKA, A. C. O., OLUBUSOLA, E. J., ABIOLA OLADELE, O., TAOFEEK OLUWOLE, A. & OLUMIDE OLASUNKANMI, D. 2015. Nigerian physiotherapists’ perception of direct access and patients’ self-referral. Nigerian Journal of Medical Rehabilitation, 18.

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