It was a reasonably modest event at WCPT (but then what isn’t compared to the scale of the congress!), and so you’d be forgiven for missing it, but the formal launch of the new Threshold Standards for physiotherapists in Australia and New Zealand could actually be one of the most significant events to have happened in physiotherapy in recent years (to view the standards, click this link: Threshold standards Australia NZ 2015).
For the uninitiated, the standards are the culmination of an enormous trans-Tasman project to align the graduating competencies and capabilities of all the schools in Australia and Aotearoa New Zealand. The project was commissioned by the Australian Physiotherapy Board and the Physiotherapy Board of New Zealand and took over 12 months to complete.
What is striking about the new standards is that they focus almost entirely on the abilities practitioners “require to effectively meet the needs of the people they serve” (Frank, Snell, Sherbino et al, 2014, p 1). Based on the CanMEDS
framework, developed by the Royal College of Physicians and Surgeons of Canada, the standards shift the focus away from the technical ‘skills’ of physiotherapy and instead emphasise the personal qualities of graduates.
The result is a framework based around seven new roles:
- Physiotherapy practitioner
- Professional and ethical practitioner
- Reflective practitioner and self-directed learner
- Collaborative practitioner
Each role is differentiated with role definitions and key competencies (see below):
While there is nothing particularly striking about the structure of this system, the language used is radically different to anything we’ve had in Australia and New Zealand before, and promises to open doors to some really innovative and interesting ways to teach, learn, practice and research physiotherapy.
Firstly, the new standards put cultural competence at the heart of practice. Although a lot more needs to be done here, both Australia and New Zealand place a great deal of emphasis on indigenous beliefs, practices, rights and values. The physiotherapy profession has been rather slow at embodying these principles though and has only really paid lip-service to this in the past. Now it looks as if this is going to change.
Cultural competence also includes “but is not limited to, age, gender, sexual orientation, race, socio-economic status (including occupation), religion, physical, mental or other impairments, ethnicity and organisational culture” (p.10), so these thresholds offer the possibility of a much more detailed engagement with diversity and inclusiveness at all levels of the profession.
The standards make explicit that physiotherapists will take an holistic, client-centred approach to practice, which might sound nice in principal, but will be much harder to implement. Physiotherapy is far from holistic, and whilst we certainly care deeply for our clients/patients, it’s a different thing to say that we are client-centred. Moving away from our biomechanical, biomedical, orthodox status to empower and advocate for our clients/patients (see competency 1.4 above) will involve a fundamental shift in power for the profession and a possibly painful transition for many traditional educators and practitioners.
On that note, one cannot fail to notice how far the pure and applied sciences of anatomy, physiology, pathology, biomechanics and kinesiology have fallen down the pop charts. Where once they were considered the foundation stones of physiotherapy, they are now the last of the six ‘Essential components of threshold competence’ (p.7), behind subjects like behaving professionally and ethically, considering each client as a whole, acknowledging the inherent power imbalance in the physiotherapist–client therapeutic relationship, reflecting on their practice and recognising the limits of their clinical expertise, that were once minor players in physiotherapy education.
Even the most ‘traditional’ statement in the document that describes the ‘Assumptions applying to the physiotherapy practice thresholds’ (p.11) brackets the pure and applied sciences into the broader context of determinants of health rather than standalone, sovereign principles:
- knowledge of relevant anatomy, physiology, pathology, other biomedical sciences relevant to
human health and function, and psychosocial and other determinants of health encompassing
cardiorespiratory, musculoskeletal, neurological and other body systems within the context of
physiotherapy and best available research evidence…
This section is one of the few places where the old divisions between musculoskeletal, neurological and cardiorespiratory physiotherapy are mentioned, and not before time. How much longer will we continue to define our specialty on the basis of these narrow, reductive terms?
What is probably most striking of all, however, if one looks closely at the ‘Overview of roles and key competencies’ on pp.13-14, is the fundamental shift in the way physiotherapy is now defined. This new definition will have a radical effect on how we educate future practitioners. At the moment, our curricula are stuffed full of techniques of assessment, diagnosis, rehabilitation and treatment. We have hundreds, possibly thousands, of hours of learning about how to measure hip flexion, how to retrain balance reactions and manually hyperinflate the chest; we spend weeks learning about the anatomy of the hand and the physiology of circulation, and all of these things are seen to be vital in defining our practice. But these new statements challenge us to think differently.
Look at the table on p.13 and see if you can see where the Boards are mandating physiotherapy schools to spend so long on these subjects. To my eye, they appear in only two, possibly three, of the 21 key competencies and compete with entirely new material on advocacy, managing conflict, empowering, physical and mental health resilience. The biggest category in terms of the number of separate competencies is now the role that deals with the ‘Reflective practitioner and self-directed learner,’ and when seen alongside substantive roles like ‘Communicator,’ ‘Educator,’ and ‘Collaborative practitioner,’ the seismic shift in the new practice framework becomes clear.
The challenge for educators will be to turn these humanistic roles into meaningful courses and curricula. We signalled how difficult this might be in two papers published in New Zealand in 2005 and 2009 (see references below), during the early part of a five-year curriculum review process at AUT University in Auckland, and so it has proven.
Staff who are trained in a traditional way of thinking about physiotherapy (where big blocks of anatomy precede applied clinical sciences before the students go out into the real world), are stubbornly resistant to change. Many came to teaching as clinical specialists and desperately want to see their area preserved in the curriculum. Few have any formal training in education, the humanities, cultural studies, philosophy or social sciences, and so find it almost impossible to conceive a different way to construct a curriculum.
In the past, the humanistic capabilities that now make up the bigger part of the new threshold statement have been marginalised in the curriculum and taught by staff with a particular interest. Now they need to move into the mainstream. But I can speak from experience when I say that it’s not easy blending biological and sociological principles in the same course. Students get confused by the different paradigms and it can add a vast volume of new material to a curriculum if it’s not done well. (And these problems come long before the battles with traditionalists who are very reluctant to imagine their subjects taught less or differently).
For those of us who have tried to find new ways to teach physiotherapy, these new threshold statements mark a turning point. They provide legislative weight to support what clients/patients, clinicians, managers, governments and others have been saying about the physiotherapy curriculum for years now…and that is that it needs a complete overhaul. How this happens and who drives this now becomes a vital question if we are going to rise to the challenge of this astonishing document.
Nicholls, D. A., & Larmer, P. (2005). Possible futures of physiotherapy: An exploration of the new zealand context. New Zealand Journal of Physiotherapy, 33(2), 55-60.
Nicholls, D. A., Reid, D. A., & Larmer, P. (2009). Crisis, what crisis? Revisiting ‘possible futures for physiotherapy’. New Zealand Journal of Physiotherapy, 37(3), 105-114.