INTRODUCTION TO ADVANCED PRACTICE
Advanced practice is not a new concept in healthcare, our nursing colleagues have been leading the way for over 50 years, developing the first roles of advanced nurse practitioner and nurse physician in response to a shortage of junior physicians, in the United States in the 1960s and the UK in the 1980s.¹ Since then, the concept of these roles remains true to their origins, but the education programs, registration, and certification have progressed significantly. Often emerging from identifiable gaps or congestion in medical services, advanced practice roles now exist in almost every area of healthcare, from pediatrics to surgical specialities, research to education, and all of the space in between. In the UK, working at an advanced practice level means that a clinician meets a measurable and defined level of practice within four areas: clinical practice, facilitation of learning, leadership, and research and development, known collectively as the Four Pillars of Practice. Although the exact definition of advanced practice differs around the world, there is a ubiquitous understanding led by the International Council of Nurses that the term defines a level of practice, rather than role specifics²—meaning that in certain areas, it is inevitable that the skills and experience of a particular professional group may lend itself more readily to a particular role. As such, the foundation built by nursing has helped to support the development of advanced practice roles for allied health practitioners (AHPs) such as physiotherapists, podiatrists, radiographers and, of course, orthotists.
THE FOUR PILLARS OF PRACTICE
In line with the Scottish government’s guidance on transforming roles within the NHS, AHP advanced practice frameworks are being developed to assist with standardizing the level of skills, knowledge, behaviors, and education required to be considered an advanced practitioner, in much the same way as had previously been done for nursing. NHS Education for Scotland provides a variety of toolkits and support for clinicians working at various levels within these four pillars,³ which form the basis of advanced practice roles, regardless of speciality.
ADVANCED CLINICAL PRACTICE
In terms of AHPs, and in particular, orthotists, our underpinning biomechanical and anatomical skill set means that we often provide expertise to services such as neurology, orthopedics, and diabetes. Therefore, it was natural that some of the first advanced orthotic practitioner roles were born from these areas. The clinical aspect of my own advanced practice role lies fundamentally in my work with orthopedics, where I have my own caseload working alongside consultant orthopedic surgeons. The patients within my clinics are most often referred for a surgical opinion or for further investigation to assist with diagnosis and treatment planning. Most of my time in these clinics is spent coordinating care from diagnosis to surgical or non-surgical treatment. I am responsible for clinical assessment, organization, and interpretation of relevant bloodwork, imaging—including x-ray, MRI, and ultrasound—the supply and administration of appropriate medications such as therapeutic and diagnostic injections, pre-listing and listing for surgery, and final post-operative review and discharge. Although it is not strictly part of my job role, where possible I also find it beneficial to observe and assist in surgery, under the mentorship of my surgical colleagues.
In 2015 when I first started in this role, there was no precedent for an orthotist to be working within orthopedics in my Health Board. Indeed, it is testament to the foresight of my consultant surgical colleague and orthopedic clinical services manager that I was even given the opportunity to apply. I like to think that in the time before and since starting the job, I have proven the worth and benefit of having an orthotist in the role, helping pave the way for other similar positions that have been created across the country since. With that said, there have been quite a few challenges to overcome in the intervening six years.
One of the fundamental elements of my role is the ability to refer for and interpret relevant clinical imaging such as plain film radiographs, diagnostic ultrasounds, and MRIs. Each aspect of medical imaging usually requires specialist permissions from the Radiology department in which the non-medical referrer works, as well as specialist post-graduate training to a defined level, which can differ depending on the area of practice and referring profession. A recognized certificate in ionizing radiation and medical exposure regulations are requirements for the Health Board in which I work, but the specific qualification for orthotists had never been defined as we had no prior history of requiring access to imaging referral. In collaboration with the Orthopedic, Orthotic and Radiology departments, we agreed on similar standards to those of other AHP professionals, and I undertook recognized post- graduate training at the master’s level as part of a larger PGCert in the theory of podiatric surgery.
Biochemistry, Hematology, Virology, and Pathology
Similarly, the requirement to refer for relevant bloodwork and biopsy is a vital element of the diagnostic process for the orthopedic service. In this instance, the ability to interpret the results in conjunction with the physical clinical assessment is necessary to assure the best outcomes and reduce clinical appointments. There was very little existing guidance in this regard when I started, and so I undertook both a post-graduate university validated qualification on clinical investigations, as well as continuing professional development courses on interpretation of blood results.
Supply and Administration of Medication
As I mentioned earlier, one of the aspects of my role is to provide therapeutic and diagnostic injections for a variety of clinical conditions. In the UK, the supply, administration, and prescription of medication is strictly controlled by government regulation and overseen by our registering body, The Health & Care Professions Council.⁴ Although orthotists do not have the authority to independently prescribe medication, we are able to supply and administer medication under a tightly controlled legal framework, using Patient Group Directions (PGD) and Patient Specific Directions (PSD). Although this legislation had been in place since 2008, there were no prior instances of orthotists having developed or worked under a PGD until 2015. In partnership with orthotic management, pharmacy, orthopedic, and spasticity services, I was involved in the development of the first orthotist-specific PGDs for corticosteroid, local anaesthetic, and botulinum toxin injections. To date we have six PGDs in regular use within our department in NHS Greater Glasgow and Clyde, as well as collaborating on various others. The legal documentation aside, specialist training and qualification was once again required to underpin the clinical skills and knowledge required to use the PGDs. Of interest, the authorization to use PGDs meant that during the COVID-19 pandemic, I and six other orthotists from our department were able to volunteer our services as vaccinators for the various vaccination clinics running in our Health Board.
Listing directly for surgery is, in my opinion, one of the greatest responsibilities that I hold as an advanced orthotic practitioner. It is also probably the area with the least formal guidance. Listing patients from my clinic for surgical procedures means that I undertake the assessment, explanation of treatment options, pre-listing for suitability, and addition to the surgical waiting list; all in the absence of the orthopedic surgeon who will be performing the procedure. As such, the authority to do so lies firmly with the surgeon for whom I am listing. I work with and list for three orthopedic surgeons, all of whom I have shadowed closely, liaised with clinically, and assisted surgically over the years, to gain the trust and autonomy for listing. To compound my own knowledge, I also completed the aforementioned PGCert in theory of podiatric surgery and undertook a Basic Surgical Skills certificate from the Royal College of Surgeons and Physicians in Glasgow.
These are just some of the clinical areas in which I personally required the addition of specific knowledge, skills, training, and forging of relationships between other specializations and departments to successfully undertake the role of advanced orthotic practitioner. However, each role is individual to the needs of the department and the distinct circumstances they face. The clinical aspects will vary, as will the weighting of the other three pillars of practice, all of which are vital for advanced practice.
FACILITATION OF LEARNING
For some advanced practitioners, the role may be less clinical and focused more acutely on education, research, or leadership. Regardless of the weighting toward one of the four pillars, there should be an element of each within the individual practice. In addition to my clinical role, I have a responsibility for the delivery of education to orthotists throughout the UK and internationally, as well as facilitating learning for other healthcare practitioners. I am proud to have been involved in the development and delivery of a large-scale education program on behalf of our professional association in the UK, the British Association of Prosthetists and Orthotists (BAPO), where alongside my colleagues we have delivered more than 30 courses on the holistic management of musculoskeletal (MSK) foot and ankle conditions.
Leadership has become an important focus within many industries over the past ten years, including the NHS, and understandably so, as leading others in a supported way is vital to the progression of any healthcare system. Over my current 15 years of clinical practice, I have become acutely aware that my own successes are a result of the fantastic leadership that I have observed and received from the team with whom I work. I can only hope that in my role as MSK Team Lead for Orthotics NHS GGC that I can provide similar support, mentorship, and inspiration to the members of my team. I cannot overstate the importance of leadership to ensure the development of future advanced practitioner posts.
RESEARCH AND DEVELOPMENT
It goes without saying that the future of any healthcare profession relies on research and development to ensure continued evidence-based practice. For this reason, some advanced practitioner roles are based almost exclusively within this pillar. Job roles can be affiliated with universities and rolling research grants, or time simply set aside for interdepartmental service reviews to demonstrate effective clinical practice. I work with BAPO not only to support the continued education of our profession, but I am also responsible for the maintenance and development of our internationally accessible Directory of Evidence-Based Orthotic Practice (DEBOP), a directory which was developed by orthotists for orthotists and is used by clinicians across the world to support patient treatment and clinical development.5
As the development of advanced practice roles continue, so do the opportunities for orthotists to expand and specialize in a variety of different areas. The non-specificity of advanced practice gives rise to endless possibilities for our small but powerful profession. I would encourage you to seek opportunities within your current service to identify areas which could lend themselves to advanced roles, and don’t be discouraged if it hasn’t been done before. After all, much like our chosen sources of midday drinks, we all have different preferences to pique our interests, attention, and focus.
Author’s note: If you are interested in accessing or contributing to the Directory of Evidence-Based Orthotic Practice, visit ckp.scot.nhs.uk/pathways/nhs-greater-glasgow-and-clyde-6/orthotics-directory-for-evidence-based-orthotic-practice.
Laura Barr, MSc, BSc (hons), PGCert, is an advanced orthotic practitioner and specialist team lead, based in Glasgow, Scotland.
1. Marchione, J. and T. N. Garland. 1997. An emerging profession? The case of the nurse practitioner. Image: The Journal of Nursing Scholarship, 29(4):335-7.
2. International Council of Nurses, 2021. Advanced Practice Nurse Network Definition and Characteristics of the Role, ICN, https://international.aanp.org/Practice/APNRoles.
3. NHS Education for Scotland, 2018. Advanced Practice Allied Health Professions, NES, https://www.advancedpractice.scot.nhs.uk/uk-progress/scotland/allied-health-professionals.aspx.
4. Health & Care Professions Council, 2021. Our Professions Medicines and Prescribing Rights, HCPC, https://www.hcpc-uk.org/standards/meeting-our-standards/scope-of-practice/medicines-and-prescribing-rights/our-professions-medicines-and-prescribing-rights/.
5. Clinical Knowledge Publisher, 2021. The Directory of Evidence-Based Orthotic Practice, CKP NHS Greater Glasgow and Clyde, http://www.ckp.scot.nhs.uk/pathways/nhs-greater-glasgow-and-clyde-6/orthotics-directory-for-evidence-based-orthotic-practice.