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CHAPTER CONTENTS

INTRODUCTION

FINAL

This chapter aims to provide the reader with an insight

Introduction

1

into what it means to be a professional (in the context

Characteristics of being a professional

2

of this

chapter,

a physiotherapist),

focusing on the

responsibilities, both ethical and practical, that are

Responsibilities of being a professional

5

inherent in claiming to be a professional working in

Becoming an autonomous profession

6

the UK.

-

NOT

The current status and privilege of physiotherapists

Clinical governance

7

as autonomous professionals will be placed in the con-

OF

ELSEVIER

Evidence-based practice 8

text of the history of the profession, and the impact of

autonomy on clinical practice will be explored. The

Clinical effectiveness

10

chapter will reflect on the implications for physiothera-

pists of the increasing expectations of both the general

public and the government for health professionals to

Applying national standards and guidelines

locally 10

deliver high-quality health services. Explanations of

Evaluating services

12

how

physiotherapists can

meet

these expectations

through clinical governance will be provided. Finally,

Continuing professional development

13

the reader will be offered a look at the possible future

CONTENTof the profession in light of the changing shape of

Having the right workforce (and using it

health services in the UK.

appropriately) 14

Physiotherapists come into the profession because

Monitoring clinical governance

15

they have an underlying sense of

and commitment

The future

15

to

helping others and improving

their quality of

life. Indeed, Koehn (1994) argues that professionals

Sources of critical appraisal tools

17

can be

thought

of as being

defined

by a distinctive

PROPERTY

commitment to

benefit the client.

Physiotherapists

Acknowledgements

18

want to be able to use their acquisition of knowledge,

References

18

skills

and attributes from qualifying

programmes to

SAMPLE

benefit people, in whatever specialty or with whichever

patient group they wish to work once qualified

for example, elite athletes, older people, people with

developmental or acquired conditions, people with

mental health problems. This chapter will help readers

understand how they can

make

benefiting patients

a reality in the context of the expectations of society

for the provision of high-quality, safe and effective

care.

1

While earlier editions of Tidy’s Physiotherapy may

The professional body for physiotherapists, the

have been popular for their prescriptive descriptions

Chartered Society of Physiotherapy (CSP), provides a

of what physiotherapists should do in particular situa-

framework for the curriculum of physiotherapy educa-

tions or for specific conditions, this edition demands

tion and approves those physiotherapy programmes

more from the reader. No two patients are quite the

that meet the requirements of the framework on behalf

same; each requires the skills of the physiotherapist to

of the profession.

carry out a full and accurate assessment, taking account

The CSP also publishes rules of professional conduct

of the individuality of the patient, and then to use clini-

and standards of physiotherapy practice derived from

cal reasoning to problem-solve and offer appropriate

within the profession, which are in harmony with those

options for treatment, on which the patient will make

of the HPC. Anyone on the HPC physiotherapist regis-

a decision. A professional is required to have the matu-

ter may call themselves a physiotherapist; only those

rity to take full responsibility for the privilege of auton-

who are members of the CSP may call themselves a

omy. This will be by maintaining a competence to

chartered physiotherapist.

practise through career-long learning and through

The breadth of activity and resources that the CSP

self-evaluation, as well as through the evaluation of

undertakes and provides seek to establish a level of excel-

present practice; by keeping up to date with the most

lence for the profession. Its education and professional

effective interventions; and by maintaining the trust of

activity is centred on leading and supporting members’

patients by doing good. Readers should realise that

delivery of high-quality, evidence-based patient care. This

while this approach is more challenging, it will also

FINAL

activity emanates from its status as the professional body

be more rewarding.

for physiotherapy in the UK and therefore as the primary

holder and shaper of physiotherapy practice. The CSP

CHARACTERISTICS OF BEING

works on behalf of the profession to protect the chartered

status of physiotherapists’ standing, which is one denot-

A PROFESSIONAL

NOT

ing excellence. It is worth noting that the relationship with

Becoming a professional requires an acceptance, often

-

the HPC is one of registrant; with the CSP it is one of

implied, of certain responsibilities, in return for certain

membership.

ELSEVIER

privileges. These responsibilities require certain beha-

While the principles of professionalism should be

viours and attitudes of individuals in whom profes-

aspired to by physiotherapists anywhere in the world,

sional trust is placed. Broadly, professionalism requires

the existence and/or role of regulators and professional

these attributes:

OF

bodies and the way these characteristics are manifested

may vary, depending on political, social and financial

▪ a motivation to deliver service to others

factors.

▪ adherence to a moral and ethical code of practice

▪ striving for excellence, maintaining an awareness of

Belonging to an organisation that sets

limitations and scope of practice

standards and ideals of behaviour

▪ the empowerment of others (Hodkinson 1995 and

CONTENT

Medical Professionalism Project 2002, both cited in

The Rules of Professional Conduct (the Rules) were

CSP 2005b).

endorsed at the very first council meeting of the CSP

To practise in the

profession of

physiotherapy

in

in 1895

(Barclay 1994)

and have been revised and

updated at intervals since. The Rules define the profes-

the UK, registration

with the statutory regulator

is

sional behaviour expected of chartered physiothera-

required. The Health Professions Council (HPC) sets

pists. The current Rules set out a number of principles,

standards of professional training,

performance and

the basis for all of which is to safeguard patients (CSP

conductPROPERTYfor thirteen professions, including physiother-

2002a).

They include

requirements that chartered

apy (HPC 2006). It keeps a register of health profes-

physiotherapists should:

sionals that meet its standards, and it takes action if

SAMPLE

▪ respect the dignity and individual sensibilities of

registered health professionals do not meet those stan-

dards. It was created by the Health Professions Order

every patient

2001 (HPC 2002). Only those registered with the HPC

▪ work safely and competently

may call themselves a physiotherapist/physical thera-

▪ ensure the confidentiality of patient information

pist (HPC 2006). It is the duty of registrants to keep

▪ report circumstances that might otherwise put

up to date with the processes and requirements decreed

patients at risk

by the Regulator; this is particularly important currently

▪ not exploit patients

because of the changing attitudes to, and legislation of,

▪ act in a way that reflects credit on the profession and

healthcare professions in recent times.

does not cause offence to patients.

▪ involving patients in decision-making

practise of its members, except those described in the

▪ being fully abreast of the evidence of effectiveness

next paragraph. The HPC considers all complaints of

in order to inform patients and offer the most effec-

this nature.

tive interventions

The Society

does however, handle complaints or

▪ evaluating their practice and measuring a patient’s

consider matters of fitness to practise concerning mem-

health gain as a result of treatment.

bers of the Society who are not regulated by the HPC.

This reflects the increasing expectations of the public to

(This includes physiotherapist’s physiotherapy treat-

be active partners in their healthcare, the expectations

ment of animals, students and the CSP’s associate

of clinical governance to provide more effective care,

members (CSP 2006).)

FINAL

and the growing demands of funders of services, as

Possessing knowledge and skills not shared

well as patients, to be able to demonstrate the benefits

by others

or ‘added value’ of physiotherapy. All these will be dis-

cussed later in the chapter.

Any profession possesses a range of specific knowledge

Standards of Physiotherapy Practice is written in a way

and skills that are either unique, or more significantly

that offers a broad statement of intent (the Standard

NOT

developed than in other professions. The World Congress

statement), which is followed by a number of measur-

-

for Physical Therapy (WCPT) has described the nature of

able statements about expected performance or activity

physiotherapy as ‘providing services to people and popu-

ELSEVIER

by the physiotherapist, student or assistant (known as

lations to develop, maintain and restore maximum move-

‘criteria’). For example, Core Standard 2 states ‘Patients

ment and functional ability throughout the lifespan’

are given relevant information about the proposed

(WCPT 1999).

physiotherapy

procedure,

taking into account

their

It adds, in a detailed description, that physical ther-

OF

apy is ‘concerned with identifying and maximising

age, emotional state and cognitive ability, to allow

informed consent.’ The criteria for this standard include

movement potential, within the spheres of promotion,

the following:

prevention, treatment and rehabilitation’ (ibid, p28).

▪ The patient’s consent is obtained before starting any

WCPT identifies the interaction between ‘physical

therapist, patients or clients, families and care givers,

examination/treatment.

CONTENTin a process of assessing movement potential and in

▪ Treatment

options, including

significant

benefits,

establishing agreed upon goals and objectives’ as cru-

risks and side-effects, are discussed with the patient.

cial and acknowledges that

this requires knowledge

▪ The patient

is

given

the

opportunity

to

ask

and skills unique to physical therapists (ibid, p28).

questions.

In the UK,

one approach

to conceptualising phy-

▪ The patient is informed of the right to decline phys-

siotherapy has been to focus on three core elements: mas-

iotherapy

at

any

stage

without that prejudicing

sage, exercise and electrophysical modalities (CSP 2002a).

future care.

For physiotherapy, the roots of the profession can be

PROPERTY

▪ The patient’s consent to the treatment plan is docu-

found in massage, the founders of the profession having

mented in the patient’s record.

been a group of nurses who carried out massage. The sig-

SAMPLE

nificance of therapeutic touching of patients still sets

These measurable criteria allow performance to be

assessed against them, through clinical audit, described

physiotherapy aside from other professions. Physiothera-

in more detail later.

pists continue to use massage therapeutically as well as a

The content of this standard and accompanying

wide range of other manual techniques such as manipu-

criteria set out the specific actions required in order to

lation and reflex therapy. Therapeutic handling under-

conform, in this case, to an aspect of Rule 2 of Rules of

pins many aspects of rehabilitation, requiring the

Professional Conduct: ‘Chartered physiotherapists shall

touching of patients to facilitate movement.

respect and uphold the rights, dignity and individual

Another description of the profession’s knowledge

sensibilities of every patient,’ which includes guidance

and skills can be found in the Curriculum Framework

1

for Qualifying Programmes in Physiotherapy (CSP 2002b).

the ability to think critically about practice, to learn

This sets out the underpinning knowledge and skills

from experience and apply that learning to future sit-

required of newly qualifying physiotherapists, setting

uations. It is the relationship between the physiothera-

this in the context of their application in professional

pist’s knowledge, his or her ability to collect, analyse

practice areas and environments. These are, in turn,

and synthesise relevant information (cognition), and

underpinned by a set of professional attributes, identity

personal awareness, self-monitoring and reflective

and relationships, such as understanding the scope of

processes, or metacognition (Jones et al. 2000).

practice and active engagement with patient partner-

This professional autonomy has, however, to be

ship. Finally, the framework sets out the outcomes that

balanced with the autonomy patients have to make

graduates should be able to demonstrate: for example,

their own decisions. Patient-centred decisions require a

‘enable individual patients and groups to optimise their

partnership between patient and professional, sharing

health and social well-being’ and ‘respond appropri-

information, with patients’ values and experience being

ately to changing demands’.

treated as equally important as clinical knowledge

and scientific facts (Ersser and Atkins 2000). Higgs and

‘

Definition

Titchen (2001) describe the notion of the professional’s

Physiotherapy is a healthcare profession concerned

role as a ‘skilled companion’. The professional is char-

with human function and movement and maximising

acterised as a person with specialised knowledge which

potential. It uses physical approaches to promote,

can be shared with the patient in a reciprocal ‘working

maintain and restore physical, psychological and social

FINAL

with’ rather than ‘doing to’ relationship, and as someone

well-being, taking account of variations in health status.

who ‘accompanies the patient on their journey towards

It is science-based, committed to extending, applying,

health, adjustment, coping or death’. This patient-

evaluating and reviewing the evidence that underpins

centred model facilitates the sharing of power and

and informs its practice and delivery. The exercise of

responsibility between professional and patient.

clinical judgement and informed interpretation is at its

NOT

A history of how the physiotherapy profession’s

core (CSP 2002b).

-

autonomy evolved in the UK can be found later in this

chapter.

ELSEVIER

Cott et al. (1995) have proposed an overarching

framework for the profession: the movement continuum

Licensed by the state

theory of physical therapy,

arguing that the

way in

As previously mentioned, physiotherapists in the UK

which physiotherapists conceptualise movementOFis what

have to be registered with the HPC in order to use the

differentiates the profession from others. They suggest

title physiotherapist and therefore to work in any setting

that physiotherapists conceive of movement on a contin-

in the UK. This is a government measure to protect

uum from a micro (molecular, cellular) to a macro (the

patients from unqualified or inadequately skilled health-

person in his or her environment or in society) level.

care providers.

The authors argue that the theory is a unique approach

to movement rehabilitation

CONTENTIn 2006, the HPC put in place a system requiring

because it incorporates

re-registration at intervals of two years, linked to an

knowledge of pathology with a holistic view of move-

individual’s commitment to

Continuing Professional

ment, which includes the influence of physical, social

Development (CPD), whereby individuals must under-

and psychological factors in an assessment of a person’s

take and maintain a record of their CPD activities and,

maximum achievable movement potential. They argue

if required, submit evidence

of this and of the

out-

that the role of physiotherapy is to minimise the differ-

comes of their CPD on their practice, service

users

ence between a person’s current movement capability

and service. Re-registration is in response to a lessen-

PROPERTY

and his or her preferred movement capability.

ing of public confidence in the National Health Service

Exercising autonomySAMPLE

(NHS) following, for example, the report into children’s

heart surgery in Bristol (Bristol Royal Infirmary Inquiry

Autonomy, or ‘personal freedom’ (Concise Oxford

2001). Equally disturbing were the revelations about

Dictionary, 7th edn) is a key characteristic of being a

the murders of so many patients by Harold Shipman, a

professional. It allows independence, but is mirrored

man who had been a previously trusted general practi-

by a responsibility and accountability for action. Cen-

tioner, where health systems failed to detect an unusu-

tral to the practice of professional autonomy is clinical

ally high number of deaths (Department of Health 2004).

reasoning, described as the ‘thinking and decision-

This has led the government to introduce a number

making processes associated with clinical practice’

of measures, including the requirement for all health

(Higgs and Jones 2000). Clinical reasoning

requires

professionals to re-register at specified intervals, in

Responsibilities of being a professional

5

order to be seen to be protecting the public through a

about meeting needs. Being a professional is a

1

more explicit and independent process (Department

privilege

in particular the trust that is bestowed by

of Health 2002). It aims to identify poor performers

the public

which underpins

the patient’s ability to

who may be putting the public at risk, as well as

benefit from treatment. However, this brings with it

providing an incentive for professionals to keep up to

weighty responsibilities.

date, maintaining and further developing their scope

of practice and competence to do their job. Disciplinary

Doing only those things you are competent

processes are in place to remove, ultimately, an indi-

to do

vidual from the register (HPC 2005). The means by

Every physiotherapist has her or his own personal

which individuals can maintain their competence are

discussed later in the chapter.

‘scope of practice’ (CSP 2002a)

that is, a range (or

FINAL

scope) of professional knowledge and skills that can

Making a commitment to assist those in need

be applied competently within specific practice settings

As stated earlier, one of the characteristics of a profes-

or populations.

When a person is newly qualified, this scope will be

ELSEVIER

sional is to want to ‘do good’. This is reflected in the

based on the content of the pre-qualifying Curriculum

ethical principles of

the physiotherapy profession,

Framework, but will also be informed by the indivi-

where there is a ‘duty of care’ incumbent on the indi-

dual’s experience in clinical placements, and the amount

vidual towards the patient, to ensure that the therapeu-

of teaching and reflective learning that has been possible

tic intervention is intended to be of benefit, as set out

as part of those placements.

in Rule 1 (CSP 2002a). This is a common-law duty,

As a

career progresses,

and as a

result of CPD,

a breach of which (negligence) could lead to a civil

some physiotherapists will become competent in high-

claim for damages.

ly skilled areas such as intensive care procedures, or

More generally, Koehn (1994) suggests, professionals

-

NOT

splinting

for

children with

cerebral palsy, which

▪ demand from the client the responsibilityCONTENTto provide,

are perceived to have moral authority, or trustworthi-

are unlikely to have been taught before qualification.

ness, if they:

Others will extend their skills in areas in which they

▪ use their skills in

the context of the client’s best

already had some experience: for example, dealing with

interests and ‘doing good’

people with neurological problems. Others will enhance

▪ are willing to act as long as it takes for assistance

their communication and life skills, as well as refining

to achieve what it set out to achieve, orOFfor a decision

their physiotherapy skills by, for example, working

PROPERTY

constantly evolving, based on professional and life

to be made that nothing more can be done to help

with elderly people or people with learning difficulties.

the client

It is the responsibility of the professional to under-

▪ have a highly developed internalised sense of respon-

stand his or her personal scope of practice as it changes

sibility to monitor personal behaviour: for example,

and evolves throughout a career. To practise in areas in

by not taking advantage of vulnerable patients

which you are not competent puts patients at risk and

SAMPLE

is a breach of the CSP’s Rules of Professional Conduct,

for example, sufficient information to allow decisions

and the

standards of the profession’s regulator, the

HPC (2003).

to be made (compliance)

▪ are allowed to exercise discretion (judgement) to do

the best for the client, within limits.

Maintaining competence to practise

Koehn (1994) argues

that trustworthiness is what

An individual’s scope of practice and competence are

stands out as a particularly unique characteristic of

being a professional

to do good, to have the patient’s

experiences,

learning from

reading,

from evaluating

best interests at heart and to have high ethical stan-

practice,

from

reflecting on

practice,

or more formal

dards. Physiotherapists not prepared to maintain such

ways of learning. It includes undertaking programmes

ethics, even in difficult and stressful situations, run

of structured CPD. Clinical reasoning skills are contin-

the risk of losing the respect as well as the trust of their

ually refined

and further

developed throughout a

patients and the public.

career through evaluative and reflective practice, lead-

ing to the ability to deal with increasingly complex

RESPONSIBILITIES OF BEING A PROFESSIONAL

and unpredictable situations.

Physiotherapists have a duty to keep up to date

Physiotherapists in the UK are granted the right to

with new information generated by research, with what

make their own decisions, in partnership with patients,

their peers are thinking and doing, and by formally

1

evaluating the outcome of their practice. The responsi-

standards (CSP 2005a). Where they do not, programmes

bility for this is dictated by the

HPC

(2003) and

of professional development should be put in place

reflected in the Standards of Physiotherapy Practice (CSP

to facilitate full compliance, as part of the individual’s

2005a). In particular, Core Standards 19 22 are con-

professional responsibility.

cerned with a requirement that individuals assess their

Physiotherapists should not be critical of each other,

learning needs, then plan, implement and evaluate a

except in extreme circumstances. However, they do

programme of CPD based on that assessment.

have a duty to report circumstances that could put

patients at risk. In the NHS, there are procedures and

Responsibility to patients

a nominated officer within each trust from whom

advice can be sought. Outside the NHS, advice can be

This chapter has already discussed the importance of

sought from the CSP. Physiotherapists are encouraged

the individual physiotherapist as well as the profession

to be proactive in supporting each other’s professional

as a whole in maintaining the attributes of

profes-

development and in promoting the value of the profes-

sionals. Trust is perhaps the most essential characteris-

sion in local workplace

settings, in policy-making

tic with which to develop a sense of partnership with

forums and in the media.

patients; in turn, this will optimise the benefits of inter-

vention. For physiotherapy, many of the other hall-

marks for building and securing trust are set out in

BECOMING AN AUTONOMOUS PROFESSION

the profession’s Rules and Standards. For example:

FINAL

The CSP was founded in 1894, under the name of the

▪ to provide safe and effective interventions (safety of

Society of Trained Masseuses. This section will not

application as well as safe and effective)

Rule 1

attempt to relate the history of the profession, except

and Core Standards 4, 8, 16

in the context of developing autonomy. However, more

▪ to treat patients with dignity and respect

Rule 2

about the early days of the profession can be found in

and Core Standard 1

NOT

the book In Good Hands (Barclay 1994).

▪ to provide patients with information about their

-

For many years, doctors governed the profession.

options for treatment/interventions

Rule 2 and

One of the first rules of professional conduct stated

Core Standard 2

ELSEVIER

‘no massage to be undertaken except under medical

▪ to involve patients in decisions about their treatment

direction’ (ibid). Even in the 1960s doctors were assert-

(informed consent)

Rule 2 and Core Standard 2.

ing that they must take full responsibility for patients

OF

in their charge

and ‘professional and technical staff

have no right to challenge [the doctor’s] views; only

Responsibility to those who pay for services

Physiotherapists have an ethical responsibility to those

he is equipped to decide how best to get the patients

fit again’ (ibid). It is hard to believe now that it took

who finance services, whether these are commissioners

more than 80 years to escape the paternalism of doctors,

of healthcare, taxpayers or individual patients, to pro-

on whom physiotherapists were dependent for referrals.

vide efficiently delivered, clinically and cost-effective

interventions and services, in order

CONTENTThe first breakthrough came in the early 1970s, when a

to give value in

report by the Remedial Professions Committee, chaired

an era when resources for healthcare are limited. This

by Professor Sir Ronald Tunbridge, included a state-

is embedded within Rule 1 of the CSP’s Rules of Profes

ment that while the doctor should retain responsibility

sional Conduct in relation to the establishment of a ‘duty

for prescribing

treatment,

more scope in application

of care’ towards the patient (CSP 2002a).

and duration should be given to therapists.

Responsibility to colleagues and

The McMillan report (DHSS 1973) went further, by

recommending

that therapists should be allowed to

PROPERTY

the profession

decide the nature and duration of treatment, although

A profession has legitimate expectations of its members

doctors would remain responsible for the patient’s wel-

SAMPLE

fare. There was recognition that doctors who referred

to conduct themselves in a way that does not bring the

profession into disrepute, but rather enhances public

patients would not be skilled in the detailed application

perceptions. Physiotherapists have a duty to inform

of particular techniques, and that the therapist would

themselves of what is expected of them. Indeed, the

therefore be able to operate more effectively if given

Rules of Professional Conduct state that knowledge of

greater responsibility and freedom.

and adherence to the Rules are part of the contract of

Eventually, a Health Circular called Relationship

membership of the CSP. The Standards of Physiotherapy

between the Medical and Remedial Professions was issued

Practice make it clear there is an expectation that all

(DHSS, 1977). This acknowledged the therapist’s com-

physiotherapists should be able to achieve all the core

petence and responsibility for deciding on the nature

of the treatment to be given. It recognised the ability of

The accountability of chief executives

1

the physiotherapist to determine the most appropriate

for quality

intervention for a patient, based on knowledge over

Although some chief executives of NHS trusts claim

and above that which it would be reasonable to expect

they were always responsible for quality, this had not

a doctor to possess. It also recognised the close relation-

been a statutory responsibility in the way it was for a

ship between therapist and patient, and the importance

trust’s finances. Chief executives now have a statutory

of the therapist interpreting and adjusting treatment

responsibility for quality.

according to immediate patient responses.

Autonomy was only achieved by being able to

The introduction of a philosophy of

demonstrate competence to make appropriate deci-

continuous improvement

sions, building up the trust of doctors and those paying

One-off improvements are not enough

the NHS

for physiotherapy services. The need to acquire skills

has to move to a culture of continuous improvement

of assessment and analysis became a key component

to achieve excellence. In addition, the emphasis

has

of student programmes from the 1970s. Today, qualify-

shifted from improving a particular aspect of care in

ing programmes stress even further the development

isolation, to examining the whole system of care, cross-

of skills, knowledge and attributes required for auto-

ing professions, departments, organisations

and

sec-

nomous practice.

tors, to ensure the whole process meets the needs of

patients through an integratedFINALapproach to healthcare.

CLINICAL GOVERNANCE

An aspiration to achieve consistency of services

So far, this chapter has explored the responsibilities

across the NHS

of being a physiotherapist from a professional perspec-

This is founded on two principles:

tive. The focus has been on the individual’s personal

NOT

responsibility as a professional. This section will put

▪ If one trust can provide excellence in a service, then

-

all that in the context of a professional’s responsibilities

so can all trusts.

▪ Local services should, where possible, be based on

to the employer organisation, whether it be in the public

ELSEVIER

or the independent sector.

national standards: for example, National Service

Frameworks or nationally developed clinical guide-

In the NHS, responsibility for the clinical safety of

lines.

patients and the quality and effectiveness of services

is maintained via a system of clinical governance. It

There is some evidence to suggest that nationally devel-

OF

seems probable this will apply equally to the indepen-

oped standards or clinical guidelines are likely to be

dent sector in the near future. However, even though

more robustly developed (Sudlow and Thomson 1997)

clinical governance is the responsibility of NHS trusts,

and that their universal implementation locally

will

its foundation is based on ‘the principle that health pro-

ensure consistency and effectiveness.

fessionals must be responsible and accountable for their

own practice’ (Secretary of State for HealthCONTENT1998). The An emphasis on continuing professional

individual’s professional responsibility is therefore still

development (CPD) and life-long learning (LLL)

paramount.

Clinical governance acknowledges the importance of

What is clinical governance?

CPD/LLL for all healthcare workers, in order to keep

up to date and deliver high-quality services.

PROPERTY

the quality ofSAMPLEtheir services and safeguarding high

1

and trusts more readily for mistakes, thus drawing

In 1991, Sir Michael Peckham, then Director of

money away from front-line clinical services. So clinical

Research and Development for the Department of

governance is about rebuilding the public’s confidence

Health, noted that ‘strongly held views based on belief

in health services, providing high-quality and effective

rather than sound information still exert too much

care and, above all, reducing the risk of harm through

influence in healthcare. In some instances the relevant

negligence, poor performance or system failures.

knowledge is available but is not being used, in other

situations additional knowledge needs to be generated

The components of clinical governance

from reliable sources’ (Department of Health 1991). At

about the same time, a relatively small group of doctors

Although clinical governance should be seen as a pack-

began to write about evidence-based medicine.

age of measures that together ensure excellence and a

FINAL

reduction in risk, it can also be viewed as a number of

‘

component parts, some of which have been in place for

Definition

a number of years and are already familiar (Figure 1.1).

An early definition of evidence-based medicine stated

They include:

that it is the ‘conscientious, explicit and judicious use

ELSEVIER

▪ evidence-based practice and clinical effectiveness

of current best evidence in making decisions about

▪ applying national standards and guidelines locally

the care of individual patients’ (Sackett et al. 1996).

▪ evaluating the effectiveness and quality of services

A recent definition has updated this, drawing on

▪ continuing

professional

development/life-long

criticisms of the initial position and stating that

learning

evidence-based practice requires that ‘decisions about

▪ having the right workforce and using it appropri-

health care are based on the best available, current,

valid and relevant evidence. These decisions should be

ately.

made by those receiving care, informed by the tacit

The following sections deal with these aspects.

and explicit knowledgeNOTof those providing care, within

the context-of available resources’ (Dawes et al. 2005).

EVIDENCE-BASED PRACTICE

CONTENTus about their condition, which treatments they find effec-

What do we mean by evidence? Is research the only

At the beginning of this chapter, it was asserted that

form of evidence? Certainly for some questions, such

people

who

want to become

physiotherapists

have

as the efficacy of particular drugs, or a particular modality

an inherent desire to ‘do good’. But how do we know

such as exercise programmes for the management of back

PROPERTY

encounter, will develop such expertise (Jones et al.

what works

what interventions have OFbeen shown

pain, research studies which compare one intervention

to be effective? It is hard to comprehend that health

with another or a placebo (randomised controlled trials)

professionals have not always sought evidence for the

can provide reliable information about the degree to

effectiveness of the treatments they use. Perhaps they

which an intervention is effective. But other forms of evi-

did

but until

the early 1990s this ‘evidence’

was

dence are also important (Figure 1.2). What patients tell

based on personal experience and on opinions derived

SAMPLE

from that experience, together with the experience of

tive, the degree to which interventions improve their abil-

colleagues, or those perceived to be experts and opin-

ity to get on with their lives also provides important

ion leaders. Is that good enough?

evidence. The physiotherapist also contributes evidence

in the form of clinical expertise, derived from clinical

reasoning experience. Thinking and reflecting on what

Evidence-

Clinical audit

Using

you are doing, as a practitioner during or after a clinical

based

patient

practice

feedback

2000). Knowledge which arises from and within practice

(practice-based and practice-generated knowledge) will

Using nationally

Continuing

Clinical

become part, along with research evidence, of your ratio-

developed

professional

nale for practice (Higgs and Titchen 2001). Sackett and

standards

effectiveness

development

colleagues reflected this in concluding their definition

and guidelines

that evidence-based practice requires integration of ‘clini-

The right

Using

Implementing

cal expertise with best available external clinical evidence

workforce and

outcome

National Service

from systematic research’ (Sackett et al. 1996).

using it right

measures

frameworks

A hierarchy of evidence is often described or used in

the literature. This ranges from (1) systematic reviews,

Figure 1.1 Components of clinical governance.

in which evidence on a topic has been systematically

Past experience,

Preferences

beliefs and values

ELSEVIER

Figure 1.2 What do we mean by ‘evidence’? (Adapted from Bury 1998, with permission.)

identified, appraised and summarised according to

NOT

from clinical reasoning experience, discussed above.

predetermined criteria (usually limited to randomised

Physiotherapists need to contribute to an ongoing

controlled trials)

said to be the strongest evidence

debate to develop a hierarchy that reflects more appro-

(the most reliable estimate of effectiveness) to (2) expert

priately a patient-centred approach to practice.

opinion, perceived as the least reliable. An example is

So what-does evidence-based practice mean for phy-

Level

Type of evidence

CONTENTpopulation (e.g. people with multiple sclerosis with

shown in Table 1.1.

siotherapists? Core Standard 4 (CSP 2005a) states that:

However, such a hierarchy fails to recognise that dif-

‘In order to deliver effective care, information relating

ferent research methods are needed to answer different

to treatment options is identified, based on the best

types of question and that, while a qualitative study

available evidence.’ A range of sources of information

may be the best research method for a particular ques-

the physiotherapist may need to draw on, including

PROPERTY

get the best results from a literature search (his or

tion, it still receives a low rating. The hierarchyOF also

research evidence, patient organisations and clinical

fails to recognise the importance of expertise derived

guidelines, is listed. What practical steps need to be

taken to identify and use research evidence?

Table 1.1 A hierarchy of evidence

▪ Think

about the clinical question you are trying

EvidenceSAMPLEobtained from well-designed non-

to answer in your information search. Identify the

III

symptoms of urinary incontinence), the intervention

Ia

Evidence obtained from a systematic review or

you are looking for (e.g. neuromuscular electrical

meta-analysis of randomised controlled trials

stimulation) and the outcome (e.g. a reduction in

Ib

Evidence obtained from at least one randomised

symptoms), and use this information to formulate a

controlled trial

search strategy.

IIa

Evidence obtained from at least one well-designed

▪ Work in partnership with an information scientist to

controlled study without randomisation

IIb

Evidence obtained from at least one other type of

her information skills and knowledge combined

well-designed quasi-experimental study

with your clinical skills and knowledge).

experimental descriptive studies, such as

▪ Look first for evidence that has already been synthe-

sised

systematic reviews, nationally developed

comparative studies, correlation studies and

clinical guidelines or standards. This saves a lot of

case studies