Joel Dunstan was in a position many physiotherapists have been before. Physiotherapy faces a high attrition rate at five to 10 years of clinical practice—and Joel was almost included among those leaving the profession.

‘When I was four years out, I got all the forms for dentistry, printed them out and started filling them in,’ Joel says. Twelve years on and glad he stuck with physiotherapy, Joel is now a primary contact physiotherapist within the Emergency Department (ED) of Cairns Hospital in Far North Queensland.

Musculoskeletal advanced and extended scope of clinical practice physiotherapists such as Joel are becoming more common. Advanced practice roles within other specialities such as cardiorespiratory and neurological physiotherapy are now gaining more attention. Sometimes hidden from the spotlight, advanced scope practitioners provide a real possibility to push the clinical boundaries of physiotherapy. However, many, including Joel, admit the ‘career pathway from the early to the middle was pretty clear but at the pointy end, to fully perform in these roles, the pathway was a lot less clear’.

Advanced scope of practice roles

Advanced and extended scope of practice roles allow practitioners to work at the full extent of their clinical practice and require additional skills outside of the general scope of physiotherapy practice. Roles like these require ongoing training and credentialing to maintain safety of care.

Musculoskeletal advanced practice roles are the most common in public hospitals with the development of physiotherapy-led orthopaedic and neurosurgical screening clinics as well as primary contact roles in EDs. Joel describes primary contact ED roles as positions that ‘draw skills and abilities of many other areas of physiotherapy practice which cannot be developed in ED’. He says the importance of a wide clinical background and professional mentorship is essential in preparation for ED primary contact physiotherapy roles.

Primary contact physiotherapists accept responsibility for the diagnostic workup and management of the patient with a musculoskeletal complaint, whether arriving on foot or by ambulance, with medical oversight when needed. Other public health advanced practice roles are now emerging, with a small group of physiotherapists exploring the boundaries of cardiorespiratory care.

Danni Dunlop, of Austin Health in Melbourne, is one such trailblazer working in the advanced cardiorespiratory field. Within the intensive care, surgical recovery and ward environments, Danni assesses and treats high-risk patients after they’ve had upper abdominal surgery. Utilising her advanced skills in haemodynamics, monitoring and prescribing, Danni assesses and manages post-operative complications that may delay mobilisation in these high-risk surgical patients.

‘To my knowledge, this is the first position like this in Australia,’ Danni says.

For now, funded through the Victorian Government Allied Health Workforce Grant Program, Danni hopes that multidisciplinary support for the position, as well as positive pilot data, will ensure its longevity beyond the life of the grant.

‘There is a lot of interest in the role … the junior doctors … the critical care outreach roles, the medical emergency team and the ICU liaison nurses really love the role so they are advocating quite hard,’ Danni says.

While some advanced practice roles are continually emerging, there are some clinicians who have been working at the top of their game for well over a decade. Neurological advanced practice is nothing new for Tamina Levy. A physiotherapist for 30 years, She was the first physiotherapist in South Australia to be involved in a multidisciplinary spasticity clinic.

Twelve years on and Tamina is still using her advanced skills in the assessment and management of complex spasticity cases while also managing a clinical leadership role. Alongside her medical and nursing colleagues at the Flinders Medical Centre in Bedford Park, Tamina uses her skills to assess and plan for botulinum toxin A injections as indicated, as well as serial casting and planning adjunct therapies to maximise the effect of the toxin. Her passion for working with neurological conditions has seen her train multiple clinicians in this area.

‘I love neurological physiotherapy, it has been challenging and rewarding, which means I haven’t become at all stale,’ Tamina says.

‘There is a gap between the early-to- mid-career physiotherapists and those ready to step into these advanced scope of practice roles.’

JOEL DUNSTAN

How do people get into these roles?

As interest and demand grow for these roles, younger physiotherapists may be asking themselves: how do I get into that? Joel believes greater clarity around these pathways is needed. ‘There is a gap between the early-to-mid-career physiotherapists and those ready to step into these advanced scope of practice roles. I think that is reflective of two things: number one is the lack of clarity on the pathway to these roles at the pointy end of the career pathway, and the second is a lack of opportunities to gain the breadth clinical experience in the public sector, including positions in outpatient departments,’ Joel says.

While Danni looked for training programs fostered within her own organisation, Joel used his diverse clinical experience in the public and private sector, coupled with tertiary programs including a master’s of musculoskeletal physiotherapy and further training programs offered within Queensland Health, to prepare himself to undertake his advanced practice role. Tamina has also done extensive postgraduate training and is currently undertaking her PhD part time. She also continues to train clinicians in neurological skills while wearing her second hat as a clinical leader.

These advanced scope practitioners have one thing in common: physiotherapy and multidisciplinary mentors. Danni describes them as essential. ‘You’re basically going to be pushing traditional boundaries so whoever it may be … are really vital in training you’. Joel furthers that, saying ‘departmental support has been necessary for cultural change’.

As physiotherapists continue to push the clinical boundaries, hopefully the pathways will become that tiny bit clearer for physiotherapists in the future. 

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