Update on proposals to define the general osteopathic scope of practice with respect to internal techniques and HVLA in paediatric patietns

1. Stiofán Mac Suibhne
Follow #OCNZ onTwitter
@OsteoRegulation

2.  Timeline of Scope Reform
 Current Scope of Practice Schema
 Amending qualifications for the existing vocational
scopes of practice: (1) pain management (2)
gerontology
 Additional Vocational Scope in Rehabilitation
 Consultation on amendments to the general
osteopathic scope of practice
 Extended scope of practice for internal techniques

3.  Determine scopes of practice
 Prescribe qualifications / accredit institutions
 Determine Competency / Recertification Frameworks
 Assess international osteopathic graduates
 Complaints – HPDT / HDC
 Competence reviews
 Fitness to practice reviews
 Professional conduct

4.  Scope of Practice Consultation 2007 – 12
 Osteopathic Capabilities Framework 2007-09
 WMA Scope Gazetted Sept 2009
 Clear SkiesThinkingWorkshop December 2009
 Scope ReformWhite Paper June & Conference 2010
 Three Cycles of OCNZ Regional Conferences
 Revised General SoP Schema January 2013
 Proposed Amendments to the SoP Schema

5. (1)The principal purpose of this Act is to
protect the health and safety of members
of the public by providing for mechanisms to
ensure that health practitioners are
competent and fit to practise their
professions.

6.  Broad Based & Inclusive General SoP
 Aligned to the strategic direction of NZ
Healthcare Policy
 Vocational Scopes for particular areas of
practice expressly included in General SoP
(Pain Management & Gerontology)
 Extended Scopes for techniques expressly
excluded from the GeneralOsteopathic SoP
 Western MedicalAcupuncture & Related
NeedlingTechniques

7.  Osteopaths are primary healthcare practitioners
 Osteopathy is a person-centred form of manual medicine
 Osteopaths conceptualise health and disease within a broad holistic
bio-psycho-social and environmental context
 Osteopathic practice may be situated within the continuum of
healthcare - wellness
 The competent practice of osteopathy requires broad diagnostic
competencies
 Osteopaths work with patients from across the lifespan

8. Osteopaths are primary healthcare practitioners. Central to
the competent practice of osteopathy is an understanding of
the role of the primary care team and referral routes within
primary care and to hospital based service.
Rogers, F., D'Alonzo, J., GE. , Glover, J., Korr, I., Osborn, G., Patterson, M., et al.
(2002). Proposed tenets of osteopathic medicine and principles for patient care.
J Am Osteopath Assoc, 102, 63-65.

9. Osteopaths are primary healthcare practitioners. Central to
the competent practice of osteopathy is an understanding of
the role of the primary care team and referral routes within
primary care and to hospital based service.
Rogers, F., D'Alonzo, J., GE. , Glover, J., Korr, I., Osborn, G., Patterson, M., et al.
(2002). Proposed tenets of osteopathic medicine and principles for patient care.
J Am Osteopath Assoc, 102, 63-65.

10. Osteopathy is a person-centred form of manual medicine
informed by osteopathic principles. Osteopathic medicine is
not confined to historical osteopathic knowledge; rather
osteopathic philosophies and concepts inform the
interpretation and application of interdisciplinary knowledge
and the basic medical sciences.
Osteopathic medicine is an evolving field of knowledge and
incorporates new concepts as our understanding of health
and disease progresses.

11. (1) Each authority appointed in respect of a
profession must, by notice published in the
Gazette, describe the contents of the
profession in terms of 1 or more scopes of
practice.

12. (2) A scope of practice may be described in any
way the authority thinks fit, including, without
limitation, in any 1 or more of the following
ways:
(a) by reference to a name or form of words that is
commonly understood by persons who work in the
health sector:
(b) by reference to an area of science or learning:
(c) by reference to tasks commonly performed:
(d) by reference to illnesses or conditions to be diagnosed,
treated, or managed

13. Post Graduate Diploma in Pain Management or Older PeoplesWellness
(Gerontology). NZQF Level 9
The diploma level qualification aims to equip registrants with evidenced
based practice approaches and critical appraisal skills
Unitec Grads have Level 9 Qual with 90 Units Research Component
ACC requiring 50% providers have PG Qualification inVocational Rehab (PG
Cert)
Council proposing that for Unitec Grads or other registrants with a Clinically
relevant Masters degree acquired post registrationVoc SoP qual reduced to
a PG Cert
Original SoP Consultation Document proposed Rehab SoP – Aligned to ACC

14. Advanced standing and post graduate study /
specialisation in areas of practice that remain within the
general scope of practice.
There is a continuum of skills / knowledge from novice to
expert. Pre-professional training prepares osteopaths to
commence practice.
 Gerontology
 Pain management
 Rehabilitation
 Child health / Paediatrics
 Sports injuries
 Occupational Health

16. Interprofessional
Relationships
Primary
Healthcare
Responsibilities
Osteopathic
Care &Scope of
Practice
Person
OrientatedCare
& Commuication
Professional &
Business
Activities
Clinical Analysis

17. Council is undertaking research to determine capabilities
for osteopathic practice with children.
Discussion with the profession and other stakeholders on
refining the boundaries of the general osteopathic scope
with regard to two specific areas of paediatric practice:
Internal techniques
Manual techniques applied to the spine
And removing Internal techniques from the General SoP
for adults & creating an extended SoP

18. In August 2013 the Council issued interim guidelines
Legitimately part of the repertoire of osteopathic
techniques (PV & PR).
Adequate information about proposed examination and
treatment to allow patents to make informed decisions.
A chaperone or support person is offered.
Universal precautions are used for infection control
purposes.

19. The Council is considering removing internal techniques
from the General SoP for under 18s.
Potential psychological harm to a child or adolescent from
such a procedure out ways the potential benefits
From a regulatory perspective children and young people
are particularly vulnerable.
It is rarely the case in osteopathic practice for any given
presentation that a single technique would be the only
approach that may be of value.

24. A range of osteopathic manual techniques (OMT) are
applied to the spine.
HVLA techniques applied to the cervical spine are often
considered the procedures that carry the greatest risk.
The literature reveals very few studies concerned with such
techniques in osteopathic practice.
Dearth of published studies relating to the use of such
techniques in children in any professional discipline

25. The Council is aware of a number of cases internationally
where manual techniques applied to spines of young
children have purportedly resulted in severe damaged or
death of a child.
Incomplete details of these cases are in the public domain,
the Council is minded to apply the precautionary principle
and consider the risks of manual procedures applied to
children.

26. Research conducted by Council in 2011 was reassuring as
no respondents reported using HVLA on patients younger
than 8 years of age.
Council thinking at present would be to seek to restrict
HVLA in children under the age of 14 (consistent with the
definition of a ‘child’ in the ChildrenYoung Persons and
Their Families Act 1989).
Whilst the risk and reward ratios are unknown for HVLA
techniques this is not a straightforward matter.

27. Cervical spine?
All regions of the spine?
+/- peripheral joints?
The forces used in motion testing or techniques other than
HVLA may also need to be considered.

33. Move the focus of what the profession
understands constitutes competence beyond
the boundaries and artificial subject areas of
traditional pre-registration training courses
to professional practice.
Progress not perfection

34.  Resource constraints
 Conventional thinking amongst administrative staff.
 Focus on the added value of reflection on practice over the
growing pains of different working practices.
 Reluctance of osteopaths to be assessed.
 Osteopathic Exceptionalism - the ultra-positivists & the insider /
outsider problem.
 An advantage of the slow burn approach with the profession has
been time for the conceptual framework to be understood and
producing practitioners that are keen to push forward with
innovation.

35.  A form of assessment that aligns learning and
assessment was required allowing the practitioner to
identify and develop a reflective approach.
 Defensible mechanism that allows evidence to be
assembled and, notwithstanding the diversity of
approaches to practice, allows competencies to be
identified within a flexible capabilities framework.
 Creating an understanding of reflective practice and a
commitment to lifelong/lifewide learning - training
and dialogue with the profession.

36. Reflective practice: ‘the capacity to reflect
on action so as to engage in a process of
continuous learning’ (Donald Schön 1930 –
1997).
One of the defining characteristics of
professional practice.

39. An understanding of the nature of ‘Practice’ is central to
designing an assessment process which is capable of
capturing evidence of an individual’s ability to practice.
 The first step in designing the assessment process was
accepting a conceptual model for osteopathic
practice.
 Then developing an analysis / deconstruction of practice
from the perspective of process - rather focussed on
academic knowledge – Osteopathic Capabilities
Framework.
 Identifying assessment tools to assess the various
components of practice. K S A

40.  Three year cycle of regional conferences to raise awareness
amongst the profession.
 Problematising current approaches and sharing an understanding
of the theoretical framework supporting the use of PebblePad
 Migrating from a p-portfolio to an e-portfolio:
 Encouraging practitioners to creatively develop and use
PebblePad as a personal learning space.
 Creating allies and project champions. Identifying potential pilot
sites for trialling professional development/recertification
processes.

41.  Conventional wisdom of evidence based practice applies
theoretical knowledge to practice.
 In reflective practice theory and practice are seen as
being reciprocally inter-related.
 Professional identity / knowledge is complex and is not
merely assembled from discreet knowledge base.
 Professional knowledge / identity arises from a
synthesis of natural and social sciences

42. Reflection-in-Action: as we work identifying learning
needs / opportunities
Reflection-on-Action: After the fact seeking
theoretical perspectives and integrating them into our
thinking
Reflection-for Action: Applying knowledge to
practice
Creating Personal reflective space / Organisational
Context. Thinking>Analysis>Self>Awareness

43.  OCNZ needs to be realistic
 Broad church
 Freshen up - maintain interest in practise
 Skills acquisition: Cognitive - Associative - Autonomous
- "OK" Plateau - Fitts & Posner
 Honesty & Openness to change / development

44.  Miller’s pyramid of competence indicates that assessment of ‘does’
reflects professional authenticity.
 Whatever one ‘does’ in the assessment must reflect practice in order for
that assessment to be authentic.
 The portfolio’s purpose is to guide learning and capture evidence
 Portfolio was the Hoorah word of ‘90s
 Evidenced Based Practice ’oos
 e-Portfolio is current Hoorah!
 Trial the e-Portfolio for the overseas assessment processes
 Reference Group to look at applications for CPD / Recertification
Processes

45.  Learning NeedsAnalysis
 Personal Development Plan
 Learning Outcome Reports
 Case based Discussion
 Critical Incident Report
 Critiquing journal articles
 Literature reviews
 Reflective statements from training courses

46.  Scope of Practice Reform 2007 - 12
 Osteopathic Capabilities Framework 2007-09
 Development of work-based competence assessment
2010
 PebblePad PreceptorTraining Nov 2013
 Unitec – Clinical Practicum 2013
 Trialled for overseas assessment 2013
 Overseas Assessment Process from Aug 2014
 Peer GroupTraining Aug / Nov 2014
 Recertification -Voluntary adoption by registrants 2015
 Recertification Mandatory 2016