Regulation Of Health Professionals Research Articles

Nursing research in Spain

The evolution of the Nursing profession in Spain over the past 40 years has determined the current situation of Nursing research. Thus, the social, political and economic context have modelled the academic consolidation of Nursing both in the University, and in the Health Care System. The aim of this paper is to describe the evolution, key milestones, and current situation of Nursing research in Spain as a result of all these influences. The full access of nurses to doctorate programs, the regulation of health professions and Nursing specialties, as well as the strong support from some institutions funding and promoting nurse-led research have been essential for the current development. There are 49 PhD Programmes for nurses, and 79 Nursing research groups, responsible for a scientific production that puts Spain in the seventh position in the world ranking of scientific production in the area of Nursing, from a total of 257 countries analyzed.

Innovation in Healthcare, Innovation in Law: Does the Law Support Interprofessional Collaboration in Canadian Health Systems?

Interprofessional collaboration in healthcare describes a model of practice where multiple health professionals work together in a team-based approach to patient care. A growing body of literature demonstrates that interprofessional collaboration advances healthcare quality and safety, improves patient outcomes and experiences of care, and promotes job satisfaction among health professionals. Governments and health organisations across Canada are working to advance interprofessional healthcare delivery. This paper examines the importance of law in supporting a shift to interprofessional collaboration in Canadian healthcare and discusses two key aspects of the legal context in which health practitioners work. First, the paper discusses trends in the legal regulation of health professions in Canada, including law reform initiatives aimed at promoting collaborative practice and expanding scopes of practice to break down the historically siloed approach to healthcare delivery. Second, the papers examines civil liability rules that courts apply when allegations of negligence are made against health care providers working in team-based situations. New legislative models that provide for expanded and overlapping scopes of practice, and which introduce new professional roles into the health workforce, may raise legal concerns regarding responsibility for patient care and outcomes. The paper illustrates how legal innovations, such as new models of health profession regulation, and legal adaptability, through judicial understanding of the modern context of health service delivery, are important to the advancement of interprofessional collaboration in Canadian healthcare.

Exploring the role of health care assistants as mobility activators for older people in an Assessment, Treatment, and Rehabilitation ward

IntroductionAs people live longer, the pressure on an already overstretched healthcare sector increases, and the expectation of an ever-increasing supply of registered health professionals to meet health care demands is unrealistic given workforce shortages. Finding viable alternatives to address workforce shortages is consequently becoming more of a focus for health services and the structure of nursing care delivery is changing to meet workforce demands. Contemporary care models show there is a trend towards a team approach, where the expertise of the registered nurse (RN) is employed in supervisory and delegation roles with second level clinical support from enrolled nurses and health care assistants (HCAs) in some settings (Cassie, 2014). Rehabilitation approaches are also changing to maximise the input and care required by older people. Specialised units in secondary care provide specific rehabilitation programmes designed by interdisciplinary teams focused on outcomes such as longevity, quality of life and even improved cognition (Ellis & Longhorne, 2005). However, when analysing how the interdisciplinary team works towards the goal of successful discharge of patients back to their community, the role RNs and HCAs play in enhancing mobility has been undervalued and underutilised (Kearney & Lever, 2010). The importance of mobility rehabilitation is supported by evidence of a positive impact on health outcomes such as increased strength, balance, flexibility and wider implications with reduced hospital stay, improved quality of life and reduction of falls (Atwal et al., 2008; Huijben-Schoenmakers, Gamel, & Hafsteinsdottir, 2009; Pryor, 2005).The HCA spends a significant amount of time with patients in Assessment, Treatment and Rehabilitation (ATR) wards. They are a logical, yet untapped source of contact to perform rehabilitation activities directed by staff who work limited hours such as allied health professionals (Pryor, Walker, O'Connell, & Worrall-Carter, 2009). This paper reports the findings from a research project examining the feasibility of health care assistants' participation in mobility rehabilitation for older people in an ATR ward.Literature reviewMobility is an important part of rehabilitation, and early mobilisation has proven to have significant positive outcomes in reducing length of stay, preventing deep vein thrombosis and pulmonary emboli, and improving overall physical function (Fox, Sidani, & Brooks, 2009; Pryor et al., 2009). Enhanced mobility can also reduce falls, and has a positive impact on aerobic and resistance exercises; a more active lifestyle improves cardiovascular and respiratory system function, and functional musculoskeletal ability well into older age (Intiso et al., 2012).Research on the role of the HCA in patient care, and specifically about mobility, is limited. The practice of HCAs is historically embedded in models of social care, but their scope of practice has changed over time due to public expectations, new technology and changing demographics, which has resulted in blurring of roles and boundaries with RNs (Department of Health, 2008). As RN roles and responsibilities increase, HCAs have become more responsible for patient care, making the modern HCA role multifaceted (Keeney, Hasson, McKenna, & Gillen, 2005). There is resultant role confusion due to issues around delegation, parameters of practice and accountability (Lizarondo, Kumar, Hyde, & Skidmore, 2010). Regardless of these changes over time there is still a heavy reliance on HCAs to meet patients' basic care needs, and provide cheaper alternatives to registered staff to address staffing and retention issues (Keeney, Hasson, McKenna, & Gillen, 2005).Researchers have explored the RN and HCA contribution to patient mobility and note deficits in current practice. Kneafsey, Clifford and Greenfield (2013) found, in a grounded theory study of the nursing team contribution to mobility rehabilitation, that RNs and HCAs focused primarily on risk assessment and patient safety. …

Is Health Practitioner Regulation Keeping Pace with the Changing Practitioner and Health-Care Landscape? An Australian Perspective.

Health-care delivery is undergoing significant evolution and change. Task substitution has resulted in some practitioner groups expanding their scope of practice by assuming more complex clinical roles, new practitioner groups have emerged, and consumer-driven demand has changed the way the public engage with health practitioners and the way many health-care services are delivered. Using Australia as a case study, this paper explores the issue of the hesitancy to include new professions in health professions regulation schemes. Despite the significant changes in the health-care delivery landscape, policy development in this area has remained relatively static, with active resistance to extending formal registration to new practitioner groups. Ignoring the issue of new practitioner groups in regulatory schemes is unacceptable from a public health perspective and runs against the key public protection objectives of health practitioner regulation. Development of pathways for the entry of new health practitioner groups into regulatory schemes must be developed as a matter of priority.

Risk for Patient Harm in Canadian Genetic Counseling Practice: It's Time to Consider Regulation.

With the increasing awareness of genetic contributions to disease in Canada, the availability of and demand for genetic testing has soared. Genetic counseling is becoming a recognized and rapidly growing (yet unregulated) health profession in Canada. We hypothesized that the potential risk for harm to the public posed by genetic counseling practice in the province of Ontario is sufficient to consider regulation. The Ontario Ministry of Health and Long-Term Care (MOHTLC) sets criteria (both primary and secondary) to identify health professional bodies that meet the threshold for regulation in the province. We developed a survey based on the MOHTLC criteria to determine if genetic counselors meet the primary criteria to be considered for health professions regulation in Ontario. We surveyed 120 Ontario genetic counselors about their clinical practice and perceptions of risk for harm to the public. Results indicate that Ontario genetic counselors are highly independent in their clinical practice and are involved in patient care activities, clinical judgement and decision-making that have the potential to harm patients. In particular, cancer genetic counselors were identified as a cohort that practices with relatively high autonomy and low supervision. In summary, our study indicates that genetic counseling practice in Ontario meets the primary criteria to be considered for regulation.

Exploring approaches to patient safety: the case of spinal manipulation therapy.

BackgroundThe purpose of this study was to gain insight into the current safety culture around the use of spinal manipulation therapy (SMT) by regulated health professionals in Canada and to explore perceptions of readiness for implementing formal mechanisms for tracking associated adverse events.MethodsFifty-six semi-structured telephone interviews were conducted with professional leaders and frontline practitioners in chiropractic, physiotherapy, naturopathy and medicine, all professions regulated to perform SMT in the provinces of Alberta and Ontario Canada. Interviews were digitally audio-recorded for verbatim transcription. Transcripts were entered into HyperResearch software for qualitative data analysis and were coded for both anticipated and emergent themes using the constant comparative method. A thematic, descriptive analysis was produced.ResultsThe safety culture around SMT is characterized by substantial disagreement about its actual rather than putative risks. Competing intra- and inter-professional narratives further cloud the safety picture. Participants felt that safety talk is sometimes conflated with competition for business in the context of fee-for-service healthcare delivery by several professions with overlapping scopes of practice. Both professional leaders and frontline practitioners perceived multiple barriers to the implementation of an incident reporting system for SMT.ConclusionsThe established ‘measure and manage’ approach to patient safety is difficult to apply to care which is geographically dispersed and delivered by practitioners in multiple professions with overlapping scopes of practice, primarily in a fee-for-service model. Collaboration across professions on models that allow practitioners to share information anonymously and help practitioners learn from the reported incidents is needed.

Health professionals' experience of teamwork education in acute hospital settings: a systematic review of qualitative literature.

EXECUTIVE SUMMARYBackgroundTeamwork is seen as an important element of patient care in acute hospital settings. The complexity of the journey of care for patients highlights the need for health professionals to collaborate and communicate clearly with each other. Health organizations in western coun

Strengthening health professions regulation in Cambodia: a rapid assessment.

BackgroundThis paper describes a rapid assessment of Cambodia’s current system for regulating its health professions. The assessment forms part of a co-design process to set strategic priorities for strengthening health profession regulation to improve the quality and safety of health services.A health system approach for strengthening health professions’ regulation is underway and aims to support the Government of Cambodia’s plans for scaling up its health workforce, improving health services’ safety and quality, and meeting its Association of South East Asian Nations (ASEAN) obligations to facilitate trade in health care services.MethodsThe assessment used a mixed methods approach including:A desktop review of key laws, plans, reports and other documents relating to the regulation of the health professions in Cambodia (medicine, dentistry, midwifery, nursing and pharmacy);Key informant interviews with stakeholders in Cambodia (The term “stakeholders” refers to government officials, people working on health professional regulation, people working for the various health worker training institutions and health workers at the national and provincial level);Surveys and questionnaires to assess Cambodian stakeholder knowledge of regulation;Self-assessments by members of the five Cambodian regulatory councils regarding key capacities and activities of high-performing regulatory bodies; andA rapid literature review to identify:The key functions of health professional regulation;The key issues affecting the Cambodian health sector (including relevant developments in the wider ASEAN region); and“Smart” health profession regulation practices of possible relevance to Cambodia.ResultsWe found that the current regulatory system only partially meets Cambodia’s needs. A number of key regulatory functions are being performed, but overall, the current system was not designed with Cambodia’s specific needs in mind. The existing system is also overly complex, with considerable duplication and overlap between governance and regulatory arrangements for the five regulated professions.ConclusionsThere is considerable scope for reform to the current regulatory system to better align the system to Cambodia’s:Current needs and circumstances;Health system strategic priorities; andInternational obligations.Cambodia is also well placed to base its reformed regulatory system on recent developments of “smart regulatory practices” for health professionals.

Corrigendum to: Approaches to management of complaints and notifications about health practitioners in Australia

In 2005, the Australian Productivity Commission made a recommendation that a national health registration regimen and a consolidated national accreditation regimen be established. On 1 July 2010, the National Registration and Accreditation Scheme (NRAS) for health practitioners came into effect and the Australian Health Practitioner Regulation Agency (AHPRA) became the single national oversight agency for health professional regulation. It is governed by the Health Practitioner Regulation National Law Act (the National Law). While all states and territories joined NRAS for registration and accreditation, NSW did not join the scheme for the handling of complaints, but retained its existing co-regulatory complaint-handling system. All other states and territories joined the national notification (complaints) scheme prescribed in the National Law. Because the introduction of NRAS brings with it new processes and governance around the management of complaints that apply to all regulated health professionals in all states and territories except NSW, where complaints management remains largely unchanged, there is a need for comparative analysis of these differing national and NSW approaches to the management of complaints/notifications about health professionals, not only to allow transparency for consumers, but also to assess consistency of decision making around complaints/notifications across jurisdictions. This paper describes the similarities and differences for complaints/notifications handling between the NRAS and NSW schemes and briefly discusses subsequent and potential changes in other jurisdictions.

Appropriate prescribing in nursing homes demonstration project (APDP) study protocol: pragmatic, cluster-randomized trial and mixed methods process evaluation of an Ontario policy-maker initiative to improve appropriate prescribing of antipsychotics.

BackgroundAntipsychotic medications are routinely prescribed in nursing homes to address the behavioral and psychological symptoms of dementia. Unfortunately, inappropriate prescribing of antipsychotic medications is common and associated with increased morbidity, adverse drug events, and hospitalizations. Multifaceted interventions can achieve a 12–20 % reduction in antipsychotic prescribing levels in nursing homes. Effective interventions have featured educational outreach and ongoing performance feedback.Methods/DesignThis pragmatic, cluster-randomized control trial and embedded process evaluation seeks to determine the effect of adding academic detailing to audit and feedback on prescribing of antipsychotic medications in nursing homes, compared with audit and feedback alone. Nursing homes within pre-determined regions of Ontario, Canada, are eligible if they express an interest in the intervention. The academic detailing intervention will be delivered by registered health professionals following an intensive training program including relevant clinical issues and techniques to support health professional behavior change. Physicians in both groups will have the opportunity to access confidential reports summarizing their prescribing patterns for antipsychotics in comparison to the local and provincial average. Participating homes will be allocated to one of the two arms of the study (active/full intervention versus standard audit and feedback) in two waves, with a 2:1 allocation ratio. Homes will be randomized after stratifying for geography, baseline antipsychotic prescription rates, and size, to ensure a balance of characteristics. The primary outcome is antipsychotic dispensing in nursing homes, measured 6 months after allocation; secondary outcomes include clinical outcomes and healthcare utilization.DiscussionPolicy-makers and the public have taken note that antipsychotics are used in nursing homes in Ontario far more than other jurisdictions. Academic detailing can be an effective technique to address challenges in appropriate prescribing in nursing homes, but effect sizes vary widely. This opportunistic, policy-driven evaluation, embedded within a government-initiated demonstration project, was designed to ensure policy-makers receive the best evidence possible regarding whether and how to scale up the intervention.Trial registrationClinicalTrials.gov NLM Identifier: NCT02604056.

Approaches to management of complaints and notifications about health practitioners in Australia.

In 2005, the Australian Productivity Commission made a recommendation that a national health registration regimen and a consolidated national accreditation regimen be established. On 1 July 2010, the National Registration and Accreditation Scheme (NRAS) for health practitioners came into effect and the Australian Health Practitioner Regulation Agency (AHPRA) became the single national oversight agency for health professional regulation. It is governed by the Health Practitioner Regulation National Law Act (the National Law). While all states and territories joined NRAS for registration and accreditation, NSW did not join the scheme for the handling of complaints, but retained its existing co-regulatory complaint-handling system. All other states and territories joined the national notification (complaints) scheme prescribed in the National Law. Because the introduction of NRAS brings with it new processes and governance around the management of complaints that apply to all regulated health professionals in all states and territories except NSW, where complaints management remains largely unchanged, there is a need for comparative analysis of these differing national and NSW approaches to the management of complaints/notifications about health professionals, not only to allow transparency for consumers, but also to assess consistency of decision making around complaints/notifications across jurisdictions. This paper describes the similarities and differences for complaints/notifications handling between the NRAS and NSW schemes and briefly discusses subsequent and potential changes in other jurisdictions.

Professional sexual abuse in mental health services: Capturing practitioner views of a contemporary corruption of care

This paper focuses on practitioner views of professional sexual abuse in mental health services in the UK. In spite of high profile cases, and changes to the law and regulation of mental health professionals in recent years, it remains a significant problem. It also presents particular challenges for colleagues and managers of services when incidents are reported or come to light through everyday practice. To date it has received little attention in research other than from within psychological therapies. This study seeks to provide a counter balance to those approaches by taking a social inequalities perspective and focusing on systemic and institutional dimensions. It draws comparisons with Wardaugh and Wilding’s (1993) theory of the ‘corruption of care’ and argues that even when mental health care is provided in the community it can still become corrupted. The paper presents the findings of a small scale study of practitioner perspectives on the subject. The findings tentatively suggest that the problem is endemic but hidden by ineffective management responses. It argues for new approaches to selection, training and support for professionals that include counter intuitive approaches to policing colleagues and institutional cultures.

Regulated Health Professions: Outcomes by Place of Birth and Training

Do foreign birth and/or the possession of foreign academic credentials affect integration into Canadian regulated health occupations? While there are a few important commonalities across the eight occupations studied, especially that the foreign born, foreign trained are less likely to work in their trained profession, there are a number of differences. Broad-based policies will, therefore, have occupation-specific impacts. Among those actually working in their trained field, place of study/birth earnings gaps are frequently not statistically different from zero and, when non-zero, are negative for some occupations and positive for others. For workers who surmount the regulatory/employment hurdles, there is no evidence of sector-wide systematic earnings penalties to foreign birth/training although such effects may exist in selected occupations.

Should acupuncture play a greater role in healthcare?

s / European Journal of Integrative Medicine 7 (2015) 432–438 437 back pain. Available evidence may not facilitate guideline development for integration into best clinical practice. Practitioner perception of the evidence base is equally important. TCM practitioners in the EU and China vary in their perceived need for research evidence, and the evidence gaps. The complexity and plurality of traditional Chinese medicine theory and practice, informed by comparative effectiveness studies, personalized medicine and TCM pattern differentiation should be incorporated into future research if it is to be effectively integrated into health care provision. Steps are needed to promote the development and implementation of academic training and research programs that support progress in this direction. It is vitally important that competent professionals, both clinically skilled and trained in research are involved in the development of the evidence base to ensure that it is appropriate and ongoing. Otherwise studies will be designed and conducted by researchers who do not understand traditional systems of medicine or by practitioners who do not fully understand research practices. If this persists, good quality effectiveness data will continue to be lacking and compromise integration into any healthcare system. With advances in biomedical, chemical and computational technology, plenty of opportunities exist to provide multidisciplinary approaches to investigate evidence-based aspects of TCM practice. An integrative approach is crucial to connect the multiplicity of expertise, scientific innovation and investigations. http://dx.doi.org/10.1016/j.eujim.2015.07.039 Acupuncture as part of the health care system: Some key facts from European and a national point of view Wolfgang Weidenhammer 1,∗, Dieter Melchart 1,2 1 Competence Centre for Complementary Medicine and Naturopathy, Klinikum rechts der Isar, Technische Universitat Munchen, Munich, Germany 2 Institute for Complementary and Integrative Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland E-mail address:wolfgang.weidenhammer@lrz.tu-muenchen.de (W. Weidenhammer). The presentation will follow two approaches to give some insight into the situation of medical acupuncture as applied by doctors in Europe and specifically in Germany. The current status as well as the development over the previous years will be demonstrated. Between 2001 and 2006, three groups of German statutory sickness organizations funded three large reimbursement and research programs on acupuncture. One of them was conceptualized and conducted by the Competence Centre for Complementary Medicine and Naturopathy at TU Munich. Apart from the well-known controlled trials to investigate the specific effects of acupuncture the program also includes a description of routine care and therapeutic safety. Between June 2001 and November 2005, approximately one million patients insured by the participating sickness funds received acupuncture with systematic documentation. Data of about 450,000 patients were analyzed complemented by a more detailed longitudinal dataset from a subsample of about 5000 patients. Moreover, a survey on the participating acupuncturists enabled the analysis of relations between indicators of therapist’s qualification and the outcome of the treatment. As a result of the acupuncture research programs the German health authorities decided in 2006 to restrict the reimbursement by social health insurance funds to low back pain and osteoarthritis of the knee. Additionally, the conditions for certified physicians changed. The consequences of these decisions for the routine medical care with acupuncture were far-reaching. Although not focused on any specific CAM modality, the EU-funded project CAMbrella (2010–2012) could reveal some key points for acupuncture. In Europe, acupuncture is mostly regulated as a treatment that may or may not be provided by regulated health professionals or other CAM practitioners. 25 countries have acupuncture treatment regulations while 12 have no specific acupuncture regulations. A systematic analysis of the provision of CAM in Europe showed that approx. 305,000 registered CAM providers (47% are medical practitioners) can be identified in the EU. Acupuncture is reported as the most available therapeutic method for both, medical (80,000) and nonmedical providers (16,380). Beyond acupuncture, the presentation will end with a brief detour on research in CAM in Europe, with the focus on research promotion by the European Commission. Possibilities for the field of CAM and issues will be demonstrated, exemplified by the Horizon 2020 program. http://dx.doi.org/10.1016/j.eujim.2015.07.040 The cost-effectiveness of acupuncture

Transition: health professionals as medical students.

It has long been acknowledged that health professionals who retrain as doctors make a significant contribution to the medical profession. Having a background as a health professional sets this group apart from the other medical students, including mature students. It is therefore important to understand more about how health professionals adapt to their role as medical students. A qualitative approach was adopted, in which interviews were conducted with 12 of the possible 30 medical students who met the inclusion criterion: namely that they were or had been registered health professionals. The most common driver to retrain was a desire to seek a fresh challenge, and they described their previous roles as limited; however, returning to student status after life as an autonomous health professional was initially very uncomfortable. Once they loosened their grip on their previous role and embraced life as a medical student the students eventually realised that, irrespective of their previous health profession, they had a set of core professional abilities that they could bring to their role as a doctor. There has been considerable focus on the support required for mature students, graduate students and students from disadvantaged backgrounds. Little attention has been afforded to the experience of health professionals as medical students. This category of individual already possesses a wealth of experience, knowledge and attitudes relevant to health care work. This experience should be built upon so that the transition from 'expert' to 'novice' is as comfortable as possible for all parties. Health professionals who retrain as doctors make a significant contribution tothe medical profession.

The experiences of pre-licensure or pre-registration health professional students and their educators in working with intra-professional teams: a systematic review of qualitative evidence protocol.

REVIEW QUESTION / OBJECTIVE The aim of this review is to identify the experiences of pre-licensure or pre-registration health professional students and their educators of intra-professional teams. The objectives of this review are: 1. To identify the experiences of pre-licensure or pre-registration health professional students about learning how to work in intra-professional teams. 2. To identify the experiences of health professional educators about teaching intra-professional collaboration across categorical and/or regulatory boundaries of professional groups. The specific question for this review is: What are the experiences of health professional students and educators learning to work in intra-professional teams? INCLUSION CRITERIA Types of participants This review will consider studies that investigate pre-licensure health professional students' and educators’ experiences of intra-professional teams. We will define pre-licensure health professional students as those students enrolled in a health-related diploma or degree program leading to the writing of a licensure or registration exam prior to engaging in practice (i.e. regulated health care provider programs). Health related programs that will be included are those that have multiple points of entry-to-practice under one disciplinary domain. This could include (but will not be limited to) disciplines such as dentistry, nursing, medicine, occupational therapy, pharmacy, physiotherapy or social work. Thus, we will consider studies that include experiences of students and educators working in various disciplinary domains (such as dentistry, medicine, nursing, occupational therapy pharmacy or physiotherapy) focusing on regulated health professions which have more than one point of entry into practice for their students (e.g. baccalaureate degree or diploma). TRUNCATED AT 250 WORDS

The experiences of pre-licensure or pre-registration health professional students and their educators in working with intra-professional teams: a systematic review of qualitative evidence protocol

The experiences of pre-licensure or pre-registration health professional students and their educators in working with intra-professional teams: a systematic review of qualitative evidence protocol

Legislating interprofessional collaboration: A policy analysis of health professions regulatory legislation in Ontario, Canada

Changes to Ontario’s health professions regulatory system were initiated through various legislative amendments. These amendments introduced a legislative obligation for health regulatory colleges to support interprofessional collaboration (IPC), collaborate where they share controlled acts, and incorporate IPC into their quality assurance programs. The purpose of this policy analysis was to identify activities, strategies, and collaborations taking place within health professions regulatory colleges pertaining to legislative changes related to IPC. A qualitative content analysis of (1) college documents pertaining to IPC (n = 355) and (2) interviews with representatives from 14 colleges. Three themes were identified: ideal versus reality; barriers to the ideal; and legislating IPC. Commitment to the ideal of IPC was evident in college documents and interviews. Colleges expressed concern about the lack of clarity regarding the intent of legislation. In addition, barriers stemming from long-standing issues in practice including scope of practice protection, conflicting legislation, and lack of knowledge about the roles of other health professionals impede IPC. Government legislation and health professional regulation have important roles in supporting IPC; however, broader collaboration may be required to achieve policy objectives.

Clinician's Commentary on Duncan et al.(1).

The Regulated Health Professions Act, which permits physical therapists to be primary contact professionals, has been adopted by most Canadian provinces, but because it applies only to physical therapists in private practice, in many provinces a physician's referral is still required before initiation of physical therapy in hospitals. Opponents of direct access to physical therapy (PT) argue that physical therapists may overlook serious medical conditions. In the acute-care setting, however, physical therapists are considered essential members of the inter-professional health care team. Physical therapists working in critical care have the knowledge and experience to relate medical stability and PT practice, which gives them a basis for initiating PT service as soon as appropriate. Numerous studies have documented the effect of early implementation of PT interventions in preventing sequelae of immobility.2–5 There is growing evidence that early mobilization of patients in the intensive care unit (ICU) is a safe and cost-effective strategy to improve patient outcomes.6–11 In ICUs where early mobilization is not part of usual care, its adoption requires a change in philosophy by the multidisciplinary team, including physical therapists, registered nurses, respiratory therapists, and physicians. Harris and colleagues12 have described a physical therapist–led programme to introduce such changes in a 16-bed medical–surgical and a 15-bed cardiovascular ICU. The process began with multidisciplinary meetings and education sessions to inform the critical-care team about the effect and safety of early mobilization. A lead physical therapist advocated early mobility and developed both solutions to overcome the identified barriers and guidelines for implementing PT services. With the initiation of this programme, the number of ICU patients receiving PT evaluations and treatment increased from 364 in 2011/2012 to 542 in 2012/2013.12 Jette and colleagues13 investigated the ability of physical therapists to practise safely—specifically, to make decisions about patient management—in direct-access environments. A survey was sent out to a random sample of 1,000 members of the Private Practice Section of the American Physical Therapy Association, 390 of whom agreed to participate in the study. The survey presented 12 hypothetical case scenarios and asked respondents to state whether, in each case, they would (1) provide intervention without referral, (2) provide intervention and refer, or (3) refer before intervention. On average, the respondents—physical therapists with an orthopaedic specialization—made the correct decision 87% of the time in musculoskeletal cases and 88% and 79% of the time, respectively, for non-critical and critical medical conditions. The odds ratios for making 100% correct decisions were 2.23 (95% CI, 1.35–3.71) for musculoskeletal conditions and 1.89 (95% CI, 1.14–3.15) for critical medical conditions. Duncan and colleagues conducted a chart review to investigate how implementing PT self-referral in the medical–surgical neurological intensive care unit (MSNICU) of the Toronto Western Hospital affected time to access of PT service and referral volume.1 They found that while day-to-day caseloads remained largely unchanged, the number of patients treated by physical therapists increased as a result of daily screening and the use of PT self-referral to capture patients who might previously have been missed. The most important findings of Duncan and colleagues' study were that PT self-referral resulted in more timely access to PT services and that for medically stable patients, it reduced the delay between admission to MSNICU and initiation of PT.1 This shorter delay between admission and PT initiation is critically important: the sooner PT assessment and treatment can be initiated, the better for the patient's overall treatment, which can lead to shorter ICU and hospital stays and perhaps even cost savings for our health care system. As an intensive-care physical therapist, I was fortunate to work in an ICU where physical therapists had blanket referrals and could evaluate patients for treatment within the first day after admission. The results of the studies cited here, including that of Duncan and colleagues,1 confirm physical therapists' capacity to be primary contact professionals and the efficacy of early intervention. I would advocate for the acceptance of this practice and/or blanket referrals throughout hospitals in Canada.

Industrial paramedics, out on site but not out of mind

Australian natural resource exploration and production companies are employing paramedics to provide emergency medical response, primary health care, injury prevention, and health promotion services in remote locations nationally and internationally. Although Australian paramedic practice has steadily evolved to include increasingly complex medical interventions in the prehospital setting, paramedics are not yet registered health professionals, and in many states and territories their title is not protected. Similarly, tertiary-level education is becoming the entry to practice standard for traditional ambulance paramedics; however, certificate- and diploma-level paramedic courses remain an acceptable pathway to private and industrial paramedic jobs. To ensure acceptable patient safety standards are maintained and to protect all related stakeholders, the role, skills, training, and professional capacity of industrial paramedics must be defined. The study objective was to explore the published literature for a definition for the discipline of industrial paramedicine. A comprehensive systematic analysis was conducted using the EBSCOhost (health), MEDLINE, SCOPUS, and CINAHL electronic databases. The primary search terms "remote", "offshore", "mining", and "oil" were combined with the secondary search terms "paramedic" and "emergency medical services". An initial search using the combined two-term sets identified 870 citations. After application of the inclusion and exclusion criteria to a title and abstract review, 69 citations met the criteria including those discovered by searching the reference lists. Of these, nine citations were excluded because full-text papers could not be found and eight citations were excluded based on review of the full article. The result was 40 articles that discuss the role of paramedics in the remote or offshore environment (ROP) and 12 articles that discuss the provision of emergency medical services in the mining or oil and gas sectors (MOEMS). There is no single definition or comprehensive role description for industrial paramedic practice within the literature. Worldwide, there is little high-quality published evidence to adequately reflect all aspects of industrial paramedic practice. However, based on the literature available, this definition is offered: 'An industrial paramedic is an advanced clinical practitioner in paramedicine with an expanded scope of practice. The industrial paramedic provides emergency response, primary health care, chronic disease management, injury prevention, health promotion, medical referral, and repatriation coordination at remote mining sites, offshore installations, and other isolated industry settings. The industrial paramedic is resourceful, adaptable, and comfortable working independently. Industrial paramedics practice on site with limited resources, remotely located from tertiary care, and use telemedicine to consult with other health professionals as required. Industrial paramedics are experts at rapidly assessing, prioritising, and establishing control in their unpredictable workspace to reduce risks and create an environment conducive to quality patient care. The industrial paramedic preferably holds a specialised tertiary qualification and is committed to maintaining their clinical competency through continuing professional development.' Further research is required to validate, refute, or expand this proposed definition.