Background Information and Justification of the Study (Introduction)
Over a period of two decades it has been observed that the professional bodies in the field of Orthotics and Prosthetics as well as other healthcare services from have been instrumental in trying to define the meaning and scope of continuing professional education for the structural basis and acknowledgement of individual progress through certifications for the same. The professionals in the field are also vying for these certifications for their professional growth and the certifications serve as tools to monitor and regulate the overall quality of continued education and in turn the public health.
The International body in the field, the International Society for Orthotics and Prosthetics (ISPO) has been instrumental in providing thought leadership and logistical as well as directional support to the above efforts. The body has been trying to ensure the quality care and the education of the professionals for greater public health around the world. As an apex body in the field it has been planning and implementing the efforts, giving directives to national and regional bodies as well as organizing trainings, running courses and also issuing certifications. The body has been organizing research as well publications and conferences to arrive at the ways and means to achieve the objective of ensuring quality care for patients and education of the professionals. The first ever conference of ISPO, as one of the main aims held in Dortmund, Germany in 2004 had tried to define the continuing professional education and certification in Europe. The conference put forth certain recommendations towards the above cause and this included the assertion that the prosthetics and orthotics profession should implement a system of continuing education that is based on the premise of proven maintenance of competencies for the same.
There is an identified need for continuing professional education to maintain the competency of the professionals at a critical level. The need is fueled by the demographic and socio economic patterns in the world population. The need translates into a scope of improvement in continued education in the field in many parts of the world that is now widely felt and acknowledged the world over. The rehabilitation efforts have been benefiting from the continued professional education initiatives of various bodies such as ISPO. As part of the ongoing research in the field, it has been found that assistive devices improve the mobility of the patients. Research has also suggested that the need for the rehabilitation efforts is much more critical from a quantitative point of view in developing world than the developed world. In the developing countries usually, the people with disabilities usually have a low social status and a limited access to prosthetic and orthotics services. As per a WHO report, there is a lack of trained personnel in the prosthetics and orthotics services. There is an increasing demand for ISPO registrations and this indicates that there is a growing demand for well trained technicians. There are specific programs and certifications for the same.
The professionals need education to be able to identify the anomalies in the physical conditions as well as the functional limitations of the patients and be able to formulate a comprehensive and effective treatment plan. Additionally, there is a need to be able to self articulate the importance of the personal and professional development in various areas such as lifelong learning to ensure continual upgrade of the skills and knowledge at pace with the latest developments in the field. The present study seeks to ascertain an optimum mix of the ways and means for the Orthotics and Prosthetics and Physiotherapy professionals to pursue continued professional education for which include activities include research, short courses, long term courses.
Review of Literature
The Orthotics and Prosthetics fraternity has identified and attempted to understand the role of continuing professional education since last decade or so. Especially, the professional bodies in the field from Europe have been instrumental in trying to define the meaning and scope of continuing professional education for the structural basis and acknowledgement of individual progress through certifications for the same. The apex body in the field, the International Society for Orthotics and Prosthetics (ISPO) has been instrumental in providing thought leadership and logistical as well as directional support to the above efforts. In fact, one of the main aims of the first conference of ISPO held in Dortmund, Germany in 2004 was to define the continuing professional education and certification in Europe. The conference put forth certain recommendations towards the above cause and this included the assertion that the prosthetics and orthotics profession should implement a system of continuing education that is based on the premise of proven maintenance of competencies. There was general agreement among the members that there is a need for continuing professional education to maintain the competency of the professionals at a critical level. The applicability of the concept was seen in a European and not just the national context.
The basis of any professional development is based on the three vocational concepts that is vocational learning that is lifelong, vocational working that is capable of coping with changes and vocational cooperation which involves integration of the professional and his competence within the community of practice. Quite significantly, the professional competence and expertise cannot be attained during the period of the training itself, however various mandatory requirements and conditions for the future performance can be set forth which can help elaborate the vocational identity as well as the competency of the professional. The vocational identity pertains to the ability to solve the tasks on a requisite level based on a trade - off between quality, quantity and profitability. Upon the attainment of the desired proficiency, the further professional development ceases to be dependent on structured and intentional learning processes, but on the changes in the technological and organizational environment of the professional.
As per a WHO report, there is a lack of trained personnel in the prosthetics and orthotics services. The prosthetics professionals usually are a part of a multi-disciplinary team and in order to ensure a better quality of service from such teams, the ISPO had taken various important measures to facilitate continued education and training of the prosthetic and orthotics professionals throughout the world. Further, various detailed and suitable training programs for the following three categories of orthotics and prosthetics professionals that is full professional orthotics/prosthetics (Category I), orthopedic technologist (category II) and orthopedic technician/bench worker (category III). The ISPO and the WHO have provided guidelines for the training of such personnel based on their role in the orthotics/prosthetics rehabilitation work. The WHO has identified the need for more such training in the developing countries.
In order to maintain better accessibility of such training, the WHO has suggested that training may be setup on a national or international basis and provisions must be made for both the initial setup of the training facility as well as the long term maintenance of the program. In order to justify the resources spent on such training programs, the outcomes of such programs need to be monitored.
The health professionals require consistent and ongoing commitment in order to provide the services in an ethical manner. This helps protect the public interests and help maintain the overall health of the people in a given region. The health professionals in various countries gain access to such continued education through programs or frameworks within which a systematic effort at imparting and monitoring the continued professional education is made available to the healthcare professionals to ensure the professional competence and development. There is a need to acquire updated knowledge, skills, and the ethical attitudes that will benefit them in their practice in a measurable way. The needs of continuing education need to be monitored or structured such that they ultimately benefit the patient or the client. The need is to present a series of clustered learning activities such that they represent a hierarchy of learning. This also requires the health professionals to select activities at any level of learning that meet their needs as well as the demands put forth by their work and practice environments. The continued education effort needs to be defined in a manner such that the professionals are required to collect competence credentials in a time bound and measured way.
Scholars have particularly focused on the need for continuing medical education with the perspective of the developing countries since the patients in such countries owing to their lifestyle are more prone to injuries and accidents that restrict their mobility and thus require more services of orthotic and prosthetic professionals. The needs for continued professional education in such countries emanated from (1) Lack of awareness and prioritization of prosthetic and orthotic services, (2) Challenges to management of particular pathological conditions, (3) The need for and desire for further professional education and development and (4) The demand for improvement in prosthetic and orthotic education. The needs for continued professional education demand a suitable modification in the training programs and their content, an improvement in the knowledge of the teachers, improvement in access to information, and making provisions to overcome gender inequality. The need for the professionals as part of their quality improvement process is to meet the needs of the disabled population and to determine the areas that need further improvement. The need is also to develop low cost prosthetic and orthotic devices, designs and services as well as structuring the further education.
Over a period of time various orthotic and prosthetic residency programs have been developed to focus on clinical training for attainment of competencies in the effective management of orthotic and prosthetic patient care in a comprehensive manner. The various competencies have thus been defined such as exemplifying the role of the orthotist and prosthetist towards providing a care that is focused on the patient, use of sound judgment with respect to the safety of self, the patients and others. They are also required to demonstrate an awareness of the human aspects of patient care and display a sense of dignity in the same. The professionals undergoing continued professional education are also expected to show an awareness of the cultural diversity and multi ethnic composition of the patients and the society at large. They are supposed to demonstrate the understanding for the clinical practices and manage the practice within the socio-cultural and business as well as the economic environment of the rehabilitation efforts being provided. They are also expected to show an understanding of the collaborative responsibility of the orthotist-prosthetist as a member of a rehabilitation team. The candidates must also be able to demonstrate the ability to critically consume, use and integrate research into the clinical practice.
The success of continued education in orthotics and prosthetics is based on fulfillment of certain systemic needs. The needs necessitate certain approaches to training and foster proper implementation of the training programs. A continued training effort at organized level requires an approach wherein strong academic and professional partnerships are established. There has to be a long terms vision for the sustainability of the training effort. The guidelines for the training programs need to be internationally recognized. There should be focus at capacity building of the programs and the content as well as delivery of the training should adhere to minimum qualitative and quantitative standards. It is also important to consider the fact that the healthcare professionals get exposure to opportunities for professional development commensurate with their up gradation as a result of the continued professional education. Apart from choosing the right methodologies for training, the choice of appropriate technologies is also paramount in ensuring the success of the training programs.
In order to ensure full accountability for the continued education for orthotics and prosthetics (O&P) and Physiotherapy (PT) professionals, there are certain guidelines that need to be followed and thus the professionals need the continued education in order to be able to demonstrate an ability to integrate and apply the foundational knowledge as well as the information of the patient to be able to direct the management of orthotic and prosthetic treatment. They need education to be able to identify the anomalies in the physical conditions as well as the functional limitations of the patients and be able to formulate a comprehensive and effective treatment plan. The professionals usually require better fabrication skills in order to be able to provide superior prosthetic and orthotic care to the patients. Further, the professionals need to be educated as to how to develop and implement an effective treatment follow up plan to ensure an optimum fit of the orthotic or prosthetic treatment. They also need to be able to monitor the outcome of the treatment plan. There is a need to be able to self articulate the importance of the personal and professional development in various areas such as lifelong learning to ensure continual upgrade of the skills and knowledge at pace with the latest developments in the field. The continued education also ensures engagement of the professional in various public domains such as community service, contribution to development of the profession. In addition, the continued education for professional development enables the professional to contribute meaningfully to the proliferation and adoption of research in the area to support the profession. Gaining an exposure to the international best practices in the field which keep getting updated with time is also a prime need that is fulfilled by the continued professional education program. Furthermore, a healthcare professional is able to develop the abilities to perform literary research at an individual or group autonomous level for a meaningful contribution to the profession as well as enrichment of one’s own professional competence.
An important need that is fulfilled through continued professional education is thought mentorship or what is termed as preceptor ship. In this context it is relevant to mention the role of mentors or preceptors in the continued professional education. Mentorship is closely associated to lifelong learning and continual professional development of orthotics and prosthetics professionals. In fact it is the first step in the professional working and ensures professional development in a sustainable as well as measured way. A systematic learning and development is possible only through maintenance of a log or record all the learning and development activities. Thus each and every activity within the purview of continued professional education must be categorically recorded. The systematic effort for the attainment of updated professional knowledge demands that a work based learning is incorporated into the learning effort or program. A professional activity or a member ship of a professional program is also necessitated in the direction to ensure competent professional development. A formal education as well as ongoing courses such as through continuous research or distance learning also widens the professional horizons. Planning or running a course also ensures advancement in the same direction and often yields better output in terms of professional development through continued higher education. Activities such as public services widen the scope of individual learning. In order to maintain the measurability of the continued professional efforts, the professionals’ competencies need to be monitored, categorized and documented. It is important for example to see the prosthetics and orthotics competencies as general and specific. The general competencies include the general abilities of the professionals working in the field such as the generic actions that they are likely to take within the context of the clinical interventions within the prosthetic and orthotic practice.
Accessing education that is close to the home is helps reduce time away from work and helps maintain a healthy balance between work and continued education for the professionals. It is important to note at this juncture that multi professional training is widely available nowadays and various courses that fulfill this condition apart from others are accessible for orthotics and Prosthetics (O&P) and Physiotherapy (PT) professionals. In general, this is a widely held view that advanced practice can mean the mitigation of boundaries between professions and can help generate competitive advantages to the professionals pursuing the same. The O & P professionals apart from the strictly technical knowledge up gradation are advised to upgrade themselves through knowledge of the leadership and management education as well which is also widely accessible nowadays in various formats that are compatible with the busy schedule of the O& P professionals.
While the extant literature on the topic has been discussed and reviewed above, the review of literature regarding the sampling and statistical techniques needs to be reviewed as well. Determination of sample size is a fundamental and most frequent question that comes across to a researcher. In addition to the purpose of the study and population size there are three criteria that need to be specified for the sample size to be determined. The specifications include the level of precision measured by the confidence intervals also called the sampling error, the level of confidence or the risk. Also, the degree of variability in the attributes measures by the variance or the standard deviation of the population is required.
While the level of precision is the range in which the actual value of the population is estimated to be, the higher the precision level, lower the precision level greater is the sampling error thus smaller is the sample size. The confidence level is the degree of the risk of a population mean lying within two standard deviations of the normal distribution obtained by means of the different samples taken from the population. Thus a 95 % confidence level means that 95 out of 100 samples will have the true population value within the range of a precision specified.
The Degree of variability is the distribution of attributes in a population and is measured by the variance or the square root of variance also known as standard deviation. The more variable a population is, the larger is the sample size required to obtain a given level of precision and vice versa. At this juncture, it is important to note that a population proportion of 50 percent indicates a greater variability than either 20% or 80%. This is because this means that a large majority of the population has or does not have the same characteristic as defined by the study. Thus a 0.5 proportion indicates a maximum variability in a population and is used to determine a minimum sample size. That is assuming a 0.5 proportion the calculated sample size shall be smaller than using any other level of proportion .
The formula for calculating the sample size for proportions is given by
n= Z2pq/e2
Where n is the sample size, Z2 is the abscissa of the normal curve that cuts of an area alpha at the tails (1-alpha) equals the confidence level, p is the proportion of the population with a given attribute, q=1-p, e is the level of precision selected .
Statement of the Problem and Objectives of the Study
It has been observed in the last couple of decades that the role of the role of O&P and Physiotherapy (PT) professionals in improving the overall rehabilitation effort especially in the developing countries wherein the lifestyles and the paucity of preventive and primary healthcare facilities necessitates a stronger response to physical trauma and disability related problems. This increasing role of the healthcare professionals and a greater need for a more focused and qualitative rehabilitation effort has also necessitated an increasing demand for the highly trained and professional O & P workers. The said demand for the better trained, more focused individuals is further increasing with increasing world population and mobility. Countries around the world thus require programs to address this problem which is assuming higher proportions with each passing year. The problem as mentioned above has also presented a challenge to the ever changing notions and relevant practices and knowledge pertaining to the field. Thus a need to more clearly define what comprises of continued professional education and what does not. The ambiguities that emerge from the same need to be minimized and eliminated for a better assessment and implementation of the continued education efforts for the healthcare professionals. In this context it is important to point out the problems that arise from these ambiguities. They give rise to the obvious question as to how to access the optimum opportunities for continued professional education. The same makes one ponder as to what could be the best ways to access the right means of continued education for the healthcare professionals.
Aims
Thus this particular study aims to find the specific needs and ways for continued training and development for O&P and Physiotherapy (PT) professionals at different levels. This identification of the needs is supposed to help the individuals, the decision making authorities as well as the professional bodies to device better opportunities for the same. Further, there is a need to identify the best ways to make higher professional education available and accessible to the professionals. This study aims to explore and investigate ways to find the best ways to provide higher professional education to O&P and Physiotherapy (PT) and other healthcare professionals. The study aims to address the need to find ways to make it accessible for a greater number of professionals at a time. Further, determining the needs for the healthcare professionals to be able to access higher levels of professional education becomes imperative and is also one of the aims of this study. Finally the study addresses the problem of finding how to develop ways to ensure better ways and means for the O&P and other healthcare professionals to access the higher levels of professional education in a manner that is efficient, economical and effective. The proliferation of opportunities creates a problem of different kind which is akin to a problem of plenty. The challenge then becomes to find our way through the clutter and look at ways to best access the identified opportunities to achieve the best quality of education for the O&P and physiotherapy professionals.
Objectives
Based on the above problems and the broad aims of the study, the objectives of the study can be stated as mentioned below.
Significance of the Study
The present study proposes to find ways and means to ensure improved and continued higher level of education to the orthotics, prosthetics and physiotherapy professionals. The study based on the survey findings shall help maintain ways to ensure continuing professional education and shall help increase the knowledge, problem solving, technical skills or professional performance standards. Also, the study will help identify the best means to access the higher levels of quality of continued education as well as better performance of the professionals in practice through optimization of the resources for continued professional development at a sustainable level. The study shall contribute to the overall improvement of public health by improving the performance of the health professionals. By suggesting ways to sustain a desired level of higher professional education, the study promises to create better conditions for the professionals to practice their continually acquired skills and knowledge and the natural beneficiary of the same shall be the public of the region where the findings of the study are likely to be adopted. The study will help improve the competency of the health professionals in the long terms and help maintain effective preventive as well as responsive mechanisms within the public health especially the mobility and emergency medical services domain. This will help improve the overall rehabilitation efforts in any given geographic or demographic domain that shall stand to benefit from the findings of the study. The same shall also provide timely rehabilitation to the people in need shall help promote the overall accessibility of quality education to professionals. The continued professional education at a sustainable level as the study proposes to suggest based on its findings shall help create an overall healthy environment and help improve the overall productivity. Thus the final beneficiaries of the study shall be the public, governments, businesses, health professionals, patients especially the trauma and accident victims.
Methodology
Research Questions
Based on the objectives of this survey above on “Continued Professional Development” for professionals in the field of Orthotics, Prosthetics and Physiotherapy (PT), the following research questions are identified.
The research questions based on the aims are as follows.
Is there a real need for continued professional education for O&P and PT professionals?
What are the specific needs for continuing professional education?
What are the best ways to make accessible continuing professional education opportunities to a larger number of professionals?
What are the needs for accessing higher level of professional education?
What are the best ways to ensure access to higher level of professional education for a greater number of professionals?
Principal Research Question
The principal research question for the survey is as mentioned below.
Q. Does the cohort as defined, need learning within the professional or alternative studies?
The cohort is broadly defined as consisting of two principal groups
Those who need the learning within the professional or alternative studies
Those who do not need learning within the professional or alternative studies
Research Design
The study follows a mixed research design, where both qualitative as well as quantitative research methods are used. The qualitative research is pursued through a review of the relevant literature as well as certain aspects of the survey designed for the study. The survey results are quantified to perform appropriate statistical tests.
Survey Design
The survey has been designed to elicit both qualitative as well as quantitative responses. The survey was performed online.
The survey design consists of dichotomous and multi-choice response format, few questions allowed qualitative feedback and are arranged according to the themes.
Sampling Design
Sampling Arena
The population or sampling arena for the study was Africa Sampling units
Sampling unit
The sampling units were specifically people in the region who belong to either the orthotics/prosthetics profession (O&T) or to the Physiotherapy (PT) category. The sample itself was a cohort of such sampling units with defined characteristics based on the research objectives and questions.
Sampling method
The sampling method used is simple random sampling for a cohort survey.
Sample Size
The estimated sample size of the cohort was 1024, based on the registrations for the survey online.
The formula as discussed above says-
n= Z2pq/e2
Where n is the sample size, Z2 is the abscissa of the normal curve that cuts of an area alpha at the tails (1-alpha) equals the confidence level, p is the proportion of the population with a given attribute, q=1-p, e is the level of precision selected.
In this case,
Z=1.96
p=0.5
q=0.5
e=0.05
Thus n=384.16 or 384. Therefore the minimum sample size is 384. Thus a sample size between 384 (minimum) and 1024 (estimated) shall yield good results insofar as proper representation of the population is concerned.
Research Tools
The survey employs structured questionnaire as research tools consisting of three sections
Demographic features
Section for Physiotherapists (PT) only
Section for orthotics/prosthetics (O&P)
The Survey consists of 35 questions (8 shared and 27 individual) related to the PT or O&P fields as applicable to the respondent.
Statistical tests/Analysis
The quantitative part of the survey findings shall be used to categorize the sample into two cohort groups as mentioned above. Each group shall be given a score indicating either a need or no need for learning as defined above. Since the groups are based on random sampling, the groups are also assumed to be randomly sampled. Each of the two groups shall be denoted as GL and GNL respectively. The groups shall be considered as having two different proportions for the existence of the said need. The proportions shall be worked out and discussed in the Analysis section ahead and the z test for equality of proportions shall be applied such that following Hypotheses are validated based on the difference d between GL and GNL:
References
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HPCSA, 2011. Continuing Professional Development Guidelines for the Healthcare Professionals. [Online] Available at: http://www.hpcsa.co.za/Content/Docs/guidelines_2011.pdf[Accessed 21 May 2016].
ISPO, 2015. ISPO Biennium Report 2013-2015. s.l., ISPO.
Israel, G. D., 1992. Determining Sample Size. [Online] Available at: http://sociology.soc.uoc.gr/socmedia/papageo/metaptyxiakoi/sample_size/samplesize1.pdf[Accessed 22 May 2016].
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NCOPE, 2011. Standards for Accreditation for The Orthotic/Prosthetic Residency Program. [Online] Available at: http://www.ncope.org/assets/pdf/2011_residency_standards.pdf?20151105[Accessed 18 May 2016].
Nicol, A., 2012. Preceptorship in Prosthetics and Orthotics. [Online] Available at: https://www.bapo.com/Framework/ResourceManagement/GetResourceObject.aspx?ResourceID=d28db7d3-b8b2-4680-8dd9-2853224f6de0[Accessed 20 May 2016].
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