PHARMACOLOGY PRACTICE AND SOUTH AFRICAN PHYSIOTHERAPISTS - PART TWO A NEEDS ANALYSIS N A T I O N A L S U R V E Y INTRODUCTION Physiotherapy is a dynamic process in which change and development within the scope of practice is ongoing (Robertson et al 2003). In many coun- tries physiotherapists are now first-line practitioners and specialization is also becoming a reality (Donato et al 2004; Robertson et al 2003). Furthermore increasing financial, as well as resource constraints result in allied health profes- sionals having an increased responsi- bility to provide a cost effective service in accordance with the evidence for best practice. Physiotherapists have recognized the importance of knowledge of pharmaco- logy and pharmacokinetics to ensure best possible treatment outcome (Lansbury and Sullivan 1998 and 2002; Grimmer et al 2002; Unger and Lochner 2005). A descriptive survey in the United States (USA) stated that advice concerning over-the-counter (OTC) drugs was reported to be one of the professional responsibilities of primary contact prac- titioners (Donato et al 2004). Although there is very little evidence to support the assumption that physiotherapists have a need for prescription rights, one study stated that front-line and rural practitioners had reported a need to prescribe, specifically non-steroidal anti-inflammatory drugs (NSAID), to complement certain manual therapy techniques (Grimmer et al 2002). Correspondence with spokespersons for physiotherapy associations in Canada, United Kingdom (UK) and Australia has also confirmed that therapists in these countries have expressed the need to expand their scope of practice to include the right to prescribe certain medicines. According to the Chartered Society of Physiotherapy (CSP) physiotherapists in clinical specialist positions in the UK may now become supplementary prescribers (CSP 2004). This enables them to administer, monitor and alter dosages as necessary within a specific Clinical Management Plan. Although they cannot yet prescribe independently, the CSP is continuing discussions with the Department of Health and seeking exemption from the Medicines Act regarding the use of local anaesthetic for use in the treatment of acute musculo- skeletal conditions. As early as 1994 the South African Society of Physiotherapists (SASP) attempted to formulate guidelines for a course to provide physiotherapists with all the knowledge required to prescribe specific categories of drugs, notably bronchodilators, mucolytics and certain skin preparations. Stellenbosch Univer- sity presented a CPD course in Pharmacology in 1995 and from the course feedback, the need for limited prescription rights was further empha- sised. This group was a small represen- tation of physiotherapists from the Western Cape and much has changed in South Africa (SA) since then, including the introduction of community service for newly qualified physiotherapists in 2003. Requirements for optimising physiotherapy service delivery in the rural areas still need to be assessed. Therapists in rural areas in Australia have highlighted the issues of non- availability of medical and other health services as reasons for their need to be able to supply, recommend and even prescribe medicines to their patients (Grimmer et al 2002). SA legislation currently prohibits physiotherapists to administer, store or prescribe medicines. The assumption that some therapists are making them- selves guilty of illegal practice and the uncertainty of the need for these rights motivated the undertaking of a nation- ABSTRACT: A national survey of pharmaceutical practice by South African physiotherapists was conducted. In this second paper, the needs relating to administration, storage and prescription of medicines are discussed. Seventy percent of respondents reported a need to legally administer and 58% reported a need to store certain medicines. More than 60% of respondents were in favour of the expansion of the scope of physiotherapy practice to include prescription of a limited range of medications after training and within certain areas of specialization or clinical competence. It is recommended that a basic pharma- cology module be part of the undergraduate curriculum with the option to expand or update knowledge and skills via CPD activities and through specialization and that legislation be revised to accommodate these suggestions. KEY WORDS: PHARMACOLOGY; NEEDS ANALYSIS, ADMINISTRATION, PRESCRIPTION AND STORAGE OF MEDICINES; PHARMACOLOGY TRAINING, SCOPE OF PRACTICE Unger M, MSc Physiotherapy (SU)1, Lochner R, Dip in Physiotherapy (UP)1 1 Stellenbosch University, Department of Physiotherapy. 18 SA JOURNAL OF PHYSIOTHERAPY 2006 VOL 62 NO 2 CORRESPONDENCE TO: Marianne Unger Department of Physiotherapy Faculty of Health Sciences Stellenbosch University PO Box 19063 Tygerberg 7550 Tel: (021) 938-9300 (w) (021) 975-7421 (h) Email: munger@sun.ac.za JRLJUN 2006 Short 31/5/06 10:27 am Page 18 SA JOURNAL OF PHYSIOTHERAPY 2006 VOL 62 NO 2 19 260 240 220 200 180 160 140 120 100 80 60 40 20 0 Under-graduate Post-graduate Workshops/courses Other 53% 7% 16% 28 Figure 1: Training in pharmacology. 220 200 180 160 140 120 100 80 60 40 20 0 1 (unimportant) --------- - 5 (very important) 4% 8% 16% 22% 50% Figure 2: Importance rating for inclusion of pharmacology at under- graduate level. 280 260 240 220 200 180 160 140 120 100 80 60 40 20 0 n o o f re sp o n d e n ts 47% 18% 11% 7% 50% 12% 53% 42% 4% 7% M IM S d ru g c o m p a n y i n fo d ru g c o m p a n y s tu d ie s in te rn e t m e d ic a l p ra ct it io n e rs p h a rm a ci st s re se a rc h p a p e rs d ru g l e a fl e t co ll e a g u e s o th e r n o n e 59% Figure 3: Sources of drug information consulted by respondents in the six months prior to completion of the questionnaire. wide survey in collaboration with the Professional Board of Physiotherapy, Podiatry and Biokinetics (HPCSA) in 2004. Part one of this two part series reported on the results relating to response rate, respondent demographics, perceived knowledge of pharmacology as well as current administration-, storage- and prescription practice by SA physiotherapists (Unger and Lochner 2005). This paper focuses primarily on the results pertaining to respondents’ needs regarding the administration, storage and prescription of medicines. Knowledge regarding pharmacology and how this is sought was also investigated. METHOD Following project approval and registra- tion (2003/147/N) by the Research and Ethics Committee at Stellenbosch University, a self-administered question- naire was sent out, together with the Bulletin of the Professional Board for Physiotherapy, Podiatry and Biokinetics, to all 4408 physiotherapists registered with the HPCSA in January 2004. A more detailed description of the metho- dology is described in Part One (Unger and Lochner 2005). The questionnaire had three sections: Information regard- ing personal details and demographics; current practice and knowledge of phar- macology; and attitudes towards drug administration and prescription respec- tively. Quantitative data was analysed and correlated with responses relating to work setting and -area, years qualified, and conditions most commonly treated, where this was appropriate. Responses to the open-ended questions were qualitatively processed and analysed. RESULTS A response rate of 10.2% (N=448) was obtained (Unger and Lochner 2005). This second paper of a two-part series will report on respondents’ attitudes towards pharmacology and the extension of the scope of physiotherapy practice to include administration, storage and prescription rights. Acquisition of knowledge Fifty three percent of the respondents received theoretical training in phar- macology as part of their undergraduate qualification (figure 1). Less than a quarter of the respondents indicated that they had either obtained or updated JRLJUN 2006 Short 31/5/06 10:27 am Page 19 their knowledge in pharmacology via post-graduate courses or workshops. Knowledge acquisition through more informal means, such as attendance of ward rounds and departmental CPD activities, journal readings or even con- versations with medical practitioners, was also reported. Sixty percent of the respondents indicated that they have never updated their knowledge. No correlations were found between work setting (rural vs urban) and post- graduate workshop or course attendance, nor for conditions most commonly treated. Seventy two percent (n=297) of the respondents rated the inclusion of a comprehensive module in pharmacology in the undergraduate curriculum as being important (Figure 2). Analysis of the final comments and suggestions indicated that knowledge of drug inter- actions, especially with physiotherapy modalities and techniques, would enable graduates to manage their patients more holistically and that they would be able to give informed advice regarding suitable medication, thereby facilitating best practice. Evidence to support the recognition of the importance of pharmacology was found in the number and frequency of drug information sources utilised by the respondents (figure 3). Regardless of training background, 90% of the respon- dents had sourced information at least once in the six months prior to the completion of the questionnaire. Administration of medicines Seventy percent (313/N) of the respon- dents indicated that physiotherapists should be allowed to administer drugs (Table 1). This view was supported by the qualitative analysis of the final comments with reference especially to respiratory and anti-inflammatory drugs. Analgesics, topical (NSAID, wound- and homeopathic-) preparations, antibio- tics and emergency drugs were also listed. Motivation for the response relating to the respondents’ experience regarding the administration of medicines are summarised in Table 2. Therapists treating in-patients in public hospitals expressed a greater need for the right to administer as compared to therapists practising in pri- vate hospitals (p<0.03). A significant correlation between therapists treating respiratory conditions and the need to administer was also found (p<0.02). No correlations between work setting (urban vs rural) and the need to adminis- ter drugs were found. Although not specifically asked in the questionnaire, respondents volunteered information regarding administration routes. These included administration predominantly via inhalation therapy and topical application. Oral ingestion, ionto- and phonophoresis and injection were also reported. Storage of medicines Although respondents felt a lesser need for the right to legally stock medicines (Table 1), analysis of their comments indicated that storing of medicines which therapists can administer, would further facilitate service delivery and minimize cost to the patient. Motivation for responses relating to storage practice was very similar to those listed for administration rights. Prescription of medicines Sixty three percent (277/N) of the respondents expressed the need to be able to prescribe medicines (Table 1). Similarly 62% of the respondents indi- cated that prescription of drugs should be part of the scope of physiotherapy practice, despite acknowledgement of the implication that such a policy change would increase insurance premiums and “....load an already full curriculum”. Although there was a significant corre- lation between the need experienced and the responses relating to the inclu- sion of the right to prescribe (p<0.001), 40 (10%) respondents indicated that although they themselves had not had the need to prescribe as yet, the option of being able to prescribe if necessary, would allow more holistic patient management. Graduates with fewer years experi- ence (mean:12.8 years; range:11.5 - 14) expressed a greater need for the right to prescribe than older graduates (mean: 17 years; range:15.4 - 18.6) (p<0.001). No other correlations were found. Reasons stated by respondents in sup- port of inclusion of pharmacology into the scope of physiotherapy (264/N), in order of frequency, were: YES NO Need to prescribe 63% 37% Should be allowed to administer 70% 30% Should be allowed to stock medicine 58% 42% Should stock emergency medicine 36% 64% Table 1: Need to prescribe, administer and stock medicines. Administration of drugs Reasons in favour of No of Reasons against No of comments (%) comments (%) Augment Rx / rehab 34% Lack of training 33% Necessity for 1st contact practitioner 24% Dr / pharmacists are better trained 21% Cost / time effective 17% PT has own skills 18% Enhances holistic approach 9% Not in PT scope of practice 11% Manage acute conditions > effectively 5% Increased insurance premiums 2% Advance professional status 4% Curriculum is full enough 2% Table 2: Comments regarding administration needs. 20 SA JOURNAL OF PHYSIOTHERAPY 2006 VOL 62 NO 2 JRLJUN 2006 Short 31/5/06 10:28 am Page 20 SA JOURNAL OF PHYSIOTHERAPY 2006 VOL 62 NO 2 21 • inclusion would encourage more holistic and comprehensive patient management (includes being able to give better advice re medication, complimenting manual therapy techniques and improving service delivery) • it would be more cost and time effec- tive for the patient • it would give increased status and an added dimension to physiotherapy which would ensure keeping up with other professions However these respondents expressed certain reservations and stated that this right should be limited to areas of specialization only, within clearly defined guidelines and the choice to do so should be voluntary. Reasons stated by the respondents who were against the inclusion of pharmacology into the scope of physio- therapy (164/N), in order of frequency, included: • doctors and pharmacists are better trained and are available for referral • increases risk, responsibility (“...little knowledge is dangerous...”) • increase in insurance premiums • doesn’t “fit” into the scope of physio- therapy - physiotherapy relies more on manual techniques and physical rehabilitation • current course already full and scope of physiotherapy is wide enough • could compromise good inter profes- sional relationships DISCUSSION Respondents to the survey seemed to have particular views regarding the issues of administration, supply, storage and pre- scription of medicines. However quali- fication of their responses was often ambiguous and analysis of comments used to motivate their opinion often negated or even contradicted their yes or no response. Respondents’ attitudes towards these issues will be discussed. Administration of medicines. Management of physiotherapy services differs for state and private practice. The assumption that the multi-disciplinary approach to patient care in our state hospitals is not optimal, due to a possible lack of cooperation between the disci- plines may have contributed to the more significant need expressed by these practitioners for the right to be able to administer medication, especially respi- ratory drugs for inhalation therapy. The need to be able to administer certain medications, however, was reported in all fields of physiotherapy practice. Although these findings were not signi- ficant, more than half of the respondents reported that inclusion of medicine administration rights would save time, and legislation of storage of these medi- cines would furthermore promote effec- tive service delivery. Contradictory to the findings of Grimmer et al (2002) respondents in rural work settings in the current survey did not report a greater need for legisla- tion of administration or storage rights. Similarly no greater need for prescrip- tion rights, was reported by these respondents. The expansion of Primary Health Care services in SA has improved patients’ accessibility to medical practi- tioners and pharmacists in these rural areas. However media reports have stated that delivery of medicines is slow and there are long queues while waiting for collection of medicines. This did not appear to affect physiotherapy service delivery. The low response rate especially from practitioners in rural work settings (Unger and Lochner 2005) may also have contributed to these findings. Prescription of medicines. Almost two thirds of respondents indicated they had experienced the need to be able to prescribe medicine. Generally respon- dents were also in favour of the inclu- sion of prescription rights into the scope of physiotherapy practice. Qualitative motivation by respondents in favour of the expansion of the scope of practice related predominantly to the enhance- ment of the profession, whereas analysis of responses opposing the inclusion related predominantly to the increase liability risk and the lack of current training in pharmacology, suggesting perhaps that with the necessary training, inclusion may very well be appropriate. Knowledge of pharmacology and training. The current survey shows that respondents are aware of the potential danger associated with insufficient knowledge when recommending and supplying medicines, even over-the- counter (OTC) and homeopathic drugs. Similar findings were reported by a study in Australia, investigating thera- pists’ knowledge shortly after the recommendation and administration of non-prescription medications was legalised (Lansbury and Sullivan 2002). These authors emphasised that informa- tion regarding drug effects, interactions with other medications and therapies, side-effects and contra-indications alone are insufficient to ensure safe practice. Thorough history taking, documentation practice, and competent administration and evaluation skills are also essential. An internet survey revealed that there is no specification that pharmacology modules are part of undergraduate physio- therapy programs (ACOPRA 2001; APTA 2002; WCPT 2003). In SA, up to 2002, the decision about the inclusion of pharmacology in the undergraduate curriculum had not been made. There is still no consensus regarding curriculum content, nor outcomes for pharmacology training. Results from this survey indi- cate that many therapists have never received formal training. Despite the recognition of the importance of the role of medicines in patient management, less than a third of respondents had sought to acquire new, or update their existing, knowledge. On the other hand, many therapists are sourcing informa- tion, mostly through informal means (refer to figure 3) and yet respondents still regard their current knowledge insufficient to be able to advise patients safely about, or to administer medica- tion (Unger and Lochner 2005). This seems to suggest that therapists have a need for formal training in pharmaco- logy as well as ongoing CPD activities to equip them with appropriate compe- tencies for safe and effective pharma- cology practice. CONCLUSIONS AND RECOMMENDATIONS Analysis of responses to the survey has identified several components essential for enhancing physiotherapy practice. A comprehensive report of the findings of this survey has been submitted to the Professional Board of Physiotherapy, Podiatry and Biokinetics. The authors have made several recommendations and these include that: 1. A module in basic pharmacology should be incorporated into the undergraduate curriculum. A theory component including pharmacokine- tics, side-effects and contra-indica- tions of a selected list of drugs should be included, as well as a practical component to ensure competent administration skills via nebulisation, iontophoresis, phonophoresis, topical application and intra-muscular injec- tion within the various domains of JRLJUN 2006 Short 31/5/06 10:28 am Page 21 22 SA JOURNAL OF PHYSIOTHERAPY 2006 VOL 62 NO 2 applied physiotherapy. This will equip a new graduate with the neces- sary knowledge and skill to function as a supplementary prescriber / legal administrator (refer to PA 58 (CSP 2004)). 2. The Professional Board (HPCSA) must amend current legislation for this to become accepted practice. 3. Individual therapists specifically trained should be given “Extended Scope Practitioner” status and allowed to prescribe, administer and supply medicines relevant to the different areas of specialization or clinical competence. 4. To accommodate the current need for knowledge it is recommended that the SASP in consultation with the various academic institutions and special interest groups, develop and offer courses. Alternatively, ongoing CPD can also be offered in form of academic publications. ACKNOWLEDGEMENTS We would like to thank Dr M Kidd from the Department of Statistical Consul- tation for his continued support. REFERENCES ACOPRA. Australian physiotherapy Compe- tency Standards [online]. 2002 [cited 2005, 09 September]; available from: http://www. acopra.com.au/file_folder/APCS_2002 Chartered Society of Physiotherapy. PA 58 - Prescribing for physiotherapists [online]. 2004 [cited 2005, 15 September]; available from: http://www.csp.org.uk Canadian Physiotherapy Association. Physio- therapy education [online]. 2001 [cited 2005, 09 September]; available from: http://www.cpta.ab.ca Donato EB, DuVall RE, Godges JJ, Zimmerman GEJ, Greathouse DG (2004). Practice analysis: Defining the clinical prac- tice of primary contact physical therapy. Journal of Orthopedic Sports Physical Therapy, 34(6):284-304 Grimmer K, Kumar S, Gilbert A and Mila- nese S (2002). Non-steroidal anti-inflam- matory drugs (NSAIDs): Physiotherapists’ use, knowledge and attitudes. Australian Journal of Physiotherapy 48:82-92 Lansbury G and Sullivan G (1998). Physio- therapy and drug administration: A survey of practices in New South Wales. Australian Journal of Physiotherapy, 44:231-237 Lansbury G and Sullivan G (2002). Physical Therapists knowledge, advice and administra- tion of non-prescription medications to their clients. 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