Are Changes Afoot? What Does The Future Hold For The Podiatric Profession?

Authors: Harrison Travis1

1*BSc Hons Podiatry Student, University of Brighton, School of Health Sciences, Eastbourne, BN20 7UR 2AResearch Fellow, Centre for Outcomes and Experience Research in Children’s Health, Illness and Disability (ORCHI

E-mail:harrison.travis@hotmail.co.uk

Citation: Harrison Travis, Chris Morriss–Roberts, Hannah Brown, Sarah George and Vinay Patel, ”Are Changes Afoot? What Does The Future Hold For The Podiatric Profession?”, Global Scientific Research Journal of Foot & Ankle, 1(1), 2018, pp. 1-10.

Copyright: Copyright © 2018 Harrison Travis et al., This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Abstract

 Introduction:

Background: The future of the profession is widely unknown due to the rapid implementation of new policies, leaving healthcare workers often in a state of uncertainty. Rising demands for podiatric intervention in conjunction with staff shortages has allowed workforce lexibility and extended scope of practice. This study aims to explore the views of experts and what they believe will be the future of the podiatric profession.

Methods:

An Interpretive Phenomenological Analysis (IPA) was conducted to explore, in-depth, the individual’s experiences and beliefs regarding the future of the podiatric profession. Participants (n=6) who are viewed as eminent within the profession were purposefully sampled and subjected to semi-structured interviews to obtain rich, in-depth data. This facilitated the comprehensive contextual analysis behind the participant’s rationale.

Results:

Thoughts around the future of the profession appear to be comparatively similar amongst participants. Using the full and extended scope of practice accessible alongside aspects of self- professional promotion are key areas deliberated upon.

The analysed interviews revealed three leading themes:

1. Workforce; envisaging what is expected from the role of the podiatrist in the future.

2. Podiatry Governance; depicted by the known and highly suggested changes to the governing body.

3. Education; the modi ication necessary to engage more with students and the relative importance this has on the profession.

Areas of controversy were registered when participants discussed their attitude towards Foot Health Practitioners (FHP) and their embodiment within the profession.

Conclusion: Despite the inadequacy of literature and understanding around this topic, the ideology amongst participants remained consistent with little discrepancy. This research provides an insight into future developments focusing upon: workforce, podiatric governance and undergraduate education.

Keywords: Future, scope of practice, student recruitment, clinical recognition, promotion, qualitative research, Interpretive Phenomenological Analysis, workforce



Description

BACKGROUND:

The podiatric profession has a constantly changing role within our society. Demographic shifts show an aging population and a rise in the prevalence of chronic illnesses [1, 2], this is predicted to prolong the growing pressure put on health services [3, 4]. Healthcare has responded by implementing policy changes such as ‘Meeting the Challenge’ creating workforce lexibility and expansion of role boundaries [5] in a bid to inance a sustainable health service, enhancing workforce productivity and tackle staff shortages [6, 7]. The public sector is receiving a vast surge in the treatment of high risk patients highlighting the demand for skilled practitioners [8]. This plays a contributing factor to the developed range of services undertaken by podiatry [9-11]. While there have been expansions in the scope of practice, furthered educational attainment and legislative strategies [11] it is apparent that recruitment, reported burnout and poor recognition are still issues the profession faces [12-14].

A recent paper examined in-depth the poor social status that podiatry has in the UK and what effect this has on the profession [15], however from this little discussion was prompted concerning the future changes. Similarly, from an extensive literature review, research has focused predominantly on previous advances for the profession and how this has permitted podiatrist’s admission and integration into healthcare services [14-20].

With a new team of appointed governance members questions arise concerning what changes will they make and how will this affect practitioners in the future? The picture is further complicated as National Health Service (NHS) management continuously make changes affecting commissioned pathways [21-23] leaving practitioners ambivalent about their future role.

This prompted the study to explore and analyse the views of podiatric experts who have the capacity to make and in luence professional identity change. This will create a reliable indication of the probable future plans and provisions for the profession. The need for this research is con irmed by the insuf icient amount of evidence available at a time of great ambiguity

METHODOLOGY:

A qualitative methodology was implemented, combining semi-structured interviews and IPA was employed as a systematic approach to retrieve rich, in-depth data. This method was deemed the most suitable way to study the phenomena gaining high quality data and achieve a greater exploration around the subject. Participant convenience, feasibility and practicality were all considerations taken into account when deciding this method [24, 25]. Semi-structured interviews permitted the interviewer to prepare the pre-determined questions, as well as, allowing for lexibility in the instance of following topical trajectories the interviewee wished to focus on [26]. The interview guide was designed to facilitate conversation leading to detail-rich answers. A technique used by starting with simple questions related to the participant’s background within the profession and then transitioning into more speci ic, in-depth questions allowed the researcher to record a pool of higher quality data [26, 27]. The questions concentrated on the participant’s involvement in the podiatric profession and their personal views towards different aspects of the future. Answers given were often followed with an explanatory question and prompts encouraging elaboration of their initial response

Participant Recruitment:

The study was granted approval by the School Research Ethics and Governance Committee, University of Brighton (as this was a University School Level, no Ethics ID/numbers are allocated. For future information please contact corresponding author).

A purposeful sampling style was employed to recruit participants for the study. This method was selected to provide a rich diversity of opinion thus strengthening the credibility of data collected [28]. Participants were recruited who are seen as high pro ile and eminent while having the capability of making changes to the podiatric profession. Information sheets and contact details of the researchers were e-mailed to six selected potential participants. Everyone who was approached agreed to take part in this study. Written consent was obtained from each participant prior to starting the interviews. Participant’s names have been changed to protect their identity.

Data Collection:

Data was collected by conducting a semi-structured interview with each participant over video call using a secure account from the University of Brighton. Some research advises the use of non face to face methods for interviewing as this allows the participant to feel more relaxed in their home environment, this creates discussion where they can talk more openly [29, 30]. Providing this opportunity to speak freely and re lectively about their own experience follows the underlying premise of data collection for IPA [31]. Each interview lasted approximately one hour with the aid of supplementary note taking. Most questions were non-speci ic to allow the participants to talk about what was important to them, this gave an in-depth personal insight of their lived experience around the matter [27]. Each interview was audio recorded and transcribed verbatim by the researcher.

Data Analysis:

See Table 1 for superordinate and subordinate themes generated.

IPA was used to analyse the data collected, being committed to exploring people’s views and opinions whilst providing a deep exploration of their lived experience [31]. Each transcript, prior to analysis, was read multiple times to create familiarity. A comprehensive analysis of the participant’s thoughts and opinions on the subject was undertaken, creating a personal meaning to each account. This was completed for all transcriptions prior to looking at emergent themes to prevent premature interpretation of themes and generalisation of the analysis process [32, 33].

The next stage involved using the initial noting to produce a set of themes stemming from the participant’s thoughts and perceptions. These emerging subordinate themes were recorded and the process was repeated for all transcripts. Emergent themes were compared and contrasted using a ‘carpeting’ technique [34] to categorise them into superordinate themes (Table 1). Each researcher independently analysed and themed all six interviews, this allowed cross comparison to improve the rigor of the results collected [35].

                                            

RESULTS:

Between the time of expressing an interest and conducting the interviews, one person’s change of circumstances meant they failed to meet the inclusion criteria and therefore could not take part in the study. Subsequently, an additional participant was invited and agreed to take part. Participants came from diverse backgrounds including: management, academia and education, the NHS and the private sector. Participants had a mean time of twenty-three years of association to podiatry. The interviews showed apparent interest in the following themes; workforce, podiatry governance and education. These subsequently were discussed and analysed in detail throughout the paper. A shared perception from all participants that were interviewed was that there is still a lot of work to be done within the profession and it is the responsibility of all the members of the profession to contribute in this future development.

After con irming the identi ied themes with the other researchers, the data analysis established three superordinate themes that were recurrent amongst the participants (Table 1).

Theme 1 – Workforce Demands:

Participants talked about the current workforce demands and how inancial complications with changing demographics have affected all healthcare professionals, especially within the podiatrist’s role. Participants interestingly, without prompting, focused towards the mind-set of practitioners and the scope of practice that is available.

Mind-Set of Practitioners:

“What we need to do now is make sure we’re integrating podiatry, there is no such thing as a diabetes, or MSK podiatrist… we’ve got to have competency in all domains. I am MSK through and through but I have Doppler in my clinic, there’s not a day that goes by I don’t consider the vascular system because I wouldn’t be doing my job properly…” – Amy

There was a sense of frustration and concern over the number of practitioners who fail to consider the full holistic approach when assessing patients and instead concentrate towards their speciality. Participants employed in more managerial positions acknowledged the importance of a holistic approach but maintained that specialisation was the way forward, allowing the integration into healthcare

Utilising Scope of Practice:

“People are quite happy to inject medicine but when it comes to giving people drugs a large number of podiatrists are too fearful… the change in what we do has truly revolutionised our practice.” – Peter

Participants felt there were not enough practitioners utilising the full scope of practice, as a result students gained reduced exposure to competencies with concerns aimed at the use of sale and supply medications.

Integration of Foot Health Practitioners:

“There is far too much separation and hostility towards foot health practitioners… in order to grow the membership we should help convert them into podiatrists.” – Peter

The attitude towards FHP’s remained relatively consistent with ive of the participants encouraging greater cooperation with them. The one other claimed that maintaining a relationship would pose as a threat limiting the capability of the profession.

Theme 2 – Constitutions:

The participants primarily re lected on the current political agenda podiatry holds and the changes presently underway. All participants appreciated the current changes by the governing body being the ‘5 Pillars of Change’ [36] and this was faced with the shared impression that with the correct implementation and support from members, it was a great opportunity for professional development.

“…I hope within the next 12 months you will see a very different membership structure to this organisation and that the members will feel more actively engaged with us moving forward, a big piece of work being done is looking at the commissioning in the NHS of podiatric services.” – Jon

“…the futures bright the futures orange.” – Josh

Professional Title:

Participants also re lected on changing the title of the governing body and how this will help bring the profession together

“Bringing the education side and the trade union side into one, we will have a professional organisation and a trade union which supports our members… the two sides don’t work that well being apart.” – Peter

Participants implied that this was a fantastic opportunity to discontinue the title Chiropody and formally be known as the College of Podiatry

“... you can quote me for all I care, I hate the word with a profound signi icance… I think it’s the biggest thing holding us back… I think anyone who keeps reporting that chiropody/chiropodist we need to keep otherwise we’ll never get any work is talking absolute rubbish, sorry, but I’m going to be honest.” – Josh

All participants felt the title chiropody was a major in luence holding back the profession due to the connotation it has with core podiatry. Routine work plays a much smaller part than it once did therefore misleading the public on the podiatrist’s role.

Professional Regulation:

“Looking at the future and how we regulate our podiatrists is a real piece of work that we’re involved with now… that’s the consultation now where we will regulate pods.” – Jon

This was treated as very exciting news and one of the big movements currently happening to shape the future of the profession

Theme 3 – Training and Promotion

Without provoking, promotion was recurrently mentioned with emphasis on how this was thought to contribute to the demise of the profession. Most participants claimed this was equally, if not more, the responsibility of the practitioners rather than the professional bodies. The general consensus was that now it is up to practitioners to converse more and promote the profession

Promoting Podiatry:

“I think that one of the things we struggle with is holding our conversation… we’re not savvy enough yet. Physios are really good at this and we’ve got to get better otherwise we’ll start to lose our voice… what we’ve got to do is actually ind our voice, shout loud and then use it.” – Amy

Participants largely documented about how, collectively podiatrists are poor at promoting and the effect this has on the profession. An association was established between promotion and recruitment so subsequently participants offered their opinions on how to address the undergraduate concerns. 

Undergraduate Statutory Funding:

“Funding for students has been withdrawn, this is a massive concern… we need more healthcare workers across the board… there’s been evidence of a signi icant drop in numbers and I’m scared in 3 years’ time that we struggle to keep the profession going… that’s what the reality is.” – Mike

All participants felt equally worried about the loss of statutory funding. Without this the profession was expected to, and indeed has, signi icantly suffered in the number of students joining the course. Despite this despair two participants remained optimistic and positive towards future recruitment claiming that it will improve again.

DISCUSSION:

This study has highlighted that due to the susceptibility of changing modern healthcare provisions, there is a great sense of uncertainty and complexity surrounding the future of the podiatric profession. A recent qualitative study, looking at expert views around the generalist podiatrist, recorded similar results concluding that participants need to embrace changes by working together as well as taking the lead as clinicians [39].

Many of the results in this study looked at the expert’s opinions of perceived problems and not necessarily de inite changes. Poor recognition was seen as primary importance for the participants and one of the greatest concerns and threats for the profession. This is in concordance with a previous study [15] which concluded that the attention should focus on upholding a monopoly over key areas. Participants felt that due to the easy nature of ‘passing the blame’ a large proportion of the poor social status podiatry receives is from its members doing their own profession a disservice. When challenged, the participants believed that individual practitioners did not do much in the way of promotion with the interpreted sense that it is somewhat unfair that practitioners believe it is other people’s responsibility to do the promotional work. The words ‘promote’ and ‘shout’ were used together on numerous occasions during the interviews which emphasises how strongly the participants feel about this subject.

“we as a profession are bad at promoting, what we need to do is shout more and tell more people the true extent of what we have to offer”

From interpretation, it is thought this belief has been exhausted with a sense of frustration due to practitioners still not adhering to it. This explanation in conjunction with the wider literature suggests that those who have chosen to ignore changes to the scope of practice have helped perpetuate the poor image the profession is often given [37]. A small sense of sympathy, however, was offered as it was acknowledged that the older generation of podiatrists would not have been fully trained to use all modern competencies. Not having the right training can easily cause discouragement and a loss of con idence in the skill set expected from today’s workforce. From this further questions and uncertainties arise regarding whether clinicians are aware of, and use, the gold standards of practice and treatments. This highlights an area of research that previously has not been widely studied and could emphasise parts of the profession needing to be revised.

Participants talked about how a wide scope of practice was associated with good recognition within healthcare. A strong belief amongst practitioners found that within the profession not enough podiatrists are taking advantage of the independent prescribing course available. This coupled with the NHS currently not universally supporting podiatrists in some areas to become independent prescribers identi ies an area of required developments [39]. Future plans from this are likely to look towards educational establishments to make this more accessible together with the pathways for podiatrists to access prescription drugs in community and hospital settings. This could have the capacity to improve the patient’s health earlier and reduce the General Practitioners waiting time.

Importantly in the interviews it was noted that promotion had a high association with recruitment into the profession. Recently it has been evident that the number of undergraduates entering the profession has signi icantly reduced because of the loss of statutory funding. It is because of this that funding for the places was one of the main enticing factors for the degree rather than actual ambition. Participants related this decrease to a “sinking” representation portraying the decline in applicants that they expected over the forthcoming years. However, there was reported evidence that university applications for 2018 entry have increased from 2017 highlighting the promotional work that universities have done. Universities have looked at completing the undergraduate course in two years to make it more appealing, this proved to be challenging with the Health and Care Professions Council requirements, however, the University of Brighton recently released their two-year masters course this [40] enticing more students to study there with other universities likely to replicate this. Participants showed variation when talking about the subject of FHP’s. The term ‘getting over this idea’ was used throughout by multiple participants and referred to the stigma associated with them. Participants believed that integration of FHP’s in to the profession would help improve the overall status of the podiatrist allowing them to complete more complex work. It was anticipated to be unpopular amongst practitioners as a large volume of the private sector workload includes routine core podiatry that cannot be commissioned by the NHS [41, 42].

“We need to get over this idea of viewing foot health practitioners as competition. If it is a competition then we should win by a landslide but it’s not, they have their skills and we have ours, we just need to utilise ours better.”

Data related to the governing body was able to con irm known changes that are to occur in the future. The changes were perceived by the participants as an opportunity for professional development and a way to increasingly engage with their members. Participants compared the future to the colour orange mimicking an old advertisement campaign to portray a bright and hopeful time ahead. This self re-assurance of the future was a common theme and after interpretation it was considered a very important factor in each of their professional lives. With the perception of a viable future for the profession it was analysed that the participants felt a sense of pride towards the profession and the contributions they had made. The need for a change to governance structure came to light when it was recognised it no longer catered for the needs of the members. In a bid to combat this more Continuing Professional Development offered at a reduced cost, cheaper consumables and a greater engagement with members were suggestions for future changes likely to happen.

It was noted in the study that a large amount of attention currently focusses on commissioned pathways for podiatry in the NHS. Commissioned pathways were treated as almost symbolic as to how well a profession is doing, the idea of greater commissioning was treated as exciting and bene icial to the profession.

The governing body is also looking into regulating podiatry instead of the Health and Carers Practitioners Council. Little information was provided as to why, but this could dramatically increase the scope of practice and recognition of the profession. This was delivered as big news, however, the minimal elaboration suggested this was still at the discussion stage. 

It was proposed that to improve ef iciency the Society of Chiropody and Podiatry and the College of Podiatry would join together to form one organisation. Participants saw this as a great opportunity for the profession to discontinue the title Chiropodist and eliminate all confusion and misconception the public has with the profession. Participants treated the title as a representation of what the profession entails. Chiropody, being unfavourable, had the association with routine core work while Podiatry held higher regard being compared to the more complex modern treatments now offered. This change is said to be voted on by members later in the year. The interpreted data implied that participants felt this had been long awaited and put off for too long. A noted frustration in their tone when talking about this topic gives rigor to their strong belief that the title has continuously withheld the profession’s true potential.

Certain limitations in luenced this study. Interviews were not conducted in person therefore there is a chance some of the participant’s bodily emotions were not recorded. The sample size was relatively small with only six participants however this could be dis-regarded as it its with the analytical technique of IPA [32].

CONCLUSSION:

The participants portray a positive outlook for the future of the profession, however, this paper has also highlighted key areas that pose as a great concern having the capability to impair the current standing podiatry has within the healthcare system. This fragility, as a result of poor knowledge and understanding, emphasises the risk of other professions taking over podiatry work due to modern workforce lexibility. Previously, it was seen that the pioneers of the profession took the lead and had the drive to make changes happen. Now it is apparent the profession can no longer rely on a select few to make these decisions. For this reason, it was concluded that all members of the profession have a responsibility to drive the need for change creating the best possible outcome for the podiatric profession. Particular attention focused towards the mind-set of practitioners within their practice as well as the hostility they can portray towards other colleagues. This egotism is said to be withholding the bene its that come with working as part of a party benefiting from each other’s cooperation. Equally by educating patients and the public of the full scope of practice available to podiatrists is determined to create a truer representation of the role podiatry plays in society and healthcare.

Is it evident that the governing body (The Society of Podiatrist and Chiropodists/College of Podiatry) are currently putting a lot of work and effort into changing the profession to achieve UK wide and international recognition. Therefore, at this time of ambiguity it is essential to be actively involved as members in supporting the changes for the greatest possible chances of furthering the podiatric profession.

ACKNOWLEDGEMENT:

We would like to acknowledge and thank all the participants who took time out of their diaries to take part in this research.

Abbreviations:

FHP: Foot Health Practitioner; NHS: National Health Service; IPA: Interpretative Phenomenological Analysis


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