The document discusses a Negotiated Work Based Learning (NWBL) program used to upskill Advanced Practice Physiotherapists (APTs) to take on an expanded primary contact role in the Emergency Department. Through two customized university modules focused on plain film radiograph interpretation and managing low-energy foot and ankle injuries, the NWBL program helped one APT gain competence in this new clinical scope of practice. A mixed-methods study evaluated the program's effectiveness, finding the APT provided high-quality care, with patients spending less time in the ED and reporting 100% satisfaction with their treatment. While limited in scope, the study demonstrates NWBL can successfully develop new clinical skills for expanding physiotherapist roles in the NHS

1. Pedagogy
to up skill Advanced Practice Physiotherapists to enhance patient journey and experience in the Emergency Department
Negotiated Work Based Learning:
Martin Troedel
Advanced Practice Physiotherapist,
Emergency Floor Therapy Team (EFTT)
The Royal Liverpool University Hospital, UK

2. Background: Role development for AP Physiotherapists in the ED
1 Department of Health. Equity and Excellence: Liberating the NHS , London; 2010
2Department of Health. European Working Time Directive: for Trainee Doctors – Implementation Update; 2009
National drivers: NHS Reforms in UK1
+ Impact of EWTD2
Local drivers: Opportunity for role development
Consultants recognised PT skills and potential
NWBL: skill development

3. Jibuike (et al, 2003)
•Unlikely to miss significant injury & crossed organisational boundaries
Ball (2007)
•Good image interpretation skills and high patient satisfaction
Taylor (et al, 2011)
•Primary contact physiotherapy can meet targets and reduce length of stay in ED
Why PTs suitable for this role?

4. Clinical context
NWBL creates bespoke University level education in the work place through a partnership agreement: not traditional ‘TAUGHT’ module

5. Collaborative approach
Let’s train our Physiotherapists to be Primary Contact Physiotherapists

6. Negotiated Work Based Learning (NWBL)
•Bespoke modules to develop new skills – Plain Film Radiograph (PFR) interpretation and Primary Contact Physiotherapy management of low energy foot and ankle trauma (LEFAT)
•NWBL merges educational theory with work-based practice and successfully translates theory into practice
2x20 credit modules at Masters level University of Liverpool
GOVERNANCE1 1 Francis, R. The Mid Staffordshire NHS Foundation Trust Public Inquiry report. London, 2013

7. NWBL: Bespoke Module Specification
Aims
Learning Outcomes
Syllabus
Resources
Learning, Teaching and Assessment
Patient safety1
1 Francis, R. The Mid Staffordshire NHS Foundation Trust Public Inquiry report. London, 2013

8. Assessment strategy
Comparable with medics
OSCE – PFR (40 cases LEFAT)
RDOPS – PFR(100 cases LEFAT) 4
4.Royal College of Radiologists, Rad DOPS Assessments, 2011, London, UK
5.Royal College of Radiologists, Mini IPX , 2013, London, UK
Mini IPX5

9. Competence to practice
OSCE – 88%
RDOPS – 100% 1
1. Royal College of Radiologists, Rad DOPS Assessments, 2011, London, UK2 2. Francis, R. The Mid Staffordshire NHS Foundation Trust Public Inquiry report. London, 2013
On-going evaluation

10. Research question
1 Boud DS. Work –based Learning: A new higher education? Open University Press, Buckingham; 2001
Has the NWBL¹ pedagogic model been successful in up skilling an Advanced Practice Physiotherapist to be competent and safe in a defined extended scope of clinical practice managing LEFAT?

11. Primary research aim
Evaluate critically the effectiveness of NWBL as pedagogy in up skilling an AP Physiotherapist to competently perform a defined extended scope of practice managing LEFAT to enhance service delivery in the ED of an acute tertiary referral NHS Hospital Trust.

12. Method
A mixed methods research approach:
•prospective pilot clinical audit
•prospective structured patient experience questionnaire (PEQ)
•retrospective data comparison Alignment with ED clinical quality indicators¹
¹Department of Health. Urgent & Emergency Care, 2010.

13. Method
Local ethical approval was granted Data collected prospectively by a single AP Physiotherapist Patient inclusion criteria were patients presenting to ED Minors with a low energy foot or ankle injury. Exclusion criteria were open fractures or wounds, burns and foreign bodies. Retrospective data was collected via iPM system¹ 4 week audit period from March 12 to April 8th, 2012.
¹iPM/Lorenzo, CSC (UK), 2012.

14. Patient experience questionnaire (PEQ)
NRES, 2011

15. Patient experience questionnaire (PEQ)

16. Age range
Mean age
16 - 67
51
Prospective pilot clinical audit results (n=14)
Demographics

17. Age range
Mean age
16 - 67
48
Prospective PEQ results (n=12)
Demographics

18. Retrospective data comparison (n=217)
Demographics
Age range
Age mean
12-89
35
Gender (n=217)
count
%
male
110
50.7
female
107
49.3
total
217
100.00%

19. Q5 Were you given enough privacy when you were being examined/treated by the Physiotherapist? (n = 12)
Count
%
Yes, definitely
12
100.00%
Yes, to some extent
0
0%
No
0
0%
Total
12
100%
Prospective PEQ results (n=12)

20. Q8 Did you have confidence and trust in the Physiotherapist? (n = 12)
Count
%
Yes, definitely
12
100.00%
Yes, to some extent
0
0%
No
0
0%
Total
12
100%
Prospective PEQ results (n=12)

21. Q9 Did the Physiotherapist listen to what you had to say? (n = 12)
Count
%
Yes, definitely
12
100.00%
Yes, to some extent
0
0%
No
0
0%
Total
12
100%
Prospective PEQ results (n=12)

22. Q12 Were you given enough information about your condition/treatment by the Physiotherapist? (n = 12)
Count
%
Yes, definitely
12
100.00%
Yes, to some extent
0
0%
No
0
0%
Total
12
100%
Prospective PEQ results (n=12)

23. Q15 Did you feel that your needs were met by the Physiotherapist? (n = 12)
Count
%
Yes, definitely
12
100.00%
Yes, to some extent
0
0%
No
0
0%
don't know
0
0%
Total
12
100%
Prospective PEQ results (n=12)

24. Prospective PEQ results (n=12)

25. Retrospective data comparison (n=217)
Total time spent in ED (minutes)
13%
27%
21%
17%
9%
5%
8%
30 - 60
61 - 90
91 - 120
121 - 150
151 - 180
181 - 210
211 - 240
Pie chart depicting percentages of total time spent in ED (minutes)
Range (minutes)
Mean (minutes)
32 - 240
114

26. Results summary
Prospective data indicated the average total time patients assessed by the AP Physiotherapist spent in the ED was 109 minutes. This data indicates all patients assessed by the AP Physiotherapist were assessed and discharged well before the four hour target for ED (DOH, 2012).

27. Results summary
PEQ data reveals a very high level of patient experience satisfaction with the AP Physiotherapist.
All respondents reported 100% satisfaction with the level of privacy and dignity maintained by the AP Physiotherapist; during consultation, examination and treatment, and that all their needs were met.

28. Study limitations
Evaluation of the work of a single AP physiotherapist – are results attributable to an individual or applicable for all AP physiotherapists?
Scope of the study was limited by time and funding resources, limiting the prospective numbers recruited and the duration of the audit period.
Scope of the study limited the ability to compare the AP physiotherapist with other clinicians such as ENPs and doctors in the Minor Injury Unit of the ED.

29. Future research
The evidence base for AP physiotherapy services in the ED indicates a developing high quality service which can decrease length of stay, improve diagnostic accuracy and provide consistently high levels of patient satisfaction.
Several studies acknowledge the need for future investigation of longer term health outcomes using randomised controlled trials, service models and cost effectiveness evaluation¹
¹Ball, 2007, Bethel, 2005, Hawes, 1996, Jibuike, 2003, Taylor, 2011.

30. Conclusion
•NWBL enabled the AP Physiotherapist to work as a primary contact physiotherapist in the ED.
•CPD and evaluation of clinical skills essential for patient safety and clinical governance1
•NWBL is beneficial for the development of AP roles for physiotherapists and is important for their on- going professional development using a unique pedagogy, as they evolve into roles previously undertaken by doctors.
1Francis, R. The Mid Staffordshire NHS Foundation Trust Public Inquiry report. London, 2013

31. Conclusion
Strengths of the study are the very high level of patient experience with the AP Physiotherapist, and the high quality of service delivery in the ED.
Evaluated critically against national indicators of quality of care delivery in the ED, the AP Physiotherapist provided the balanced and comprehensive care ED’s strive to achieve²
Future investment will help to support a culture of research to evaluate these pioneering services.
2 Department of Health. Urgent & Emergency Care, 2010.

32. AP Physiotherapists in the ED
‘...enhance the ability of departments to meet government targets by reducing waiting times...deliver quality outcomes... and they are popular with patients...’¹
¹Bethel , 2005 Taylor , 2011

33. Co-authors: Julie Bridson-Walton, Head of Postgraduate Studies, Institute of Learning and Teaching, Faculty of Health and Life Sciences, University of Liverpool, UK Fiona Cowell, ESPP, Trauma Clinics Dr Lawrence Jaffey, Consultant Emergency Physician Mr Badri Narayan; Consultant Orthopaedic Surgeon The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK Contact: Martin.Troedel@rlbuht.nhs.uk
Questions/discussion?