As the public consultation on the advanced musculoskeletal standards is launched https://skillsforhealth.org.uk/have-your-say-on-the-musculoskeletal-advanced-practice-and-governance-framework/
I wanted to offer a narrative, primarily directed at students and less experienced practitioners. The reason to do this as one of the authors of the document is to really try to encourage the views from you, as you are the Advanced Practice and Consultant practitioners of tomorrow, and I will be retired and consulting YOU for my various MSK issues. Your views are vital, and just because this looks “advanced” and “special”, the reality is this should, if it is to be useful, be part of your career aims, goals, values from day one for anyone with an interest in MSK, and not be seen as “special” at all.
So, within the document there are capabilities built around MSK practice and these have been mapped against the multi-professional framework for advanced clinical practice in England https://www.hee.nhs.uk/sites/default/files/documents/multi-professionalframeworkforadvancedclinicalpracticeinengland.pdf . So the MSK framework looks to operationalise the integrated 4 pillars into a bespoke model that reflects your day to day practice. But I thought it might be helpful for you to offer some reflections that are more general in how this frameworks underpins the characteristics of the modern MSK practitioner, and to do this I have highlighted some more general considerations that I hope when you read them may offer some direction of travel and give you the encouragement to get involved in the consultation, as you have advanced practice skills, characteristics and abilities already, perhaps you don’t realise it. This is not about experience, how many weekend courses someone has done or the number of webinars attended. If you can learn from experience and mistakes, and reflect well, you will rapidly build the “skills” as such that you need. This of course starts on day one.
I describe myself as a MSK generalist. I have worked in primary, community and secondary care, I see multi-body parts, I work in diagnostics and offer injections and support patients through rehabilitation from the older person, sedentary, sports and young. So, I don’t have a “specialism”, and in that sense the pointers below are I think the “specialisms” of advanced practice rather than saying I am a spine, shoulder, foot specialist. Therefore, if you have a look at these reflections below, you will probably see you do this yourself in some way, shape or form, and in fact it is you who should be commenting on the frameworks just as much as the “specialists”. The characteristics that make you a great student, newly qualified practitioner are exactly the same as a great Advanced clinician: the difference is the knowing, appreciation and the evidencing of those skills and putting them into practice with the benefit of some clinical experiences –which will inevitably will come, but you should recognise it starts from day one.
MSK advanced practice is about rehabilitation.
Rehabilitation of individuals and the population you serve is a vital component not something as I was once told “you just do the final bits don’t you?” – it remains as integral to every interaction we have – it is THE intervention of choice, and comes in multiple formats. The “skills” (think C) of rehabilitation such as Communication, Compassion, Clinical reasoning, Common-sense and Core skills done really well can all be worked on from day one and are advanced when used skilfully. There is nothing fancy about printing a rehabilitation plan, but to bespoke one that is tailored, progressive and goal orientated is advanced, skilful and headline stuff. Throw in the reassurance of Confidence, Competence and Capability and you have an extremely valuable clinician.
Advanced practice is not about requesting things.
The advanced practice in this is the reasoning behind these choices, the interpretation of the findings, the communication of those findings and the reassurance you offer with respect to the relevance. It is about the action you take with the results, which requires knowledge but really importantly responsibility for that action. Taking responsibility is a characteristic you already have, just learn to develop it, and so don’t get hung up thinking, requesting an MRI is an advanced skill, it’s not, the accountability for actions is far more reflective of the level. You can develop these from day one.
Advanced practice is valuable across the whole system.
In all forms of practice you can influence. Primary to tertiary, community, cross boundary. Knowing how to influence the benefits of MSK practice to a wider population, through not only classically described MSK practice but also public health, emotional well-being and activating physical inactivity are hallmarks of advanced practice. You can do this from day one, it’s a really powerful hallmark of advanced care.
Advanced “hands on” skills are not a hallmark of advanced practice.
Good quality handling is needed in any form of practice, respiratory, neurology, frailty, MSK. It can inform, reassure, support. There is no magic to this in MSK, and the advanced MSK clinician needs another C here – Critical thinking. Applying any intervention needs to be evidence based, judicious, person centred and designed to inform, and lead to the realising of the potential. Whether its task, movement, of part of diagnostic reasoning, the Advanced bit of any handling is Communication and Clinical reasoning. Why are you doing something, what does it mean, does it offer evidence based value? These are the advanced skills of handling, not the handling per se. Of course skilful guidance is extremely valuable, watch a clinician gain a frail patient into standing on a ward can leave you thinking “how did they do that?!” –well, the key was not only how they used handling to reassure and guide but listen to HOW they did it, the words they used, the time they utilised with the patient and the understanding of the person before any of it started. These are advanced “skills” from day one which you can use.
Advanced practice is not about the title or the badge: leadership key.
Advanced practice uses a range of learning styles, leading styles and harbours great emotional intelligence. The advanced practice clinician wants to get the best out of others, and gets great value in developing others over and above their own needs or reputation. There was a time when for me when “extended scope practitioner” just seemed like a title that took a lot of space on a badge. When I gained these roles the badge was not important, the leadership was the step up and not the “scope” which is not reflective of the role. Now we use the term advanced practitioner rather than ESP, and high quality leadership, was so often missed in the early days of the “extended scope/big badge” development as a lot of time was taken up knowing a lot about orthopaedic surgery and perhaps leadership took a back seat. These leadership principles can begin from day one.
So, I hope you will engage in the consultation. I hope as students and what you might perceive as “less qualified” realise that you are VERY qualified to get involved and your view massively counts. I hope you can see that although we have to have capabilities to support safe practice, much of advanced practice is about behaviours, seeing the wider picture and being broad (not special!).
As one of the authors in the primary care road map and MSK standards I want to state some important acknowledgements. These standards will not be perfect, they will and must change with feedback, the advancement of science and practice and the development of the professions must influence future iterations. A good way to demonstrate your emerging clinical and leadership behaviours is to constructively influence change, so why not get involved in this?
Thanks for reading.
Dr Neil Langridge.