Survey design

A cross-sectional online descriptive survey design enabled the collection of empirical data across Australia.17–19 An online questionnaire was developed using Qualtrics (Qualtrics, Provo, Utah, USA), thus enabling Australian-wide participation with no geographical or time zone constraints.17 20

Participants

Participant inclusion criteria are described in box 1. According to data published by the Physiotherapy Board of Australia, 30 004 physiotherapists were registered with the Australian Health Professionals Registration Authority (AHPRA) at the time of the survey.21

Procedure

AHPRA privacy policy22 prohibits approaching AHPRA-registered physiotherapists directly. Therefore, an advertisement containing a link to the online survey was emailed to all members of the APA, including all clinical and professional networks. A reminder advertisement was sent via email 4 weeks after the initial email to promote participation in the survey.17 19 20 IP addresses were not saved to ensure participant anonymity. The APA membership was selected as the recruitment platform as it is representative of all physiotherapy specialties and levels of experience (qualified and student physiotherapists) across Australia, with 23 153 members at the time of survey.23 Word-of-mouth referrals to the survey through professional networks were promoted in the email to facilitate capturing the views of non-APA members.17 19 20 Data collection took place 1 March–30 April 2017. Participants accessed the questionnaire via the online link. Completion of the survey was anonymous and entirely voluntary.17 19 20 Participant consent was gained using an online information and consent form.17–19 Researcher contact details were supplied to enable any questions or concerns to be answered prior to completing the online questionnaire.17–19

Questionnaire development

Data from a mixed methods systematic review examining the barriers to and facilitators of NMP internationally informed the questionnaire design and specific question inclusion.5 Questions were optimised through consultation with experts in the fields of physiotherapy, NMP and Australian state/federal law and health policy.17–19

The questionnaire consisted of four sections:

1. Demographic information including participants’ age/gender/number of years qualified/specialty/location.

2. Participants’ perceptions of the positive and/or negative aspects of physiotherapist prescribing to the profession as a whole.

3. Participants’ perceptions of the impact of physiotherapist prescribing to them as an individual.

4. Participants’ perceptions regarding the potential wider impacts of physiotherapist prescribing.

Sections 1–3 used closed questions to collect quantitative data. Section 4 contained two open-ended questions to allow the participants to answer without limitation.17 19 In-built survey logic ensured that participants were shown questions that were pertinent to them based on their previous answers. Before completion, participants were encouraged to share any additional information that they deemed relevant, capturing useful insights not addressed elsewhere in the questionnaire.17–19

The questionnaire was piloted to test for internal consistency and optimise user experience.18 Ten participants (n=7 registered physiotherapists, n=3 student physiotherapists) were purposely sampled to represent the physiotherapy profession in Australia.17–19 Following the pilot, Anglo-Australian terminology was clarified, and small changes were made to the linguistics and survey logic. Pilot participants were not excluded from completing the final questionnaire. The final questionnaire can be found in online supplementary file 1.

Data storage

All electronic data were stored in password-protected computer files only accessible by study investigators. Participants who disclosed personal details were additionally protected via coding on data files.17–19 The password-protected files will be retained for 10 years, satisfying ethical and university policies.

Data analysis

Demographic data (section 1) were tabulated, and primary descriptive analysis of the data was completed using IBM SPSS Statistics for Macintosh, V.22.0. Comparisons of proportions from questions in sections 2 and 3, addressing objectives 1 and 2, were conducted using the PEDro CI calculator (http://www.pedro.org.au).24 25 Calculations of absolute risk reductions (ARRs) with 95% CIs were used to determine the likelihood that health sector or geographical location were associated with specific views.25 Thematic analysis was used to ensure the transparent synthesis of data addressing objective 3, collected in section 4 of the online questionnaire. This analysis enabled the identification of key themes within a structured analytical framework.26 Answers were coded line-by-line using NVivo 11 software (QSR International, Melbourne, Australia) by one researcher (TDN) and were verified by a second researcher (TJ). Independently generated themes/subthemes were then examined by a panel of experts for confirmation and agreement.26

Patient and public involvement

The development of this study was informed by the experiences of patients and the general public acknowledged in the literature. Due to the study’s objectives, patients and the general public were not used in design of the study or in participant recruitment. The results will be disseminated to all interested parties through publication and presentation at professional conferences.

Demographics

A total of 883 participants (3% of all AHPRA-registered physiotherapists) completed the questionnaire. Demographic data are presented in table 1. Fifty-eight per cent of participants had been qualified for more than 10 years, with the majority of participants (88.4%) gaining their primary professional qualification in Australia. The largest proportion of participants (n=536, 61%) identified musculoskeletal physiotherapy as their specialty area of practice. Of those working clinically, 52% of participants worked in the private health sector. There were participants from every state and territory, with the majority practising in New South Wales (n=299, 34%), Victoria (n=234, 27%), Western Australia (n=130, 15%) or Queensland (n=115, 13%). Seventy-eight per cent of participants worked in a major city.

Participants’ perceptions about the impact of physiotherapist prescribing on the physiotherapy profession

Six hundred and eighty participants (79%) reported that they strongly agreed or agreed that autonomous prescribing responsibilities should be introduced for physiotherapists in Australia, with 144 participants (12%) against the introduction (figure 1). Potential benefits and concerns were identified.

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Figure 1

Physiotherapists’ belief as to whether physiotherapist prescribing should be introduced in Australia; potential benefits and participants’ concerns.

The participants reported that physiotherapist prescribing could have a range of benefits in the Australian healthcare system (figure 1). The most commonly identified benefit was an improvement in the delivery of health services (80.1%; n=707). Reduced costs of healthcare delivery to the consumer, as well as a reduction in the overall cost of healthcare and an improved consumer experience were also identified as potential benefits of NMP in Australia. Participants’ concerns about the prescription of medicines by physiotherapists centred on quality and safety issues. In particular, concerns about whether physiotherapists have the knowledge required to train as a prescriber (34.8%) and a potential increased safety risk to consumers (34.1%) were raised. One-third of participants (33.1%) were concerned that the expected remuneration for this service would not reflect the increased professional risk.

Figure 2 illustrates participants’ opinions about the number of years of experience a physiotherapist should have prior to being permitted to train as a prescriber. The majority of participants felt that physiotherapists should have 3 years or more of experience (68.4%), with 34.6% believing this should be at least 6 years.

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Figure 2

The number of years’ experience a physiotherapist should have prior to being able to train as a physiotherapist prescriber.

Participants’ perceptions about the impact of physiotherapist prescribing to them as an individual

Six hundred and eight participants (71.2%) would be extremely likely (n=397, 47%) or somewhat likely (n=211, 25%) to train as a prescriber if this were permitted, while 174 participants (20.3%) would not. Figure 3 outlines the key motivators and deterrents among participants to train as a prescriber.

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Figure 3

Likeliness to train as a prescriber: motivators and deterrents.

Key motivators cited included the ability to provide improved quality of care (n=646, 96.0%) and the improved professional reputation associated with NMP (n=416, 61.8%). Some participants included increased job satisfaction (n=303, 45.0%) and remuneration (n=125, 18.6%) as motivating factors. Additionally, some participants (n=72, 10.7%) reported being motivated by potential clinical and cost efficiencies for both for the consumer and healthcare provider through enhanced clinical pathways, improved access to medicines and optimisation of clinical knowledge.

The most common deterrent for training to be a prescriber was the belief that this will not change the care that the individual physiotherapist would provide to their patients (n=152, 61.8%). Concerns around an increased level of clinical responsibility were also highlighted as potential deterrents (n=108, 43.9%). Some participants felt that they did not have sufficient background knowledge to undertake the prescribing course (n=76, 30.9%). Additionally, participants reported that the cost of training or distance to travel to universities would be too great or that they were nearing retirement and did not want the additional stress of training to become a prescriber. Furthermore, it is noted that a small number of participants reported that they would not train as prescribers as they are employed in non-clinical roles (n=35, 14.2%).

Influence of health sector and geographical location

The percentage of participants from different health sectors and geographical locations, who agreed or strongly agreed with autonomous prescribing responsibilities being introduced for Australian physiotherapists and those who stated that they were extremely likely or somewhat likely to want to train as a prescriber are summarised in table 2.

Participants working in the private sector were significantly more likely to agree that autonomous prescribing responsibilities should be introduced for physiotherapist in Australia than those who work in education, not-for-profit organisations and the military (ARR 9.8%, 95% CI 0.8 to 20.2). No significant difference (ARR 1.7%; 95% CI −4.0 to 7.6) was seen between participants who worked in the private or public healthcare sectors. Participants working in the private sector were significantly more likely to train as prescribers than those working in the public sector (ARR 9.9%; 95% CI 3.5 to 16.4) or other areas, such as within educational or research institutions (ARR 23.3%; 95% CI 12.8 to 33.8). A significantly higher proportion of participants in city regions expressed a wish to train as a prescriber compared with those in remote regions (ARR 19.8%; 95% CI 0.8 to 39.2). Those practising in cities (ARR 24.0%, 95% CI 5.8 to 43.9) and regional areas (ARR 19.5%, 95% CI 0.4 to 40.1) were significantly more likely to agree with the introduction of physiotherapist prescribing than those from remote regions. However, there was no significant difference (ARR 4.4%, 95% CI −2.2 to 12.0) between participants who practise in major cities compared with regional areas.

Wider impacts of physiotherapist prescribing

Participants were asked to provide additional comments about how NMP may impact the overall level of care that the profession is able to provide. In total, 230 participants provided comments.

Four major themes were identified:

1. Clinical and cost-efficiency.

2. Access to prescription medicines.

3. Optimal therapeutics and clinical effectiveness.

4. Time management.

Table 3 lists the number of participants that reported or discussed each theme and provides illustrative quotations.

Clinical and cost-efficiency

One hundred and eighteen participants commented that the introduction of autonomous physiotherapist prescribing would have positive effects on both clinical and cost-efficiencies for patients, clinicians and the health economy. Participants identified the positive impact on the overall patient journey as a potential benefit of NMP by reducing unnecessary appointments with general practitioners (GPs), specialists and surgeons. Specifically, participants recognised the current frequency of referrals from physiotherapists to GPs for analgesic review, access to oxygen therapy, bronchodilators and antibiotics and ongoing pharmacological spasticity management. A common sentiment was that if physiotherapists could provide these services themselves, patients could have more timely access to appropriate medicines, which in turn would complement physiotherapeutic interventions and accelerate patient improvement/recovery. Participants also anticipated that NMP could reduce acute injury recovery times and minimise the risk of chronicity, which in turn could reduce pressures on medical services and end costs to the consumer, Medicare and private health insurers. Furthermore, the presence of physiotherapist prescribers in emergency departments and specialist multidisciplinary clinics was anticipated to reduce waiting times for patients, thus helping to meet performance measures set by governing bodies.

Access to prescription medicines

Seventy-one participants provided comments concerning potential improvements in accessing prescription medicines for all Australians regardless of geographic or other socioeconomic factors. Specifically, it was suggested that physiotherapist prescribers in rural and remote regions could issue prescription medications to patients who might otherwise have limited access to medical professionals. However, no participants from rural/remote regions identified this theme within their responses. Participants from metropolitan and regional areas expressed concerns that patients in rural and remote regions may struggle to navigate an overburdened and expensive healthcare system, frequently waiting for weeks and travelling great distances to see their GP for medications such as analgesics to supplement treatment from their physiotherapists. Participants from all locations identified potential benefits of NMP to healthcare consumers (regardless of location) whose principal healthcare practitioner is a physiotherapist, including persons with physical disabilities and those involved in sports where acute injuries are managed pitch-side by the team physiotherapist.

Optimal therapeutics and clinical effectiveness

Fifteen participants reported the potential for improved optimisation of medicines in line with physical and psychosocial interventions and therefore enhanced clinical effectiveness. Participants stressed optimal and appropriate use of analgesics across all specialties, especially where adjustments (escalation or de-escalation) to prescriptions are required in line with physiotherapeutic intervention. It was felt that that the multimodal skills and techniques used by physiotherapists would promote a more integrated use of medicines into the overall patient management, with medicines forming just one part of a more comprehensive and coordinated approach. Participants specialising in women’s health echoed this statement highlighting the appropriate use of anticholinergics and vaginal oestrogens necessary to holistically treat many of their patients.

Participants agreed that the close working relationships between physiotherapists and their patients, due to the comprehensive time spent completing physiotherapeutic interventions may be used to promote patients’ compliance to their prescribed medicines. Physiotherapist prescribers with the appropriate knowledge and skills could legally reinforce the appropriate use of medicines, better recognising poor adherence, dependency, abuse or adverse side effects masquerading as conditions treated by physiotherapists.

Time management

Nine participants suggested that the time requirements needed to train as a physiotherapist prescriber and ongoing time required for continuous professional development (CPD) may be prohibitive to introducing NMP in Australia.

Likely, time away from clinical work for education and development and NMP duties were seen to potentially interfere with tasks currently performed by clinicians. Furthermore, participants felt that although greater efficiency and access to medicines may benefit heath consumers, time presently spent treating patients in the current scope of practice would be lost to procedures related to prescribing medicines. In other words, although NMP may decrease medical practitioners’ workload, this would instead increase pressures on already understaffed physiotherapy departments and possibly even threaten clinical outcomes.

Further insights

The final question allowed participants to express any additional thoughts and views about physiotherapist prescribing that they deemed important and had not already been captured. Two hundred and sixty-six participants provided comments. Three major themes were identified:

1. Quality and safety: clinical governance, policies and procedures and education.

2. Professional issues.

3. Physiotherapy professional priorities.

Table 4 lists the number of comments that discussed each theme and subtheme, providing Illustrative quotations from participants.

Quality and safety

Two hundred and seventeen comments were received regarding quality and safety concerns around NMP. These focused on clinical governance, policies and procedures and educational requirements for prescribers.

One hundred and forty-four participants proposed that adequate clinical governance, policies and procedures should be in place for physiotherapist NMP to be successful. Participants identified the need for a clear scope of practice linked to a physiotherapy-centric formulary that is endorsed and regulated promoting transparency and safety. Participants raised concerns that statutory processes and procedures defining a limited formulary could quickly become outdated due to medical advances. Meanwhile, other participants identified that a limited formulary based around the profession’s specialist areas of practice would be safest, protecting clinicians from pressures to prescribe out of scope. Participants were concerned that unless communication channels were maintained between physiotherapist prescribers and GPs, there is a risk that patients could shop around for prescriptions, potentially aiding the abuse of prescription medication and causing clinical incidents. Participants were also concerned that the increase in professional risk due to physiotherapist prescribing would lead to an increase in indemnity insurance premiums.

Seventy-three comments were received with regards to education. Participants recognised that the scope of practice must be absolutely clear, endorsed and underpinned by a robust clinical education framework. They felt that thought must be given to the process of assessment and selection of appropriately qualified assessors from outside the profession including medical doctors and pharmacists to ensure quality and safe practice among prescribers.

Access to prescribing courses for physiotherapists living in regional and remote areas was highlighted as a potential issue due to the distance to the nearest university. Participants recommended that the regulatory body should dictate compulsory annual CPD hours, and periodic reassessment of competency should be mandatory. Participants had varying opinions with regards to when physiotherapists should be able to train and qualify as prescribers; however, the participants agreed that current preregistration physiotherapy programmes should be updated to include pharmacology and therapeutics on their syllabi in preparation for the future.

Professional issues

Thirty-nine participants provided comments on important professional issues. Participants noted that the introduction of physiotherapist prescribing could change the ‘physiotherapy brand’, weakening the public’s perception of physiotherapists as experts in manual therapy and exercise, leading to potential loss of patients to other emerging healthcare professions. It was suggested that a marketing campaign may be necessary to manage public expectation and minimise consumer confusion.

Interprofessional relationships between physiotherapists, medical practitioners and pharmacists were highlighted as being fragile. Participants warned that members of the Australian Medical Association would not support the introduction of physiotherapist prescribing, alluding to the possibility that medical doctors might see the introduction as a direct challenge to their authority and private businesses, leading them to reduce referrals to physiotherapy. Participants specifically identified the impact this may have on practice revenues in the musculoskeletal and sport specialties. That said, other participants reported great support from medical colleagues and the greater multidisciplinary team, citing the streamlining of current clinical services and patient pathways, alongside improved access medicines as key reasons for positive interprofessional support. Participants warned that although these efficiencies would reduce service costs, establishing physiotherapist prescribing would require an initial coordinated investment to ensure appropriate governance, clinical education and safe/quality implementation across Australia.

Physiotherapy professional priorities

Forty participants commented on the profession’s professional priorities. Participants described the risks of junior physiotherapists underdeveloping their traditional physiotherapy skills used to treat impairments and instead depending on medicines. To mitigate these risks, a robust career progression framework would need to be introduced to ensure ongoing high-level professional development across all specialties. To safeguard the good reputation of the profession, participants focused on maintenance of quality and safety for patients and clinicians. Physiotherapist prescribing should be introduced in a structured and organised manner with all physiotherapists supporting each other, even if they do not wish to prescribe themselves. Furthermore, participants also commented that the ability for physiotherapists to directly refer to specialist medical or surgical practitioners and ensuring appropriate patient rebates for imaging would have a positive clinical impact.

Strengths and limitations

This is the first study investigating the perceptions of AHPRA-registered physiotherapists about the potential introduction of NMP among physiotherapists in Australia, and so, alongside the data from student physiotherapists presented in the related article, provides an important overview of the current associated professional landscape. The data should be used to guide the APA, health departments and political leaders towards successful implementation of physiotherapist prescribing in Australia. As with all survey-based research, limitations are inherent due to selection and response bias. The survey was anonymous, so participants may have biased the results by completing the online questionnaire multiple times. Furthermore, physiotherapists with strong views or vested interests may be more likely to complete the questionnaire, meaning that their answers may not reflect the views of the wider profession.

A representative survey response rate (as per precursory power calculations) was achieved.13 Although only 3% of AHPRA responded, this reflected the response rate of a previous national evaluation of physiotherapists,37 where similarly, it was not possible to contact all registered physiotherapists directly due to the AHPRA privacy policy. Physiotherapists who were not APA members at the time of the survey would have been unaware of the questionnaire unless they were provided with a link to the questionnaire through professional networks. It is impossible to determine why 97% of AHPRA registered physiotherapists did not participate; therefore, the risk of bias remains unknown and should be considered when interpreting the results. In line with recent Australian regulatory data,38 the sample was representative of all registered physiotherapists in Australia in terms of age, gender and state in which they practise. Unfortunately, no national demographic data exist demonstrating the geographic location or health sector of registered physiotherapists’ employment. It is therefore likely that the comparable demographic profile of the study’s sample to contemporary national evaluations enhances generalisability of the data to the greater physiotherapist population in Australia and reduces risk of bias.