July 17, 2013 Sam Baker Senior Project Officer Allied Health Professions- Rural and Remote Generalist Project Health Workforce Australia (HWA) Email: samantha.baker@hwa.gov.au Dear Ms Baker Re: Response to discussion points raised at Allied Health Professions Australia (AHPA) Board meeting 20 June 2013 with regard to HWA Allied Health Professions- Rural and Remote Generalist Project Thank you for the opportunity to respond to the questions pertaining to the Rural and Remote Generalist Project (the Project) posed by Etienne Scheepers at his meeting with AHPA on 20 June 2013. It is pleasing to see HWA exploring innovative solutions to address the rural allied health workforce crisis. The APS has responded to the discussion points with a specific focus on the psychology profession to assist HWA in its work. Response to discussion points 1. How does the group define generalist? There is no one widely accepted definition of generalist psychologist. For example, it can be defined by what it is not. That is, a generalist psychologist is usually not considered to be a psychologist with an endorsed area of practice 1 or someone eligible for membership of an APS College. In this sense, the definition of generalist is associated with extent of training and supervision, as well as formal recognition by regulatory and professional bodies. However, the term generalist can also refer to the type of practice undertaken by a psychologist. Registered psychologists with or without an endorsed area of practice may be delivering a generalist practice in the sense that they may be delivering services across the lifespan and spanning a number of professional areas. 2. What skills or areas of competency do Allied Health Professionals need to acquire/require to be work ready for rural and remote practice? Generic Professional Technical/clinical? Psychologists who practice in rural and remote areas are not required to hold any additional skills or competencies to those working in urban environments. Psychologists who work in these regions are often relatively junior, particularly in the more remote locations. For example, the 2008 Australian Psychology 1 Registration with an endorsed area of practice is a criteria of registration under the Psychology Board of Australia that a psychologist becomes eligible for following completion of the required formal education and supervised practice.
Workforce Study reported that a high proportion (approximately 45%) of relatively inexperienced psychologists work in remote locations. 2 In contrast, almost 30 per cent of psychologists in regional locations reported having over 16 years experience as a psychologist. Moreover, just over 10 per cent of the psychologists with recognised skills in particular areas of psychology (APS College membership) practice in regional locations, but very few of these psychologists provide services in rural and in particular, remote locations. There is limited research on the skills and competencies that might support effective rural psychological practice. However, there are a number of professional and personal attributes often considered useful for rural psychological practice in Australia and overseas, particularly Canada. 3 These include: Ability to identify and manage ethical and professional situations such as boundary issues and dual relationships. These issues are common to all psychologists but magnified in rural and remote practice. Ability to manage professional and legal requirements including safe storage of files. These requirements are common to all psychologists but rural and remote practice poses the additional challenges of travel and non-normative practice settings. Ability to effectively deliver psychological services using various technologies including telephone and videoconferencing Awareness of the impact of rural culture and the potential need to consider this when conducting assessments and implementing treatment protocols. The obvious example of this is the requirement for cultural and clinical competence to work in a safe and respectful manner with Indigenous clients. However, it is also important to note that rural culture per se impacts on individuals in multiple ways and can require a psychologist to be able to safely and effectively make adjustments to standard urban-developed protocols for working with clients. For example, this can include being able to effectively engage with rural clients to develop a therapeutic alliance, and work in a variety of nonstandard settings such us sitting with a client on a river bank or in a community hall. Awareness of the social determinants of health and their role in psychological wellbeing A capacity to adopt the role of advocate for socially appropriate services for rural communities. This can be an unusual role for a psychologist unless trained in community psychology. Personal attributes such as independence and flexibility that support a psychologist to adapt best practice to the limited resources at hand in a safe and effective manner. Breadth of professional knowledge and skills that span some of the traditional areas of specialised practice in psychology 4 (particularly clinical, counselling, health, community, and organisational psychology). There is limited focus on rural practice in psychology undergraduate and postgraduate training. The generic skills that would be of value to psychologists in rural practice include: 2 Mathews, R. (2011). Profile of the regional, rural and remote psychology workforce. InPsych, 33(5), 12-13. 3 Malone, J. (2011). Professional practice out of the urban context: delivering Canadian rural psychology. Canadian Psychologist, 52: 289-295. 4 The Psychology Board of Australia refers to these as areas of practice endorsement.
Ability to work as part of a multidisciplinary team Good verbal and written communication skills. This is required of any psychologist but magnified in rural practice where there is a need to interact with a broad range of community members including health professionals, local health service providers, local agencies such as schools, and relevant others Ability to work independently. 3. What distinguishes standard practice and rural generalist practice in your profession? Currently, the concepts of standard practice and rural generalist practice are not frequently employed in relation to the profession of psychology. The psychology profession is characterised by a wide range of areas and types of practice making it difficult to define a standard practice. This issue is further complicated by the Psychology Board of Australia (PsyBA) standards that only distinguish between practice by a registered psychologist and registered psychologist with endorsement in an approved area of practice. There are extensive requirements set out by the PsyBA that specify the formal education and supervised practice requirements needed to obtain an endorsement in a specific area of practice. It is unclear whether the term generalist is appropriate to use for a registered psychologist as a registered psychologist may choose to work with a specific cohort of individuals because of their acquired expertise in the area (for example, only work with young people). Equally, a psychologist with an endorsed area of practice could be considered to be doing generalist practice if they were working across several areas of psychology. For example, an endorsed clinical psychologist may be working with individuals with a mental health issue in line with their training, as well as providing services more typically associated with counseling and health psychology. The generalist rural practice that is sometimes referred to in psychology is a way of describing the pressure on psychologists in non-urban regions to see whatever comes in the door. In other words, a psychologist in rural practice (whether or not that have an endorsed area of practice) is likely to see a broader range of client presentations than their urban counterparts. While all psychologists must work within the boundaries of their professional competence, there is less opportunity in rural regions to work with a limited range of issues/clients as might be the case in major cities. A rural psychologist might need to be able to work with both adults and young people including clients with mental health issues, psychological issues related to physical health issues, substance misuse, and general counseling. They may also be expected to take an advocacy role and to partake in community-focused interventions and activities as well as the more traditional psychological work with individuals. In terms of the three generalist roles described in the document, the APS provides the following feedback on the viability of the models for psychological practice: a) Full scope rural and remote practitioner: Often experienced psychologists are unable to work to full scope because of the case management service delivery models favoured by many mental health services; psychologists in these services, regardless of geographical location, are required to practice as case
managers rather than undertake assessments and deliver evidencebased interventions commensurate with their training as a psychologist Psychologists are bound by the APS Code of Ethics to practice within the boundaries of their professional competence. For many psychologists, especially new graduates, this can be challenging in rural regions because of the pressure to see whatever comes in the door. The capacity to work to a full scope expert generalist role in rural and remote regions, including across the lifespan and across some areas of psychology, is likely to require additional training and supervision. The APS would strongly support the development of accredited, accessible and affordable training pathways to support rurally-based psychologists to work in this full scope expert generalist role. With regard to non-complex skill sharing, the APS is concerned about the tendency to view counselling as a non-complex skill that can be undertaken by several professions. The types of talking therapies that have been shown to be effective with mental health problems and behaviour change associated with lifestyle issues require more than a conversation and providing support and advice. Skilled counselling requires techniques of empathic listening, nondirective engagement with the client, a range of at times quite complex therapeutic strategies and an ongoing systematic program of delivery to ensure the foundations of effective behaviour change and emotional equilibrium for the client. When poorly delivered, counselling interventions can cause significant and long lasting harm. b) Expanded scope of practice (depth): Advanced skills in some specialties may be an advantage to psychologists in certain rural communities (e.g., advanced mental health skills or educational/developmental skills). Essentially, this is currently available to psychologists by completing further postgraduate training and supervision that is determined by the PsyBA and leads to an area of endorsed practice. Access to this type of program is restricted for rural practitioners because of the limited number of places available, requirement to travel, high costs of postgraduate training, and difficulty obtaining appropriate supervision in rural and remote regions. c) Expanded scope of practice (breadth): There would be limited capacity for psychologists to have sideways role extension (complex sharing of skills and tasks) with other health professions beyond that which already exists with psychiatrists, mental health nurses, and some social workers and occupational therapists with mental health training. As indicated above, delivering talking therapies requires more than a superficial level of training. Introducing a generic workforce of lower level trained individuals to provide mental health services to vulnerable people experiencing mental health conditions risks compromising client care. The APS understands that limited prescribing rights may be considered a component of expanded scope of practice (breadth) and would be supportive of this with adequate levels of training,
credentialing, on-going supervision and continuing professional development There would be value in all health professionals working in rural and remote settings being trained to screen and identify a community member who may be at risk of a mental illness so that an appropriate referral can be made to a qualified mental health practitioner There would be value in all health professionals working in rural and remote settings (including psychologists) to be able to provide basic first aid and assist in a life support situation. This would require regular training and accreditation There would be value in removing the requirement for a GP diagnosis and referral in order to access psychologists under Medicare and Access to Allied Psychological Services (ATAPS). This is particularly onerous in rural and remote regions with limited access to medical practitioners able to refer under Medicare. 4. What are the perceived risks/barriers to progressing this project? The document presented at the AHPA Board meeting (20 June 2013) provides limited information about the methodology and deliverables associated with the Project. It is therefore difficult to identify specific risks and barriers associated with progressing the Project. In general, the APS strongly recommends that HWA seek to find a balance between innovation and pushing professionals to practice beyond their level of competence. It is not acceptable to expose people in rural Australia to second class health care and the concomitant risk of harm. More generally, the risks/barriers to generalist roles for psychologists include: Impact on an already limited (and often junior) workforce if greater experience/breadth/depth of practice become important requirements for rural practice Lack of scope in existing awards to adequately reward expanded scope of practice; lack of rewards may be a disincentive to uptake The need to address the portability of accreditation in an expanded scope of practice beyond rural regions; lack of portability may be a disincentive to uptake Ability of expanded scope of practice to comply with PsyBA standards and requirements The need to establish strong clinical governance mechanisms to support expanded scope of practice Degree of attractiveness of expanded scope of practice training pathways to higher education institutions; who will deliver the training? Capacity for practitioners to fund enrolment in potentially expensive postgraduate higher education Capacity to access appropriate supervision in expanded scope of practice in rural areas It is already difficult for psychologists to access quality continuing professional development in rural and remote regions. What supports will be in place for psychologists with an expanded scope of practice to access relevant professional development? 5. What s needed to promote/progress work in this area? Concept (e.g. training pathway), operationally (e.g. clinical governance, credentialing/clinical privileges)?
The APS would strongly recommend the development of accredited training pathways to support rurally-based psychologists to work in the full scope rural and remote practitioner role. Such practice might span a number of professional areas including child and adolescent psychology, clinical psychology, educational developmental psychology, counselling psychology, health psychology, and community psychology and the capacity to deliver services across the age spectrum. However, progress toward this goal will require attention to all the risks and barriers outlined in the response to question 4. In addition to pursuing training pathways, the APS contends that the capacity of the rural psychology workforce could also be enhanced by freeing-up psychologists currently employed in case management roles to enable them to work to their scope of practice, in particular to conduct assessments and deliver evidence-based interventions. There is evidence that case management can be undertaken by para-professionals 5, freeing up psychologists to practice as a psychologist. It is important to flag the current pressures on the rural psychology workforce. The training pathways to registration as a psychologist are complex and recent changes by the PsyBA have meant that the internship pathway has limited viability, regardless of location. However, in rural regions where access to postgraduate pathways to registration is also limited, the reduction in psychology internships has serious consequences for the future workforce. This may impact on the ability to progress a rural generalist model. Yours Faithfully Dr Louise Roufeil Executive Manager, Professional Practice (Policy) 5 D. Rickwood (2005). Pathways of recovery: Preventing further episodes of mental illness (monograph). Canberra, ACT: Department of Health and Ageing.