The role of allied health assistants in supporting occupational therapy practice
DEFINITION OF ALLIED HEALTH
Allied health may be defined as those health professions that are distinct from medicine and nursing.
Allied health encompasses a broad group of health professionals who use scientific principles and evidence-based practice for the diagnosis, evaluation and treatment of acute and chronic diseases; promote disease prevention and wellness for optimum health, and apply administration and management skills to support health care systems in a variety of settings.
The professions included as allied health vary from country to country; however, estimates have suggested that as much as 60% of the U.S. healthcare workforce may be classified as allied health. Allied health plays an essential role in the delivery of health care and related services in the U.S. and throughout the world.
Allied health professionals are concerned with the identification, diagnostic evaluation, and treatment of acute and chronic diseases and disorders; provision of dietary and nutrition services; rehabilitation services; and the management and operation of health systems. Allied health professionals apply scientific principles and evidence-based practice in order to optimize patient or client outcomes. Allied health professionals must also attend to the prevention of disease and the management of patients with chronic disease. Thus, the scope of allied health practice extends to the individual, the family, the community and to public education; many allied health professions specialize in the promotion of optimum function and health and the improvement of health-related quality of life. In addition, heath care administration and health systems management are important components of allied health.
Professions that are often listed as “allied health” include many of the well-known non-nurse, non-physician health care providers including audiologists and speech language pathologists; physical therapists, occupational therapists and respiratory therapists; diagnostic medical personnel (medical laboratory scientists, cytogenetic technologists, diagnostic molecular scientists, histotechnologists, and pathologists’ assistants); imaging specialists (radiographers, nuclear medicine technologists, and sonographers); nutritionists and dietitians; and physician assistants. Others often included in allied health include dental personnel (dental hygienists and dental assistants); emergency medical personnel (EMTs, paramedics); exercise science professionals (athletic trainers, exercise physiologists, kinesiotherapists ); health information technologists; health educators (asthma educators, diabetes educators); counselors (genetic counselors, mental health counselors, family therapists); specialists in cancer diagnosis and treatment (medical physicists, medical dosimetrists, and radiation therapists); pharmacy personnel (pharmacy technicians and assistants) and other healthcare providers and support personnel, such as medical assistants. There are also a very large number of less well known health care professions generally considered as allied health. Table 1 lists many of the allied health professions, as well as the sources listing these as allied health professions.
Allied health educational programs seek to prepare competent allied health professionals and leaders for practice across multiple health care settings. Allied health educational programs are offered at a variety of postsecondary educational institutions.
There are a number of major allied health organizations in the U.S., including, but not limited to, the Association of Schools of Allied Health Professions (ASAHP).
Federal Definitions of Allied Health
Allied health is defined in the Federal Code and further defined in The Patient Protection and Affordable Care Act (ACA). Allied health is also included in eligibility criteria for participation in grant programs administered by the U.S. Department of Labor and the U.S. Public Health Service. The ACA (P.L. 111-148) defines allied health professionals as follows: 1) ALLIED HEALTH PROFESSIONAL.—The term“allied health professional” means an allied health professional as defined in section 799B(5) of the Public Health Service Act (42 U.S.C. 295p(5)) who— (A) has graduated and received an allied health professions degree or certificate from an institution of higher education; and (B) is employed with a Federal, State, local or tribal public health agency, or in a setting or in a setting where patients might require health care services, including acute care facilities, ambulatory care facilities, personal residences, and other settings located in health professional shortage areas, medically underserved areas, or medically underserved populations, as recognized by the Secretary of Health and Human Services.
Title 42, Chapter 6A, Subchapter V, Part F, Sec. 295p of the Federal Code states that the term ”allied health professionals” means a health professional (other than a registered nurse or physician assistant) who has not received a degree of doctor of medicine, a degree of doctor of osteopathy, a degree of doctor of dentistry or an equivalent degree, a degree of doctor of veterinary medicine or an equivalent degree, a degree of doctor of optometry or an equivalent degree, a degree of doctor of podiatric medicine or an equivalent degree, a degree of bachelor of science in pharmacy or an equivalent degree, a degree of doctor of pharmacy or an equivalent degree, a graduate degree in public health or an equivalent degree, a degree of doctor of chiropractic or an equivalent degree, a graduate degree in health administration or an equivalent degree, a doctoral degree in clinical psychology or an equivalent degree, or a degree in social work or an equivalent degree or a degree in counseling or an equivalent degree.
RESOLVED, the Association of Schools of Allied Health Professions (ASAHP) Board of Directors approves the above definition of allied health on this 27th day of October, 2015.
Center for the Health Professions at UCSF http://www.futurehealth.ucsf.edu/Public/Center-Research/Home.aspx?pid=88
ASAHP web site http://www.asahp.org/definition.htm).
(2. Trends Trends Association of Schools of Allied Health Professions, FEBRUARY 2011, p. 4; )
CAAHEP) accredited programs that prepare entry level practitioners in 22 health sciences professions http://www.caahep.org/Find-An-Accredited-Program/
The Health Professions Network (HPN) is a collaborative group representing allied health professions; http://www.healthpronet.org/about/index.html
Allied Health Workforce Analysis Los Angeles Region, Timothy Bates, M.P.P. Susan Chapman, Ph.D, R.N. The Center for the Health Professions, May, 2008, UCSF Center for the Health Professions 3333 California Street, Suite 410 San Francisco, CA 94118 http://futurehealth.ucsf.edu Appendix A, p. 62
The AMA’s Health Care Careers Directory (http://www.ama-assn.org/ama/pub/education-careers/careers-health-care.shtml ) lists information about more than 80 careers in health care and 8,600 accredited educational programs in those health care fields, listed in the following categories:
Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services, Bureau of Health Professions (BHPR ) http://bhpr.hrsa.gov/healthworkforce/reports/factbook.htm#Allied%20HealthNational Center for Health Workforce Analysis: U.S. Health Workforce Personnel Factbook
TABLE 1. ALLIED HEALTH PROFESSIONS
Anesthesiologist assistant3, 4 Anesthesia technologist/technician3, 4Anesthesia technology4
Cardiovascular technologists and technicians3, 5 Cardiovascular technology4
Behavioral disorder counselors5
Clinical laboratory workers1 Medical technologist2, Medical laboratory technologist2, Medical laboratory scientist2 Medical and clinical laboratory technicians5
Dental hygienists1, 5 , dental assistants1, 5 dental laboratory technicians 1
Diagnostic medical sonography4 Diagnostic medical sonographers5
Dietitians1, 5, Dietetic technicians1, 5 dietetic assistants1 Registered dietitian2 Nutritionists 5
Electroneurodiagnostic technologist3 Electroneurodiagnostic technology4
Emergency Medical Technician EMT, Paramedic 1,3,4 , 5
Exercise science (personal fitness trainer, exercise physiologist, and exercise science
professional) 3Exercise physiology4 Exercise science 4Personal fitness training4
Health information technologists1, Health information administrators1 ; Health information management2
Home health aides5
Kinesiotherapist2 ,3 Kinesiotherapy4
Marriage and family therapists5
Magnetic resonance technologist2
Medical assistant3, 5 Medical assisting4
Medical illustrator3Medical illustration4
Mental health counselors5
Nerve conduction studies technologist2
Nuclear medicine technologist2, 5
Occupational therapists1, 2, 5Occupational therapy assistants1, 5 Occupational therapist aides5
Ophthalmic medical assistants1, 2, optometric assistants and technicians1 , Paraoptometrician2
Orthotics and Prosthetics 1 Orthotist2, 3,4, and Prosthetist2, 3, 4 Orthoptist2, 3 Orthotic and prosthetic technician4
Other social and mental health service workers1
Pharmacy assistants1 Pharmacy Aides5 Pharmacy technicians5
Physical therapists1, 5 Physical therapy assistants1, 5 Physical therapist aides5
Polysomnographic technologist2,3 Polysomnographic technology4
Psychiatric aids5 Psychiatric technicians5
Radiologic service workers1 Radiologist assistant2 Radiologic technologist2, 5Radiologic t technician 5 Radiology administrator2
Recreational Therapist2, 5 Recreational therapy4
Rehabilitation counselors5 Other rehabilitation service workers1
Respiratory therapy workers1 Respiratory therapist2, ,3, 5
Specialist in blood bank technology/transfusion medicine4
Speech pathologist1 Speech –language therapists5
Substance abuse and behavioral disorder counselors5
Surgical technologist2, 3, 5 Operating room technicians, 1 Surgical assistant3 Surgical assisting4
Vocational rehabilitation counselors 1
Additional areas listed by BLS as health occupations Allied Health Workforce Analysis Los Angeles Region, Timothy Bates, M.P.P. Susan Chapman, Ph.D, R.N. The Center for the Health Professions, May, 2008, UCSF Center for the Health Professions 3333 California Street, Suite 410 San Francisco, CA 94118 http://futurehealth.ucsf.edu Appendix A, p. 62 Detailed Listing of Occupations Represented by Broad Standard Occupation Code Groups Used in this Report SOC 21-1010: Community and Social Service Counselors Substance Abuse and Behavioral Disorder Counselors Educational, Vocational and School Counselors Marriage and Family Therapists Mental Health Counselors
Quantitative and qualitative findings drawn from the audit conducted by 16 allied health professionals are provided below. As presented in Table 2, 51 positions were trialled across a range of geographic regions, clinical areas and levels. Twenty seven of these positions were newly recruited for the pilot project, and 24 were redesigned or upgraded from existing positions to align with the pilot trial. The duration of the positions varied, with 22 trialled for less than 6 months, and 29 positions being trialled for between 7 and 9 months.
As reflected in Table 2, 41 of these positions, including two trainee positions, 25 full (standard) scope of practice positions and 14 advanced scope positions were audited by the teams. Ten positions were not audited because they were vacant at the time of the audit, or had recently been filled and the incumbents were still becoming established in the position. The mean duration of these 41 positions at time of audit was over six months, (range 2–9 months) and well over half were in acute and metropolitan settings.
The audit documented that only 56% of AHA roles (23 positions) had clear and comprehensive task lists that specified the level of complexity and autonomy required for the positions. As a consequence, half of the incumbents (21 positions) were found to be performing duties that were not recorded on the task list. This issue has been previously noted  as problematic in implementation of assistant positions, and was seen as a key issue to be addressed.
Some of the additional duties identified in the audit included case conferences, staff meetings, equipment maintenance, administration backfill and patient transport. While performing a number of support functions is fundamental to AHA positions , auditors found that AHAs performed a greater portion of non-clinical duties (particularly administration) than would be expected for a role intended to primarily focus on direct patient care. Auditors found that 22% of assistants (9 positions) in trial roles were performing tasks for which they had not been adequately trained. Review of the audit reports indicated that this was often due to insufficient time for training within the brief time frame of the project. However in some cases AHAs performed such tasks as a result of inappropriate delegation of duties, being assigned tasks which were too complex for the level of position.
Scope of role and delegation
Auditors noted that almost half of the incumbents (46%, 19 positions) were not working to the full scope of their position, despite having been in the trial positions for an average of over 6 months. Qualitative findings indicated that in some teams there was limited understanding of the scope of the trial positions and insufficient time for training, which resulted in limited opportunities for assistants to gain experience in all aspects of their role. The audit revealed that while assistants in advanced level positions mostly performed tasks equivalent to full (standard) scope positions, only a third of their time was spent performing more complex advanced level tasks. Based on audit interviews, this relative underutilisation of advanced level assistants may be attributed to a number of factors including ambiguity in duty statements or the unwillingness of professionals to delegate more complex tasks (despite those tasks being recorded on the task list). Interestingly while recent studies have noted numerous concerns with greater use of assistants [30, 31], they do not appear to have recognised underutilisation and the practical implications of underutilisation in these positions.
In some cases AHPs did not sufficiently analyse their activities or the respective patient clinical pathways to identify tasks that could be permanently delegated to an advanced assistant. In a few cases, because these tasks were not frequently performed by the professional, they did not bother to delegate them. Even though AHAs were generally underutilised, audit findings indicated that in a number of settings, advanced level AHAs were successfully working at a considerable level of independence, and with relatively complex patients. Further, some were assisting with conducting education sessions, and making decisions on patient care plans according to the protocol and within their delegated role. Based on these observations and findings, and the opinions of workplace supervisors, it was concluded that there was sufficient differentiation between the full (standard) and advanced scope of practice positions to warrant two separate roles in practice.
Based on data obtained by the auditors, it would appear that in more than half of the trial roles (61%, 25 positions), allied health professionals’ withheld delegation of clinical tasks to assistants. While this issue has been generally noted in the broader assistant literature [31, 32], the current practice-based audit in an allied health setting documented a number of dimensions. Audit summaries indicated that the professional’s readiness to delegate was related to: (a) their familiarity with the task list, (b) the quality of their relationship with the assistant, (c) their confidence in the assistant and, (d) their belief about whether the task was appropriate to be delegated to an assistant.
Further, some professionals expressed concern about expansion of the assistant’s scope of practice, when as a delegated function, the professional remains accountable. In some instances, professionals believed that such tasks should be retained within their scope of practice; and some had insufficient experience, skills, and knowledge to confidently delegate responsibilities. From the perspective of assistants, some were not adequately trained to perform more complex tasks due to insufficient time, competing demands, and because there was no formal training for the advanced level role. Audit interviews confirmed previous research noting reluctance to delegate [22, 29] and found that in this sample, professionals delegated less when they didn’t know the assistant or lacked confidence in their ability. Likewise, in cases of staff turnover or when professionals were unfamiliar with the task list, delegation was limited.
These findings go beyond current literature by highlighting potential areas to direct training for AHAs and professionals. Clearly it is important for all assistants to achieve appropriate levels of competency. It is also important that all professionals have adequate understanding of the importance of delegating, skills in delegation, and confidence in the structures of delegation. Greater optimisation of assistants may be achieved if the process is based on skills and confidence rather than relying on established relationships .
Based on audit findings, 42 of 49 (85%) of the key accountabilities in the generic role descriptions required changes, compared with 11 of 53 (20.7%) of the key accountabilities in the contextualised role descriptions (used for pharmacy, medical imaging and social work). These findings provide an interesting practice-based confirmation of studies which have identified unclear role descriptions and blurred role boundaries as problematic . Feedback obtained in the current audit indicated these changes to the generic role descriptions were necessary because the generic language used was not always relevant to the discipline, clinical area, or geographical location. An example of how key accountabilities were contextualised is provided in Table 5. Further, respondents indicated that the level and nature of professional supervision should be more clearly described for each role.
Table 5 Example of generic and contextualised role descriptions (communication and referral)
Full size table
Audit data indicated that the contextualised role descriptions more accurately reflected the duties than did the generic ones. While generic role descriptions promoted some consistency in the role and scope of practice across disciplines, clinical areas and geographic locations, feedback from staff audited suggested that their value was limited when they were too generic. A number of allied health professionals reported difficulties with interpretation of role terminology across disciplines. Tailored role descriptions such as those used in this study for medical imaging, social work and pharmacy were found to promote role standardisation with greater clarity while still enabling transferability to various clinical areas and locations within the discipline. This is consistent with recent studies which have recommended more structure and greater clarity in AHA role descriptions .
Despite the positive judgements of specialist assistant positions reported in interviews, the audit data did not demonstrate more appropriate use of the skills of these AHAs compared with those under generic role descriptions. This was a surprising finding. It would appear that while tailored role descriptions are important, optimal utilisation of these positions is a function of factors beyond the written description .
Induction and training
As noted in a recent systematic review , the training and induction of assistants is a highly important but contentious area. In the current audit, on the job training, whether delivered as part of a formal qualification or not, was identified as the primary source of training for the trial positions. Seventy six percent of assistants (31 positions) in trial positions had either completed or were enrolled in a Certificate IV Allied Health Assistance. Additionally, 85% (35 assistants) reported that in-service training and activities had an important function in training them for their role, and 27 (66%) said the same of other formal training courses. Auditors found that the time required to train the AHAs to be effective in their positions varied from 1–3 months for those in full (standard) scope roles to 3–6 months for assistants in trainee roles and those in advanced roles.
Recognising that all of the pilot trial positions were new or redesigned, relatively few (41%, 17 positions) had a formal training plan in place. This was identified as another issue of concern. Auditors noted that this was attributed to the short time frame of the trial, that training requirements for the new roles had not been determined, and a preference for informal training on an ad-hoc basis. However, if such plans had been established at commencement and reviewed regularly they may have substantially reduced the amount of time that the incumbents took to perform effectively in their positions. Audit findings suggested that “on the job” training, whether part of a formal qualification or not, remains the most appropriate, accessible and relevant form of training for AHAs within publically funded health services in Queensland.
While the Certificate IV Allied Health Assistance was seen as the most relevant qualification for assistants within Queensland publically funded health services, audit results suggested it was insufficient for assistants working at an advanced scope of practice level. This may also have impacted effectiveness and delegation, and is an issue for future consideration of advanced level roles. From the present audit, and in light of issues identified in the literature , it is clear that there were a number of inconsistencies in the training of AHAs.
Audit data also revealed that 28 assistants (68%) in trial positions received formal one-on-one supervision. Despite this, almost half of audited positions (46%, 19 positions) reported that this was inadequate, due to the infrequency of the sessions or the limited experience of the assistant. Findings suggest that supervising professionals underestimated the level of formal supervision required by incumbents in trial positions. While most had formal supervision arrangements, nearly half of the assistants described them as inadequate for their needs. Recognising that many AHAs feel unprepared for their roles , more comprehensive supervision arrangements would have been preferable. This was also identified as an issue for future consideration in the implementation of AHA positions.
The audit noted that nearly half of the assistants were not working to the full scope of their role at the time of audit. It was noted that in the case of a redesigned role, it takes at least three months, and in the case of a new role it takes approximately six months for an AHA to reach an effective skill level. Further, it appeared that trainee positions (which recruited inexperienced staff) and advanced level positions (for which there was no formal training available) were comparatively slow in demonstrating efficacy. Some full (standard) scope roles (which closely resembled existing roles with which professionals were familiar) reached effective skill levels comparatively quickly. This may have impacted on findings in the current short duration trial, and has implication for planning the time frame of future trials.
Limitations of this study
Based on data analysis and debriefing with auditors on completion of the audit, it appeared that the audit tools while generally useful, lacked sensitivity. This may have limited the potential interpretation of the data, particularly in terms of differentiating between full (standard) and advanced scope positions. For example, the tools adequately captured how frequently a task was performed, but not how much time was spent on each task. Similarly, the tools did not result in sufficient detail about task complexity and level of supervision for the audit team to reliably assess the appropriate level of the position.
While the diversity of sites, locations, service settings and professional contexts was part of the intended rationale of this pilot project on a state-wide level, it may have also clouded results that may have relevance to one context or setting (positively or negatively). Likewise the focus in this study on general themes, may have obscured variation in the data across contexts or settings. As such, these findings should be taken as a general indication, and should form the basis for more targeted future research.