An Interpretative Phenomenological Study Exploring the Experiences of Extended Scope Physiotherapists. Does Viewing them as Institutional Entrepreneurs Engaged in Institutional Work Provide an Understanding of these Experiences?

Objectives: To understand the experiences of physiotherapists as Extended Scope Practitioners (ESPs) working in acute NHS hospitals using the concepts of Institutional Entrepreneurs engaged in Institutional Work.

Design: A qualitative study using an interpretative phenomenological framework.

Methods: In depth, semi-structured interviews which were analysed thematically using the steps suggested by Van Manen (1992). Themes which emerged represented the experiences of all the participants. Once the themes were identified the concepts of Institutional Entrepreneurs and Institutional work were applied to provide an understanding of the ESPs` experiences.

Participants: 12 ESPs from three acute hospitals from a variety of clinical specialties (2 gynaecology, 3 neurology, 2 orthopaedics, 2 paediatrics, 1 pain management, 1 cardiology, 1 respiratory).

Results: The first theme identified the motivation of the participants to extend their remit and create opportunities for the new role. The impact of this, for some participants, was a confused professional identity not aligned with physiotherapy. They felt different to physiotherapists in the way they thought clinically and their methods of practice. This manifested itself in their refusal to wear a uniform. The second theme explored negotiation and agreements of clinical boundaries between the participants, consultants, managers and other clinical staff. The ESPs were proactive and astute basing their actions on both a professional and business logic. They knew when to propose or create an opportunity, when to consider alternatives and when not to act based on the professional relationships with other professions, NHS pressures or likelihood of success. The final theme identified the adaptive nature of ESP roles. The participants were sensitive, and felt vulnerable, to NHS change. They voiced concerns over the sustainability of such posts in terms of succession planning and a lack of framework to develop such roles in the future.

Using the typography of Institutional Work provided an understanding of the ESPs` experiences. It identified successful and less successful types of work and enabled discussion on what can be achieved at the micro, individual level, what needs input from the macro, profession level and how the two can support each other. It also identified weaknesses to be addressed that would benefit the professions development.

Conclusion: The results from this study address the dearth of literature on the experiences of ESPs and provides details which will have resonance with physiotherapists and insight for other professions. It is recommended that a more robust ESP professional network, to champion and diffuse new practice into the NHS, is needed. Secondly there is a need for a recognised and nationally validated education programme for extended practice. This study refines the institutional work concept and highlights the inter-relationships between diverse types of work. It challenges the assertion of a sequential order of institutional work and illustrates how individuals embedded in the institutions of the NHS and physiotherapy can stimulate change through strands of institutional work that are sympathetic to the workplace environment and culture. This study provides empirical evidence that institutional work is performed by ordinary individuals which can diffuse through a profession. In doing so it provides insight for physiotherapists and other professions as to ways and means this can be achieved.