14 participants were interviewed. 12 were female, six worked in a regional setting, and 7 in community health services. Individual demographic information of the included participants has been reported in Table 3. Interview duration ranged from 28 to 90 minutes.
Table 1 Demographic details of participants
Participant
|
Gender
|
Practice setting
|
Metro/Regional/Rural
|
State
|
1
|
F
|
Acute hospital
|
Regional
|
VIC
|
2
|
F
|
Private practice
|
Regional
|
WA
|
3
|
F
|
Private practice/acute hospital
|
Metro
|
VIC
|
4
|
F
|
Community health/private practice
|
Rural
|
WA
|
5
|
F
|
Community health/private practice
|
Rural
|
WA
|
6
|
F
|
Community health
|
Rural
|
VIC
|
7
|
F
|
Acute hospital/community health
|
Regional
|
NSW
|
8
|
F
|
Community health
|
Rural
|
VIC
|
9
|
M
|
Community health
|
Regional
|
VIC
|
10
|
F
|
Sub-acute hospital, private practice
|
Regional
|
VIC
|
11
|
F
|
Acute hospital
|
Metro
|
NSW
|
12
|
F
|
Podiatry university lecturer
|
Metro
|
VIC
|
13
|
F
|
Community health
|
Metro
|
VIC
|
14
|
M
|
Acute hospital
|
Regional
|
NSW
|
Overview
The results from the interviews outline complex and multi-level influences which impact on Australian podiatrists’ ability to implement the reablement model. Three themes were generated from the thematic analysis process: (i) It’s not what I was taught, “I am just a podiatrist”, (ii) Reconciling practice with competing pressures, (iii) funding influences on podiatry practice and reablement. These themes are summarised in Table 4.
Table 2 : Definition of identified themes
Theme
|
Definition
|
It’s not what I was taught, “I am just a podiatrist”
|
Traditional podiatry practice is delivered through the medical model of care which is incongruent with the reablement model.
|
Reconciling practice with competing pressures
|
Time constraints and the demands from organisational policy and government requirements are a barrier to the delivery of reablement in podiatry.
|
Funding influences on podiatry practice and reablement
|
Funding for podiatry services do not support reablement interventions and have influenced the public perception of podiatrist’s scope of practice.
|
Themes
It’s not what I was taught, “I am just a podiatrist”
Participants saw the value and opportunity afforded by the reablement model through the promotion of increased independence in older age, although there was strong recognition that reablement does not fit with traditional approaches to practice utilised by podiatrists. Some participants reported that it was not part of the podiatrist's role to contribute to reablement and that once the older person had reached their clinic, there was no point at an attempt for reablement. Participants positioned podiatry practice within a biomedical approach, medicalising foot-care through linking their client's inability to perform their own foot care to a pre-existing medical condition. The focus of podiatry care was described as optimising foot health and mainly treatment focussed with clients taking a passive role in care. Interestingly, reflection on practice also raised the topic of ageism within podiatrist’s practice. Participants acknowledged broad-based assumptions were often made based on a clients age, and this had a major influence on clinical decision making:
I think it’s something that I think people would associate more with something like physio or exercise physiology … say if someone’s had a stroke and they have really intensive physio or OT or whatever the therapy is to help them I guess get back to independence and whatever it is their goals are that they’re working towards. I think podiatry’s much more seen as a treatment-focused profession. (P7)
I think sometimes we have a tendency, [to], take things away from people and then they feel like they're not in control or they're not, they're not participating in it. (P12)
Participants also described a lack of knowledge and skills to implement the reablement model in a purposeful way, often remarking that reablement is much better suited to physiotherapy and occupational therapy practice. Most participants struggled to articulate what reablement informed podiatry practice would look like. There was also a general acknowledgement that it would be very difficult to quantify and develop outcome measures on podiatry interventions to support reablement:
I am curious to know for reablement what interventions that podiatrists would be doing and how that’s measurable and reportable. I don’t know that any are available, and I am not sure whether we are taught about improving function. It's more about fixing the problem, then when we can't fix the problem, we take over that job for people. (P3)
When participants expressed how they believed podiatrists align with the reablement approach to aged care, they explained the role of facilitating reablement rather than participating in a client’s reablement process. Participants described this by defining their role in an older persons reablement process as maintaining foot health so that the older person would be able to complete a reablement program and maintain a presence in their community:
I do find in podiatry reablement that we’re working with, mostly, it’s really probably more around maintenance. And that is maintaining something so that people - their function may not improve, but it might - it’s particularly around mobility, for us, really trying to keep people as mobile as they can so they are able to be at home for as long as they wish. (P8)
Some participants stated that their professional training had not equipped them with the necessary skills to deliver reablement services. Participants who understood the aims of the reablement model were often employed in community health settings, working within multi-disciplinary teams that included other allied health professionals, who had been the primary source of knowledge regarding the reablement model. Participants felt strongly that formal educational training was needed to facilitate the integration of the reablement model (and other biopsychosocial models of care) in their podiatric clinical practice:
I think at uni you learn about what interventions there are to fix problems with people’s feet, but unfortunately, I don't think we have much of a focus on function, um, you know, maximising function for people. Once you are working in the profession, you know working with physios and OT's [Occupational Therapists] then the words you see about reablement they definitely become clear in their meaning. (P13)
Reconciling a reablement practice with competing pressures
Podiatrists face a range of work-related pressures which they reported as impacting on their clinical practice and ability to deliver reablement informed care. The following sub-themes describe the two most frequently described barriers to implementing the reablement model: (i) time constraints, (ii) keeping everyone happy.
Time constraints
Lack of time was consistently reported as a major barrier for the implementation of reablement within podiatry practice, with the additional tasks and increased time spent with individual clients challenging to integrate into their current workflows.. Participants working in private practice settings reported 20 minute appointment times were insufficient time to appropriately assess, design a care plan, and educate on an intervention plan. Given the major shift in their clinic structure required to integrate the reablement model there was little motivation to integrate it into clinical practice. Likewise, for participants working in a service where the provision of a reablement model was a requirement, they described the additional tasks were a burden on their already busy workload:
But to do something like [reablement] also something that takes time. And it’s the care planning: when you sit down and do the care plans for people, it takes time. When you review the care plan it takes time. So, they’re this big-time barrier. (P8)
Many participants could not realistically allocate more time with individual clients to deliver reablement interventions. Some participants described that the current demand for podiatry from older people necessitates “churning through the patients, getting the waiting list sorted and that means doing things for them” (P9). Participants described addressing the challenge of heavy workloads and high service demand by having standardised workflows where their clients were passive recipients receiving care. In practice this meant doing tasks for older people rather than attempting to assess and rebuild capacity:
I think that to teach someone to do a job that I could do for them, especially under the time my consult lasts for, then that would be a major intrusion on my time. It’s easy to do just keep doing it for them. If reablement requires podiatrists training and teaching patients to perform self-care for their feet and develop skills, then yes, something like that would be a major problem. (P3)
Keeping everyone happy
Meeting the demands of managers and requirements for government funding often created tensions. Some suggested the provision of sub-optimal care was a risk in order to accommodate various competing administrative demands.
I mean you're working to the organisations policies [and] you're trying the meet the needs of what the patient wants. Then you add what the government wants you now to do this reablement thing. For a lot of patients that just doesn’t work. […] There is a risk there for the patient that we do say "yes I've 'reabled' them", and that's just to make the organisation happy that they're meeting what the government wants. (P7)
Funding influences on podiatry practice and reablement
Generally, podiatry services were not funded appropriately to deliver reablement interventions. Participants described the tensions between delivering time intensive reablement interventions against the overall costs of running podiatry services. Participants described how current Commonwealth government funding arrangements tended to promote a dependency model of care which conflicted with the Commonwealth’s own goal to promote reablement services.
A major barrier for podiatrists to implement reablement concerns current funding arrangements which only cover the cost of the actual time spent in consultation with the patient. Options are limited to fund preventative and supportive aids (such as footwear and orthotics). As the following quote highlights, there is frustration amongst podiatrists that the prohibitive costs of preventative and supportive aids can support a cycle of dependency relying on hands-on podiatry intervention:
It is a cycle because you see them re-present. That's my frustration because […]I want to address the underlying reason they are here in the first place. And the fact is that the money isn’t there to be able to pay for it. The money pays for me and the consumables that I have in my clinic, nothing long-term for the patient. (P1)
Many podiatrists commented on the impact of Medicare rebated Team Care Arrangements (TCA) and how this had, over time, created business models which relied on a client “churn” (P1) to “make the money and keep [the practice] going” (P12). Some podiatrists could not reconcile the economic viability of adopting a reablement model given the structure of podiatry clinics:
It will be a bit harder to implement in the private setting to take their focus away from, from the financial aspect of things. Taking time to do reablement with a patient will limit the amount of patients that a podiatrist could see in a day, and that will reduce their revenue, and that would be a huge barrier to doing reablement type care in those settings. (P9)
Across the interviews, there was a sense that the expansion and bulk billing of the Medicare funded TCA had masked the cost of care provision which many felt devalued their care and decreased engagement from clients. This had the unintended consequence of increasing client's dependency on podiatry services and, in turn, led to client's adopting a more passive role in their care which is incongruent with the aims of the reablement model:
The [TCAs] have definitely made people more dependent. Well, it is the same with anything as you get older. If you don’t use it, you lose it. So, if people are really trying hard to bend down to cut their toenails and they can, then they are going to keep doing that. But if they find that somebody else can do it for them, and they are not trying to bend down, then they probably are going to lose that. (P2)