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Propagating Professional Skills in a Warmer Climate
Propagating Professional Skills in a Warmer Climate ISABELLE MILLWARD MCSP Superintendent Physiotherapist, Local and Community Services, Bloomsbury Health Authority
Key words: Experiential learning, development. SUInIIIary: This article gives a profile of a typical Overseas post and
outlines the skills returning physiotherapistscan bring with them. It requests greater recognitionof the contribution overseas experience can make to our own services.
Biography: Isabelle Millward trained at the Joint Services School of
Physiotherapy, RAF Halton. She spent three years in East Malaysia, returning in 1984 to work in Brixton with a community assessment and treatment team for people with leaming difficulties.She is nav superintendentphysiotherapist for local and community services in Bloomsbury Health Authority. She maintains an involvement in Overseas development work, particularly in the selection and training of paramedical staff.
IF someone were t o ask me t o write an advertisement for physiotherapy posts in developing countries it might go like this (using popular terminology):
PHYS IOTHERAP1ST ‘An exciting opportunity in experiential learning awaits you! We offer a broad spectrum of outlets, which provide ample scope for widening clinical skills and enhancing managerial abilities through service development and staff training. A chance to use your initiative and rise to the challenge - develop with us!’
I
1
If the promotional angle seems a trifle unorthodox - it doesn’t emphasise the ‘giving’ nature of the work - all the better. I am setting out t o demonstrate how individuals and services in this country can reap the benefits of such experiences. While I d o not intend t o belittle the value of sharing one’s knowledge, I wish t o underline how growth of ideas, skills and confidence result from that sharing w e gain a pound of knowledge for every ounce w e impart. The best way I can achieve this objective is t o hang my coat on my o w n experiences, which were in south-east Asia. I spent three very warm and humid years sniffing the breezes from the Sulu Sea, in a coastal t o w n on the northeastern shores of Sabah. This beautiful State, the size of Wales, is federated with Malaysia and forms a large mouthful of what was Borneo. A jungle-clad mountainous region, with coastal plain frilling the western aspects, it supports a population of 1.2 million. The multi-ethnic composition encompasses indigenous Kadazan, immigrant Chinese, Malay and Indians - 11 races in all, which endows the State with a colourful cultural background and occasional tensions. I worked in a town which is the principal port of the eastern coast. Its ostensible population of 114,000 is swelled by thousands of refugees and unofficial immigrants from the troubled Philippines. These people, living in poverty, find their homes in the numerous shanty satellites and water villages which have sprung up around the town. The urban
phpbtherapy, May 1989. vol75, no 5
population is greatly augmented by the countless villages poked out into the jungle which turn t o the town for services and support. It can take people from rural districts several days by river or foot t o reach help. Thus, the 395-bed hospital where I was based serves a very large population with widely varying needs and access t o the services it offers. I was there t o set up a physiotherapy service for both inpatients and out-patients, equip the department and train a nurse t o take over when I left. I was also asked t o make working visits t o a district hospital further east, with a view t o setting up a physiotherapy unit there and training a nurse t o run it. I can remember feeling awed and nervous at Heathrow, rather hoping some family member would prevent me passing irretrievably into the departure lounge. Instead they all waved encouragingly, and I headed towards the Equator. Once faced by work there is n o time t o be awed, because orientation is the priority. The Health Service in Malaysia is run from Federal, not State, resources. Therefore, the total allocation of funding t o the service is dictated by central government and the economics which affect treasury finance. Yet individual States may be extremely wealthy. This leads t o ironic situations whereby a rich State, such as Sabah, has a Health Service which is unable t o reflect its financial status. The State cannot supplement Federal services directly but employs indirect methods for improving the quality of care t o its o w n population. This may involve private health facilities for citizens, which provide extra health care at low or n o cost. The rigidity in funding can cause difficulties if one is seeking sources of capital for new projects and, indeed, created some stress for me in just such a venture. However, one learns ways around such problems. When I was ready t o analyse the needs of the situation I found the following areas required exploration: 0 Staff and patients had no real knowledge of what physiotherapy can offer. This is not unknown in Britain either.
A wide variety of conditions and injuries presented, with few specialists t o turn t o for advice. The most impressive work was done in m y hospital by just t w o consultants, one a general surgeon, and the other a physician. The turnover of patients was generally high. Once a patient was medically stable, discharge was encouraged. The bonus was no waiting lists. The drawback was n o rehabilitation. Getting patients back for out-patient therapy presented immense difficulties t o the families. Home visits were equally problematic, w i t h patients living several days’ journey away from the hospital, or in one of the jumbled Kampong Ayer, where with thousands of others they became lost t o us, going under one of several names, and with no address system more accurate than, for example, Mile 7. The lack of support services such as patient transport, social service benefits, and free aids. Some of these situations are no longer so alien t o our own Health Service.
299
The assets were many, although some are seen more easily with hindsight: 0
I received enthusiasm and support from the hospital staff.
0 The novelty of offering a comparatively new treatment
option aroused interest. East Malaysians are keen t o have a range of treatment models, both Western and Asian, from which t o select. Since patients exert greater control over choice of treatment, one cannot take their continued support and attendance for granted. Apart from making me consider what sort of choices I had ever offered patients in England, this led me to ponder how British patients have been bred t o passivity. I am happy this situation is slowly changing. There were lots of resources locally. Voluntary organisations and special interest groups could offer people and finance. The town also had a considerable population of dollar millionaires and expatriates who were all useful sources of funding and skills.
I had freedom t o select my own priorities. I had some clear objectives. There was an educational role t o fulfil for staff, patients and counterpart nurse. There was the emphasis on essential physiotherapy and paring away avoidable routine work. And, regrettably, there was a strong desire t o surround myself with the sort of equipment I had been bought up t o believe was essential to my professional standing, and without which I felt decidedly undressed. It is easy t o forget the true meaning of ‘hands on‘. The nature of the project changed half-way through the second year when a series of coincidental actions gave birth to a new direction. The Medical Services appointed an Australian in-service training officer; a multi-professional team from Australia came t o tour Sabah with a workshop on spinal injuries; a respected paediatrician from England did a study tour of hospitals in the State; and t w o district hospitals (stimulated by the workshops) each requested me t o train a nurse in basic physiotherapy. These incidents reinforced each other t o develop into the idea of setting up a foundation physiotherapy service across the State by offering training in basic physiotherapy skills t o selected nursing staff from each of the 12 district hospitals. This was seen as an interim measure until more Sabahans could be recruited into training at the school of physiotherapy in Kuala Lumpur and so this aspect of the project needed t o be explored as well. Since, at this stage, I was the only physiotherapist in Sabah - hence a rare commodity - this seemed the best way t o use the time I had available. Over the next 18 months we developed the course, set it up, ran and evaluated it. Doing this meant acquiring knowledge and skills of effective planning, organisation, funding, implementation and evaluation. It was through hard learning processes that this knowledge was acquired, but lessons learned in this 0
300
manner are never forgotten. What can one draw out of these experiences, and how night they be used t o enhance our skills within our own :ountries? A list of some of the skills I think it is possible to acquire from these and similar experiences will enable you to decide for yourself if these are desirable assets. One can learn: 0 The skills of pacing and how t o avoid burn-out.
How t o analyse and state a case of need, backed up with ogical, relevant argument.
0 0
That the most effective treatment tool is one‘s hands.
0 The importance of assessing needs accurately.
0 The need for thorough planning and preparation. 0
To respect every person as an important individual.
0 That staff motivation is essential. 0 That staff support and recognition is vital.
One can learn: 0 How t o ‘sell the product’. 0 How t o tap sources of funding and methods of creative acountancy.
0 How to suit horses for courses or rather courses for horses.
0 The art of negotiation and re-negotiation. 0 The importance of ensuring continuity and consistency of service.
0 That diplomacy and tact are not synonymous with weakness. 0 That assertiveness does not mean aggression.
0 That other cultures have perhaps more t o teach 3s than we have t o teach them. 0 That most people can do most things if they put their minds to it.
The clinical experience provides exposure to a wide range of injury and disease. Presented against a culturally different background, it provides a challenge t o one’s skills and training, while encouraging the growth of new ideas and treatment approaches. I would like our profession t o acknowledge the impact which overseas work experience can bring to our own services, in the light of changing priorities nationally. We should place more value upon, and facilitate, the opportunity to work abroad. We should recognise overseas experience as a constructive career-enhancing move. By doing this we can develop a better international perspective within the profession, and our services will reap benefits in growth of ideas, approaches and skills.
Physiotherapy, May 1989. W/75, no 5
Key words: Experiential learning, development. SUInIIIary: This article gives a profile of a typical Overseas post and
outlines the skills returning physiotherapistscan bring with them. It requests greater recognitionof the contribution overseas experience can make to our own services.
Biography: Isabelle Millward trained at the Joint Services School of
Physiotherapy, RAF Halton. She spent three years in East Malaysia, returning in 1984 to work in Brixton with a community assessment and treatment team for people with leaming difficulties.She is nav superintendentphysiotherapist for local and community services in Bloomsbury Health Authority. She maintains an involvement in Overseas development work, particularly in the selection and training of paramedical staff.
IF someone were t o ask me t o write an advertisement for physiotherapy posts in developing countries it might go like this (using popular terminology):
PHYS IOTHERAP1ST ‘An exciting opportunity in experiential learning awaits you! We offer a broad spectrum of outlets, which provide ample scope for widening clinical skills and enhancing managerial abilities through service development and staff training. A chance to use your initiative and rise to the challenge - develop with us!’
I
1
If the promotional angle seems a trifle unorthodox - it doesn’t emphasise the ‘giving’ nature of the work - all the better. I am setting out t o demonstrate how individuals and services in this country can reap the benefits of such experiences. While I d o not intend t o belittle the value of sharing one’s knowledge, I wish t o underline how growth of ideas, skills and confidence result from that sharing w e gain a pound of knowledge for every ounce w e impart. The best way I can achieve this objective is t o hang my coat on my o w n experiences, which were in south-east Asia. I spent three very warm and humid years sniffing the breezes from the Sulu Sea, in a coastal t o w n on the northeastern shores of Sabah. This beautiful State, the size of Wales, is federated with Malaysia and forms a large mouthful of what was Borneo. A jungle-clad mountainous region, with coastal plain frilling the western aspects, it supports a population of 1.2 million. The multi-ethnic composition encompasses indigenous Kadazan, immigrant Chinese, Malay and Indians - 11 races in all, which endows the State with a colourful cultural background and occasional tensions. I worked in a town which is the principal port of the eastern coast. Its ostensible population of 114,000 is swelled by thousands of refugees and unofficial immigrants from the troubled Philippines. These people, living in poverty, find their homes in the numerous shanty satellites and water villages which have sprung up around the town. The urban
phpbtherapy, May 1989. vol75, no 5
population is greatly augmented by the countless villages poked out into the jungle which turn t o the town for services and support. It can take people from rural districts several days by river or foot t o reach help. Thus, the 395-bed hospital where I was based serves a very large population with widely varying needs and access t o the services it offers. I was there t o set up a physiotherapy service for both inpatients and out-patients, equip the department and train a nurse t o take over when I left. I was also asked t o make working visits t o a district hospital further east, with a view t o setting up a physiotherapy unit there and training a nurse t o run it. I can remember feeling awed and nervous at Heathrow, rather hoping some family member would prevent me passing irretrievably into the departure lounge. Instead they all waved encouragingly, and I headed towards the Equator. Once faced by work there is n o time t o be awed, because orientation is the priority. The Health Service in Malaysia is run from Federal, not State, resources. Therefore, the total allocation of funding t o the service is dictated by central government and the economics which affect treasury finance. Yet individual States may be extremely wealthy. This leads t o ironic situations whereby a rich State, such as Sabah, has a Health Service which is unable t o reflect its financial status. The State cannot supplement Federal services directly but employs indirect methods for improving the quality of care t o its o w n population. This may involve private health facilities for citizens, which provide extra health care at low or n o cost. The rigidity in funding can cause difficulties if one is seeking sources of capital for new projects and, indeed, created some stress for me in just such a venture. However, one learns ways around such problems. When I was ready t o analyse the needs of the situation I found the following areas required exploration: 0 Staff and patients had no real knowledge of what physiotherapy can offer. This is not unknown in Britain either.
A wide variety of conditions and injuries presented, with few specialists t o turn t o for advice. The most impressive work was done in m y hospital by just t w o consultants, one a general surgeon, and the other a physician. The turnover of patients was generally high. Once a patient was medically stable, discharge was encouraged. The bonus was no waiting lists. The drawback was n o rehabilitation. Getting patients back for out-patient therapy presented immense difficulties t o the families. Home visits were equally problematic, w i t h patients living several days’ journey away from the hospital, or in one of the jumbled Kampong Ayer, where with thousands of others they became lost t o us, going under one of several names, and with no address system more accurate than, for example, Mile 7. The lack of support services such as patient transport, social service benefits, and free aids. Some of these situations are no longer so alien t o our own Health Service.
299
The assets were many, although some are seen more easily with hindsight: 0
I received enthusiasm and support from the hospital staff.
0 The novelty of offering a comparatively new treatment
option aroused interest. East Malaysians are keen t o have a range of treatment models, both Western and Asian, from which t o select. Since patients exert greater control over choice of treatment, one cannot take their continued support and attendance for granted. Apart from making me consider what sort of choices I had ever offered patients in England, this led me to ponder how British patients have been bred t o passivity. I am happy this situation is slowly changing. There were lots of resources locally. Voluntary organisations and special interest groups could offer people and finance. The town also had a considerable population of dollar millionaires and expatriates who were all useful sources of funding and skills.
I had freedom t o select my own priorities. I had some clear objectives. There was an educational role t o fulfil for staff, patients and counterpart nurse. There was the emphasis on essential physiotherapy and paring away avoidable routine work. And, regrettably, there was a strong desire t o surround myself with the sort of equipment I had been bought up t o believe was essential to my professional standing, and without which I felt decidedly undressed. It is easy t o forget the true meaning of ‘hands on‘. The nature of the project changed half-way through the second year when a series of coincidental actions gave birth to a new direction. The Medical Services appointed an Australian in-service training officer; a multi-professional team from Australia came t o tour Sabah with a workshop on spinal injuries; a respected paediatrician from England did a study tour of hospitals in the State; and t w o district hospitals (stimulated by the workshops) each requested me t o train a nurse in basic physiotherapy. These incidents reinforced each other t o develop into the idea of setting up a foundation physiotherapy service across the State by offering training in basic physiotherapy skills t o selected nursing staff from each of the 12 district hospitals. This was seen as an interim measure until more Sabahans could be recruited into training at the school of physiotherapy in Kuala Lumpur and so this aspect of the project needed t o be explored as well. Since, at this stage, I was the only physiotherapist in Sabah - hence a rare commodity - this seemed the best way t o use the time I had available. Over the next 18 months we developed the course, set it up, ran and evaluated it. Doing this meant acquiring knowledge and skills of effective planning, organisation, funding, implementation and evaluation. It was through hard learning processes that this knowledge was acquired, but lessons learned in this 0
300
manner are never forgotten. What can one draw out of these experiences, and how night they be used t o enhance our skills within our own :ountries? A list of some of the skills I think it is possible to acquire from these and similar experiences will enable you to decide for yourself if these are desirable assets. One can learn: 0 The skills of pacing and how t o avoid burn-out.
How t o analyse and state a case of need, backed up with ogical, relevant argument.
0 0
That the most effective treatment tool is one‘s hands.
0 The importance of assessing needs accurately.
0 The need for thorough planning and preparation. 0
To respect every person as an important individual.
0 That staff motivation is essential. 0 That staff support and recognition is vital.
One can learn: 0 How t o ‘sell the product’. 0 How t o tap sources of funding and methods of creative acountancy.
0 How to suit horses for courses or rather courses for horses.
0 The art of negotiation and re-negotiation. 0 The importance of ensuring continuity and consistency of service.
0 That diplomacy and tact are not synonymous with weakness. 0 That assertiveness does not mean aggression.
0 That other cultures have perhaps more t o teach 3s than we have t o teach them. 0 That most people can do most things if they put their minds to it.
The clinical experience provides exposure to a wide range of injury and disease. Presented against a culturally different background, it provides a challenge t o one’s skills and training, while encouraging the growth of new ideas and treatment approaches. I would like our profession t o acknowledge the impact which overseas work experience can bring to our own services, in the light of changing priorities nationally. We should place more value upon, and facilitate, the opportunity to work abroad. We should recognise overseas experience as a constructive career-enhancing move. By doing this we can develop a better international perspective within the profession, and our services will reap benefits in growth of ideas, approaches and skills.
Physiotherapy, May 1989. W/75, no 5