Total frequency
count Know where their limitations and boundaries are, i.e., when the should be
seeking advice or help (when something is beyond ESP scope or the individual’s competency level)
55
134
Team player 22
Thirst for knowledge and motivated to learn, and commitment to life-long learning
20 Keep up-to-date and be aware of latest research and evidence base or be
willing to challenge practice
18 Professionalism, trust, honesty and integrity 14
Ability to make independent decisions 10
Willing to learn new skills and apply them in practice 10 Appreciate the need for keeping good records 7
Time-management skills 7
Reflective and self-critical 7
Interest in chronic disease management 5
Ability to assess gaps in own knowledge and act on learning needs 3
The data reduction process requires a balanced view on the part of the content analysis researcher. If there are too many verbatim statements or if too much ‘authentic citation’ is used, then analysis may be incomplete (Elo & Kyngäs, 2008); conversely, if verbatim statements are excluded then the richness of the data may be lost, and the researcher risks representing the data inaccurately. Some units of text in the round one data represented a personal opinion (which was sometimes quite forthright) and this made the data reduction process challenging at times; it was important not to lose the core essence of some of these statements by putting one’s own interpretation on them. These particular units of text ranged in size from a single sentence to a clause or paragraph, but none of them concerned competencies not already covered by the other units of text; therefore, no attempt was made to collapse them. It was important not to lose their intended meaning or impact, since this might have threatened the validity of the study. Instead, they were retained as 50 verbatim statements and these are listed in Appendix VIII. These statements covered a number of issues facing ESPs in MSK medicine. For example, the level of skill acquisition required of ESPs compared with doctors, the need to have skills in medical differential diagnosis in order to recognize the non- MSK causes of MSK presentations, the differences between the ESP and the usual physiotherapy role, and the importance of ESPs knowing the limitations of their practice. Some of the qualitative data presented arguments for and against ESPs examining other systems:
135 ‘Specific systems examination, e.g., abdominal, internal – should be the remit of physicians’. (GPwSI)
‘ESPs should be able to examine cardiovascular, respiratory and abdominal systems as well as MSK’. (Consultant rheumatologist)
‘In view of the difficulties of differential diagnosis where pains may be referred from non-MSK origin the ESP will need to examine systems other than just the locomotor system’. (Consultant orthopaedic surgeon)
‘Skills need to exceed junior doctors as need to encompass traditional medical skills…’ (ESP)
‘They should have some idea of examining the abdomen, the chest and heart as well’. (Consultant orthopaedic surgeon)
Medico-legal issues were also mentioned, especially in relation to ‘medical’ skills’: ‘You can debate whether they should be able to lay hand on abdomen, listen to heart and lungs, etc. My feeling would be that they [ESPs] should not perform a partial superficial examination because what if they miss something? Far better to draw the boundary here, and refer on to a doctor’. (Consultant rheumatologist)
The triage role of ESPs working in MSK interface clinics and the requisite competencies involved also featured:
‘Tier 2 services provide a substantial triage function, deciding whether patients should be managed in the Tier 2 service or referred onwards to secondary care. This presupposes that the clinicians seeing the patient in a Tier 2 service are able to triage patients effectively’. (Consultant orthopaedic surgeon)
‘ESPs should be able to triage complex conditions presenting in community clinics, including those with multiple pathologies or systemic pathology’. (GPwSI) ‘Essentially, if the role involves screening patients for specialists then knowledge at that specialist level is mandatory; without it mistakes are inevitable, either missing serious diagnoses or over-investigating and over-referring’. (Consultant orthopaedic surgeon)
136 ‘Having an ESP as an independent practitioner is a mistake – community ESPs don’t work – they need to be in secondary care, working alongside secondary care consultants’. (Consultant orthopaedic surgeon)
Twenty-two of these anonymous verbatim statements (shown in bold in Appendix VIII) were chosen to go through to the next round. These statements were selected because they were representative of all 50 statements; including all 50 items would have made the second questionnaire unacceptably long. The 22 verbatim statements were included in round two as complementary feedback data; they were not included in the main competency list since they did not represent new competency items. However, in order to focus attention on this qualitative feedback, experts were asked to indicate their level of agreement with these 22 verbatim statements using a separate four-point scale.
6.6 Summary
This chapter presented the steps taken during the first round of the Delphi survey, from recruitment of the expert panel to dissemination of the questionnaire. The amount of qualitative data generated in this first round was considerable and at its conclusion, ninety-nine competencies were available for rating in round two, alongside 22 complementary verbatim statements. The next chapter describes the steps taken in the second round of the Delphi survey.
137 Chapter 7
The Second Questionnaire Round
7.1 Introduction
The previous chapter presented the process of conducting the first Delphi round, which resulted in the identification of 99 potential competencies and 22 complementary verbatim statements. This chapter presents the second Delphi round, from the development of the second questionnaire through to the data analysis and subsequent results.
7.2 The Second Delphi Questionnaire Round
The questionnaire used in round two was based on the results of round one, but it was more structured than the first questionnaire. It retained the same six themed headings and presented experts with the 99 competency items identified in round one, interspersed with the 22 complementary verbatim statements.
7.2.1 Development of the Second Questionnaire
Experts were asked to rate the 99 competencies on a three-point scale that partly reflected the scoring system allocated to personal specifications within NHS job descriptions (‘essential’, ‘desirable’, ‘not relevant’). The 22 complementary verbatim statements were given a separate four-point scale (‘agree strongly’, ‘agree’, ‘disagree’, ‘disagree strongly’) and were incorporated into each theme. The aim of the second round was to identify the competencies that reached an a priori consensus setting (this is defined in section 7.3); the items not reaching the a priori consensus would then be sent through to the third and final round for rerating. Comments boxes at the end of each themed section provided space for any additional remarks and this was encouraged, particularly where experts rated a competency item as ‘not relevant’. The comments boxes also provided non- responders from round one with the opportunity to add their own competency statements. Furthermore, experts could reinstate items in these comments boxes if they felt that their comments from the first round were not represented. The second questionnaire was piloted with four individuals, none of whom was an expert panellist. These individuals were the two MSK ESPs who had helped with
138 coding in round one, and the two research supervisors. The second questionnaire was then ready for dissemination (Appendix IX).
7.2.2 Questionnaire Dissemination and Data Collection
The second questionnaire was sent to the 72 experts who had volunteered to take part in round one, therefore including those experts who had not responded in the first round - in accordance with the recommendations of French, Ho & Lee (2002). Experts were asked to return the questionnaire within four weeks and were advised that a first ‘reminder email’ would be sent to non-responders after two weeks, and that a second ‘reminder email’ would be sent a few days before the completion deadline. A personalized pre-notification email was sent one week prior to sending the second questionnaire, and a further personalized email was sent to each expert on receipt of a completed questionnaire, to thank him or her for participating in the study.
7.3 Analysis of Round Two Data
The a priori consensus rule used in this study stated that items scoring 70% or more in the ‘essential’ or ‘desirable’ category would be retained and would not be sent through to the next round for rerating. Items scoring less than 70% would be sent through to the next round for rerating. Items scoring 25% or more in the ‘not relevant’ category would be discarded. The ratings of the 22 verbatim statements from the first round were analysed separately.
7.4 Results for Round Two: Competency Items
The response rate in this round was 60/72 (83%). The respondent group comprised 19 ESPs, 11 GPswSI, 12 consultant rheumatologists, 14 consultant orthopaedic surgeons, one consultant neurosurgeon, and three consultant neurologists. Three neurosurgeons who had responded in round one failed to respond in this round, but two non-responders from round one (one consultant orthopaedic surgeon and one consultant rheumatologist) did respond in this round.
139 Forty-eight competencies met the a priori consensus (Table 7.1) and these items were removed from the Delphi survey at this stage; the modal scores are shown in shaded boxes. The experts rated all these items in the ‘essential’ category, except for two knowledge-related items: ‘video or DVD educational material’ and ‘online modules or e-learning’, which were rated ‘desirable’.
Table 7.1 Round Two Items Reaching the a priori Consensus Theme 1: History-taking skills
Respondents n=60 (%) (7 competencies)
Essential Desirable Not
relevant History of presenting complaint 60 (100) 0 (0) 0 (0) Consider the impact of presenting complaint on the
patient (functional activities, mental status etc.)
57 (95) 3 (5) 0 (0) Factors, medical or otherwise, that could influence
treatment outcomes or prognosis
54 (90) 6 (10) 0 (0)
Drug history 49 (82) 11 (18) 0 (0)
Medical and surgical history 47 (78) 13 (22) 0 (0)
Neurological history 46 (77) 12 (20) 2 (3)
Social and family history 43 (71.5) 16 (26.5) 1(2) Theme 1: Use history-taking skills to identify
the following conditions or presentations
Respondents n=60 (%) (3 competencies)
Essential Desirable Not
relevant ‘Red flags’ or possible serious underlying pathology 59 (98) 1 (2) 0 (0)
Common MSK conditions 57 (95) 3 (5) 0 (0)
Use the history to direct an appropriate physical