Developing competencies for remote and rural senior allied health professionals in Western Australia

Competency frameworks are an increasingly popular clinical governance, performance management, and professional development tool in health care. However, to date there is a dearth of information relating to competencies for allied health professionals (AHPs) working in remote and rural environments. This project aimed to develop a competency framework for senior level AHPs across a core of allied health professions in remote and rural Western Australia. The framework was designed to be used by individual AHPs to identify areas of professional proficiency and weakness, by staff managing senior AHPs when undertaking performance development processes, and by an organisation to identify common areas of need among disciplines that can be addressed through targeted support strategies.

that most importantly competency frameworks 'provide a language for talking more precisely about leadership knowledge and skills… [they] offer a way to deepen current conversations about the specific knowledge and skills necessary for leaders' 8,p55 , and provide a mechanism for measuring these.
Identifying competencies also has the potential to allow for the development of new work roles in health and increased efficiency of the healthcare workforce.Job re-design that includes using skilled workers in roles beyond the traditional scope of their work, is seen as one way of addressing future challenges in heathcare delivery 6,9 .Allied health assistants in rural and remote areas working under the supervision of AHPs are an example of this; they have the potential to increase work efficiency by increasing caseload throughput 10 .

WA Country Health Service
The WA Country Health Service (WACHS) is the state government provider of health and allied health services to rural and remote Western Australia (Fig1) 11 .The WACHS employs both base-grade and senior-level AHPs.In general, senior AHPs are charged with higher duties, which may include an advanced clinical role, the management and planning of service delivery, staff management and various other context specific duties.In WACHS, senior AHPs are occasionally line managed by AHPs of the same discipline working in a senior management role; however, more frequently this is by a manager with a different professional background.Senior AHPs in the areas of audiology, dietetics, occupational therapy, podiatry, physiotherapy,

Aim and scope of project
The aim of the Senior Allied Health Competencies Project was to develop a competency tool for senior allied health practitioners within WACHS.The primary target was AHPs from a core group of disciplines, including audiology, occupational therapy, physiotherapy, speech pathology, social work, podiatry and dietetics.
Drawing on the Skills for Health project in the UK 12 , the project team conceptualised the competencies necessary for rural and remote allied health practice as including three intersecting broad domains (Fig2): generic competency; professional competency and technical competency.
Generic competency includes skills shared by all those within a health organisation and are not specific to health service provision roles (eg leadership and management, communication and interpersonal skills).Professional competency refers to skills shared by those in a healthcare role that are required by all health professionals or a specific subset (eg allied health competencies, and health professional competencies).Technical competeny describes skills relevant to a specific context, setting or patient group, and may include profession-specific competencies, specialty specific competencies or program-specific competencies.This includes profession-specific clinical competencies which are generally specified on a discipline-specific basis by professional associations, governing boards or program leadership organizations (examples 13,14 ).
While alluding broadly to all domains of practice, this project is primarily focussed on professional competency necessary for rural and remote allied health practice across a range of professions.By its nature there is some overlap among the competency domain areas.Because of this, and because there are currently no existing generic competencies that exist for AHPs in WACHS, the potential was anticipated for rural and remote AHPs to identify generic competencies they believed were important to their role.The competency tool was intended to be used to identify the learning and developmental needs of senior staff, including areas of strength and proficiency.The framework was designed to be used either by individual AHPs for self-assessment, with peers or with line managers in the performance development process.

Project steps
The purpose of this project was consistent with a quality assurance (QA) endeavour, and carried minimal risk to participants, had voluntary participation, and protected participants' privacy.Exemption from formal ethical review was initially sought from and granted by the University of Western Australia Human Research Ethics Committee on the basis of QA.Institutional ethical approval was provided by WACHS.A small project working group was established to advise and support the project officer on aspects of project development and management (eg project planning and methodology, monitoring progress, project promotion, and participant recruitment).These preliminary steps were followed by two substantive project stages: a formal literature review, and the development and refinement of the competencies via a Delphi review process.
Literature review: A review of the available literature was undertaken to identify potential competencies and competency frameworks in health management, with particular reference to the allied health field.The literature review aimed to identify existing competency frameworks for senior rural and remote AHPs, and in the absence of these to identify other competency frameworks with applicability to senior rural and remote AHPs.With the exception of one item relating to financial skills, the mean response scores were between 1 and 2, indicating general agreement on the appropriateness and importance of each competency.Based on the feedback received the draft framework was refined to reflect the hierarchy as ranked by respondents, and then consolidated to reduce areas of repetition (respondents valued a short document for ease of practical administration).As well as the previously mentioned item relating to financial skills, two further domain areas that scored relatively poorly (research and evaluation, and consumer involvement in services) were consolidated and abbreviated to reflect their relatively low ranking (although overall these were considered relevant to the role).At the conclusion of this round there were 107 competencies.

Rural and Remote allied health competenciessenior professional framework
The final Rural and Remote Allied Health Competencies -Senior Professional (RRAHC-SP) framework consists of 88 competencies under 33 sub-domain and 8 overarching domain areas (Fig3).The complete tool is available (http://www.wacountry.health.wa.gov.au/alliedhealthcompetencies).
To assist in using the RRAHC-SP, five cyclical steps were recommended.First, the competencies most relevant to current work role are identified (Fig4).Second, the level of proficiency in these competencies is rated as emergent, developing, refining or highly developed.These are rated either by an individual, a peer or a manager.This allows for the identification of priority competency areas that in the third step are listed in the summary of priority competencies table within the document.Fourth, these priority areas are integrated into a learning plan (eg performance management plan, supervision plan, mentoring plan, individual learning plan, departmental/team learning plans).The fifth and final step is to operationalise the plan, and to reflect and review progress on a regular basis.
social work and speech pathology (excluding mental health and aged care), including vacant positions, are approximately 103 full time equivalent (FTE) of the WACHS workforce (pers.comm.; Human Resource Information System, Western Australian Department of Health; 16 May 2008).As a way to support these senior AHPs, WACHS aimed with this project to articulate in detail the competencies required by these professions.It was anticipated that the competencies could inform a range of strategies to enhance support for this workforce.

Figure 1 :
Figure 1: WA Country Health Service (WACHS) health regions in Western Australia.

Figure 2 :
Figure 2: Conceptual model of rural and remote allied health competency areas.

Focus
group interviews 27 were used in the second Delphi round to allow in-depth interrogation of the refined competencies.A purposive sampling strategy included key informants who had provided in-depth feedback during the first Delphi round and other AHPs recruited to encompass each of the target disciplines and WACHS regions.Sixteen participants took part in four focus groups, either face to face or via videoconference.Focus group interviews lasted between 60 and 90 min.A guided interview schedule was used to examine the relevance, appropriateness and utility of the framework as a whole, domain areas, each individual competency, and format and layout.Again, feedback was consistently positive about the document content.Participants again highlighted the need for a succinct document and, as a result, a number of competencies were again prioritised and consolidated (eg a domain on 'human resources' was incorporated as a sub-domain of 'professional skills').The third and final Delphi round involved the circulation of the developing framework to the AHRG, WACHS population health directors and managers, and all senior AHPs within WACHS for review via organisational email distribution lists.Fourteen responses were received.Feedback was consistently positive.Comments were received on language, wording, grammar and clarity and these comments were incorporated in the final draft document.Following final proofreading the competency framework was disseminated to senior allied health staff in WACHS for final endorsement.

Figure 3 :
Figure 3: The domain and sub-domain areas of the rural and remote allied health competencies -senior professional.

Figure 4 :
Figure 4: Example of a service planning competency with work relevancy and competency ranking scale.