Professional Practice

Blog 1: Scope of Practice as Defined by Massage New Zealand

'Does the Scope of Practice as defined by Massage New Zealand fit with the legal requirements under the Healthcare Practitioners Competence Assurance Act and does it accurately reflect our scope of practice as Massage Therapists?'

I strongly believe that to have a defined industry standard regarding the level of competency and professionalism required to call oneself a massage therapist is critical to the recognition of massage therapy as a viable healthcare profession. However this portends some positive and negative aspects.

In favour of defining a scope of practice within Massage Therapy, is the corresponding faith in the massage industry by the public, recognition by the government and therefore eligibility for ACC funding and access to MT by low income families via the public healthcare system (McQueen, personal communication, 21st May 2009) and academic recognition in the realm of research.

The drawbacks of defining an enforceable Scope of Practice are the resultant limitations placed on the massage therapist with regards to techniques used, staying within their personal scope of practice and qualifications required to practice as a healthcare professional (it may be that a qualification at diploma level is required in order to be recognised as such). 

Standardization of qualifications and the course framework will therefore become routine, and the expansion of massage therapy as a developing profession may be limited.  There are concerns over placing such definite boundaries around healthcare professions due to the HPCAA and the consequences of this: "The resulting legislation is complicated and undermines professional functioning. Its effect may be exactly the opposite of its intention.." (Briscoe, 2004).

There is currently no portion under either scope of practice defined by Massage New Zealand which specifically addresses the use of the title 'massage therapist' by practitioners who do not hold the relevant qualifications.  This would be legally enforceable under the HPCAA, but may not discount other related words such as 'bodyworker' being used by an unregistered massage practitioner.

Confusion may ensue if say, some practitioners have only completed some weekend courses in relaxation massage and proceed to advertise themselves as masseuses/masseurs, whereas other registered practitioners holding the requisite qualifications defined within the HPCAA are advertising themselves as massage therapists. 

The problem here lies with the terminology used: the general public particularly the older demographic, may need to be re-educated about the difference between these terms as some may not know a difference exists. For example, it is not likely, common or even legal in current society for an individual to advertise themselves as a doctor without the requisite medical qualifications and rigorous training. According to Gilbey (2008) if an individual attempts to portray themself as a doctor to the wider public but are not a registered healthcare professional, they are liable to be fined up to $10,000 under the HPCAA. 

For these reasons, a practitioner of massage would need to ensure that they were not breaching the terms of the HPCAA by incorrect use of title (e.g. massage therapist) according to what is outlined within the HPCAA, providing massage therapy is included the next time the Act is amended.

The Scope of Practice for both a Certified Massage Therapist and Remedial Massage Therapist is detailed thoroughly by Massage New Zealand, and fits with the current legislation defined under the Preliminary and Key Provisions 8: 'Health practitioners must not practice outside scope of practice.' (HPCAA, 2003) Essentially, the scope of practice outlined by MNZ applies mostly to the "delivery of soft tissue therapy" and basic client assessment. This places us securely within the defined scope of practice for massage therapy and hardly encroaches onto the turf of other healthcare disciplines.

I feel it is beneficial to have these boundaries in place as this will ensure that the research within the defined scope of practice is more thorough and that we may delve deeper into the profession of soft tissue manipulation and therapy, rather than spreading our focus over many other healthcare disciplines. We are massage therapists, therefore our main focus should realistically be on soft tissue manipulation.

Since the area of myofascial release has not been claimed as a main method of therapy by any other healthcare discipline (with the possible exception of osteopathic medicine (Ward, Hruby & Jerome, 2002)), it is most likely that massage therapy can claim this as a developing area of expertise directly relevant to the scope of practice within this field of study and research, as it is a manipulation of the fascia (soft tissue).

As a result of this proposed academic exploration into the sphere of massage therapy, we would be in a better position to achieve our desired goal as defined under the MNZ Code of Ethics: professional image.

Within the MNZ scope of practice, there also appears to be a glaring absence regarding practitioner competence, fitness to practice and quality assurance of the goods and services provided (in this case massage), which may also bring up legal issues concerning the Consumer Guarantees Act (1993). The intention of Section 3 in the HPCAA was to ensure the safety of the public, exclusion of practitioner liability and confidentiality of client and practitioner records except in special circumstances. This is important in terms of setting an industry standard that is reliable, professional, legally watertight, and protective for massage therapists as practitioners. As a result, the inclusion of this clause is crucial to the perception and reputation of massage therapy as a professional practice among clients, other healthcare practitioners and the general public.

Cultural competence also appears absent from the scope of practice defined by MNZ, however there is some vague mention of refraining from prejudicial behaviour and discrimination.  This is particularly unprofessional in New Zealand as all other spheres of healthcare (eg. midwifery, medicine, physiotherapy, etc) currently include a section on this and the relevance of the Treaty of Waitangi. 

Finally, there is a large amount of energy concentrated on ensuring that untoward sexual advances are not made by the massage therapist, and client relationships stay strictly professional.  This is over emphasized under the Code of Ethics reminding others of the earlier association between massage therapy and the sex industry, and while this is definately part of the history of massage, it is not wise to give it so much emphasis if our goal is to appear professional.

Overall, I feel that the Scope of Practice defined by MNZ is incomplete in places and too superficial in others and so does not fit with the legal requirements of the HPCAA.  In order for Massage Therapy to be included in the next amendment of the Act, a greater emphasis on legal, cultural and educational competence is vital and there must be clarity on why these are necessary.  

However, with recognition as a healthcare profession under the HPCAA, we must realise that our Scope of Practice will be limited as a result.

References:

Briscoe, T. (2004). New Zealand's Health Practitioner's Competence Assurance Act: A missed opportunity for improvements to medical practice, The Medical Journal of Australia, 180 (1), p. 4-5.

Gilbey, A. (2008). Use of Inappropriate Titles by New Zealand practitioners of acupuncture, chiropractic and osteopathy, The New Zealand Medical Journal, 121 (1278), p. 1.

Massage New Zealand. (2009) Certified Massage Therapist: Scope of Practice. Retrieved on the 20th May, 2009 from: http://massagenewzealand.org.nz/about-us/scope-of-practice-cmt/

Massage New Zealand.  (2009) Code of Ethics.  Retrieved on the 20th May, 2009 from: http://massagenewzealand.org.nz/about-us/code-of-ethics/ 

Massage New Zealand. (2009) Remedial Massage Therapist: Scope of Practice. Retrieved on the 20th May, 2009 from: http://massagenewzealand.org.nz/about-us/scope-of-practice-rmt/

Ministry of Health. (2008) Health Practitioners Competence Assurance Act 2003. Retrieved on the 21st May, 2009 from: http://legislation.knowledge-basket.co.nz/gpacts/public/text/2003/an/048.html

Parliamentary Counsel Office of NZ. (2008) Consumer Guarantees Act 1993. Retrieved on the 21st May, 2009 from: http://www.legislation.govt.nz/act/public/1993/0091/latest/DLM311053.html

Ward, R., Hruby, R. & Jerome, J. (2002) Foundations for Osteopathic Medicine. USA: Lippincott Williams & Wilkins, p. 1034.

Pathology: Condition 1

Pathology: Musculoskeletal
Condition 1: Osteoporosis
Final due: 5th June, Peer assessment: 19th June 2009.

Description:

Osteoporosis is defined as a systemic skeletal condition in which the bone tissue deteriorates faster than it is being formed, leading to thinning and weakness of bones. It is not possible to cure osteoporosis (Laroche, 2008), which is an irreversable, degenerative disease of the bone. According to Nevitt (1994), prevention is the best form of cure, as the loss of bone strength that occurs as a result of the loss of bone tissue is permanent. The risk is greatly increased in the elderly due to the slowed production of bone and the heightened possibility of falling and therefore fracturing bones. The best prevention is to build up stronger bones during childhood/adolescence when metabolism is at its peak, in order to reduce the likelihood of osteoporosis occurring later in life.

Etiology:

Osteoporosis is a standard part of the ageing process, and can occur as a secondary condition alongside other systemic diseases and endocrine disorders such as hyperthyroidism and diabetes (Sweet, Sweet, Jeremiah & Galazka, 2009).
It is characterised by loss of bone density and greater fragility of bone tissue, which is exacerbated by various etiological factors, such as a family history of osteoporosis, regular smoking and alcohol consumption and insufficient sun exposure, resulting in low vitamin D levels (Morgan & Kitchin, 2008).  A diet low in calcium, certain medications (e.g. glucocorticoids) and low oestrogen levels also increase the likelihood of this disease (Sweet et al, 2009).
In women, the onset of osteoporosis appears most commonly after menopause, in anorexics, and otherwise hormonally or nutritionally deficient individuals (Morgan & Kitchin, 2008).

Signs & Symptoms:

According to Premkumar (1999) bone pain and stress fractures may be present in the initial stages but as the progression is so subtle, the condition may go unnoticed until the event of a fracture, by which time the disease is in its advanced stage and acute damage has occurred. As osteoporosis is a subtle condition that gradually appears during the later stages of the client's life, there is no way of identifying the exact date of initial bone deterioration, and due to its irreversable nature it may require the remainder of the client's life to reach the peak of its expression.  Loss of height and bone deformities such as kyphosis of the spine can indicate that the acute stages of the disease are present in the spinal bones (Holt, 2008).

Morphology:

A deficiency in the minerals that form bone tissue, particularly calcium and phosphate, can force the body to extract these from the bones in an effort to achieve homeostasis. This leads to accelerated osteoclastic resorption (Laroche, 2008) which results in the bone tissue presenting as demineralised, brittle and fragile, breaking easily with little stress (Premkumar, 1999).

Incidence:

1.3 million bone fractures per annum in the overall population have been caused by osteoporosis in the United States (Cooper, 1999). Within this population, 1 in 8 men will suffer from an osteoporotic fracture in their lifetime as will 1 in 2 white women (Sweet et al, 2009).

Indications for MT:

Exercise, gentle massage particularly excercising caution over bones and bone structures, light to medium massage pressure over stiff neighbouring muscles using the fingertips in a circular motion or alternatively, the palm of the hand (Salvo, 2008).

Contraindications for MT:

Deeper massage over bones and greater stroke pressure. Deep tissue massage techniques near the site of osteoporotic bone are also contraindicated as these may aggravate the progression of bone fractures and so must only be used with necessary caution by a qualified practitioner (Leidig-Bruckner et al, 1997).

References:

Boschert, S. (2002) Risk Factors Don't Always Predict Osteoporosis. San Francisco: Internal Medicine News. Retrieved on the 16th May, 2009 from: http://www.internalmedicinenews.com//article/PIIS109786900271086X/fulltext

Cooper, C. (1999) Epidemiology of Osteoporosis. Southampton: Osteoporosis International. Retrieved on the 16th May, 2009 from: http://www.springerlink.com/content/865w7gj0t4496n1p/fulltext.pdf?page=1

Holt, E. (2008) Osteoporosis. Retrieved on the 16th May, 2009 from: http://www.nlm.nih.gov/medlineplus/ency/article/000360.htm

Laroche, M. (2008) Treatment of Osteoporosis: All the Questions We Still Cannot Answer. The American Journal of Medicine, 121 (9), p. 746.

Leidig-Bruckner, G., Minne, H., Schlaich, C., Wagner, G., Scheidt-Nave, C., Bruckner, T., Gebest, H. et al. (1997) Clinical Grading of Spinal Osteoporosis: Quality of Life Components and Spinal Deformity in Women with Chronic Lower Back Pain and Women with Vertebral Osteoporosis. Journal of Bone and Mineral Research, 12 (4), pp. 663 - 675.

Morgan, S. & Kitchin, B. (2008) Osteoporosis: Handy Tools for Detection, Helpful Tips for Treatment. The Journal of Family Practice, 57 (5), p. 313.

Nevitt, M. (1994) Epidemiology of Osteoporosis. San Francisco: University of California. Retrieved on the 16th May, 2009 from: http://www.ncbi.nlm.nih.gov/pubmed/7984777

Premkumar, K. (1999) Pathology A - Z: A Handbook for Massage Therapists. Calgary: Lippincott Williams & Wilkins.

Salvo, S. (2008) Mosby's Pathology for Massage Therapists. New York: Elsevier Health Sciences, p. 112.

Sweet, M., Sweet, J., Jeremiah, M. & Galazka, S. (2009) Diagnosis and Treatment of Osteoporosis. American Family Physician, 79 (3), p.193 - 200, Table 2.