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Abstract

This article discusses the interface between health policy and education. Taking as a case example the power that regulatory “responsible authorities” have under the New Zealand Health Practitioners Competence Assurance Act 2003 to define scopes of practice of health professionals, including that of educator, the article discusses the implications of such power with regard to health authorities determining curricula, and approving – or disapproving of – certain educators. The authors argue that such power, wielded by government appointees, represents a conservatising agenda, compromises the role of the university to be “a critic and conscience of society”, and threatens the future of both independent health professionals and their educators. The research, conducted over some five years, is informed by relevant publications on professional regulation and the registration of professionals, and a critical review of the publications and websites of the various responsible authorities. The initial hypothesis that these authorities had – and have – different and differing views of this scope of practice and of the extension of their powers, was confirmed.

Keywords

Health regulation scopes of practice

Introduction

During the process of writing contributions for a book about the registration of psychotherapists and the regulation of psychotherapy (Tudor, 2011), and as colleagues working in the tertiary education sector with an interest in health care policy, including regulation and, specifically, the education and training of health professionals, we began to share our background research into the policies of different regulatory or “responsible authorities” (RAs) under the Health Practitioners Competence Assurance Act 2003 (“the HPCA Act” or “the Act”). In this article, we present this research and, in doing so, pose some critical questions for health professions and professionals, RAs, and government(s). This discussion is of significant value for educators as the pre-qualifying preparation of practitioners and their ongoing professional development is influenced by the wider political and social contexts in which the practice exists and services are designed and delivered.

The Health Practitioners Competence Assurance Act 2003 and scopes of practice

Under this Act, responsible authorities must specify scopes of practice and issue notices of such scopes (§11). All 16 RAs, covering 22 professions, have specified a principal, predominantly clinical scope of practice which is defined with reference to the title of the professional: chiropractor, dentist, and so on. Between them the RAs have identified 42 different scopes. With one exception, that of “registered nurse”, the protected title does not include the word “registered” (see Table 1). For discussion of the history of these professions and their governing bodies see Shaw and Tudor (2015), and for discussion of the development by the different RAs of the various scopes of practice see Tudor and Shaw (2015). Table 1 summarises:

the 22 professions covered by the Act;

the 16 relevant authorities responsible for those professions or, more accurately, the “responsible authorities” who, in consultation with the profession, define certain scopes of practice and, therefore, certain protected titles;

the various current clinical scopes of practice; and

where RAs have defined a scope encompassing educating and/or training, the title of this scope.

Table 1.

Professions and responsible authorities under the Health Practitioners Competence Assurance Act 2003, and their scopes of practice.

Profession	Responsible authority (Board/Council) under the HPCA Act 2003	Clinical scope of practice	Scopes of practice relating to educating/training
Chiropractic	Chiropractic Board New Zealand (CBNZ) \| Te Poari Kaikorohiti o Aotearoa	Chiropractor (CBNZ, 2004)
Dentistry, dental hygiene, clinical dental technology, dental technology, and dental therapy	Dental Council of New Zealand (DCNZ) \| Te Kaunihera Tiaki Niho o Aotearoa	Dentist, Dental Therapist, Dental Hygienists & Auxiliaries, and Dental Technicians (DCNZ, 2004)	Registration and Annual Practicing Certificate (APC)
Dietetics	New Zealand Dieticians Board (NZDB)	Dietician (NZDB, 2004)
Medical laboratory science, and anaesthetic technology	Medical Laboratory Science Board (MLSB) \| Te Poari Mātai Oranga	Medical Laboratory Scientist, and Medical Laboratory Technician (MLSB, 2004)	Registered practitioners may apply for a training scope of practice
Medical radiation technology	New Zealand Medical Radiation Technologists Board (NZMRB) \| Te Poari Ringa Hangarua I Raruke	Medical Radiation Technologist, Radiation Therapist, Nuclear Medicine Technologist, Sonographer, and Magnetic Resonance Technologist (NZMRB, 2004) Diagnostic Imaging – General Magnetic Resonance Imaging Technologist, and Trainee (NZMRB, 2008)
Medicine	Medical Council of New Zealand (MCNZ)	Medical Practitioner (MCNZ, 2004)	Teaching as a Visiting Expert, Postgraduate Training (MCNZ, 2010, 2014)
Midwifery	Te Tatau o te Whare Kahu \| Midwifery Council of New Zealand (MCNZ)	Midwife (MCNZ, 2004, 2010)	Education providers must be approved by the Midwifery Council in order to deliver certain education programmes and courses (see MCNZ, 2012)
Nursing	Te Kaunihera Tapuho o Aotearoa \| Nursing Council of New Zealand (NCNZ)	Registered Nurse, Nurse Practitioner, Nurse Assistant, and Enrolled Nurse (NCNZ, 2004)	Registration and APC
Occupational therapy	Occupational Therapy Board of New Zealand (OTBNZ) \| Kaihaumanu Tūroro o Aotearoa	Occupational Therapist (OTBNZ, 2004)	Registration and APC
Optometry, and optical dispensing	Opticians Board	Optomotrist, Optomotrist with Therapeutic Pharmaceutical Agents, and Dispensing Optician (ODOB, 2004)	Educator, Educator Optomotrist with Therapeutic Pharmaceutical Agents Endorsement (ODOB, 2004)
Osteopathy	Osteopathic Council of New Zealand (OCNZ)	Osteopath (OCNZ, 2004), and Osteopath using Western Medical Acupuncture and Related Needling Techniques (OCNZ, 2009)	Teaching as a Visiting Expert, Postgraduate Training
Pharmacy	Pharmacy Council of New Zealand (PharCNZ)	Pharmacist, and Intern Pharmacist (PharCNZ, 2004a, 2004b)	Registration and APC
Physiotherapy	Physiotherapy Board of New Zealand (PhysBNZ)	Physiotherapist, and Postgraduate Physiotherapy Student (PhysBNZ, 2004)	Visiting Physiotherapy Presenter (PhysBNZ, 2004), Educating (PhysBNZ, 2008a, 2008b), Visiting Physiotherapy Presenter/Educator (PhysBNZ, 2009)
Podiatry	Podiatrists Board of New Zealand (PodBNZ)	Podiatrist, Podiatric Surgeon, Podiatric Radiographer Imager, and Podiatric Prescriber (PodBNZ, 2004)	Visiting Podiatrist Educator (PodBNZ, 2006, 2013)
Psychology	New Zealand Psychologists Board (NZPB)	Psychologist, Trainee or Intern Psychologist (NZPB, 2004) Educational Psychologist (NZPB, 2005), and Counselling Psychologist (NZPB, 2010)	Registration and APC (only if educating or training students in clinical practice)
Psychotherapy	Psychotherapists Board of Aotearoa New Zealand (PBANZ)	Psychotherapist, Psychotherapist with Child and Adolescent Psychotherapist Specialism, and Interim Psychotherapist (PBANZ, 2008)	Educating (PBANZ, 2008, 2012b)

The education/educating scope of practice

From the summary in Table 1, we extrapolate a number of points:

Not all “responsible authorities” define a scope of practice with regard to education Four RAs, covering chiropractors, dieticians, medical radiation technologists and midwives do not have an educator scope of practice, although the Midwifery Council of New Zealand (MCNZ) does require “education providers” to be approved by the Council in order to deliver certain education programmes and courses (see MCNZ, 2012). A further five RAs, covering dentists, nurses, occupational therapists, pharmacists, and psychologists, do not have a specific scope of practice for educators or trainers but do require practitioners involved in the education and training of health professionals in their field to be registered (i.e. clinical) practitioners and require such “practitioners” to have an annual practicing certificate (APC), though the New Zealand Psychologists' Board (NZPB) has clarified that this requirement only applies to those educators or trainers educating or training students in clinical practice, not in other aspects of clinical training, such as theoretical papers. These requirements raise an interesting anomaly: for those practitioners (encompassing 13 professions) who are not required to have an APC in order to be educators, their clinical registration in effect constitutes a generic registration; for those practitioners who are required to have an APC (i.e. the nine professional titles that fall under dentistry, nursing, occupational health, pharmacy and psychology), their practicing certificates in effect represents their clinical practice, not their educational practice (a point to which we return later).

A minority of responsible authorities define an educator/educating scope of practice Only five RAs, covering medical practitioners, optometrists and optical dispensers, physiotherapists, and podiatrists define an educator/educating scope of practice, though the Podiatrists' Board of New Zealand (PodBNZ) only defines this with regard to a “Visiting Educator” (see next point). A sixth RA, the Psychotherapists' Board of Aotearoa New Zealand (PBANZ) did identify this as a scope of practice (see PBANZ, 2008) but has not defined it.

A minority of responsible authorities define a “Visiting Educator” scope of practice Four RAs, covering medicine, osteopathy, physiotherapy and podiatry define a “Visiting Educator” scope of practice, though, in 2009, the Physiotherapists' Board changed its previous (2004) requirement that a visiting presenter/educator was required to be registered to the permissive option that such visiting practitioners may be registered. In 2011, the PBANZ proposed this as a scope of practice (see PBANZ, 2011 ), naming some 18 conditions an overseas visiting educator would have to fulfil in order to work as an educator/trainer, a proposal that was widely rejected by the profession (see PBANZ, 2012b; Tudor, 2012). Following this response, the PBANZ withdrew this proposed scope of practice and instead drew up a statement which includes a “suggestion” that Visiting Psychotherapist Presenter/Educators and/or their hosts contact the Board with certain information regarding the name, qualifications and topic of the presenter, and the limited period of the visit (less than 30 days); as well as confirmation that the visiting educator will not be undertaking clinical work with members of the public, and that she or he is not registered in New Zealand and will not claim to be so registered (PBANZ, 2012b). This means that, in effect, the MCNZ (MCNZ, 2012), the Osteopathic Council of New Zealand (OCNZ), and the PodBNZ (2012) are the only RAs who require overseas practitioners and/or educators who deliver some form of education or training such as a keynote speech, lecture or workshop while visiting Aotearoa New Zealand or coming here for that purpose, to apply for registration.

Responsible authorities offer different justifications for their educator/educating scope of practice The principal purpose of the Act is “to protect the health and safety of members of the public by providing for mechanisms to ensure that health practitioners are competent and fit to practice their professions” (Section [§] 3(1)). In a review of the Act, and with regard to prescribing scopes of practice, the Director-General of Health (2009) advanced certain principles which RAs should follow, including: “defining scopes only as needed to protect public health and safety rather than responding to professional preferences” (Director-General of Health, 2009: 9). Few RAs, however, justify their definition or extension of scopes of practice with reference to the public health and safety principle or, more broadly, to the “public protection” argument. Both the Dental Council of New Zealand (DCNZ) and the Pharmacy Council of New Zealand (PharCNZ) have made similar arguments that: “practice goes wider than clinical dentistry to include teaching, research, and management given that such roles influence clinical practice and public safety” (DCNZ, 2004), and “The practice in this context goes wider than pharmacists directly working with patients to include teaching, advising, research, policy development and management, given that such roles influence clinical practice and public safety” (see PharCNZ, 2004a: 2969), respectively. When, in 2004, the Physiotherapy Board of New Zealand (PhysBNZ) established its original scopes of practice, it clarified that, according to the Board: “The practice of physiotherapy is not confined to clinical practice, and encompasses all roles that a physiotherapist may assume such as patient/client care, health management, research, policy making, educating and consulting.” After further consultation, in 2008, it amended its original scope of practice, and included the phrase “wherever there may be an issue of public health and safety” (PhysBNZ, 2004). Although we think this caveat is significant, the use of the word “wherever” renders it somewhat ambiguous in that it could be taken to mean “whenever”, as in quite specifically when (and only when) there is an issue of public health and safety, or “whenever”, as in any (possible) circumstances in which an issue of public health and safety could potentially arise. The former reading of this phrase sets the bar quite high for the proof of a or the connection between a role, such as that of an educator, and its impact on public health and safety; and the latter reading sets it so low that all roles a health professional might fulfil could be said, ultimately, to have an influence on public health and safety. Two years later, when defining the scopes of practice “Teaching as a visiting expert”, and “Postgraduate training”, the MCNZ stated that these involved:

assessing, diagnosing, treating, reporting or giving advice in a medical capacity using the knowledge, skills, attitudes and competence initially attained for the MB ChB degree (or equivalent) and built upon in post graduate and continuing medical education, wherever there could be an issue of public safety. (MCNZ, 2010)

The Occupational Therapy Board of New Zealand (OTBNZ) has a wide-ranging definition of the circumstances in which registration with a current practising certificate is required, including: “(f) if the practitioner has a role which can influence the practice of occupational therapy directly or indirectly, through being responsible for training and/or supervising an occupational therapist to practice competently” (OTBNZ, 2004). These statements, in effect, present assertions and claims as distinct from coherent and robust arguments, or, indeed, any evidence:

That there is a direct, causal connection between an educator's input and a student's subsequent practice.

That there is a causal connection between an educator's input and a student's subsequent practice specifically with regard to public safety.

That an educator who is a registered (clinical) health practitioner is a safer educator with regard to public safety than an unregistered practitioner, irrespective of their experience, training, qualifications and/or even accreditation or registration as an educator or teacher.

Responsible authorities vary in the spheres of influence they define for themselves in terms of scopes of practice or roles It is clear that RAs operate differently, and appear to respond to their responsibilities to define scopes of practice or roles in one of two ways:

By aligning the protected clinical title of the particular health profession with all the roles that the practitioner might undertake, and, therefore, requiring that practitioners in these roles are required to be registered and to have APCs (as clinicians) – as do the PharCNZ and PhysBNZ (all scopes); followed by the Nursing Council of New Zealand (with regard to education, research, policy-making, and management); the DCNZ (with regard to education, research, and management); and the Medical Council of New Zealand (with regard to postgraduate education, research, and management).

By distinguishing between the clinical and other scopes of practice in terms of their influence on public safety, as is required by the Director-General of Health (2009), and, therefore, requiring practitioners to be registered and to have APCs (still as clinicians) only if the RAs assess this as necessary – as do the OTBNZ, the OCNZ and PhysBNZ generally; and as do the MCNZ (with regard to education providers teaching certain courses), and the NZPB (only if the educator is educating or training students in clinical practice). Five RAs, i.e. the Chiropractic Board of New Zealand, the New Zealand Dieticians Board, the Medical Laboratory Science Board, the New Zealand Medical RadiationTechnologists Board and the MCNZ make this distinction and conclude that registration and APCs are not required to undertake scopes of practice and roles outside the clinical scope.

The interface between health and education

The different policies of various responsible authorities under the HPCA Act are significant not only for particular health practitioners and their eligibility to practise in different scopes and roles, but also in considering the interface between health policy and education. The HPCA Act identifies fourteen functions of authorities appointed in respect of a health profession, one of which is: “to prescribe the qualifications required for scopes of practice within the profession, and, for that purpose, to accredit and monitor educational institutions and degrees, courses of studies, or programmes.” Together with the power to define scopes of practice, this means that RAs can claim authority over, in the case under discussion, education, in a number of ways:

by defining education as a scope of health practice;

by prescribing educational qualifications for health practice and practitioners; and

by accrediting and monitoring educational institutions, courses, or programmes – and, thereby, prescribing – and proscribing – practice.

We discuss each of these briefly.

Education as health practice

The role of the RAs with regard to education is of particular interest as the tertiary education of health professionals in Aotearoa New Zealand generally takes place within government-regulated and -funded educational institutions that are already subject to high levels of monitoring and quality assurance, including stakeholder input. While it is completely appropriate that the RAs, as well as other interested parties including stakeholders, such as employers and students/trainees, are involved in the monitoring of the education and training programmes of health professions (point 4 above), it appears less appropriate and certainly arguable that they should influence to such a degree the processes of defining and deciding scopes, qualifications and what gets accredited – and what does not.

Furthermore, what should be an interface between two fields or disciplines appears largely one-sided. There is no equivalent educational policy that gives what would be viewed as “responsible authorities” in education, i.e. universities, the power to define what health practitioners may or may not do. Nor do politicians or policy-makers appear to be aware of the overlap between these two fields. In a discussion document about the review of the HPCA Act, published by the Ministry of Health (2012), an appendix notes the Acts (of parliament) that interface with the HPCA Act. It names eight different Acts as well as the Trans-Tasman Mutual Recognition Arrangement, but not the Education Act 1989. This appears a strange and significant omission. In this country, academic freedom is enshrined in the Education Act 1989 (§161), and the purpose of a university is described in the Education Amendment Act 1990 (§4) which outlines the characteristics of universities, including that: “They are primarily concerned with more advanced learning, the principal aim being to develop intellectual independence” (§4(i)), and that: “They accept a role as critic and conscience of society” (§4(v)). In this context, those Boards and Councils which have extended the definition of the term “practice” to encompass educating and, on that basis, accredit training programmes/courses on certain conditions, including that educators/trainers on such programmes are registered health practitioners, threaten the freedom of practitioners to be independent educators and trainers. In some professions, this is clearly a part of a conservatising – and controlling – agenda. In one consultation document, the PBANZ (2012a) stated that it regards supervisors as “agents of the Board”, which then makes them, agents of the state. By the same logic and attitude, educators would become agents of the RAs and the state – and, significantly, through health, not education. This particular RA also refused to approve two qualified, experienced and senior practitioners as supervisors of registered practitioners specifically because they were critical of regulation and the HPCA Act; so much for academic freedom!

The prescription of educational practice

While RAs and other institutions have a legitimate interest in the education of practitioners within their respective disciplines, their involvement in education should not be above critique. The education of health practitioners is a particularly contested field as the practice and delivery of health care and education, both traditionally expensive and highly valued endeavours, converge.

In terms of the professions themselves the very act of seeking professional recognition through regulation can be seen as aligning with conservative and conservatising agendas (Fay, 2013). The conventions of delivering clinical care within large organisations have the ability to conservatise practice as protocols are established and valued above the personal narratives (Stevenson, 2005) of practitioners and service users. Within the educational context institutions such as universities and regulatory authorities have the potential to impact on professions as a whole, an impact that is manifested through the self-perpetuating bureaucracy of large organisations, personal, professional and historical allegiances, and/or the political and economic drivers that fund the professions (Barker, 2008).

This convergence of education and health care brings with it extensive and often opposing views on planning, delivery and evaluation which, within the context of central funding, potentially heightens the scope for conservatising agendas as standardisation is demanded, often under the guise of quality management.

The accreditation of programmes and the monitoring of institutions

By claiming authority over education, the predominantly unelected “responsible authorities” (under the HPCA Act) that currently regulate certain health professionals, are, in effect, attempting to colonise a field that is not their own; this also applies to the fields of research, consultancy, and management. This is of particular concern because the power asserted by RAs in terms of approving educational programmes:

Is a substantial and significant power, as it impacts on the way professions evolve and how practitioners think and work; on the experience of those RAs that currently accredit programmes we see a worrying trend of increased caution and conservatism amongst educators and away from critical thinking and radical praxis, and interdisciplinary learning and practice. This serves only to isolate professionals, professional practice, and the professions themselves.

Assumes and asserts educational expertise, whereas the field of health professional education has its own expertise and is supported by research and practice developments around the world. The RAs do not necessarily have or incorporate educational expertise on their Boards and Councils, and yet assert the right to define and assess educational practice including the content of the curriculum and the qualifications and (registered) status of staff, thereby prescribing and proscribing practice and practitioners.

The interrogation of health professional education by RAs, which are primarily concerned with governance and public safety, requires that learning within the various professional groups is viewed in these terms – of regulation, governance, assurance, and audit – and in isolation (for arguments against which see, for instance, King and Moutsou, 2010; Tudor, 2011).

The accreditation of an educational or training programme by additional external authority, in this case another branch of the state, is inevitably followed by monitoring. Indeed, the HPCA Act specifically states that if an RA accredits an educational institution, then it must monitor that educational institution (§12(4)); given the requirements that some RAs make regarding the curriculum and the staff, this further extends the authority and influence of the RAs.

Conclusion

Given the issues outlined in this article, and the imperative of academic freedom on educators, we suggest that a more appropriate approach for ensuring alignment between education providers, professions and RAs, and for managing resources, would be to require that educational quality management systems for both the education sector and the RAs participate in a collaborative and engaged approach. This would acknowledge the authority and expertise of the RAs to register and monitor clinical practitioners over which they have jurisdiction, as well as the expertise of education providers to educate and assess students. This mutual acknowledgement would support a collegial relationship between both, rather than the costly system that currently exists, and the adversarial system that is implied in the RAs' power to extend scopes of practice and, thereby, their scope of influence.

There are also questions to be asked about the potential overlap of scopes of practice beyond the RAs. For example, we note that, while the RAs may identify educational practice as a specific role, there is also a Teachers' Council in Aoteraoa New Zealand that registers educators working in the compulsory education sector and whose remit could logically extend to educational practice in other sectors such as health. Indeed, for those generally in favour of statutory regulation and state registration, it would be logical to require educators, teachers/trainers and supervisors to be accredited or registered as such, as distinct from being registered as clinical practitioners.

Perhaps the resolution lies in the open appreciation of expertise between organisations as they recognise that their roles are not necessarily adversarial. Educational institutions should be acknowledged as holding the content and process expertise and resources to deliver, assess and evaluate education, while contributing to the wider profession and sector and acting as a repository for knowledge and as the critic and conscience of society. RAs, in turn, should be acknowledged for their legislated mandate to monitor certain health professionals (though not the whole profession or health care field). The roles of these organisations are not mutually exclusive and there is no reason why educational providers and RAs cannot work together. Our experience, however, is that RAs have a tendency to set themselves apart as the all-powerful regulator with the power to assert expertise regarding pre-registration learning and practice development as well as continuing professional development. We contend that this devalues the educational and professional expertise of educators and, ultimately, disempowers the development of those professionals and the professions themselves.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Keith Tudor Keith is a Professor of Psychotherapy and currently the Head of the Department of Psychotherapy & Counselling at Auckland University of Technology in Aotearoa New Zealand. His research and teaching interests include: psychotherapy education and training; psychotherapy and politics; psychotherapy and culture; transactional analysis; humanistic psychology and psychotherapy; person-centred therapy; constructivism and co-creativity; positive mental health; and mental health promotion.

Susan Shaw Susan is currently the Associate Dean (undergraduate) of the Faculty of Health and Environmental Sciences and Director of the National Centre for Interprofessional Education and Collaborative Practice, both at Auckland University of Technology in New Zealand. Susan's research and teaching interests include: the political and social context of health; responses of patients and practitioners to the experience of chronicity and disability innovation; and quality in health professional education.

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