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Let's go round again?

Tick, tock, tick, tock, tick, tock. Is it time to change the whirligig of junior rotations, asks Matthew Limb

The junior carousel lasts for at least two years. Although it isn't mandatory, most physiotherapy graduates - no matter what their age or experience - get on it. Typically, their first two years practising physiotherapy are taken up by rotations - moving from one job in an acute setting to another every six months or so. But it's time to ask whether the rotation system has had its day. Is it still the best way for new physiotherapy graduates to start their careers and develop skills that best benefit patients? Or is there a more flexible, responsive solution waiting in the wings?

Until quite recently, the CSP was recommending the benefits of traditional rotations for new graduates, says CSP education officer Jenny Carey. However, guidance on the issue is under review as the pattern of services, jobs outlook and training needs of students change. 'It's timely to look at the whole rotation system and move away from the traditional system,' says Jenny. As Jill Higgins, CSP director of learning and development, comments: 'It's about looking at different ways of cutting our cloth. It's about considering what is required of us as a profession to keep going.'

Jenny notes: 'The shortage of jobs means we're trying to say graduates should consider any post as a physio where they can use their clinical reasoning and other skills. Rotations are changing - some of them are in much more specialised areas of practice. I also think no one's really looked very carefully before at the skills current graduates have.'

Jenny acknowledges many clinicians remain convinced rotations are the only way for graduates to progress their careers. 'A lot of students pick this up when they're on clinical placement and then think, unless they can get a first post with a structured rotation, it's not worth going for.' However, she adds: 'There will have to be change if even 25 per cent of this year's graduates are going to find jobs. They are going to have to accept a traditional acute rotation is only something a very few can do and valuable experience can be gained in an intermediate care or community setting.'

This is the view from the Society, but what do members think? Manager Maggie Boase is director of therapies at King's College Hospital. She points out several developments are driving a re-think on rotations. These drivers for change include the current jobs crisis for juniors, as well as service developments in the NHS, in particular the shift to primary care. 'We used to say we needed this acute rotational model, but now having juniors work solely in primary care is equally valid,' Maggie observes.

'We need to develop staff for the settings in which they're working. They don't have to work in intensive care or acute orthopaedic inpatients. There can be rotations into anything that provides best value for patients.'

Maggie led a CSP workshop in March exploring ideas for managing juniors in non-traditional settings and was encouraged to hear juniors who were working in the community speak positively about their experience in these roles. In addition, delegates at the workshop discussed how to make 'better use' of new graduates. As Maggie highlights, a third driver for change is the make-up of the student body - because it is transforming.

She explains how the current rotations system grew up around a traditional model of education. Within this most degree students came straight from school and needed a grounding in standard acute physiotherapy before deciding where to specialise. 'That has been an extremely useful model but now things are different.' Maggie points out that with more mature students entering training or people who bring specialised experience, such as assistants, the need for new approaches to rotations grows. 'The product at the end is different than we used to have,' she says.

But what about the juniors themselves and those with recent experience of rotations, what do they think? Leanne Payton qualified from the University of Manchester last June, and started work at Wythenshawe Hospital in September. She is on her third rotation. Leanne says: 'I do like the idea of rotations because I think it gives you more options. As a student you don't always get to experience everything from your placements, so this helps to further your knowledge in all the different areas and widen your opportunities for the future.'

She recently completed a rotation in women's health, a new experience for her. 'I'm still broadminded as to what specialty I want to go into eventually - I'm still gaining from each rotation really.' Leanne feels rotations give 'a more grounded view'. However, she acknowledges she is not sure what the alternative is. Marc Hudson, a senior II physio also at Wythenshawe Hospital, south Manchester, says he has yet to be persuaded regarding changing the rotation system. He points to some of the system's benefits. 'Juniors may have a bad experience on a particular patch but then enjoy another, with a different senior and a different dynamic, which means they end up staying in the profession when otherwise they might have left.'

Like Leanne, he highlights many students graduate without knowing exactly where they want to go in the profession, and hence need the breadth of experience and challenges rotations provide. Carol Owen chairs the Organisation of Chartered Physiotherapists in Private Practice. She sees a strong case for continuing with the rotation system. 'It depends on the quality of rotation to some extent but I think it's a good way of gaining experience once you've qualified,' she says. Carol raises the question of probationary internships (similar to the house officer year of graduating medical students), which could represent an alternative to rotations. 'At one time people were talking of doing your degree then doing an extra year or so as a probationary internship. But she adds: 'With something like that you may get a wider range [of experience], but with the NHS as it is at the moment, I don't see that's viable.'

Ruth Allarton, a lecturer at Sheffield Hallam University, heads up teaching programmes at the university for physiotherapy and three sports disciplines. She has been grappling with graduate training and development issues in recent talks she's had with local managers and workforce planners on ways to resolve the junior jobs crisis. Ruth believes the rotations debate must address two key questions. First: What is the skill set managers require from new graduates? And second: What are managers going to do with graduates when they get them?'

She proposes changes to the rotation system should be based on evidence. 'Managers do say juniors need a lot of support. So I think that's one area we need to look at - why do they need a lot of support? Is it that the expectation of the students needs to be managed, or is it what clinicians expect from them and how they manage that?' She adds: 'These are big questions for the profession. They can't be answered locally, it needs a national push.'

As well as the changing face of the student population, the junior jobs crisis and the shift to primary care, Ruth addresses another driver for change. Developments across the profession, including the way assistants are working more independently, 'change what you need from your first new graduate'. One consequence, she says, is that 'doing rotations in the traditional sense may not be the best way to develop them or manage them'.

Ruth suggests putting juniors through rotations where they operate under tight supervision for lengthy periods can be a form of spoon-feeding, which keeps them in a comfort zone. 'I suppose I'm challenging managers to say, are you treating them as independent autonomous learners and using the skills they have when they come out of graduation? It's whether we need them to be hitting the ground running, operating at a higher level and solving more complex problems.'

She suggests there could be benefits in new graduates focusing earlier on a specialist area rather than continuing to develop a broad base, which may not be needed for much of their careers. This suggestion raises the possibility that, for some graduates, rotations could be holding them back.

Making your mind up ahead of the game and choosing to specialise can early bring career benefits. Frontline is aware of one mature student working in musculoskeletal outpatients who graduated less than three years ago and who has recently been promoted to a senior I position. This follows 12 months as a senior II in a similar service, and 18 months as a junior in a non-rotational or specialist role. Such rapid career progression would not have been possible if a traditional rotations path had been followed. Cases like this advance questions about how many other able juniors are being held back and stifled by rotations. The more rapid progression from junior to senior II roles that early specialisation can bring has other benefits, such as freeing up junior jobs more quickly for graduates.

Maggie Boase also accepts a case could be made to create non-rotational or specialist junior jobs. This could work in particular for those who have spent years as assistants in specialties such as learning disabilities. 'It may still be good for them to do a neurology or orthopaedic outpatient physio-type rotation, but you can't make that hard and fast.' So what is the solution? Is it moving to more rotations in non-traditional settings or reducing the number of rotations? Is it creating more specialist junior posts, and encouraging more students to think ahead about what they might like to specialise in when they graduate? The latter might make for more interested students and more lively dissertations. Should the profession fast track the more able graduates? Or is it time to consider switching direction completely and trying out probationary internships?

Maggie sums up what the only answer can be. As with most aspects of life, there isn't one solution. She says: 'I think it should be horses for courses. It's about flexibility and variety to meet the needs of the health service and to just offer up as much opportunity as possible for new graduates.'

Further information

Frontline wants your views and news. What do you think? Is the rotations system in need of a shake up? We'd also like to hear from managers and trusts with examples of non-traditional junior posts. Email Frontline features editor Catherine Blackledge at blackledgec@csp.org.uk

Vox pop

Frontline put out a request on iCSP asking physiotherapy students: Should graduates be expected to do rotations? Yes or no? The response was fantastic, with many students taking the time to tell us a little bit more about how they feel (see below). The results of our survey are:

  • Yes, graduates should be expected to do rotations 77.6 per cent
  • No, graduates should not be expected to do rotations 22.4 per cent

'Yes, although I'm conscious that the main reason for saying yes is because a) it's the "norm" and b) most clinicians have told me that I "need" to do it in order to gain broad experience, that is, if I don't do it, it won't look as good on a resumé later on,' James Noble.

'I think there should be a choice. If there is a specific field of interest a junior wishes to follow then this should be encouraged from the off. However, rotations do allow a greater knowledge base for future seniors,' Jon Lambley.

'I feel students should have the choice... As a final year student I already have a good idea as to what I would like to specialise in, and I know there are many other students on my course who feel the same. Most of them have an idea as to what they like doing and what they are better at... Surely if we are treating patients for a condition we are more interested in and therefore have better skills it would mean improved patient care?' Anouska Mills

'From a CPD perspective, my choice is yes. However, the current approach of expecting juniors to rotate could be seen as not allowing a freedom of choice to those who have already decided on which specialisation they wish to pursue. Maybe a system could be offered to allow the individual to choose whether they wish to take a rotational post or specialise right away, thereby allowing the individual to choose their own destiny,' Carl Holland.

'No. I have a disability so will find it difficult to do all the core rotations, but this is expected of you in every job I have seen,' Jenni Tuson.

Making your mind up

Paul Stern believes there are successful alternatives to the rotations route if students know where they want to specialise. He graduated from Keele University last summer, and now works there as a leisure coordinator for three days a week, leading exercise and phase IV cardiac rehabilitation programmes. In addition, he works one day each week at a private gym in Shrewsbury and does some weekend work with part-time physiotherapists at Stoke City's football academy. He says: 'I actually didn't look or apply for junior physio jobs because I wanted to concentrate more on the exercise side of things. When I studied, it was the exercise placement I enjoyed more than the physio-type placement, so I decided that was the route I wanted to go down.'

Paul accepts choosing to miss out on rotations brings some risks. 'Obviously, further down the line it might be a problem if I decide I fancy doing a job in the NHS. I'm aware perhaps I'll never work on a ward as a respiratory physio and that might be something I would have enjoyed.' He also acknowledges securing ongoing training could be problematic - either he will have to be self-funded or rely on support from the university. But, he stands by his decision not to seek a junior post.

'I'm getting a lot more experience in the areas I really want to go into. A lot of the skills I've learned as a physio I apply to the work I'm doing now and I'm working with a lot of the populations I would work with as a physio. In some ways, I can offer them more, with the exercise experience I've got.'

Paul says his work at the university opens up opportunities for taking up research into exercise, in conjunction with the physiotherapy department. He is considering doing a masters degree in exercise science and expects to do more work in cardiac rehabilitation in future. 'I don't think the fact I haven't had my rotations will be a problem if I've gained experience in that area.' He adds: 'I do think it can work doing something other than the traditional rotations, absolutely. If you really know what it is you want to go for, why not go into it straight away?'

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Article Information

Issue date

3 May 2006

Volume number

12

Issue number

9

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