Flatt J, ND; 1 Hahn S, PhD. 2
1 PhD Candidate. School of Health, University of New England, Armidale, NSW, Australia
2 Senior Lecturer. School of Health and Human Sciences. Southern Cross University, Lismore, NSW, Australia
Submitted: 30 August 2012
Accepted for publication: 13 November 2012
Abstract
Objectives: The implementation of the 2003 Health Practitioners Competence Assurance Act (HPCA) in New Zealand has enabled change from voluntary to statutory self-regulation for Complementary and Alternative Medicine (CAM) occupations. This is a development with important consequences for professional associations and their memberships. However, due to long-standing exclusion from state regulatory frameworks, in-depth understanding of the outcomes associated with such a change may be lacking. This could be particularly true for practitioners, who have historically relied on their associations to direct change processes. To explore the level of knowledge on this issue, this study examined CAM practitioner perceptions toward a shift from voluntary to statutory self-regulatory status.
Methods: A survey questionnaire exploring regulatory issues was sent to registered naturopathic and western herbal medicine practitioners within New Zealand.
Results: Responses show that sampled practitioners have a general lack of knowledge of regulatory systems and feel excluded from the process of regulatory change. Potential positives and negatives associated with such change are identified and discussed.
Conclusion: Fully informed knowledge regarding the implications of change from voluntary to statutory self-regulation is not present for naturopathic and western herbal medicine practitioners. Improved discussions regarding regulation and effective dissemination and uptake of information are required.
Introduction
Throughout the western world, review of the regulatory status of selected CAM modalities is in progress.1-7 This is paralleled in New Zealand where a CAM policy agency and regulatory pathway for novel health modalities have been established.8-10 Chiropractic and Osteopathy currently have statutory regulation, and the New Zealand Registrar of Acupuncturists (NZRA) and the New Zealand Association of Medical Herbalists (NZAMH) have applied for shift to this status.11-16 Naturopathic associations have not embraced change,17 the Therapeutic Massage Association of New Zealand (TMANZ) intends to submit for statutory regulation,18 and other CAM occupations are undecided on this issue at the time of writing.
While research and investigation into CAM in New Zealand has occurred,8,19-23 there is minimal published literature examining regulatory issues. Consequently, occupations have no domestic research that can help to inform their discussions. It is known that regulatory change can create fierce debate, and as professional associations take the lead on this issue it is possible that practitioner viewpoints may be overlooked or marginalised. 24,25 Based on the possibility that practitioners may access limited information and have minimal understanding of regulation issues, this paper explores the hypothesis that New Zealand CAM practitioners have incomplete views of regulatory change.
Five questions of interest underlie this research. These are integrated into this paper to address the hypothesis and explore practitioner perception of regulatory change based on current knowledge.
- Do practitioners distinguish between voluntary and statutory self-regulation?
- Are practitioners informed of the consequences of regulatory change?
- What are the dominant practitioner concerns with regard to statutory self-regulation?
- What do practitioners see as the benefits of statutory self-regulation?
- Is change to statutory self-regulation regarded as worthwhile?
Due to Australian research allowing comparison,26,27 naturopathic and western herbal medicine practitioners in New Zealand were targeted for sampling. These occupations have similar educational standards and practice method, creating considerable cross-over between these two groups. Similarly, there is a shared history between naturopathic and western herbal medicine in New Zealand and Australia, making meaningful comparison between these countries possible.
Methods
A survey questionnaire was developed, consent was received from professional associations, and ethics approval was gained from Southern Cross University Human Research Ethics Committee (ECN-05-137). Inclusion criteria for participants were professional practicing membership of one of the four major CAM associations within New Zealand: the Association of Natural Therapies (ANT); the South Pacific Association of Natural Therapies (SPANT); the New Zealand Society of Naturopaths (NZSN); and the New Zealand Association of Medical Herbalists (NZAMH). The surveys were forwarded for distribution to 417 professional members and 120 surveys were returned, equating to a response rate of 29 percent.
Practitioner and Practice Profile
|
Table 1: Association Membership, Professional Qualifications and Professional Title |
|
Association Professional Qualification Professional Title SPANT 18 (13%) Bachelor of Health Science 21 (12%) Naturopath 89 (56%) |
| ANT 28 (20%) Diploma of Naturopathy 90 (53%) Herbalist 54 (34%) |
| NZSN 36 (25%) Diploma of Herbalism 60 (35%) Other 16 (10%) |
| NZAMH 60 (42%) |
Demographic information was gathered to identify any correlation between work situation and regulatory knowledge. Survey respondents were distributed across the four involved associations, with the majority describing themselves as members of the national herbal association (NZAMH). Most held a naturopathic diploma and utilised the professional title of naturopath (table 1). At the time of writing, bachelor programs were a recent introduction to the curriculum in New Zealand.
Practitioners typically worked less than 25 hours weekly and averaged under 11 years practice experience. Over three-quarters stated they had less than 20 patient visits per week and an annual income of less than $35,000.00 (table 2).
|
Table 2: Summary of Respondents’ Clinical Practice Profile |
|
Years in Practice Full or Part Time Practice <1 yrs 7 (6%) <10 hrs/wk 41 (35%) |
| 1–10 yrs 63 (52%) 10–25 hrs/wk 41 (35%) |
| 11–20 yrs 32 (27%) 26–40 hrs/wk 29 (25%) |
| >20 yrs 18 (15%) >40 hrs/wk 6 (5%)
Average # Patients per Week Average Annual Income ($NZ) <5 pts/wk 43 (37%) <$10 000 36 (32%) 5–20 pts/wk 50 (44%) $10 000-$35 000 50 (45%) 21–40 pts/wk 17 (15%) $35 001-$70 000 17 (15%) >40 pts/wk 5 (4%) >$70 000 9 (8%) |
Current Regulatory Knowledge
Practitioners were questioned about the regulatory information they accessed. Many respondents identified multiple knowledge sources; however the foremost were the professional associations. General knowledge of CAM regulatory systems was queried and just under half did not know, or were unsure, of CAM regulation in New Zealand. Practitioners were asked about the current regulatory framework governing their professional practice, with nearly three-quarters correctly identifying voluntary self-regulation (table 3).
|
Table 3: Regulatory Knowledge |
|
Regulatory Information Source Familiar with NZ Own Professional CAM Regulation Regulatory System Professional Association 106 (68%) Yes 61 (54%) Voluntary 78 (73%) |
| Training Institution 19 (12%) No 25 (22%) Statutory 6 (5%) |
| Colleagues 12 (8%) Unsure 28 (24%) Unsure 21 (22%)
Other 19 (12%) |
Specific aspects of regulatory knowledge were then explored. Most practitioners were aware of possible regulatory changes, however the majority stated they did not have enough regulatory knowledge or were unsure of the consequences of regulatory change. Over three-quarters stated that they wanted more information regarding regulation and the associated changes, and half felt excluded from regulatory discussions (figure 1).
Perceived Effects of Proposed Regulatory Changes
Practitioners were then asked if a change to regulatory status would positively affect twenty-four specific thematic areas. Findings are presented in groupings reflecting positive, negative, and unsure responses (figures 2 and 3).
Practitioners’ perceived regulatory change as positive to themes of professional status, equity, and relationships; as well as integrative practice, shared care and health subsidies. Professional competence, practice standards, conduct and discipline, education standards and continuing education were also perceived to be positively affected.
Practitioners’ perceptions of negative effects related to association fees and freedom of practice. A majority of respondents were unsure of the effects regulation might have on income, litigation, research access, and biomedical influence. Varied differences of opinion existed on occupational boundaries, career prospects, medicines access, medicines quality, patient numbers, patient well-being and patient access.
Overall, practitioners regarded regulatory change as positive in areas that entailed professional competence and practice. Issues of cost recovery and practice freedom elicited negative responses, while patient concerns, medicines, medical influence and practitioner career issues were considered with a degree of uncertainty.
Discussion
The survey findings indicate that practitioner perceptions of proposed changes to regulatory status of naturopathic and western medical herbalist practitioners in New Zealand are generally positive; however the level of knowledge underlying these perceptions is low due to a lack of information and exclusion from discussions. These results support the perception that practitioner regulatory knowledge is incomplete and that marginalisation from regulatory discussions may be occurring.
Do practitioners distinguish between voluntary and statutory self-regulation?
Practitioners have difficulty understanding regulatory systems. Almost one-quarter of respondents are unfamiliar with their own regulatory status and almost half are unclear of practice regulation in New Zealand. There is a disconnect between the identification of regulation within the broader CAM community and the sampled practitioners’ own regulatory status. Education regarding regulatory changes, and knowledge of the frameworks of voluntary and statutory self-regulation is lacking.
Are practitioners informed of the consequences of regulatory change?
Only one-quarter of practitioners felt knowledgeable of the possible consequences of statutory regulation, with this knowledge unrelated to practice demography. One professional association has distributed information and surveyed its membership regarding transferring to statutory self-regulation.15,28,29 Associations are the primary source of regulatory information and the lack of dissemination of this to members raises questions of knowledge sharing and translation. With half of surveyed practitioners stating they felt excluded from regulatory discussions, the need to create an inclusive environment where information is made freely available to practitioners is evident.
What are the dominant practitioner concerns with regard to statutory self-regulation?
Of primary concern to practitioners is the perceived cost of association membership. This is legitimate, as 70 percent of participants worked part-time with low patient numbers, and association fees will rise due to regulatory compliance cost-recovery. Patient numbers, income and career prospects were also major themes, indicating a perception of uncertain career improvement due to regulatory change. Practitioners were also divided in areas relating to influences arising from statutory regulation such as freedom of practice, biomedical influence, occupational boundaries, medicines access and medicines quality. There appears to be apprehensiveness that change to regulatory status will adversely affect the perceived positive aspects of voluntary self-regulation. Conversely, the current low level of renumeration that arises from practicing within this framework also contributes to the identified negative concerns.
What do practitioners see as the benefits of statutory self-regulation?
Professional practice and education were perceived as positively affected. This may be a reflection of the belief that statutory guidelines will create enhanced clinical competency and improved training. Practitioners were undecided as to whether research access would improve. However, if education standards increase, research access and involvement will develop as a consequence. 5,8,22,24-27,30
Is change to statutory self-regulation regarded as worthwhile?
There is general optimism regarding regulatory change, and this attitude is prevalent despite a low level of received information. If practitioners are supplied with accurate and easily understood literature, their understanding will be improved and they will be able to substantiate their perceptions of regulatory change.
Conclusion
This research was based in the hypothesis that New Zealand naturopathic and western herbal medicine practitioners have underdeveloped and incomplete views of proposed regulatory changes. The findings of this study affirm the presence of unclear concepts of regulatory systems, a perceived lack of regulatory information for practitioners, and a feeling of exclusion from regulatory discussions. Practitioners have definite positive, negative and unsure responses to thematic areas relating to regulatory change.
There are two main differences in perception towards statutory regulation between Australian and New Zealand naturopathic and western herbal medicine practitioners. There is a greater positive perception of research access amongst Australian practitioners that may reflect differing education standards.31 These same practitioners also have a more positive stance towards medicines access, a difference that may reside within changing medicines regulation creating uncertainty for the New Zealand sample.32
Although professional associations have disseminated some regulatory information to practitioners in New Zealand, it appears that more effective knowledge translation methods are required to ensure knowledgeable participation and equitable discussion. Importantly, the literature describes social closure and jurisdictional boundary change as fundamental and contested concepts within these discussions. These are features of professionalisation that refer to the monopolisation of markets and the management of associations into closed systems asserting authority over specified areas.33 These processes are occurring within CAM regulatory changes in jurisdictions such as Canada, and will occur in New Zealand through the introduction of protected title and a scope of practice statement under the HPCA. 21,33,34
Practitioner understanding of the intricacies of these topics may be lacking as a result of low dissemination of information, and this could contribute to concern and uncertainty around the issues of freedom of practice and career progression under the statutory regulation framework. Consequently, the practitioner vision for practice within this framework may differ from their association leaders, a disparity found within other groups undergoing similar change.25,33,35 This may reflect another observation found within CAM professionalisation processes; the lack of cohesion between members and their professional representatives. This is an identified problem in regulatory matters involving occupations and the State, and this requires active consideration, exploration and management.35
To circumvent these issues, professional associations and their practitioner membership need to come together and be proactive in examining and integrating regulatory information; with all those involved playing a dynamic role in the future of their professions. This survey provides information that can be utilised to inform the opinions of professional association leaders, practitioners, and improve the way regulatory change is undertaken. This process may then move forward in a transparent manner with participatory decision-making based in shared knowledge.
Acknowledgements
This study was partly funded by the Department of Natural and Complementary Medicine at Southern Cross University. Thanks to Scott Hahn for his valued input and to Avena, the journal of the New Zealand Association of Medical Herbalists, for releasing this article.
Competing Interests
Jeff Flatt was the convenor of the NZAMH political sub-committee from 2002-2004.
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