Because of rapid growth and increased use of complementary and alternative medicine (CAM) in the United Kingdom, pressure has been put on the practitioners in complementary therapies (CT), as Mills (2001b) stated many practitioners in the UK are largely unregulated. Ruggie (2005) claimed some courses are not taught professionally or consistently. According to the House of Lords Sixth report in 2000, it critically highlighted some issues on CAM, for example, regulators, health care professionals, providers and educators (2001a). It recommended setting up the appropriate standards and defining core competencies by regulatory bodies.
The report of the National Working Group (2005) and Skills for Health, the Complementary and Natural HealthCare, qualification report (2009) also criticised their educational standards and qualifications.
Therefore, this literature review mainly focuses on reviewing the current educational system for complementary therapies and the related training and Continuing Professional Development (CPD) provided, and also explores the relevant regulations for CAM and their requirements of qualifications. In addition, examining professional education and training support to the development of complementary therapies as well as discussing with the current development of CPD activities.
This literature review firstly discusses, the classifications of CAM, their regulations and main issues of education, training and CPD regarding the House of Lords report; secondly, identifying the requirements of qualification for practitioners in complementary therapies; thirdly, reviewing the impacts of educational development in complementary therapies, how the professional education, training and CPD support their professions and careers in the future. It also discusses the key roles of training and CPD in complementary therapies. Ruston et al (2003b) suggested the focus of training and CPD is on the process of learning and their outcomes. Finally, updating the development of the regulatory body and suggestions for further development on training and CPD are also discussed.
It appears there is an increase in using CAM treatments in the United Kingdom (UK). The term 'complementary' became popular in the 1980s (Vos and Brennan 2009). However, there is no particular definition of CAM, which enables consumers to understand the wide range of CAM treatments available. In contrast, the CAM industry offers a wide range of approaches and philosophies to healing and relaxing (Vos and Brennan 2009).
The Centre for CAM at the University of Exeter in 2000 estimated that there are 48,000-60,000 practitioners of CAM in the UK (Mills and Peacock 2000). Nevertheless, they argued that there were no significant figures to show how many of them are qualified as being professional practitioners, as they are not required to obtain licences in order to practise. In addition, their 'educational and practice standards in these unregulated areas vary widely (Vos and Brennan 2009 p.353)'. Mills (2001b) stated that 'CAM practitioners in the UK are free to practise as they wish (p.158)'.
The Review of Regulations for Complementary Therapy
In terms of regulation implications and their educational and practice standards, a House of Lords Select Committee Enquiry into CAM made a report of their findings in 2000 (Thomas et al 2001). The regulations were made very clear in the report as it classified CAM into three groups (Appendix). With reference to the report, Mills (2001b) claimed that the practitioners are expected to achieve relevant educational standards. Mills (2001a) also stated training for CAM professionals should be standardised and accredited, in particular, they should include basic biomedical science as well. Therefore, he explained that Group 1 defines as 'an individual diagnostic approaches and substantial weight in the CAM sector (p.35).' Group 2 is therapists who use 'complementary conventional medicine and do not purport to embrace diagnostic skills (p.35) such as therapies of aromatherapy, reflexology or shiatsu. However, those in Group 2 play significant roles in alleviating and relaxing aspects. In the same way, they are aimed to 'operate as an adjunct to conventional medicine, mainly make claims in the area of relaxation and stress management (The House of Lords report 2000, para 4.18). Therefore, the report (2000) suggested therapies in Group 2, they 'should organise themselves under a single professional body for each therapy (para 5.23)' and 'should be trained to the standards comparable to those set out for that particular therapy by the appropriate CAM regulatory body (para 5.83)'.
However, Mills (2001b) argued that practitioners who classified as complementary therapists (CT) are 'unlikely to tackle critical diagnostic issues or face the prospect of serious interaction with medical treatments (p.159)'. In that case, the report (2000) suggested certain levels of training tend to link to the expertise claimed by the practitioners. Furthermore, it recommended that 'training in anatomy, physiology and basic biochemistry and pharmacology should be included within the education, practitioners are likely to offer diagnostic information, such as the therapies in Group 1 and 3a (para 6.43)'.The report also mentioned 'the CAM therapies, particularly those in Group 1 and 2, should identify CPD in practice as a core requirement for their member (para 6.34)'. According to the report's recommendations, hence, there are different roles of a regulatory body and a professional body in CT. A regulatory body mainly promotes the process of regulations and sets minimum requirements for CPD; a professional body promotes and supports the practitioners and their profession and CPD activities, helping members to achieve the requirements of CPD (FHT 2006).
Conversely, the report of the National Working Group (NWG) on the Regulation of complementary therapy to the Minister for Health and Children (2005) stated the courses of CT vary widely and often show unacceptable levels of quality, even in a single therapy. The NWG's report suggested that 'the development of robust system of therapies in Group 2 is essential (p.22)' and CPD would need a degree of consultation between providers and the professional bodies.
In other European Union (EU) countries, 'there are few healthcare activities that are allowed with government authorization (Mills 2001b p.158)', tend to establish their own systems of regulation. Countries such as Denmark and Holland, the Danish parliament established an effective register from June, 2004. Holland has regulated CAM therapies since 1993 that included education, vocational training and CPD (NWG's report 2005). Furthermore, 'the European Forum for CAM (EFCAM) was formed in 2004 in response to the EU Commission's call for single umbrella body (p.59)'. It aims to promote the interests of professional practitioners, patients and users of CAM in Europe.
Requirements of Qualification for Practitioners in Complementary Therapy
Referring to Skills for Health, the Complementary and Natural HealthCare, qualification report (2009) stated, the national qualification of CT, there are currently a total of seventeen vocational qualifications available on National Vocational Qualification (NVQ) Level 2 and 3, as 'NVQs state the minimum level skills required to perform a particular task or job (Forrester et al 1995 p.17)'. However, this report (2009) argued that many courses may not have the parameters of recognized qualification from a Sector Skills Council. On the other hand, the UCAS database shows that the foundation degrees and the degrees courses, in full time or part-time, are commonly oriented towards the subject areas mentioned in Group 2. 'Reflexology, aromatherapy, massage, nutrition, anatomy and physiology are commonly occurring aspects of those courses content (p.5)'. Above all, the University of Westminster possibly provides some good approaches to CT qualifications. However, this report (2009) stated that higher education (HE) providers do not always provide the depth for practices in the particular areas and 'the availability of discipline specific qualification through HE providers is very limited (p.27)'. Under these circumstances, the qualification report (2009) concluded that people who wish to pursue a career in CT, seem uncertain as to where to start or what course will provide the best opportunity for CT development. As they found many courses only provide an introduction to the discipline, moreover, they do not provide the essential input to become a fully registered practitioner. In that case, it may create barriers to stop individuals becoming as practitioners.
Apparently, the practitioners work closely in the health care or clinical care sectors. Referring to the House of Lords report (2000), therapies in Group 2 'should comply with core professional principles, and relevant information about each body should be made known to medical practitioners and other healthcare professionals (para 5.23)'. Berkshire Healthcare (2010) described all Trust staff and healthcare professionals who are practising on CT, they must hold approved qualification required. In contrast, the Royal College of Nursing (RCN) guidance (2003) mentioned 'nurses, midwives or health visitors will not necessarily need complex external training (p.8)', unless they are doing the practitioner level. It appears there is much confusion about the required qualifications for members who are practising CT in healthcare sector. Conversely, in the United States (US), it seems that probable members of conventional medicine; health professional groups; the public and other organisations have established the agreed levels of training, education, the standards of CPD and a scope of practice (NWG's report 2005).
What professional education and training do or do not support for Complementary Therapy professions
Deverell and Sharma (2000) explained a profession as a distinct type of occupation. We recognise that practitioners in CT are part of this occupation. Particularly, we expect professional practitioners to deliver professional treatments. However, Mills (2001b) argued that there are 'few formal obligations to meet any particular standard (p.158)'. We feel that it appears to be difficult to identify the professional practitioners in terms of their various qualifications. The House of Lords Report (2000) highlighted there is variation in the levels of the professional in the CAM in terms of different training and educational standards. Skills for Health, the qualification report (2009) also claimed that there is a lack of clarity about whether these courses will enable the individual to practice. Deverell and Sharma (2000) described the word 'professional' as a person or an activity proficient, trained or learned and adept in practising.
In general, the qualification report (2009) claimed that some courses may not enable all students to become recognised practitioners, for example, aromatherapy courses taking place in college or university, mostly provide theory. Therefore, these courses may not be recognised by The Aromatherapy Council. On the other hand, massage therapists who 'are not required by law to belong to a professional association and need not have completed a specified course of training (p.14)'. It also argued that reflexology courses may create confusion for potential practitioners as it explained some courses appear to be 'free-standing (p.20)'. Therefore, it suggested the practitioners must decide the value of those courses. This report seems to raise the questions that the professional education and training does not necessarily support CT professions, nevertheless, Skills for Health suggested working closely with Complementary and Natural Healthcare Council (CNHC), a single federal regulator founded since 2006, to support the process of regulation, the development of course contents and CPD, it appropriately supports and develops the specific qualification for inclusion in recognised accrediting frameworks.
The Roles of training and CPD in Complementary Therapy
Above all, what impact does the current situation of education and training in CT have for practitioners? What is the appropriate training for the practitioners? How CPD supports their further development?
Skills in England (2002) claimed that the rate of workers who are receiving some form of training is high in the UK. However, the duration of training is short and often dominated by on-the-job-training. We believe that the training on offer to practitioners in CT is similar in situation to many other workers. Most of the courses are probably offered for only a short period, on a part-time basis on a single therapy. Forrester et al (1995) described training is the bridge between education and job-related skills, retraining involves skills updating at work as well relating to those objectives held by organisations. However, some training in CT merely provides forms of professional knowledge rather than skill practices. Ruston et al (2003b) suggested that the courses may make informally or workplace centred activities. Moreover, some training is undertaken online. Freshwinds Institute for Integrated Medicine (FIIM) has developed a range of professional association, Federation of Holistic Therapists (FHT), accredited online training and CPD programs (FHT 2010). It tends to benefit current practitioners and may solve their barriers (time, income and travel) to access training and CPDs. However, it may not provide an opportunity to fully practice all skills. As Skills for Health, the qualification report (2009) mentioned many courses may merely provide an introduction to the discipline. The House of Lords report (2000) suggested that 'the relevant professional regulatory body of a specific CAM therapy that should set objectives of training and define core competencies appropriate to their particular discipline (para 6.61)'. It also suggested CAM therapies should identify CPD in practice as an importance part for the practitioners.
Armitage et al (2003) described CPD as an essential part of being a professional. Single therapy training may be suitable for a new comer who wants be a practitioner in the future. In contrast, CPD activities may commonly be chosen by the registered practitioners. Those activities are often held in one day or at weekend workshops by FHT or other private organisations. Ruston et al (2003b) argued it is likely to take action for being a member of professional bodies and gaining hours of attendance. In general, CPD appears to be an opportunity for practitioners to develop their practices and knowledge further. However, Ruston et al (2003b) claimed that CPD activities focus on the rates of participation rather than the learning outcomes. Although there may have the problems to access CPD activities such as time, cost, location (Friedman and Phillips 2001), those activities may provide platforms for personal development and lifelong learning. In addition obtaining up-to-dated information and sharing their practices and experience with other practitioners (Ruston et al 2003a), the professional associations can possibly verify their professional standards at the same time. No matter what the various CPD activities offered by professional associations either online or workshops, it tends to support the practitioners and their professional development constantly (Friedman and Phillips 2001).
It seems to use a long time to establish and modify the development of CAM and its regulations completely, however, the Foundation for Integrated Health (FIH) has been working with government and the complementary and natural healthcare disciplines to establish regulatory frameworks for the professions (the qualification report 2009).
CNHC is the federal regulator recognised by the Department of Health (CHW 2010), where is the place to standardise the training development, the recognition of knowledge and skills for practitioners in CT as well as monitoring the availability of suitable qualifications. 'Further disciplines are likely to come on board during 2009 (the qualification report 2009 p.4)'.
Ruston et al (2003b) suggested training and CPD for practitioners that may use multiple methods of learning such as focus-group discussions, participating conferences, reading, reflecting and case studies. It seems to be more flexible to the different levels of the practitioners. Friedman and Phillips (2001) also emphasised to 'regard the individual as the best judge of learning needs (p.10)', thus, it may help to enhance the statues of their professions in the future.
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