The value of individuals undertaking multiple, varied roles within health care is recognised both in policy and practice (Alderwick & Dixon, 2019; Kanani, 2014; Johnson, 2019). Whilst the career pathway that is most clearly visible to physiotherapists, nurses and other allied health professionals (AHPs) and predominates in undergraduate education involves a traditional clinical role, a range of diverse career options exist, including commissioning, public health, private and third sector work, managerial, research, and education. These options provide a range of opportunities for personal development and speak to key strategic values of the professional bodies. For example, the Chartered Society of Physiotherapy (CSP) is committed to empowering members, embracing change and advocating for the profession in different settings (CSP, 2020).

In order to increase the sharing and uptake of knowledge between different sectors, and raise awareness of these opportunities, we champion the importance of boundary spanning roles. This piece explores a multi-system approach to supporting boundary spanning roles and portfolio careers, presenting two case examples from physiotherapy. Whilst this piece focusses on the physiotherapy profession, we believe the issues discussed are relevant to nursing, midwifery and other AHPs. We challenge the profession to consider how it prepares and supports its membership for such roles throughout the career pathway.

Boundary spanning roles involve individuals that are embedded within more than one organisation with an intended purpose to bring together knowledge, skills and ideas from different perspectives, to facilitate co-designed, evidence-based decision-making and practice (Bornbaum et al., 2015; Swaithes et al., 2019). Traditionally, this has been achieved through portfolio careers, whereby diverse skills from different settings are acquired from multiple part-time roles over time. In contrast, evolving boundary spanning roles are frequently co-funded by different organisations and create opportunities to better understand current contexts from varied organisational perspectives to facilitate change in real time.

For many years, physiotherapists have undertaken lecturer–practitioner roles (Gosling, 1999; Stevenson et al., 2004), likely representing the first boundary spanning role within the physiotherapy profession. Contemporary boundary spanners are increasingly diverse, including roles in NHS commissioning or higher level management, national organisations such as Public Health England (AHPF, 2015) and Health Education England, University leadership, and research implementation (Hadley-Barrows et al., 2017).

Whilst these emerging roles are not seen to be any more or less valued than pure clinical roles, we believe the profession and professional bodies should champion a range of career options, especially considering the NHS has recently advocated portfolio careers in other disciplines such as general practitioners and practice nurses (Interim, 2019). The CSP's scope of practice recognises the evolving nature of the profession in response ‘to changing opportunities for professional and career development’ and that ‘practice may challenge the boundaries of the scope of practice of UK physiotherapy’. Individuals who adopt ‘cross-boundary’ roles can support the implementation of best-practice physiotherapy at a systems and organisational level. Benefits may include: enhancing understanding of individual systems and creating more whole systems working; improved understanding of drivers and barriers to change; filtering best evidence and translating it to varied stakeholders in a meaningful way, thus overcoming ‘language’ barriers; creating and strengthening organisational relationships and networks (Swaithes, 2020).

From an advocacy perspective, such roles may improve the ‘physiotherapy voice’ in multiple health arenas (policy, commissioning, service design) and encourage a collaborative approach across diverse teams that minimises silo working. Furthermore, these roles can support the development of a skilled, confident profession who can rapidly access and apply different knowledge and skill sets to different contexts, view problems from multiple perspectives and facilitate change.

Recognising these benefits, we challenge the profession to consider how to best support and facilitate boundary spanning roles and portfolio careers as ‘mainstream’ physiotherapy career options. Considering this more broadly, we question whether we as a profession, along with other external agencies, including patients and the public, have an outdated perception of what we think physiotherapists should be? First Contact Physiotherapists are one example of how the physiotherapy profession has challenged perceptions, but how do we push boundaries further to ensure that physiotherapists are increasingly represented in other non-patient facing roles such as senior management within Integrated Care Systems, Executive positions at Universities or senior roles within Public Health?

Case study 1 (Box 1) presents an example of a contemporary boundary spanning role whereby an academic physiotherapist spans both a local University and Clinical Commissioning Group organisation. The role provides a conduit to evidence-informed commissioning and practice-informed research, illustrating how individuals who adopt ‘cross-boundary’ roles can support the implementation of best-practice physiotherapy at a systems and organisational level.

Case study 2 (Box 2) illustrates similar multi-system benefits of a boundary spanning role which incorporates ‘traditional’ physiotherapy clinical practice with service evaluation, research and implementation. Case study 2 highlights the importance of leadership across organisations and the multiple actors and agencies required to work in collaboration to establish the role.

In preparing the next generation of physiotherapists, should we push the boundaries of undergraduate programmes to include a broader portfolio education? We believe core skills should be retained but providing students with additional opportunities to gain credits in management, public health, implementation or health economics could be considered. Additionally, we need to consider if traditional ‘clinical hour’ placements could be adapted to expose students to alternative providers. This may ensure that next-generation physiotherapists develop transferrable skill sets that are applicable to a range of career options early in their careers, enabling them to pursue their preferred pathway as a graduate rather than further along their career path (White, 2020). Universities and placement providers should champion alternative career options, provide novel physiotherapy placements and enhance readiness for future ‘practice’(Cole, 2018).

Whilst the benefits of innovative boundary spanning schemes are recognised (Hadley-Barrows et al., 2017; Simkins et al., 2020; Stevenson et al., 2017), the challenges associated with infrastructure support, as identified in case study 2, may mean these roles are less ‘visible’ to undergraduates and postgraduates alike. For those who do seek cross boundary working, this is often personally driven, with individuals ‘building’ such roles, yet the resources and energy required to attempt this (especially in early career stages) are often prohibitive. Whilst the relatively recent initiative of NIHR clinical–academic fellowships is an example of a system-facilitated boundary spanning pathway that is advantageous to nurses and AHPs (NIHR, 2018/2019, 2020), this competitive opportunity still integrates relatively traditional cross-boundary working between clinical practice and research domains.

We believe a key area in which the profession must evolve is the creation and support of more split-post opportunities at each pay band, with collaboration between diverse organisations to secure such jointly funded posts, as illustrated by our exemplar cases. This may help overcome current challenges for physiotherapists working across boundaries, including uncertainty surrounding job security and career progression, particularly if forced to accept short, fixed-term contracts; feelings of isolation as a consequence of not being part of a fixed team or peer group (Lowe & Bithell, 2000); the risk that combining dual roles may result in ‘burn out’ from competing demands; or concerns around deskilling in one area whilst pursuing development in another. In considering these issues, along with the evidence from case studies 1 and 2, we propose that a multi-system approach (Figure 1) is required to overcome key challenges and to facilitate the development of boundary spanning roles.

Boundary Spanning—a multi-system approach

Whilst this piece focusses on the physiotherapy profession, several issues, transferable to other healthcare professionals (HCPs) including nursing, midwifery and other AHPs, have been identified. First, for all professional groups, it is imperative that both career diversity and specialism are valued by supporting innovative posts at all career stages. Second, if we want to empower individuals, embrace organisational change, and advocate for professions that create and share knowledge across systems, then we need people who understand and embed themselves within those different systems to influence from within. Finally, by drawing upon lessons learnt from other professions, placements and internships, we can begin to share ideas across professional boundaries, reducing silo working and multi-system change. All professional bodies, universities and ‘boundary spanners’ themselves have a role in advocating for such career pathways and providing infrastructure and tailored support.

In taking this debate forward, we propose that all professional groups should consider the provision of diverse student placement options outside of the traditional clinical arena to provide greater flexibility on the make-up of clinical hours for graduates. Furthermore, we challenge professional bodies to fund fellowship opportunities for the purpose of boundary spanning, and advocate for the commissioning of boundary spanning roles, mentoring, conferences and workshops to encourage strong relationships between academic, clinical and policy making colleagues.

Continue the dialog #physiocareers

ACKNOWLEDGEMENT

Laura Swaithes is funded by a National Institute for Health Research (NIHR) School for Primary Care Launching Fellowship. Jonathan Quicke is part-funded by an NIHR CRN West Midlands Research Scholarship and part funded by the Haywood Foundation. Nicola Walsh is part funded by Bristol, North Somerset and South Gloucestershire CCG. The views expressed are those of the author(s) and not necessarily those of the NHS, NIHR or the Department of Health and Social Care.

CONFLICT OF INTEREST The authors declare no conflicts of interest. Box 1

Case study example 1

Professor of Knowledge Mobilisation & Musculoskeletal Health

Roles:

Research, education, supporting evidence-based commissioning

Route to role:

Clinical physiotherapist & Quins RFC (NHS and Private)—CLINICAL

Lecturer Practitioner (NHS and Kings College London [KCL])—CLINICAL & EDUCATION

Research Associate & PT PhD student (Applied Research Collaborative [as was] & KCL)—RESEARCH

Senior Lecturer and PT PhD student (University of the West of England Bristol (UWE) & KCL)—EDUCATION & RESEARCH

Career Development Fellow (Arthritis Research UK)—RESEARCH

Associate Professor (UWE)—EDUCATION & RESEARCH

Professor (UWE & Bristol North Somerset and South Gloucestershire CCG)—RESEARCH, EDUCATION & CROSS-SECTOR KM

Employers:

University of the West of England, Bristol

Bristol, North Somerset & South Gloucestershire CCG (through Research Capability Funding)

Key boundary spanning role facilitators:

Clinical Effectiveness and Research Team (CCG); Centre for Health & Clinical Research and Department of Allied Health Professions (UWE).

Benefits of boundary spanning:

Provides NHS with expedited access to evidence and assists with interpretation

Provides NHS with easier access to skill sets available within academia

Facilitates more informed research questions that are relevant to health care

Build better networks for grant applications and facilitates early adoption through strong relationships

Challenges:

Academic and NHS organisations frequently work to different timeframes (NHS often rapid response, academia more time rich)

Different languages and terminology that is often organisation specific and can be a barrier to mutual understanding

Significant time needs to be invested to create trust and to be able to see value in role

Box 2

Case study example 2

Academic Clinical Lecturer in Physiotherapy (2.5 days a week) & Haywood Foundation Activity Coordinator embedded in the NHS (2.5 days a week).

Roles:

Research, research implementation, clinical practice and service evaluation

Route to role:

BSc Physiotherapy (University of Nottingham)—STUDENT

Junior rotational and senior musculoskeletal posts (NHS)—CLINICAL

Pain specialist physiotherapist and part time MSc Physiotherapy student (private sector/ University of Nottingham)—CLINICAL & STUDENT

PhD student (Keele University)—RESEARCH

Academic Clinical Lecturer in Physiotherapy (Keele university/ NIHR/ NHS)—RESEARCH, EDUCATION, CLINICAL, CROSS-SECTOR KM

Research Scholar and Haywood Foundation Activity Coordinator (Clinical Research Network West Midlands/ Keele university/ NHS/ 3rd Sector)—RESEARCH, EDUCATION, CLINICAL, CROSS-SECTOR KM

Employers:

Key boundary spanning role facilitators:

Keele University School of Medicine leadership team; NHS line manager & Research and Innovation lead (MPFT); Haywood Foundation committee.

Benefits of boundary spanning:

Each different role influences and informs the other offering knowledge, skills and network benefits to employers and musculoskeletal stakeholder partners.

Varied and challenging career working with a wide range of musculoskeletal stakeholders from people with musculoskeletal conditions through to policy makers and academics.

Challenges:

No fixed career path, temporary contracts and competitive grant funding, personal career uncertainty and challenges creating, delivering and sustaining each role over time.