Reprinted from Massage Today,
March 2003 (Vol. 3, Num. 3)
P.O. Box 6070 Huntington Beach, CA 92615 •USA
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The RamblemuseSMKeith Eric Grant, Ph.D. |
Swimming Upstream Towards Effective Practice
The error that I’m concerned about is to see training as the focus and not learning. This is not a trivial distinction. Training can become a solution looking for a problem and such a one-dimensional focus can undermine the creation of coherent learning strategies. Training has a role to play but only as part of a wider learning strategy. For instance, we know, from much serious research, that most of what makes people effective in their work does not come from training or education. For most jobs there is an 80/20 rule – 80% of the learning that is of value is from a whole range of activities that the education and training establishment choose to belittle by labeling them ‘informal’ (for example learning from colleagues, from the work itself, from being coached or mentored, from projects, etc.). — Ian Cunningham 1
Every now and again, I find myself grabbing some morsel of thought and running upstream through the frothing waters of accepted massage opinion like a salmon on its return to its home waters. This time the morsel stems from a question posed to me about “how to improve the profession of massage”. The center current of opinion, down which most previous effort has been run, is that credibility for massage practice is obtainable by coercing the profession together through licensing and mandatory certification. Licensing, however, was never a tool designed by the government to imbue credibility and excellence of practice. It was only intended to protect the public from practices that could cause great physical or economic harm and for which reasonable consumer knowledge and caution were inadequate remedies. There are no medical statistics indicating that massage practices, especially at the levels covered by licensing, fall into this camp. Mandatory certification has similarly fallen short of addressing needs of practice that are sufficiently focused to be evident and useful. Applied nonspecifically, certification exams needlessly eliminate many people who are not proficient at short-term memorization yet could contribute successfully into the more kinesthetic subpractices of massage. Simultaneously, such exams are often too general to benefit subpractices more dependent on the manipulation of remembered details. 4, 5
Instead of the route of government-coerced cohesion, I believe that it is past time to acknowledge and value our diversity of subpractices. It is time to create guidelines that provide specific guidance to schools, students, and employers for what we actually do in different venues or subpractices of massage. I have taken a rough cut at defining a set of such subpractices in Table 1. One observation immediate from Table 1 is that the subpractices do not organize in a single line of increasing knowledge and skills. Nor are the various subpractices all at the same level of knowledge and skills but simply in different directions of applied technique. We can thus meaningfully talk about tiers and experience only within a given subpractice. Across the total scope of practices, there are different needs for details of anatomy and clinical technique, skills of basic touch and human presence, formality of personal appearance, business skills, and interpersonal skills of communication, psychology, and sociology. In many of the areas, communication skills and understanding of the applicable psychology may be as or more important to outcomes than particulars of massage technique. The importance of attitude and support noted for sports injuries will be equally applicable to supporting recovery from illness in hospital settings or enhancing quality of life for the aged. 2, 7
My looking for guidelines on the process of creating guidelines has resulted in Table 2. Key aspects of the process are that it be evidence based, that it involves all key players, and that it allow for its own evolution. We must take on the intensive process of first defining massage
subpractices and then working with all affected parties to define knowledge, skills, and abilities needed to practice effectively in each venue. It is only by hammering out a rough consensus of all participants for each subpractice that we will achieve workable guidelines. It is only when such guidelines have proven to be both useful and widely used that they should be considered to be standards.
| Table 1: Listing and descriptions of suggested subpractices for which to create guidelines. | |
| Subpractice | Description |
| Chair | Basic touch, stress management, & relaxation. Applicable to public settings |
| Clinical/Orthopedic | Range of motion, tendinosis treatment, injury recovery |
| Emotional Reconnection | Working with issues of grief and marginalization |
| Geriatric | Life quality enhancement, sensory stimulation, interpersonal connection |
| Hospital-Based | Pain and anxiety control, nurturing of the sick in a medical setting |
| Infant/Pediatric | Parental bonding, nurturing, sensory/emotional development |
| Postural | Improvement of muscle balance; freeing of fascial adhesions |
| Prenatal/perinatal | Increase of comfort and emotional support |
| Psychoneurological Integration | Aiding sensory integration with ADHD, autism, high sensitivity |
| Relaxation/Wellness | Stress management, nurturing, and interpersonal connection |
| Spa Modalities | Nurturing, pampering, skin health |
| Sports | Facilitation of athletics and movement; normalization of hypertonicity |
| Trauma/Abuse Recovery | Emotional recovery, somatic reassociation, building touch trust |
In seeking to form guidelines that promote our ability to engage effectively in a subpractice of massage, it follows immediately that we need a measure for effectiveness. In this, we owe a debt to the Italian economist Vilfredo Pareto (1848-1923). In 1906, Pareto observed that twenty percent of the Italian people owned eighty percent of their country's accumulated wealth. This 80/20 rule of imbalance has since been found to be applicable to many situations 6, 8.
Based on the 80/20 rule, we may reasonably expect that, day to day, 80% of the tasks will be performable using about 20% of the subpractice experts domain specific knowledge and skills. The implication is that, if a person entering the subpractice comes with this 20% of the subpractice down cold, they will be able to accomplish much without having to stop constantly to consult a mentor or information resource. In all likelihood, they will have much more time and leeway to accumulate incrementally via experience the subsequent 80% of skills and knowledge. By encoding such expectations into guidelines that meet the criteria of Table 2, I believe that we can do much to make our efforts at training and practice more effective.
You've got to be very careful if you don't know where you are going because you might not get there. — Yogi Berra
| Table 2: Attributes of guidelines for effective practice. Adapted from Field and Lohr (1990) 3. | |
| Attribute | Discussion |
| Validity | Compliance with a guideline should clearly improve the effectiveness of early practice by those entering a subpractice of massage. |
| Reliability/Reproducibility | The evidence and process used should lead to essentially the same guidelines if produced by multiple independent groups of experts. |
| Applicability | Guidelines should be specific to the needs of each subpractice. |
| Flexibility | Guidelines should identify expected exceptions to the recommendations. |
| Clarity | Guidelines should use unambiguous language, define terms precisely, and use logical, easy-to-follow modes of presentation. |
| Multidisciplinary process | Guidelines should be developed by a process that includes participation by representatives of key affected groups. |
| Scheduled Review | Guidelines should include planned reviews to review new field experience or changing professional consensus. |
| Documentation | The procedures followed in developing guidelines, the participants involved, the evidence used, the assumptions and rationales accepted, and the analytic methods employed should be meticulously documented and described. |
References
1. Cunningham, Ian: 2000, Developing a Learning Strategy, People Management, December 2000, < http://www.selfmanagedlearning.org/FreePublications/Learning%20Strategy%20Pub.htm>.
2. Dunn, Tedi, and Marian Williams, 2001: Massage Therapy Guidelines for Hospital & Home Care, 4th ed., Information for People, Olympia WA, < http://www.info4people.com/BK%20MTG.html>
3. Field, Marilyn J., and Kathleen N. Lohr, eds., 1990: Clinical Practice Guidelines: Directions for a New Program, Committee to Advise the Public Health Service on Clinical Practice Guidelines, Institute of Medicine, National Academies Press, < http://www.nap.edu/catalog/1626.html>.
4. Grant, Keith Eric, 2002: A Review of Issues in Massage Governance, < http://www.ramblemuse.com/articles/masg_governance_rev.pdf>.
5. Grant, Keith Eric, 2002: The Emperor Has No Clothes — Taking a Critical Look at National Certification, Massage & Bodywork, Oct/Nov 2002, Associated Bodywork & Massage Professionals.
6. Hafner , Arthur W. , 2001: Pareto's Principle: The 80-20 Rule, < http://library.shu.edu/HafnerAW/awh-th-math-pareto.htm>.
7. Roos, Robert, 1996: On the Mend — Make Up Your Mind to Get Well, Physician and Sportsmedicine, July 1996 Health Track Supplement, < http://www.physsportsmed.com/issues/1996/07_96/mend.htm>
8. Vaccaro, Pamela J., 2000: The 80/20 Rule of Time Management, Family Practice Management, September 2000, American Academy of Family Physicians, < http://www.aafp.org/fpm/20000900/76the8.html>.
This is the preprint version of a column published in the printed and online editions of Massage Today, March 2003, <http://www.massagetoday.com/>.
