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Conclusion
- Susan Nancarrow, Southern Cross University, Australia, Alan Borthwick, University of Southampton
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- The Allied Health Professions
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- 10 March 2021, pp 191-202
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Summary
In this book, we have illustrated that the allied health professions are innovative, responsive, nimble and able to adapt to a wide variety of changing population needs and organisational contexts. On the one hand, as illustrated by the example of the podiatric surgeons in Chapter 6, allied health professions have successfully used managerialism to contest one of the most highly protected domains of medicine – orthopaedic surgery. On the other, as the example of the OTA role suggests, managerialism is eroding the core philosophies of the allied health professions and replacing them with an emphasis on technically focused tasks and competencies. Further, where the dominant, neo-Weberian theories of the professions focus on the protection of a monopoly of knowledge, the allied health professions are actively and consensually involved in the disaggregation and codification of their work so that it can be transferred to other allied health professions and the support workforce.
Allied health professionals have also demonstrated that they can adapt to a range of different organisational and clinical contexts, adjusting their roles and responses accordingly. However, unlike their medical and nursing counterparts, which have large institutionalised hierarchies to support their roles, allied health professions are often moving outside their narrow clinical boundaries and across organisational and institutional settings without a clear structure to fortify them. Perhaps this reflects the shift from a pure profession towards a hybrid profession (Noordegraaf, 2007), which has flexible boundaries, adapts to a range of organisational contexts and responds to the needs of the clients with which they work. The implications of this shift for the allied health professions themselves are still unclear.
The value and meaning of the allied health collective
Despite the prolific use of the term ‘allied health’, our analysis brings us no closer to a unifying definition of the confederation of allied health professions. It is clear that allied health professionals are distinct from medicine and nursing; however, those professional boundaries are beginning to blur as allied health professions take on traditional medical roles, such as prescribing and point-of-care testing (Buss et al, 2019).
The Allied Health Professions
- Susan Nancarrow, Alan Borthwick
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Drawing on case studies from optometrists, physiotherapists, pedorthists and allied health assistants, this book offers an innovative comparison of allied health occupations in Australia and Britain. Adopting a theory of the sociology of health professions, it explores how the allied health professions can achieve their professional goals.
Index
- Susan Nancarrow, Southern Cross University, Australia, Alan Borthwick, University of Southampton
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- The Allied Health Professions
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- 10 March 2021, pp 231-241
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5 - The support workforce within the allied health division of labour
- Susan Nancarrow, Southern Cross University, Australia, Alan Borthwick, University of Southampton
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- The Allied Health Professions
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- 10 March 2021, pp 131-150
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Summary
This chapter examines the support workforce associated with the allied health professions. We have used the term ‘support workers’ to describe this group because they do not occupy a fully professional space, and they have emerged from the division of allied health labour (Saks and Allsop, 2007; Saks, 2020). We acknowledge that numerous other titles are used to describe workers in this domain of work (Buchan and Dal Poz, 2002; Saks and Allsop, 2007; Bach et al, 2008; Lizarondo et al, 2010). Support workers tend to be vocationally trained and, in many cases, their roles are designed and adapted to meet local requirements.
We distinguish the support workforce from the emerging and existing allied health professions on the basis that support worker roles are derived from the division of labour of existing allied health roles, whereas emerging professions (described in Chapter 4) have generally developed a niche professional repertoire and practise autonomously. Support workers are differentiated from ‘professions’ because they do not have ownership over a unique body of knowledge or theoretical framework that defines their role. Contemporary taxonomies of allied health professions tend to reinforce the notion of the professional project (Larson, 1977) by specifying minimum standards, such as required levels of training, continuing professional development, codes of conduct and quality monitoring standards (Health Care Professions Council, no date; Allied Health Aotearoa New Zealand, no date; Allied Health Professions Australia, no date). As we discuss in this chapter, there are few opportunities for support workers to become allied health professionals unless they meet these requirements.
The delegation of lower-status tasks to an auxiliary workforce is a well-established technique of professions to achieve internal closure (Hugman, 1991). However, the niche areas of practice and lack of recognised areas of specialisation have important implications for the roles of support workers and the advancement of the allied health professions. First, the clinical tasks that can be delegated by allied health professionals fall within a narrow scope of practice that is derived from the niche offering of the specific allied health profession. Second, allied health professions lack the internal professional career hierarchies that enable them to advance professionally as they cast off unwanted tasks to auxiliary staff within their own division of labour, losing some of the advantages of delegation that are apparent within the large professional hierarchies of medicine and nursing.
References
- Susan Nancarrow, Southern Cross University, Australia, Alan Borthwick, University of Southampton
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Contents
- Susan Nancarrow, Southern Cross University, Australia, Alan Borthwick, University of Southampton
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Acknowledgements
- Susan Nancarrow, Southern Cross University, Australia, Alan Borthwick, University of Southampton
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1 - The allied health collective
- Susan Nancarrow, Southern Cross University, Australia, Alan Borthwick, University of Southampton
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- The Allied Health Professions
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Summary
This chapter examines the concept of allied health as a collective comprised of constituent professional groupings. Here, we describe the development of the allied health professions over the past century from the perspective of both the development of individual professions and the emergence of allied health under medical hegemony. Concepts that will be explored include considerations around a heterogeneous group of occupations attempting to work together to achieve a single professional project. We also examine the international health and social care organisational and policy contexts and the importance of the various regulatory frameworks.
What are the ‘allied health professions’?
The allied health professions are distinct from the medical and nursing professions in numerous ways. Collectively, allied health professions comprise approximately one third of the total health workforce. Due to large jurisdictional variations in inclusion in the allied health collective, as well as challenges in capturing allied health workforce data, the exact numbers and scale of the allied health professions vary widely and are difficult to determine accurately (Olson, 2012; Nancarrow et al, 2017).
Unlike medicine and nursing, which have strong brand recognition, large individual professional size, internal hierarchies, recognised specialisms and, importantly, a strong political voice, the allied health professions are a confederation of independent disciplines, each of varying size and focusing on a niche area of practice. Allied health professions face the dual challenge of negotiating their discrete professional territory within the boundaries of the allied health collective, while attempting to achieve recognition and a voice alongside their larger medical and nursing counterparts.
The established allied health professions share with nursing a period of growth in the 20th century that was subject to medical dominance, largely characterised by one of three modes of domination: subordination, limitation and exclusion (Turner, 1985). For Turner, these related directly to the extent to which the ‘paramedical’ professions were subject to medical authority in the form of direct instructions in practice (thus depriving the profession of autonomy), by permitting autonomy within a limited jurisdiction (to a discrete body part, such as in dentistry, or a distinct therapeutic technique, such as in pharmacy) or, indeed, by rejection of the scientific legitimacy of its claimed knowledge base (as in chiropractic).
7 - Post-professionalism and allied health
- Susan Nancarrow, Southern Cross University, Australia, Alan Borthwick, University of Southampton
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- The Allied Health Professions
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- 10 March 2021, pp 173-190
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Summary
This chapter examines the way the allied health workforce is being redefined and reshaped in the 21st century to respond to an increasingly complex healthcare delivery context. Specifically, we explore the way that new types of roles and workers have been systematically engineered through a process of disaggregation of health profession work into discrete tasks that are then reconfigured into new roles (Pain et al, 2018). We use the term ‘post-professional’ to describe this workforce (Randall and Kindiak, 2008; King et al, 2019). These new roles are designed to meet the needs of specific populations and may or may not align with traditional profession-based profiles and values.
This chapter explores the emergence of a growing ‘post-professional’ workforce, which comprises qualified health practitioners from a range of clinical backgrounds (typically allied health and nursing) who adopt new skills, either formally or informally, to become part of a new workforce with common skills and a shared title while also maintaining their primary profession. In other words, a range of existing professions actively codify and commodify new and/or existing tasks that are then adopted by other professional groups to form a new professional identity. These workers could be described as ‘interprofessional practitioners’ (Shield et al, 2006), as opposed to an interdisciplinary team, in which multiple practitioners come together to achieve a common goal. In some cases, these new identities are formalised into new roles, such as the diabetes educator, rural generalist or generalist mental health practitioner. In other cases, the roles may be less formal, such as assessment and case management roles.
The post-professional workforce described here is also distinct from transdisciplinary practice (Thylefors et al, 2005). Transdisciplinary practice assumes a high degree of role interdependence and role overlap between practitioners, and may rely on the transfer of codified tasks between practitioners; however, the practitioner retains their primary professional identity. This differs from the post-professional workforce, in which the worker develops a new, recognised identity based on the transferred tasks, which may be reinforced through training and the adoption of a new, common title.
4 - Emerging allied health professions
- Susan Nancarrow, Southern Cross University, Australia, Alan Borthwick, University of Southampton
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- The Allied Health Professions
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Summary
The health professions are in a constant state of growth and evolution, with new professions continuing to emerge, many in response to new techniques and technologies, and being included under the umbrella of allied health. This chapter explores the emergent allied health occupations, that is, those groups that have recently achieved a level of consistency of title and organisation to then pursue professionalism.
Examples of occupations that have professionalised since the middle of the 20th century include exercise physiologists, rehabilitation counsellors, ODPs, DEs, genetic counsellors, perfusionists and sonographers. In 2020, AHPA introduced affiliate membership for a range of professions, including some emerging ones, for example, lymphoedema therapists, counsellors, diabetes educators, hand therapists, dermal clinicians, hearing aid audiologists, myotherapists, pedorthists, psychotherapists and spiritual counsellors. Not all these professions are recognised allied health professions in all jurisdictions.
A notable exception to the recognition of new allied health professions is the NHS. When the Professions Supplementary to Medicine Act 1960 was introduced, 12 professions were recognised. At the start of 2020, the NHS formally recognised 14 allied health professions: arts therapy, chiropody (now podiatry), dietetics, dramatherapy, medical laboratory sciences, music therapy, occupational therapy, orthoptics, physiotherapy, radiography, prosthetics and orthotics, speech and language therapy, clinical sciences, and paramedics (Larkin, 2002). Since 2005, just after the formation of the HPC, the recognised allied health professions in the UK have remained relatively stable. An important contribution of this chapter is the way that regulatory frameworks and funding structures influence the development of new professions.
There is limited published literature on the history and sociology of emerging professions. Some of the new professions (sonographers, perfusionists and genetic counsellors) have emerged as a direct response to new technologies. For example, perfusionists are responsible for operating the cardiopulmonary bypass machine during cardiac surgery, a technology that was first applied in the 1950s (Arsenault, 2000). Diagnostic sonography developed rapidly during the 1950s, and established the basis for the growth of the imaging profession (Hassall, 2007).
The dominant, largely neo-Weberian theories of professionalisation from the 20th century focused on the ways that occupational groups enhanced their status by staking a claim to a body of knowledge and preventing encroachment by others (Saks, 1983; Witz, 1992; Harrits, 2014).
6 - Specialisation in allied health
- Susan Nancarrow, Southern Cross University, Australia, Alan Borthwick, University of Southampton
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- The Allied Health Professions
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There are several allied health professions that may be regarded as ‘mature’, in the sense that they have become an established part of mainstream health service provision, been recognised by the state and have a voice at policy level (Larkin, 1983; Hugman, 1991; Witz, 1992). Within that broad definition, they are also marked by a structure characterised by internal divisions recognised as specialisms within the discipline, demanding further forms of education, training and credentialing beyond baseline registration requirements (Hugman, 1991). Largely, these specialist fields of practice comprise roles with higher-level skills and knowledge, and thus attract a greater degree of prestige and, commonly, better remuneration (Hugman, 1991; Borthwick, 2000). While many of the long-standing allied health professions possess some types of internally recognised speciality forms of practice, relatively few enjoy state recognition in the guise of separate regulatory provisions or legislation. However, state health policies aimed at workforce flexibility have led to new opportunities for allied health professions to secure formal recognition for roles that were previously exclusive to the medical profession.
A discussion of the pursuit of specialisation for physiotherapists in Australia sheds light on some of the challenges faced by allied health professions as they seek to develop their own recognised specialisms (Bennett and Grant, 2004). In particular, the specialist areas need to be: recognised by peers and external agencies; associated with a career structure for clinicians; and associated with a commensurate remuneration and reward structure. Interestingly, the Physiotherapy Board of New Zealand (2020) endorses and regulates a range of specialisations within the physiotherapy profession, such as pelvic health, neurology, older adults, paediatrics and hand therapy. Other areas of practice may be endorsed at the discretion of the board. It is unclear whether, or how, they have addressed the issues raised by Bennet and Grant, and how these endorsed specialities differ in practice from special interests supported by other professional groups and bodies, with the exception of the endorsed, regulated title.
A growing area of expanded practice for allied health practitioners is the acquisition of legal rights to independently prescribe medicines; another is the legitimated practice of invasive surgery by non-medically qualified allied health professions.
List of abbreviations
- Susan Nancarrow, Southern Cross University, Australia, Alan Borthwick, University of Southampton
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- The Allied Health Professions
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Introduction
- Susan Nancarrow, Southern Cross University, Australia, Alan Borthwick, University of Southampton
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- The Allied Health Professions
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Summary
This book helps to prepare allied health professions for a new and different future by telling the story of their past – specifically, the sociological, economic, political and philosophical pressures that have shaped the professions. For most of the past half-century, the allied health professions have focused on creating legitimacy through the pursuit of research evidence and the standardisation of practice. Yet, there has been very little analysis or understanding of who the allied health professions are – either individually or collectively – how and why they have developed, and their role and relationship to the health system and other professions. This book helps to address this gap in order to give the allied health professions the tools they need to navigate the sociopolitical landscape of the future.
Many allied health professions have ancient origins; however, the concept of the collective of ‘allied health’ as a group of professions is only decades old. Allied health professions can make an important contribution to society; however, in many cases, that contribution is not fully realised because allied health is poorly understood and largely underutilised. Many allied health professions have only recently professionalised, and new professions continue to emerge. At the same time, changing population demographics, new technologies and a shift in emphasis towards the management and prevention of chronic illness create a constantly changing landscape for the health workforce. This means that allied health professions are having to develop and shape their identity in a dynamic landscape.
This book compares the allied health professions, both as a collective and as individual disciplines, in Australia and the UK. Australia and the UK were chosen as a basis for comparison because the allied health professions have emerged in each jurisdiction from similar philosophies, regulatory structures and training approaches, which allows meaningful comparison. The different funding and system contexts provide a comparative basis to understand the impact of different features on allied health professionalisation.
We start from the position of the similarities between the allied health contexts in both countries. Politically, neo-liberalism has been influential in driving the healthcare funding models and accountabilities in both nations, though different healthcare funding systems have facilitated varied flexibilities within the allied health workforces in each context.
2 - Diversity in the allied health professions
- Susan Nancarrow, Southern Cross University, Australia, Alan Borthwick, University of Southampton
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- The Allied Health Professions
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Summary
The allied health professions, and indeed all contemporary Western professions, have been shaped by a set of distinct social forces and contexts that were a product of their formative era. The Industrial Revolution saw the rapid organisation of labour at a time when social class, British colonialism and paternalism were dominant themes in much of the Western world. For the professions, the consequences have included a highly organised, hierarchical and strongly genderdifferentiated workforce. Social policies have evolved over the past half-century to try to explicitly reduce gender and racial inequalities in education, the workplace and health service delivery, with varying levels of success in allied health.
This context is important for understanding both the evolution of the professions through a sociological lens, and also their contemporary context. In many ways, the world has moved on but the professions (particularly the highly structured and gendered health professions) are relics of their post-industrial era formation. At the start of the 21st century, the stereotypical allied health profession is still predominantly female, middle-class and white. The narrow analysis of any areas of diversity from an allied health perspective means that this is a limited field; however, there are dominant paradigms in the literature on the sociology of the professions that are important for diversity. Gender is the obvious position; however, ethnicity and socio-economic status are also important considerations.
Intersectionality recognises that social differences and divisions do not operate separately, but rather intersect. Examining diversity from an intersectional perspective enables us to consider that several classification systems coexist and interact – such as gender, ethnicity/race, sexuality, socio-economic status and even professional status – without reducing them to singular positions (Styhre and Eriksson-Zetterquist, 2008).
We found no analysis of the diversity of the allied health professions collectively, and only sparse discussion of the diversity within the individual professions. Yet, diversity, in all its forms, is important to understanding the social identity of the professions and how they came to their current position, their underlying assumptions about others and the world, and the way they are perceived by others. As with other chapters in this book, it is our goal not only to paint a picture of the current position of allied health, but also use this knowledge to help understand how the future can be shaped in a way that most effectively reflects the value of the professions to society.
3 - The established allied health professions
- Susan Nancarrow, Southern Cross University, Australia, Alan Borthwick, University of Southampton
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The largest recognised group of allied health professionals is comprised of the established state-and self-regulated professions. These professions have claimed clear philosophies and sometimes anatomical domains and scopes of practice that differentiate them from each other, and other emerging disciplines. This chapter draws on the examples of optometry and radiography, one of which was established prior to the advent of the era of medical dominance, and the other during it. It thus illustrates the way allied health professions responded to the challenge posed by medicine in defining the new health division of labour that took hold in the early 20th century. It also illustrates the different ways in which these professions later identified with other allied health professions: one as part of the broader collective; the other remaining separate from it (Larkin, 1983; Boyce, 2001, 2006). As was explained in Chapter 2, and should be borne in mind when considering the context of the account that follows, they also serve as useful exemplars of the contrasting gender divide within the allied health professions. Radiography became a primarily female profession, and optometry remained a mainly male profession (though, interestingly, the former remains stable but the latter is becoming more feminised) (Register, 2010; Healy et al, 2015).
Those allied health professions with a long pre-modern history – that is, the groups that emerged prior to the period in which medical dominance became firmly established – experienced medical opposition and resistance in their bid for recognition and state registration during the early to mid-20th century (Larkin, 1981, 1983, 2002). Equally, those that emerged during the period of ascendancy in medical authority experienced the same forces at work. Thus, the neo-Weberian framework is key to understanding the development of these professions, and its various strands become immediately clear as the story unfolds, both the strategies of exclusion, limitation and subordination of the medical profession, and the resistance of the allied health exemplars as they attempted to advance their own professional projects (Saks, 2015, 2017, 2018). As medical hegemony became firmly established, a ‘medico-bureaucratic alliance’ emerged, allowing medicine to assume both social and cultural authority in determining healthcare priorities on behalf of the state (Larkin, 1983).
Frontmatter
- Susan Nancarrow, Southern Cross University, Australia, Alan Borthwick, University of Southampton
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- The Allied Health Professions
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Six - The Interface of Health Support Workers with the Allied Health Professions
- Edited by Mike Saks
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- Support Workers and the Health Professions in International Perspective
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- 02 March 2021
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- 23 July 2020, pp 101-124
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Introduction
This chapter describes the way the health support workforce interfaces with allied health professions, first through an international perspective, and then with greater focus on the UK and Australian contexts. Allied health practitioners have been working with support workers since at least the mid-20th century (Salvatori 2001), with evidence of formal training for occupational therapy assistants in the United States as early as the 1950s – while several professions saw a proliferation of assistants during the early 1970s in Canada and the UK (Robinson et al 1994; Webb et al 2004). Since then, despite varying levels of opposition from professional bodies and inconsistent access to training and professional support, support workers are now a key component of many health and social services contributing to the care provided by a wide range of allied health disciplines (Farndon and Nancarrow 2003; Saks and Allsop 2007; Salvatori 2001). As a result, support workers are a growing and increasingly diverse group of practitioners supporting the delivery of various allied health services.
Allied health support workers have been introduced primarily as a way to increase allied health capacity to meet the needs of an expanding and ageing population and to account for a shortfall in professionally qualified practitioners (Salvatori 2001). They have also been seen as an economically effective way to deliver safe and skilled care, while enabling the professional workforce to upskill to provide more specialist services (Foster 2006). The support worker role is therefore seen as a way to free up the time for allied health professionals to carry out more complex tasks by maintaining or increasing the capacity of care previously delivered by professionally qualified practitioners (Pullenayegum et al 2005; Stanmore et al 2005). Consequently, the expansion of support workers has been a focus of recent health workforce reform in the UK and various Australian states with policies targeting growth in numbers, expansion of roles and the introduction of new types of roles (Saks and Allsop 2007; Wanless 2002).
One challenge of understanding the support workforce associated with allied health is the lack of central coordination. Consequently numerous roles, models and worker titles have emerged (Bach et al 2008; Buchan and Dal Poz 2002; Lizarondo et al 2010; Saks and Allsop 2007).
The ‘Designated Research Team’ approach to building research capacity in primary care
- Jo Cooke, Susan Nancarrow, Vicky Hammersley, Lisa Farndon, Wesley Vernon
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- Primary Health Care Research & Development / Volume 7 / Issue 1 / January 2006
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- 31 October 2006, pp. 78-86
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Trent Focus, a Research and Development Support Unit, have introduced the ‘Designated Research Team’ (DRT) approach to building research capacity. This approach funds protected time to develop research ideas and skills for a team with limited research experience. This paper uses the example of a successful team of podiatry researchers to illustrate the approach to, and outcomes of, a DRT. It draws on documentary analysis of meeting notes and annual reports, and team members' views collected during a recorded reflective session of the team at the end of the funding period. The DRT were successful in achieving agreed outcomes, including completing the project, submitting and publishing in peer reviewed journals, and presenting at conferences. They were also able to attract further funding, and engage with international collaborations and research activity. The unique contribution of this paper is that it focuses on facilitating factors to building research capacity based on a practice example. These include: enabling protected time, effective managerial support, applied and timely research training at relevant levels to expertise, immediate access to supervision and mentorship, a critical mass of research expertise within the team, and an encouraging workplace environment. Importantly, research undertaken was seen as a means to improve practice and the status of the professional group. ‘Accessible’ academic support including outreach work and attitudes of the team members and supervisors towards teaching and learning were important. Process factors enabling success include the use of project management techniques, clear delegation of tasks, effective lines of communication and accountability, and high levels of social capital and commitment between team members. The paper highlights ways forward to using these facilitating factors to build further research capacity, and to use this approach to highlight other areas of research capacity outcome measures.