Physiotherapists Working with Physiotherapist Support Personnel

Physiotherapists Working with Physiotherapist Support Personnel

Guide to the Standards for Professional Practice

2010 College of Physiotherapists of Ontario

2010

Contents
Physiotherapists Working with Physiotherapist Support Personnel

Introduction ......................................................................................................................... 2 Frequently Asked Questions ......................................................................................... 2 General

Who is a physiotherapist support person? .............................................................................. 2 The difference between a physiotherapist support person and others ............................. 2 Who is not a physiotherapist support person?....................................................................... 2 When is a physiotherapists support person accountable? .................................................. 3

Competence & Assignment

Ensuring that a physiotherapist support person is competent ........................................... 3 Can a physiotherapist assign ongoing re-assessments? ..................................................... 4 Can a physiotherapist support person complete outcome measures? .............................. 4 Can a physiotherapist support person carry out a care map or plan? ............................... 4 What should be considered when assigning care? ............................................................... 5

Communication
Requirements to obtain consent when involving a physiotherapist support worker ..... 5 Must physiotherapists co-sign notes by physiotherapist support persons? ..................... 5

Supervision
Considerations when determining an adequate level of supervision ................................ 6 Considerations regarding planned or unplanned absences ................................................ 6

Practice Scenarios
Scenario 1 ..................................................................................................................................... 7 Scenario 2 ..................................................................................................................................... 7 Scenario 3 .................................................................................................................................... 8

Appendix A ........................................................................................................................10 Appendix B .........................................................................................................................11 References .........................................................................................................................12

2010 College of Physiotherapists of Ontario www.collegept.org NOTE: ThIs Guide to Physiotherapists Working with Physiotherapist Support Personnel is intended to assist registrants in understanding the expectations of the College as dened in the Standard for Professional Practice: Physiotherapists Working with Physiotherapist Support Personnel, and in conjunction with other standards of practice for the profession, including those dened in the Standards for Practice for Physiotherapists.

Page 1

Introduction
Physiotherapists frequently utilize physiotherapist support personnel in different environments to assist in the delivery of physiotherapy care to their patients. When using physiotherapist support personnel, registrants are responsible to assess each patient to determine a plan of care before assigning aspects of that care to a physiotherapist support person. Once assigned, the physiotherapist supervises the care and continues to have responsibility for the patient. Other responsibilities include ensuring the competence of the physiotherapist support person, providing adequate supervision, and performing ongoing assessments. The Colleges expectations of registrants when assigning and supervising care provided by physiotherapist support personnel are described in the Standard for Professional Practice Physiotherapists Working with Physiotherapist Support Personnel. This Guide is a supporting document to aid registrants in applying the principles within the Standard. It does not replace the need to review the Standard. The Guide contains two main sections: Frequently Asked Questions (FAQ) and Practice Scenarios. The FAQs are divided into topics: General, Competence & Assignment, Communication, and Supervision. There are two Appendices that outline the factors to consider when assigning and supervising care as well as options for care when absent from the workplace.

Physiotherapists Working with Physiotherapist Support Personnel

Frequently Asked Questions

1. Who is a physiotherapist support person? The term physiotherapist support person refers to anyone who provides care under the direction and supervision of a physiotherapist. The physiotherapist is accountable for the treatment planning and instructions provided to the physiotherapist support person about care. 2. What is the difference between a physiotherapist assistant, rehabilitation assistant, physiotherapy aide, or other terms that may apply to a physiotherapist support person? In Ontario, physiotherapist support personnel are not regulated and do not have a protected title. Each job setting therefore utilizes a variety of job titles such as PTA, rehabilitation assistant, physiotherapy aide etc. to describe the role of various employees. Remember, it is not the job title that determines whether someone is a physiotherapist support person or how the physiotherapist will decide to assign and supervise the care provided by a physiotherapist support person, but rather the competency of the individual. 3. Who is not a physiotherapist support person? An individual is not acting as a physiotherapist support person when the care that he or she

Page 2

provides has neither been assigned by nor supervised by a physiotherapist (i.e. the physiotherapist is not accountable). A few examples of circumstances where individuals would not be considered physiotherapist support persons include: Individuals who are providing care that may be recommended by but not assigned by a physiotherapist. In other words the physiotherapist is acting as a consultant. In this case, the support person is being asked by someone else (such as a family member or case manager) to act on the recommendations of the physiotherapist. The support person is providing care that was assigned by another health professional. For example, the support person is employed by an organization and acting in a dual role providing assistance to a variety of health care providers. In other words, the support person also provides patient care that is not a component of a physiotherapy treatment plan and has not been assigned by a physiotherapist.

Physiotherapists Working with Physiotherapist Support Personnel

In both examples, the use of the term physiotherapist support person would be inaccurate as a physiotherapist is not assigning treatment to or providing supervision for ongoing care. 4. When is a physiotherapist support person accountable? While the physiotherapist retains overall accountability for physiotherapy care (i.e. the assessment, treatment planning and outcomes of care), the physiotherapist and physiotherapist support person are each accountable for their own actions. Together, they are accountable to act in the best interests of the patients. It is important for the physiotherapist and physiotherapist support person to understand each others roles and responsibilities. Clear communication of this will help to ensure a mutual understanding of accountabilities in addition to ensuring the best interests of the patients and minimizing the risk of harm.

Competence and Assigment

5. What methods can a physiotherapist use to ensure that a physiotherapist support person is competent to carry out treatment? While the Standard indicates that physiotherapists must ensure the competency of the physiotherapist support persons to whom they assign care, the College does not prescribe a specic method for physiotherapists to determine competency. At the most basic level, physiotherapist support persons would need to have the necessary knowledge to perform the treatment and be able to demonstrate their competence to the supervising physiotherapist. When determining a physiotherapist support persons competence, the physiotherapist could ask knowledge based questions, discuss hypothetical scenarios, review precautions, contraindications or emergency procedures to manage potential risks, and ask the physiotherapist support person to

Page 3

demonstrate a particular technique. It is not enough for the physiotherapist to rely on the knowledge that the physiotherapist support person may be a graduate of a physiotherapist assistant program. Depending on the risk involved in the assigned task the physiotherapist may require repetitive demonstration of the task under supervision before allowing the physiotherapist support person to perform the task independently. 6. Can a physiotherapist assign ongoing reassessment to the physiotherapist support person? No, a physiotherapist is responsible for performing reassessments periodically. The frequency of the reassessments depends on a variety of factors including the acuity of a patients conditions and the rate of recovery. The Standard for Professional Practice Record Keeping indicates that at a minimum the physiotherapist must document a reassessment every 3 months. The physiotherapist may use observations made by the support person or use data that the support person has collected as part of his/her reassessment but this does not replace the physiotherapists professional obligation to perform ongoing reassessments. 7. Can physiotherapist support personnel complete outcome measures? Yes, it is possible for a physiotherapist support person who has the appropriate knowledge, skills and abilities to complete outcome measures. While the Standard states a physiotherapist must not assign treatment that has an evaluative component that immediately inuences the treatment program, this does not prohibit physiotherapists from assigning data collection tasks to the physiotherapist support person. 8. Can a physiotherapist support person carry out a care map or plan? Yes, in some situations it may be appropriate for the physiotherapist support person to carry out a change in treatment that has been explicitly described in a care map. In the case of a care plan or care map, the decision making or evaluative component regarding the treatment plan has already been determined and documented by the physiotherapist. The physiotherapist support person is not being asked to make an interpretation or create a new course of action but rather to follow a pre-determined plan of care. For example, a care map indicates that patients who achieve grade four strength of their quadriceps should advance to the next dened exercise documented in the care map. In this case, it may be permissible for the physiotherapist support person to implement the next phase of the care plan. After obtaining consent, the physiotherapist would need to make certain that the physiotherapist support person was competent to measure muscle strength and safely carry out the dened exercises outlined in the care plan. The physiotherapist would also need to ensure that the physiotherapist support person knows when to alert the physiotherapist to unusual circumstances or to stop the intervention.

Page 4

Physiotherapists Working with Physiotherapist Support Personnel

9.

What should be considered when assigning care? A number of factors should be considered when assigning patient care to a physiotherapist support person. These factors are described in Appendix A. There are ve categories of factors to reect on including: patient factors (e.g. acuity of the condition), physiotherapist support personnel factors (e.g. knowledge and skills), environmental factors (e.g. workload demands), physiotherapy treatment factors (e.g. the risk associated with the treatment), and the physiotherapist factors (e.g. sphere of competence). In addition to these factors, a risk management approach should be taken when deciding on the appropriate course of action. A physiotherapist should consider the evidence with respect to likelihood and severity of risk balanced with benets of potential outcomes. In practice, consideration of these factors and determining risk may occur very quickly; in complex situations the need for a decision may involve more thought and planning.

Physiotherapists Working with Physiotherapist Support Personnel

Communication
10. Is a physiotherapist required to obtain consent from a patient or a substitute decision maker when involving a physiotherapist support person in the delivery of care? Yes, physiotherapists must obtain consent from their patients or the patients substitute decision maker to include the physiotherapist support person in the provision of care. This requirement is outlined in the Standard. The patient needs to understand the roles and responsibilities of each team member as part of the consent process. Patients should have the right to make informed choices about who provides their health care. Physiotherapist support personnel cannot be assigned the activity of obtaining consent but may want to incorporate the step of reconrming a patients consent before beginning the treatment. The physiotherapist should document that consent was obtained. 11. Is a physiotherapist required to co-sign health record entries completed by a physiotherapist support person? No. The physiotherapist support persons entries in the patients health record do not require a co-signature; however, physiotherapists need to monitor entries made in the patients record to ensure that record keeping standards are being met. The Standard for Professional Practice Record Keeping and the Guide to the Standard for Professional Practice Record Keeping provide additional information about record keeping expectations.

Page 5

Supervision
12. What should be considered when determining an adequate level of supervision? Question #9 looked at factors for assigning care. These same factors can be applied to supervision. Refer to Appendix A to review the list of possible factors. Some examples include: risks to the patient, availability of the team members, degree of isolation of the physiotherapist support person, caseload, complexity of the treatment to be provided, and the expectations of the employer. Consideration of these factors will impact the type and level of supervision needed to ensure safe, quality care. If the physiotherapist considers these factors and determines that adequate supervision cannot be provided, then care should not be assigned to the physiotherapist support person. Physiotherapists should consider how they would justify their model of supervision to their peers, patients, and others. 13. What considerations must a physiotherapist make regarding planned or unplanned absences (i.e. vacations, illnesses, education)? It is important that physiotherapists have a plan in place to manage absences from the work place whether planned or unplanned. Considerations include: how patients will be contacted and informed of the absence, as well as how to ensure continuity of care or minimize disruption to treatment. The length of the absence is also an important consideration as it relates to ensuring the continuity of care. For example, an unexpected absence of one day would likely be managed quite differently than an expected absence of a week or two. In either situation, the physiotherapist must consider the best interests of each patient under his or her care when determining the plan for care of patients during an absence. A plan that is adequate for one patient may not be adequate for all patients under a physiotherapists care. For each patient, the physiotherapist has three basic options: 1) It may be appropriate for some patients to continue to receive treatment from a physiotherapist support person; 2) It may be necessary to transfer the care of some patients to another physiotherapist; or 3) It may be necessary to discontinue or hold treatment until the physiotherapist returns. These options are further described in Appendix B. If care is assumed by another health care provider, who is not a physiotherapist, the physiotherapist support persons role will change because physiotherapy treatment can no longer be provided. In any situation, it helps to have a plan in place to manage these situations to ensure the needs of the patients are being met.

Page 6

Physiotherapists Working with Physiotherapist Support Personnel

Practice Scenarios
1. Over the last two months Ali, the physiotherapist and Salima, the physiotherapist support person, have been treating Joy as she recovers from a back injury. Last month, Salima completed a Pilates instructor program. Currently, Ali does not have any formal training in Pilates. Joy and Salima developed a great rapport during treatment sessions and Joy would like Salima to provide an individual Pilates program. Ali agrees that Pilates could help Joys recovery. Consider the following questions: Can Ali assign a Pilates exercise program to Salima as part of the physiotherapy treatment plan?

Physiotherapists Working with Physiotherapist Support Personnel

In this scenario Ali does not have training in Pilates. The Standard indicates that the physiotherapist must be competent to perform the care that is to be assigned to the physiotherapist support person and supervised by the physiotherapist. In this case, it would be inappropriate to assign Pilates to Salima as part of the physiotherapy treatment plan. If Salima provides Pilates training to Joy would she be considered a physiotherapist support person?

Salima would not be considered a physiotherapist support person when providing Pilates instruction to Joy because this activity would neither be assigned or supervised by Ali. He could refer Joy to Salima to provide independent Pilates training, as a separate service. What if Ali and Salima were both trained in Pilates?

If Ali and Salima were both competent to provide Pilates training it is possible that Ali could assign the Pilates exercises as part of the physiotherapy treatment program. Ali would need to rst determine that Pilates was an appropriate and necessary physiotherapy treatment based on the assessment. Furthermore, Salima would need to receive specic directions and supervision related to the assigned care. Finally, Ali would need to provide ongoing reassessments to determine the need for changes in treatment, including Salimas role. 2. Ray is a physiotherapist support person working full time in a long term care facility. Kasia, the physiotherapist, assigns and supervises the treatment Ray provides. A few days ago, Kasia was invited to an extended weekend getaway. Due to the limited notice Kasia was unable to nd another physiotherapist to replace her. What are Kasias options related to her patients care?

Physiotherapists in any treatment setting should have a plan in place to manage planned or unplanned absences. In this scenario, Kasias absence is planned but with minimal notice. Appendix B provides three options for care when a physiotherapist will be absent from the work-

Page 7

place. Only two of these options will apply to Kasia because she has already determined that there is not another physiotherapist available. Kasia will want to ensure that patients are informed and that safe, appropriate care can be provided. To do this, she will need to determine which patients can continue to be seen by Ray in her absence and which patients should wait until her return. Kasia will use the factors in Appendix A and consider each patients best interests. It is important to note that Kasias determination as to which patients can continue with Ray in her absence should be made on a case by case basis for each individual patient. Kasia and Ray will also need to ensure clear communication about each of their roles and responsibilities. In addition to considering the factors in Appendix A, Kasia will want to adopt a risk management approach to determining the level of supervision of each patient and consider the potential risks and the evidence as to likelihood and severity of any potential negative outcomes. 3. A physiotherapist support person, Janet and the casual physiotherapist, Kayla, each provide patient care on weekends at the local hospital. Janet carries out treatment that has been assigned to her for the patients already assessed and under the care of the full time physiotherapist, Padma. Kayla only works on weekends to assess patients newly referred to physiotherapy services and to treat patients that Padma has transferred to her. Consider the following questions: Who is accountable for the care provided by Janet on the weekend Kayla, the casual physiotherapist or Padma, the weekday physiotherapist? Why is a communication plan so important in this scenario?

Physiotherapists Working with Physiotherapist Support Personnel

The physiotherapist that assesses a patient and assigns treatment to a physiotherapist support person is the person accountable to ensure that the care is delivered safely and effectively. In preparation for assigning weekend coverage, Padma needs to reect on the factors listed in Appendix A and the options in Appendix B to determine A) which patients to assign to Janet, B) which patients should be transferred to Kayla, and C) which patients should wait until Monday. Part of the plan to ensure Janets ability to provide safe and effective care may include using Kayla as a point of contact but Padma remains accountable for the care she assigns and the instructions provided to Janet. If Padma transfers patients to Kaylas care and following an assessment Kayla decides to assign some of the care to Janet, then Kayla would be accountable for the care provided to her patient by Janet. Communication is crucial. Any patients that were seen during the week and will be treated over the weekend need to be aware that Padma will not be present and that Kayla will become their physiotherapist or Janet will be providing care on Padmas behalf. If Padma decides that Janet will continue treatment for certain patients, she needs to make certain that Janet clearly understands

Page 8

her responsibilities and the patients know what to do if they have any concerns. Additionally, Kayla needs to agree to and understand her role as a contact person. Having a plan in place to manage unexpected emergencies is also necessary to ensure the patients interests are protected.

Page 9

Physiotherapists Working with Physiotherapist Support Personnel

Appendix A
Factors to Consider when Assigning and Supervising Care to Physiotherapist Support Personnel: Patient Factors: patients needs, best interests, consent, acuity, stability, and complexity of condition(s) including physical, mental and social aspects, predictability of change of condition(s), patients ability to direct care and communicate needs Physiotherapist Support Personnel Factors: knowledge, skill, and experience with task, experience with patient population and environment; working relationship with the physiotherapist and other team members, maturity, judgment, dependability, and level of trust Environmental Factors: availability of resources, degree of independence or isolation, size of caseload or workload demands Physiotherapy Treatment Factors: technical skill required, advanced training and complexity of tasks, potential risk of harm related to intervention Physiotherapist Factors: ability to provide supervision, scope of practice, sphere of competence

Page 10

Physiotherapists Working with Physiotherapist Support Personnel

Appendix B
Options for Care When the Physiotherapist is Absent from the Workplace There are three options for care during an absence. Before making a decision physiotherapists should evaluate each patient individually. Primary importance should be given to ensuring the needs of each patient can be met while minimizing any potential risks. Additionally physiotherapists will need to factor in the length of the absence when making care decisions that are in the best interests of their patients. It is likely that all three of the following options could be used during a short-term absence but only options 2 and 3 would apply to longer term absences. The options are as follows: 1. After considering all factors, the physiotherapist could decide that it is safe and appropriate for the physiotherapist support person to continue to provide patient care to certain patients. In this case, the physiotherapist retains accountability for the patients care. After considering all factors, the physiotherapist could decide that the patients care requires the expertise of a physiotherapist (or other care provider) and cannot be safely provided by a physiotherapist support person. In this case, the patients care should be transferred to another physiotherapist (or alternate care provider). The accepting physiotherapist takes accountability for the patient, reassesses the condition and determines the appropriate treatment (this could include assignment of care to a physiotherapist support person). After considering all factors, the physiotherapist could decide it would be in the patients best interest to discontinue treatment until the physiotherapist returns.

Physiotherapists Working with Physiotherapist Support Personnel

2.

3.

Page 11

References
Essential Competency Prole for Physiotherapists in Canada. Accreditation Council for Canadian Physiotherapy Academic Programs, Canadian Alliance of Physiotherapy Regulators, Canadian Physiotherapy Association, Canadian Universities Physical Therapy Academic Council. 2009 Standard for Professional Practice: Physiotherapists Working with Physiotherapist Support Personnel. College of Physiotherapists of Ontario. 2010 Standard for Professional Practice: Record Keeping. College of Physiotherapists of Ontario. 2007

Page 12

Physiotherapists Working with Physiotherapist Support Personnel