Supervision of Physiotherapist Support Workers Guide

Physiotherapist support workers (PTSWs) are the most diverse group of health-care providers that physiotherapists supervise. Some PTSWs have extensive on the job training but limited or no formal education in the provision of physiotherapy services. Some will have a diploma from an accredited post-secondary physiotherapist assistant education program. In other cases, individuals with a four-year kinesiology degree, or a physiotherapy degree from another country may work as PTSWs.

PTSWs are essential to the delivery of physiotherapy services in many settings. When incorporated into the practice setting appropriately, PTSWs help to build capacity in the health-care system. Sharing workloads between members of the physiotherapy team extends the delivery of safe, effective physiotherapy services to more Albertans in need of physiotherapy services.

This document is primarily intended for use by physiotherapists, and provides:

• Guidance to you and to other interested parties regarding the rules that govern physiotherapy practice and the supervision of PTSWs in the delivery of physiotherapy services.
• Recommendations for how to meet performance expectations and regulatory requirements related to the supervision of PTSWs.

Visit the College’s website for resources related to the supervision of other supervisee groups.

Notes on Language

Physiotherapist Support Worker (PTSW): an unregulated health provider working under the supervision and direction of a physiotherapist. PTSWs have a range of educational backgrounds and experiences. The College employs the title “physiotherapist support worker” to encompass this breadth of backgrounds and experiences. A PTSW may also be referred to as a physiotherapist assistant, rehabilitation assistant, therapy assistant, or rehabilitation aide.

Supervision: According to the Standards of Practice, supervision is defined as “the action or process of watching and directing what someone does or how something is done.” Supervision carries an explicit requirement that you (the supervisor) evaluate the competence and performance of the PTSW (the supervisee) to ensure that safe practice occurs and that your clients receive quality physiotherapy services. Supervision may involve providing direction, instruction, observation, collaboration and idea exchange, and co-ordination of activities.

Mentorship is a relationship that supports both personal and professional growth and often continues for an extended period. Mentors can be external or internal to the work environment, engage in reciprocal learning, share knowledge, and provide feedback to mentees. However, mentors do not typically provide formal evaluation of the mentee.

The terms supervision and mentorship are often used interchangeably; however, they are not the same, and it is important to distinguish between them. Mentorship relationships do not provide the oversight necessary to address the safety and quality considerations required by the College.

Delegation means granting another party the authority and power to perform parts of one’s job. It involves entrusting a task to another person. With delegation the responsibility for the performance of a task is transferred to another party. In these relationships the individual delegating the task does not provide ongoing oversight or supervision of the other party’s performance of the task.

In Alberta, physiotherapists do not delegate physiotherapy services to another party, they assign services which the other party provides under direct or indirect supervision.

The language of assignment and supervision reflects the ongoing responsibilities you, the supervising physiotherapist, have in relation to the activity assigned, its performance, and your supervision of the activity.

Indirect supervision vs independent supervision: PTSWs do not provide physiotherapy services independently. Physiotherapists are always responsible and accountable for providing oversight of the PTSW’s activities and performance.

The minimum requirement is the use of indirect supervision.

You are responsible for determining what an appropriate supervision strategy is, and monitoring the effectiveness of the supervision strategy, the quality of the care provided by the PTSW, and the client’s outcomes.

Principles of Physiotherapist Support Worker Supervision

The following principles underpin the use of PTSWs in the delivery of physiotherapy services. We will elaborate on each principle further in the next section.

1. Client interests come first.
2. Role and responsibility clarity is mandatory.
3. Client consent is required.
4. Supervision is context dependent.
5. “Appropriate supervision” exists on a continuum.
6. Supervision is an active pursuit.

Physiotherapists work with PTSWs and others in a manner that serves the client’s interests.

In every case, you and the PTSW each have a duty of care to the client and are accountable for your acts and omissions. Your inclusion of a physiotherapist support worker in the practice setting must arise from the intent to increase access to quality, safe, effective physiotherapy services for the benefit of clients.

Physiotherapy services are “services provided by or under the direction of a physiotherapist.”

When considering the question “who’s responsible for the services provided?” it is imperative to remember some key facts about physiotherapist support workers:

• Many, but not all, PTSWs have post-secondary training.
• PTSWs are unregulated health providers. They are not subject to standardized education or competence requirements, or the completion of a licensure examination prior to starting to work as a PTSW.
• Though common, accreditation of physiotherapist assistant education programs is not mandatory.

The knowledge, skills and competencies of PTSWs cannot be assumed to be uniform. For this reason, you are always responsible for the physiotherapy services that you assign to PTSWs, the appropriateness of that assignment, and for the provision of appropriate ongoing supervision of both the care provided and the client’s progress. You are responsible for:

• Assessing the client
• Assessing the PTSW’s skills and ability to help provide care to the client
• Assigning appropriate services to the PTSW
• Providing ongoing monitoring of the effectiveness of those services

The PTSW is responsible for:

• Accepting accountability for their assignment
• Identifying when an assignment is beyond their skills and competencies
• Addressing situations where an assignment exceeds their abilities or a client’s status changes necessitating a reassessment

In some contexts, a person who works as a PTSW may also perform tasks assigned by another individual, whether that individual is another physiotherapist, another regulated health professional, or a manager or administrator. However, when a task is part of a physiotherapy treatment plan, the physiotherapist who assessed the client and assigned the services to the PTSW is responsible for that assignment unless another physiotherapist intervenes in the client’s care.

Scenario: Inpatient Weekend Physiotherapy – Who’s Responsible?

It’s the Friday before a three-day weekend. You assess a client who is admitted to hospital. The client fits the criteria to receive weekend physiotherapy services. You know the knowledge and skills of the PTSW who is working this weekend, and the client’s needs can be met by assigning their care to the PTSW for the next three days.

You assign the client to be seen by the PTSW. You provide direction about the treatment to provide, and any circumstances that would require the weekend physiotherapist to reassess the client.

On Saturday, the PTSW treats the client consistent with your instructions. In this instance you are responsible for the services assigned to the PTSW and are providing indirect, remote supervision of those services.

On Sunday, the PTSW discovers that the client’s status has changed. The client now fits the criteria for a reassessment by the weekend physiotherapist. The PTSW notifies the weekend physiotherapist who reassess the client on Sunday afternoon. Once the weekend physiotherapist intervenes in the client’s care, they become responsible for the client’s care. They remain responsible for the client’s care and for any services they assign to the PTSW until the client is transferred back to you on Tuesday when you return to work.

Tasks Assigned to the PTSW by Others

When a support worker is performing tasks that were not assigned by a physiotherapist, the support worker is accountable to the supervisor who assigned those tasks. You, the PTSW, the client, and other health-care team members must know who is responsible to supervise the tasks assigned. If there is no supervising physiotherapist, the services provided are not physiotherapy and must not be referred to, presented as, billed as, or otherwise implied to be physiotherapy.

In many situations, it is easy to identify who the supervisor is. However, in some situations, whether a supervisor-supervisee relationship exists is less obvious. For example:

• If you provide consultation services in a group home environment, school system or other setting and provide recommendations to another party about the needs of an individual or group, without expecting your ongoing involvement in the client’s care.
• If you work with other members of a multidisciplinary team that includes both regulated health professionals and unregulated health providers to deliver team-based care to an identified client population.
• If you work collaboratively with personal trainers or kinesiologists in a community recreation center or exercise facility.

If you are unsure if you have supervisory responsibilities toward an unregulated health provider, ask:

• Are you employed by the same employer?
• Are there oversight and reporting responsibilities in your job description?
• Are there reporting responsibilities in the unregulated health provider’s job description?
• Do you monitor the performance of the unregulated health provider or provide feedback as part of a performance management program?
• Have you been asked to “sign off on” or “certify” the unregulated health provider’s skills?
• How are services provided by the unregulated health provider described to clients or others?
• Are the unregulated provider’s services billed or invoiced as physiotherapy services (e.g., by using the supervising physiotherapist’s registration number)?

If you answered yes to one or more of these questions, you need to clarify who the unregulated health provider reports to and who provides supervision or oversight of their services.

If you are the supervising physiotherapist, you have oversight responsibilities in relation to the PTSW. By definition, you are in a position of power relative to the PTSW and have responsibilities related to both the client and the supervisee.

Your supervision responsibilities necessitate that you maintain appropriate professional boundaries and avoid situations where your professional judgment is affected or could be affected by your relationship with the PTSW. If asked to supervise an individual with whom you have a pre-existing close personal relationship, you should carefully consider whether you are able to fulfill the requirements of supervision fairly, objectively, and impartially. If an alternate supervisor is available, the College recommends that you refrain from supervising those with whom you have a pre-existing close personal relationship.

You must be aware of and sensitive about relationships with supervisees, and the impacts of power, trust, respect, and physical closeness on relationships with supervisees.

The client must be aware of and consent to the involvement of supervisees in the provision of their physiotherapy care.

Clients have the right to choose who their health-care providers will be. The right to bodily autonomy means that clients must be aware of the role and skills of individuals involved in their care and that this information is provided in a clear and transparent manner.

• How is the quality of their care assured through the use of the PTSW and your supervision?
• Who can they speak to if they have a concern or complaint?
• What are the implications of declining physiotherapy services provided by a PTSW (e.g., will their decision effect treatment frequency)?
• What other options are available to the client if they decline services from the PTSW?

If you work with a PTSW or group of PTSWs, you must:

• Communicate this to the client
• Obtain consent for the involvement of the PTSW(s) in the provision of physiotherapy services
• Use mechanisms to ensure that clients know who each team member is, their professional designation and role (e.g., introductions, name tags)

Client, physiotherapist, PTSW, and practice setting factors all contribute to the context of care, risks encountered in the practice setting, and appropriateness of PTSW involvement in client care.

Client factors

• Diagnosis
• Acuity
• Receptiveness to the PTSW’s involvement in their care

Physiotherapist factors

• Background, education, and judgment
• Familiarity with the client population and condition
• Relationship with the PTSW
• Awareness of the PTSW’s competencies

PTSW factors

• Background, education, and judgment
• Insight regarding their own skills and abilities
• Familiarity with the client population and condition
• Degree of confidence with the assigned task
• Requirements of the position description

Setting factors

• Practice setting (e.g., Critical Care, Private Clinic, Extended Care Facility)
• Workload demands
• Supports available in the practice setting including proximity to peers and other practitioners
• Frequency of change/service disruption

There are a range of risks encountered in physiotherapy practice. The nature, severity, and potential consequences of common and rare but foreseeable risks encountered in each practice setting must inform your approach to supervision. The College encourages an intentional approach to identifying and mitigating practice risks to make both risks and mitigation strategies apparent to all parties, and to facilitate a consistent approach to risk management in the supervision and assignment of physiotherapy services across sectors and settings.

The risks you identify must inform the:

• Level and method of supervision
• Need for a formal written supervision plan
• Frequency of monitoring of client response to assigned care and of the PTSW’s performance
• Parameters for progression of the supervision plan

As a rule, the higher the risk, the more direct your supervision, more limited your client care assignment, and the more frequent and extensive your monitoring and reassessment of both the client and the PTSW.

Supervision exists along a continuum from greater to lesser oversight and can be described by the level of access a PTSW has to their supervisor. It is anticipated that supervisees will travel back and forth along this continuum depending on the context described above.

Levels of supervision can be described as:

• Direct supervision: You are present, in the treatment room, observing the actions of the PTSW.
• Indirect, present: You are present on site but on a different unit or in a different treatment room.
• Indirect, accessible: You are available by phone or other methods of communication and can attend the workplace if necessary.
• Indirect, remote: You are not present at the worksite and cannot readily attend the workplace if contacted by the PTSW.

If employing remote supervision you must include clear parameters for when the PTSW must stop the planned treatment and contact you or your designate. If you use this level of supervision, you must develop contingency plans to manage urgent or emergency physiotherapy needs (e.g., establishing emergency communication protocols and coverage).

Many different strategies can be used to deliver appropriate supervision, including direct observation, supervisee discussions, and chart audits. In all cases, the services assigned must be consistent with the level of supervision provided, supervision strategies employed, and the competencies of the supervisee. The quality and safety of physiotherapy services is the first consideration.

The appropriate frequency of use of any supervision strategy will vary depending on the sector in which care is provided, the severity of the client’s condition, and the physiotherapist and supervisee considered (e.g., daily vs weekly or even monthly caseload review).

You should always be able to explain your rationale for how supervision is being provided.

Supervision Strategies

Direct

Direct supervision means that you are present and able to directly observe/assess the PTSW’s competence, provide input into their performance, and intervene if a safety concern arises. Direct supervision means that you are not simply “on-site” but that you are in the treatment room and actively engaged in supervision. Direct supervision ensures you have direct knowledge of the PTSW’s performance.

Indirect or remote

When a PTSW has demonstrated a reasonable level of competence in a particular practice context and with a specific client population, you may opt to provide indirect supervision. There is a range of supervision methods available that constitute indirect supervision. Not all methods are appropriate for all PTSWs or practice settings. Consider client factors, supervisor and supervisee preferences, and practice context to determine which strategies are appropriate.

Supervisee discussions

Ongoing dialogue should be part of all supervision plans. Discussions should occur regularly to review client cases, monitor the PTSW’s actions and decisions and client outcomes, and to inform the need for reassessment. This form of supervision is also important for addressing the PTSW’s questions when faced with unfamiliar situations or unexpected outcomes. Discussions can be held in person or remotely.

Chart reviews

Chart reviews provide you with information about the completeness, quality, and appropriateness of care provided by a PTSW. A chart review can also be used to determine if the PTSW’s documentation is consistent with the Documentation Standard. Finally, chart reviews can be used to monitor client progress and identify when a change to the treatment plan is required.

Client/colleague discussions

Multi-source feedback helps to evaluate professionalism and non-technical competencies. Gathering input from clients or from other members of the multidisciplinary team helps you to assess the PTSW’s communication and collaboration skills. This type of feedback should be used to inform discussions with the PTSW and may also help to identify concerns regarding technical skills that you should monitor or reassess in greater detail.

Virtual supervision

Audio or video conferencing may be used to supervise a PTSW.

You can use virtual care to fulfill your supervision responsibilities if the PTSW is leading the client care session, and you are using technology to enable observation of the services they provide.

Virtual supervision allows the physiotherapist to directly observe the actions of the PTSW, providing a significant level of oversight of the PTSW’s actions. However, due to its nature it does differ from “direct supervision” as it is traditionally understood, specifically due to the inability to physically intervene if a safety concern arises.

The appropriateness of use of virtual supervision depends on the specific context of the situation, including:

• The practice context and supports (technological and professional) that exist within the practice setting.
• The treatment being provided to the client and its related risks.
• The PTSW’s training and individual competence to deliver the treatment.
• Your competence to provide supervision using audio or video conferencing technologies.

Note: Review the Virtual Care Guide for Alberta Physiotherapists for more information about virtual care and professional expectations, to ensure that regulatory requirements are addressed. Remember that if you are using virtual methods of supervision, you, the client, and the PTSW must all consent to the use of audio or video conferencing.

Supervision requires your active involvement.

You are responsible for:

• Providing appropriate supervision.
• Assigning appropriate tasks to supervisees.
• Ensuring the client receives safe, quality, and effective physiotherapy services.

You are accountable for client outcomes.

You have clear, ongoing responsibilities to the PTSW and the client in four key areas:

• Assessment: Evaluate both client needs and the PTSW’s knowledge, skills, and competencies.
• Assignment: Assign appropriate tasks to the PTSW.
• Monitoring: Oversee the PTSW’s performance of assigned activities.
• Reassessment: Review client progress, outcomes achieved, and quality of care provided by the PTSW.

Below, we consider each of these requirements in greater detail.

Assessment

All supervisor-supervisee relationships begin with a period of direct observation to enable you to assess the technical and non-technical competencies, performance, behavior and judgment of the PTSW in the clinical setting.

During the assessment phase, you must be able to directly observe and assess the PTSW’s competence, provide input into their performance, and intervene if a safety concern arises. Generally, this direct observation is achieved when in the same location as the PTSW during the assessment period. However, in some circumstances, virtual observation and assessment of PTSW skills and competencies using telecommunication technology may be possible, depending on the context and supports in place to mitigate risks and ensure accurate assessment.

You are accountable for both the assessment itself and how you completed it. You are also ultimately responsible to determine how to assess a PTSW’s skills and competencies.

This assessment shows you where a PTSW is on the continuum of skills and training and will directly influence the activities that you will assign to the PTSW as well as the level and method of supervision needed to ensure safe and effective services are provided. You may also identify opportunities for skill development or additional training for the supervisee.

Do you need a supervision plan?

At this point, you plan for how you will fulfill your supervision obligations.

Though it’s up to you to determine how formal to make your supervision plan, at minimum take some time to reflect on:

• The supervision methods you will employ when the PTSW completes specific tasks or works with identified client populations.
• The frequency of monitoring the PTSW’s performance of your assignments.
• The anticipated date for review and updating of the supervision plan.
• The mechanisms you will use for ongoing monitoring and re-assessment of the PTSW’s performance and client outcomes related to the assigned activities.
• Any limits you have imposed on the PTSW’s practice, based on their current performance.
• Any specific concerns or issues that the PTSW needs to address and resources available to support the PTSW to address areas of concern.

You may continue to employ direct supervision techniques for certain treatments or client groups, depending on:

• Your assessment of the PTSW’s competence
• Your confidence in the PTSW’s performance of assigned activities and professional judgment
• The nature of the activities assigned and client factors

If you are new to supervision of PTSWs, it is recommended that you write out a formal supervision plan to aid in this process.

Assignment

When assigning tasks to supervisees:

• The sole consideration must be the interests of the client.
• You must only assign and supervise activities which you yourself are competent to perform.
• You are responsible for the assignment of services to PTSWs and must identify the activities to be assigned.

Within the practice setting, it is realistic that a PTSW may have skills and competencies that differ from yours, (e.g., in cases where you are working with an experienced PTSW, or the PTSW’s background includes training that differs from your own).

If a PTSW were to perform a task or activity that you are not competent in, you would not be able to evaluate the appropriateness of the task, nor assure the quality and safety of the services provided. You would not be able to take over the delivery of the physiotherapy service if the PTSW was absent due to vacation or illness. For these reasons, you may only assign those tasks and activities that you yourself, are competent to perform.

You have the sole responsibility to decide what tasks or services to assign to a PTSW.

When making these decisions, you must consider the client’s needs, the PTSW’s skills and competencies, your competencies, and any contextual factors that affect the safety of the assignment. The tasks and activities assigned must be documented in the client record. The method used to monitor the performance of that assignment is part of the supervision plan.

The client’s safety, and the effectiveness of the physiotherapy services provided is of utmost concern when deciding to assign services to a PTSW. If using indirect or remote supervision, client safety can be at risk due to limited access to supervision. In these cases, the assignment and supervision plan should include parameters and protocols to direct the PTSW’s actions including:

• Progression of treatment (e.g., exercise progressions or limits).
• Anticipated milestones that may require that you update the care plan.
• Circumstances where a reassessment is required.
• Emergency situations that require stopping physiotherapy services and how to manage such situations, including referral to you or a designated physiotherapist, and situations where referral to another health professional may be required.

These parameters and protocols are a key part of the assignment and will differ depending on the context of care, and the competencies and judgment of the PTSW. You must have a clear understanding of the skills and judgment of the PTSW before developing supervision plans and these parameters.

However, regardless of the supervisee’s education, experience, and competence, there are some tasks that must never be assigned to PTSWs (from the Supervision Standard of Practice):

• Any part of a restricted activity.
• Interpretation of referrals, diagnosis, or prognosis.
• Interpretation of assessment findings and determination of treatment procedures and treatment goals and the planning, development, or modification of treatment plans beyond pre-set parameters.
• Initial discussion of treatment rationale, clinical findings, and prognosis with clients.
• Documentation that should be completed by the physiotherapist.
• Discharge planning.
• Any treatment that requires the physiotherapist support worker to employ clinical reasoning, analysis, and decision-making to change the established plan of care without the input of the supervising physiotherapist.

Monitoring

You are ultimately accountable for the appropriateness of the supervision you provide and for the quality, safety, and effectiveness of the services provided to the client. You have the authority and responsibility to establish ongoing monitoring strategies and supervision requirements.

Ongoing monitoring may involve the use of both direct and indirect forms of supervision, employing different supervision strategies, as indicated by the practice context, client needs, and skills and competencies of the PTSW. Monitoring is used to track the:

• Consistency of the PTSW’s actions with your assignment
• Quality of the services provided by the PTSW
• Client’s response to the services provided by the PTSW
• Need for reassessment or changes to either the treatment plan or the supervision plan

You should always be able to explain:

• How you determined the appropriate supervision approach for a given PTSW, client, and treatment plan.
• How you monitored the services provided by the PTSW and the client’s response.

As the professional relationship between yourself and the PTSW matures and as the skills of both you and the PTSW develop, the supervision plan, nature of assignments, and nature of ongoing monitoring may change. However, you must always provide some supervision and monitoring of your supervisees.

Reassessment

Reassessment refers to:

• The need to reassess the PTSW’s performance and change the supervision approach as needed.
• The requirement to reassess the client and the outcomes of physiotherapy services to ensure that the services provided address the client’s needs.

You must not assign a client to receive treatment from a PTSW and never reassess the client again.

The frequency of your reassessment of the client must reflect the anticipated trajectory of client progress or change and will differ depending on the client’s condition and the sector in which you work. At a minimum, you are responsible for the decision that physiotherapy services are no longer required and for discharge planning.

Similarly, the frequency of reassessment of the PTSW’s skills and the supervision plan must consider the skills and training of the PTSW, the initial supervision plan, the tasks assigned to the PTSW, legislative and regulatory considerations, and the context of practice.

1.What happens if a PTSW deviates from the assignment I provided?

You are responsible for providing supervision and for the services you assign to the PTSW. The PTSW is responsible for their actions or omissions when providing physiotherapy services.

If you assign services to a PTSW that you have assessed to be within the PTSW’s skill set and which are appropriate for the client in question, and the PTSW later deviates from that assignment, the PTSW is responsible for their actions.

You would be responsible for the monitoring of the PTSW’s activities and for identifying the discrepancy.

This may also become a performance management concern within an employment context.

2.When am I required to be “on-site”?

You must employ direct observation methods at the start of the supervisor-supervisee relationship until you know that the PTSW is competent to do the tasks assigned and are confident in their judgment. This direct observation is usually completed through being on site with the PTSW during the assessment period. However, in some circumstances, virtual observation and assessment using telecommunication technology may be possible, depending on the context and supports in place to mitigate risks and ensure accurate assessment. Once you have determined that the PTSW is competent and performing at an acceptable level, you may be able to change to other approaches.

After the initial period of observation, you must provide direct observation:

• If the PTSW is learning a new skill.
• If you have concerns about the PTSW’s performance of the assignment.
• If the PTSW is performing an activity for which direct supervision is required.

3.Do the PTSW and I need to be employed by the same employer?

You must be able to fulfill your supervision obligations. You need to have unimpeded access to the PTSW’s work site so you can observe the PTSW and access client records when needed to fulfill your supervision responsibilities. You also need to have sufficient authority within a worksite that you can establish and enforce any parameters around the PTSW’s client care assignments.

4.Can I bill for treatment provided by a PTSW using my registration number?

Physiotherapy services are services delivered by or under the supervision of a physiotherapist. For a service to be appropriately called physiotherapy all the requirements established in the Standards of Practice must be met.

This includes, but is not limited to:

• The Supervision Standard of Practice which outlines requirements for providing appropriate assessment, assignment, monitoring, and reassessment of the client, communicating the role of supervisees, and obtaining consent for the supervisee’s involvement in the client’s care.
• The Funding, Fees, and Billing Standard of Practice which states that all billing records need to be transparent.
• The Documentation Standard of Practice which requires that the client’s chart clearly indicates the individual who provided the services.

It is important to remember that payers have their own policies related to what they will or will not pay for under extended health benefits.

5.What about documentation of services provided by PTSWs? Can PTSWs document the services they provide under my supervision?

Yes. The College’s perspective is that the best individual to document services provided is the individual who delivered the services. The clinical record needs to identify who provided the services and details about those services. If several team members are involved in the delivery of a treatment session, the record must identify the treatments provided by each team member during the treatment session.

Depending on their training, PTSWs may have received training in how to complete documentation for services provided. However, if they have not been trained in documentation, you will need to provide training to ensure documentation that is consistent with the Documentation Standard. You also need to monitor documentation done by the PTSW to ensure that it adheres with the Standard.

6.Am I required to co-sign client documentation written by the individuals I supervise?

There is no legislated requirement to co-sign client records and doing so may not be appropriate depending on the circumstance.

If you co-sign notes, it can be interpreted to mean that you agree with the accuracy of the details contained in the chart note. When co-signing a record, the expectation is that you have confirmed the content of the note through independent or concurrent assessment or treatment of the client. Before co-signing a chart, you must be sure that you can verify the details documented. If you were not present throughout the treatment session, you may not be able to do so and are advised not to co-sign the client record.

7.How should a supervisor document that they completed a chart review, if they do not co-sign a chart?

If you are using chart reviews as the means of supervision, you would enter a note in the client record indicating that a chart review was completed, the date of the chart review, and your name, and any decisions or plans that result from your chart review. For example, if you plan to reassess the client based on the findings from the review, or if you plan to continue with the treatment program and for how long.

8.Can PTSWs complete outcome measures?

It is up to you to determine what is assigned. This may include assigning the administration of outcome measures, if you are satisfied that the PTSW is competent to administer the outcome measure accurately.

However, PTSWs must not be assigned the task of interpreting assessment findings, including the results of the outcome measure.

Testing protocols which depend on clinical reasoning, analysis, and decision-making for their safe and effective completion must not be assigned to a PTSW.

Regardless of who administers a standardized test, it is your responsibility to interpret the findings of the outcome measure and determine how treatment will be modified based on the findings.

9.Can I assign my PTSW the task of removing acupuncture needles?

NO. PTSWs must not be assigned any restricted activity or portion of a restricted activity.

PTSWs are not allowed to remove acupuncture needles as this is a part of the restricted activity of using needles in practice for the purpose of acupuncture.

10.How many PTSWs am I allowed to supervise at one time?

The College does not specify how many PTSWs you can supervise. However, it is your responsibility to provide adequate supervision consistent with the Supervision Standard of Practice. You must only agree to supervise the number of PTSWs that you can reasonably and feasibly provide adequate supervision to. This number will vary depending on the sector, practice setting, client population, and other contextual factors.

It is important to remember that the requirements of the Supervision Standard must take priority over other considerations.

11.What are my responsibilities when supervising a support worker who provides both physiotherapy and occupational therapy functions for a client?

You are responsible for supervising support workers when they are performing the physiotherapy tasks that you assigned to them.

Physiotherapists and occupational therapists have overlapping scopes of practice and competencies. All parties must clearly understand which parts of the client’s treatment plan are physiotherapy and which aspects are not.

In these situations, you are expected to collaborate with the occupational therapist to coordinate the support worker’s assignment and the care provided to the client.

12.What are my responsibilities when working with someone who is trained as a kinesiologist, Pilates instructor, or similar?

That depends on whether a supervision relationship exists between you and the other individual. Sometimes kinesiologists or other health and wellness providers work as supervisees, and sometimes they work as autonomous service providers. All parties must understand the working relationship between you and the other service provider.

If there is a supervision relationship, then you must fulfill the supervision responsibilities identified in the standard and in this guide.

If the health and wellness provider is operating as an independent service provider, you do not have a supervision obligation. In this case the other party is an independent service provider and is responsible for all aspects of the services they deliver. Their services must not be billed as physiotherapy.

13.Do the requirements to supervise PTSWs differ in different client-care settings?

No. In any active treatment model, whether in a hospital, continuing care, private clinic or other setting, if a physiotherapist assigns components of the physiotherapy treatment program to PTSWs, they must provide appropriate supervision considering the client’s best interests, client factors, the PTSW’s competence and performance, and the context of the practice setting.

14.What are my responsibilities if I work as a consultant?

In a consulting model, you provide consultation and recommendations (such as education, or programming) which are carried out by the client’s family, facility staff, or another third party.

In this model:

• You are not acting as a supervisor of the individual carrying out your recommendations.
• You are accountable for the consultation, the recommendations made, and any training you provide to enable others to carry out the recommendations.
• Family members or facility managers are responsible to provide the services or to supervise facility/organization staff who provide the services.
• You are accountable to ensure that both the client and the facility/organization are aware of this.

For example, you may provide consultation to a group home regarding a stretching program for a client with spasticity and may teach the group home staff how to perform the stretches with the client. You are responsible for the consultation, education, and information given to the group home about the plan of care and instruction about the circumstances that should trigger a repeat physiotherapy consultation. You are not responsible for the supervision of the group home staff.

15.Who obtains consent for a PTSW’s involvement in a client’s care?

You are responsible to obtain client consent for the PTSW’s involvement in the delivery of physiotherapy services.

The PTSW obtains ongoing consent for the services they have been assigned at the time of service and prior to providing the service.

16.What are my responsibilities when I share supervision duties with another physiotherapist?

When two or more physiotherapists share supervision responsibilities, it is ideal that they communicate and collaborate to assess the PTSW’s skills and competencies and develop and refine the supervision plan. A shared understanding of the PTSW’s skills and knowledge, working relationships and responsibilities will provide clear direction for the PTSW and support effective supervision.

17.Who is responsible if a PTSW is supervising a student enrolled in a therapist assistant program?

Typically, you and the PTSW share student supervision duties. Often the PTSW will spend more time working with the student in their day-to-day activities. However, you are ultimately responsible for the physiotherapy services the client receives.

Your responsibilities include evaluating the skills of the PTSW student and ensuring that the assignments made to both student and PTSW are appropriate.

18.I am going to be away next week on vacation. What should I do about the services I’ve assigned to my PTSW? Am I responsible for these assignments while I am away?

The answer depends on your assessment of the PTSW’s competence, the practice setting, and client population served, client acuity, and the duration of the absence.

If you are confident in the PTSW’s competence and judgment, you may choose to provide remote indirect supervision while you are away (e.g., through a case discussion prior to and following the absence). In this scenario, you remain responsible for the client care assignment and for the treatment provided by the PTSW. If taking this approach, you are expected to provide clear parameters to the PTSW regarding:

• The treatment plan.
• Situations where the treatment should be discontinued.
• Situations where re-assessment by an alternate physiotherapist should be arranged (e.g., change in the client’s medical status, pending discharge).

You are expected to identify a regulated physiotherapist who the PTSW could contact in the event of an emergency or unanticipated situation. You may also need to change the assigned services to ensure client safety, while also ensuring the client receives some physiotherapy services.

You should only take this approach if the PTSW has demonstrated sound clinical competence and sufficient judgment to enable safe remote indirect supervision.

If the PTSW requires closer supervision, you are unwilling to take on the risks related to remote indirect supervision, or you are concerned with the PTSW’s competence, judgment and ability to adhere to the treatment plan and parameters established, supervision responsibilities must be transferred to another physiotherapist available to provide supervision during your absence.

All parties must be aware of the supervision expectations, and which party is responsible to provide supervision.

19.What if I am going to be away for an extended period?

Client safety and the quality and effectiveness of physiotherapy services received are of paramount concern. Using indirect, remote forms of supervision may be appropriate for a brief absence, but if you are going to be away for an extended period, the responsibilities of supervision must be transferred to another physiotherapist willing and able to provide supervision.

20.Who is the PTSW’s supervisor: the unit manager or the physiotherapist?

It depends on the situation and the services being provided. Remember that if physiotherapy services are provided, they must be supervised by a physiotherapist.

There is nothing that would prevent a unit manager from being the direct supervisor of an unregulated health provider or group of unregulated health providers.

A unit manager who is also a physiotherapist could opt to supervise all PTSWs working on the unit, or a physiotherapist on the unit could supervise one or several PTSWs.

There is no rule that says that only a physiotherapist may supervise activities such as mobilization or therapeutic exercise; however, if a physiotherapist is not involved in the provision or supervision of an activity, (i.e., if a non-physiotherapist unit manager is the supervisor), it must not be described or implied to be physiotherapy.

All parties must know who is providing supervision and oversight of the PTSW’s actions and be aware of their responsibilities.

21.What aspects of supervision should be documented in the client record?

When a client provides consent to be treated by a PTSW the consent should be documented. In addition, when you assign tasks to a PTSW, the tasks assigned, and parameters of treatment must be documented in the client record.

22.My colleague says that they have assessed a PTSW’s skills and that the PTSW is competent to perform all the tasks I regularly assign to PTSWs at my workplace. Do I need to assess the PTSW’s skills for myself?

The Supervision Standard of Practice states that the physiotherapist:

• Assesses the knowledge, skills, and judgment of support workers.
• Assigns only those tasks/activities that fall within the support worker’s competence.

While you could opt to trust the assessment of the PTSW’s skills that your colleague made, remember that in the event of an issue or client complaint, you are the person who will be held accountable for having assessed those skills and competencies and for the assignment decisions arising from that assessment, not your colleague. Due to the potential implications of this choice, it is not recommended.

Responsibilities:

Both Supervisor and Supervisee:

• Communicate openly, honestly, and regularly.
• Respect professional boundaries.

Supervisors

• Determine the client care assignments and the level of supervision required.
• Accept accountability and responsibility for PTSW competence assessment, assignment, and ongoing monitoring and evaluation.
• Only assign, monitor, and evaluate activities that are within your own personal scope of practice and competence.
• Develop a supervision plan with client care needs, service delivery models, and the PTSW’s skills and abilities in mind.
• Discuss the supervision plan with the PTSW before assigning client care activities.
• Establish client communication and consent processes related to the PTSW’s involvement in the client’s care.
• Intervene if there are client safety concerns or risk of harm arising from the PTSW’s care.
• Retain responsibility and accountability for providing appropriate supervision.
• Decline the responsibility of supervision if you are unable to meet the expectations set out in the Standard.
• Ensure your employer understands your professional obligations regarding supervision.

Supervisees

• Accept accountability for your performance of assigned duties and adherence to the assignment and any parameters established by your supervisor.
• Identify when an assignment exceeds your individual skills and competencies and advise your supervisor of the limits of your skills and competencies.
• Take appropriate action when situations arise which render an assignment inappropriate (e.g., the client’s status changes, necessitating a reassessment or a change in care plan).

Checklist for Supervisors of PTSWs:

• Review the Essential Competency Profile for Physiotherapy Assistants in Canada.
• Consider the PTSW’s skills and competencies when deciding which activities to assign.
• Ensure that others within the practice environment are aware of regulatory requirements regarding supervision of PTSW.
• Retain responsibility and accountability for the activities you assign to PTSWs.
• Assign only those activities that you yourself are competent to perform.
• Never assign restricted activities or any component thereof.
• Never assign client assessment, reassessment, interpretation of findings, discussion of treatment rationale, development or modification of treatment plans or discharge planning.
• When working in team-based or multidisciplinary practice settings, clearly establish if there are situations where the support worker is acting under the supervision of someone other than yourself.
• Ensure that in instances where the support worker is providing health-care services without the supervision of the physiotherapist, these services are not represented to clients or payers as physiotherapy.

Before You Begin:

Whether you are a new supervisor or are simply entering a new supervision relationship, consider the following questions and seek more information if needed before you begin:

Questions for Supervisors

• Does a supervision relationship exist?
• Am I competent to provide supervision?
• Am I competent in the tasks I am assigning to my supervisee?
• What’s my plan for providing supervision to my supervisee?
• Do I have the resources and supports I need to provide supervision effectively?

Questions to Ask Your Supervisees:

• Do you understand the supervision plan and the parameters I have placed around your practice?
• Do you know what to do if something unexpected happens with one of our clients?
• Do you understand the parameters for progressing clients, if any, and when to seek assistance from me?