Supervision is an essential competency for physiotherapists working in Canada’s health system. While no one supervision model will apply to all contexts of physiotherapy practice, this guide provides a framework to support effective supervision in clinical practice to help ensure that the College of Physiotherapists of Alberta’s Practice Standards are met.
This document provides guidance to physiotherapists who provide supervision to others, including physiotherapist support workers, physiotherapy students, physiotherapist interns, and physiotherapists on the General Register. It also provides guidance to supervisees, employers, and others regarding the rules that govern physiotherapy practice.
The intent is to help regulated members, unregulated health providers, and other stakeholders understand the expectations outlined in the College of Physiotherapists of Alberta’s Standards of Practice. The guide summarizes the requirements that regulated members must meet and provides recommendations for how to meet the expectations. The overarching objective is the delivery of effective supervision and safe, quality physiotherapy service provision with and by supervisees.
Part 1 of this guide begins with a general discussion of the rationale for supervision and a review of the general principles and requirements of supervision, before discussing methods of supervision in detail. Specific considerations related to different categories of supervisees are discussed in Part 2 of this guide.
Supervision is defined by the Merriam Webster dictionary as “the action or process of watching and directing what someone does or how something is done” and is an essential competency of physiotherapists practicing in Canada. Supervision can vary in terms of what it includes and may involve elements of direction, guidance, observation, collaborative working, the exchange of ideas and co-ordination of activities as appropriate to the context of physiotherapy practice and the supervisee in question.
A crucial feature of the supervisory relationship is that the supervisor has an explicit requirement to evaluate the competence and performance of the supervisee to ensure that safe practice occurs and that patients receive quality physiotherapy services.
Within the context of physiotherapy practice, supervision may be provided to unregulated health providers including:
- Physiotherapist support workers without formal physiotherapy or rehabilitation-related training
- Physiotherapist support workers who are enrolled in or who have completed formal training programs
- Physiotherapy students.
Supervision of regulated health professionals including physiotherapist interns on the Provisional Register or physiotherapists on the General Register (in a limited set of circumstances) is also common.
Supervision helps build capacity in the health-care system and helps to ensure that patients receive the right care, in the right place, at the right time, provided by the right provider. Effective supervision allows the sharing of workloads between members of the health-care team to increase the volume of physiotherapy services provided within a practice setting, as in the case where a physiotherapist works with a physiotherapist support worker to deliver physiotherapy services.
Effective supervision also enables supervisees to continue to develop their individual competence and skills, receive feedback on their performance of those skills and provide safe, quality physiotherapy care. This is true of all supervisees, including physiotherapist support workers, students, physiotherapist interns and physiotherapists on the General Register who are learning a new skill.
The requirement to evaluate the competence and performance of a supervisee alters the nature of the relationship between supervisor and supervisee as compared to that of colleagues, or mentor and mentee.
Supervisors should be thoughtful about their relationships with supervisees, ensuring that relationships with supervisees do not impair the supervisor’s objectivity or professional judgment, or prevent the supervisor from placing the patient’s interests first and foremost when fulfilling their supervisory duties.
Similarly, if asked to supervise an individual with whom the supervisor has a pre-existing close personal relationship, the supervisor should carefully consider whether they are able to fulfill the requirements of supervision fairly, objectively, and impartially. When an alternate supervisor is available, the College of Physiotherapists of Alberta strongly recommends that individuals refrain from supervising those with whom they have a pre-existing personal relationship.
Supervision not Mentorship
Physiotherapists often use the terms supervision and mentorship interchangeably; however, the two are not the same, and it is important to distinguish between them.
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, but do not typically provide formal evaluation of the mentee. Mentorship relationships are important and support ongoing professional development; however, these informal relationships do not provide the oversight necessary to address the safety and quality considerations which supervision offers.
Supervision not Delegation
The terms delegation and supervision are often used interchangeably; however, supervision and delegation are not the same. Delegation means to grant another party the authority and powers to perform parts of one’s job. With delegation, the responsibility for the performance of a task is transferred to another party; however, 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. The framework provided by the Physical Therapists Profession Regulation contains no provision for the delegation of the physiotherapist’s authority or physiotherapy services. Throughout the PTPR, “supervision” is the language used, reflecting the ongoing responsibilities of the supervising physiotherapist regarding the activity assigned, its performance and the appropriate supervision of the activity performed by the supervisee.
Indirect not Independent
The College of Physiotherapists of Alberta frequently hears from supervisors and supervisees alike who comment that the supervisee is working independently; however, from a regulatory perspective, this is not the case, and indeed it is critical that all parties understand that supervisees do not provide physiotherapy services independently.
The nature of the supervision relationship means that the supervisor is always responsible and accountable for providing oversight of the supervisee’s activities and performance. The extent of that supervision or oversight must be appropriate for the supervisee’s skills and competencies and will look different when comparing supervisees. Appropriate supervision ranges from direct one-on-one supervision at all times, up to and including infrequent monitoring. However, even in instances where very little oversight is required because of the skills and competencies of the supervisee, there remains a requirement to provide some form of appropriate supervision until the supervisee-supervisor relationship comes to an end or the supervision responsibility is transferred to another supervisor.
The first question to consider is whether a supervisor-supervisee relationship exists. In some situations, the answer is clear, such as when a physiotherapist agrees to supervise a physiotherapist intern or physiotherapy student. In such cases the supervisory relationship involves formal documentation of the relationship, such as a supervision agreement submitted to the College of Physiotherapists of Alberta in the case of a physiotherapist intern, or a letter of offer of a clinical placement for a student physiotherapist.
In other situations, the existence of a supervisor-supervisee relationship is less obvious. Examples include:
- When a physiotherapist provides consultation services in a group home environment, school system or other setting and provides recommendations to another party about the needs of an individual or group, without the expectation of the physiotherapist’s ongoing involvement in the patient’s care.
- When a physiotherapist works with other members of a multidisciplinary team that includes both regulated health professionals and unregulated health providers to deliver care to an identified patient population.
- When a physiotherapist works collaboratively with personal trainers or kinesiologists in a community recreation centre or exercise facility.
Defining when a supervisory relationship exists can be challenging. The characteristics of these relationships will vary depending on many factors and are as unique as the individuals involved. The table below presents characteristics of professional relationships that make a supervisory relationship more or less likely.
- This is not a definitive list.
- The absence of any single factor does not necessarily indicate that a supervisory relationship does not exist.
- These characteristics are intended to help physiotherapists to consider whether they have a supervisory duty, and whether they need to discuss their supervisory responsibilities with their peers, managers, or others.
|More likely to be a supervisory relationship||Less likely to be a supervisory relationship|
Employed by the same employer
One or both parties are self-employed or are employed by different organizations/individuals.
Reporting and oversight responsibilities are established in both physiotherapist and supervisee job descriptions.
Job descriptions do not include supervisory or reporting responsibilities.
Services of both physiotherapist and supervisee are presented to the patient as physiotherapy.
Services of each party are marketed or presented separately; distinctions between services offered by each party are clearly delineated to the patient.
Physiotherapist monitors the performance of the other person or provides feedback as part of employer performance management programs.
No expectation of ongoing monitoring of performance/services. No feedback expected/required as part of employer performance management programs.
Physiotherapist is asked to “sign off on” or “certify” another person’s skills.
Physiotherapist may provide basic education in defined tasks but does not verify or certify the skills or performance of the other party.
Services of both physiotherapist and supervisee are billed as physiotherapy using the supervisor’s the College of Physiotherapists of Alberta registration number.
Services of physiotherapist and the other party are billed separately.
Exception: Registered members of he College of Physiotherapists of Alberta (e.g., PT interns) always bill for their services using their own registration number, regardless of the supervisory relationship.
The other party’s invoices do not make use of the physiotherapist’s registration number.
When physiotherapists are working with unregulated health providers, they are advised to clarify who the unregulated health provider reports to and who is providing supervision or oversight of that provider’s services.
Services which are not supervised by a physiotherapist must not be referred to, presented as, billed as, or otherwise implied to be physiotherapy.
Responsibilities regarding patient care vary depending on the supervisee in question; however, in every case the supervisor is responsible:
- To provide appropriate supervision.
- For assessing the competence of the supervisee to perform a clinical assessment or provide physiotherapy services before making an assignment.
- For the tasks assigned to supervisees.
The supervisee is responsible:
- To know the limits of their personal skills
- For the care that they provide
If a supervisee deviates from the tasks assigned by their supervisor, the supervisee is accountable for their actions.
In every case, both the physiotherapist supervisor and the supervisee have a duty of care to the patient and are accountable for their acts and omissions.
The limits of what can and cannot be assigned to a supervisee and the specific details of responsibilities relevant to different supervisee groups are determined by the role of the supervisee, the purpose of supervision, and the parameters established by the Standards of Practice. See Part 2 of this document for details specific to different supervisee groups.
Some requirements of supervision are specific to the individual being supervised; however, other principles and requirements hold true regardless of the supervisee in question. The following principles and expectations must be applied to all supervisor-supervisee relationships.
Both Supervisor and Supervisee
- Serve the best interests of the patient, holding patient safety and quality of care as the primary concern at all times.
- Ensure that the expectations identified in the Standards of Practice are adhered to when providing physiotherapy services.
- Communicate openly, honestly, and regularly.
- Respect professional boundaries.
- Determine the supervisee’s patient care assignment and the level of supervision required, regardless of who is managing the patient’s care.
- Accept overall accountability for supervisee competence assessment, assignment, ongoing monitoring, and evaluation.
- Only assign, monitor, and evaluate activities that are within the supervisor’s own personal scope of practice and competence.
- Develop a supervision plan with patient care needs, service delivery models, and the supervisee’s skills and abilities in mind.
- Discuss the supervision plan with the supervisee before assigning patient care activities.
- Intervene if there are patient safety concerns or risk of harm arising from the supervisee’s care, and communicate with appropriate authorities as necessary (e.g., the employer, Unit Manager, the College of Physiotherapists of Alberta).
- Retain responsibility and accountability for providing appropriate supervision.
- Decline the responsibility of supervision if unable to meet the expectations set out in these guidelines.
- Ensure the employer understands the physiotherapist’s professional obligations regarding supervision.
- Accept accountability to fulfill their assigned duties.
- Identify when an assignment exceeds their individual skills and competencies.
- Take appropriate action when situations arise which render an assignment inappropriate (e.g., the assignment exceeds their skills and competencies or a patient’s clinical status changes necessitating the supervisor’s re-evaluation or a change in care plan).
The core requirements of supervision are outlined in full in the Supervision Standard of Practice. Broadly speaking, the physiotherapist supervisor is expected to:
- Assess the knowledge, skills, and competencies of the supervisee before assigning any task.
- Assign tasks to the supervisee that are consistent with the supervisor’s own skills and competencies, and the competencies and skills of the supervisee.
- Explain the roles of both the supervisor and supervisee in the provision of physiotherapy services.
- Confirm that the patient consents to care provided by the supervisee.
- Monitor the care provided by the supervisee to ensure that quality and safe physiotherapy services are provided, using supervision strategies appropriate to the patient, practice context, and supervisee’s competence.
- Reassess the patient’s status intermittently to assess the appropriateness of ongoing service delivery by the supervisee, and that the tasks assigned are appropriate for the patient’s clinical status and progress.
Physiotherapists must understand that within a supervision relationship, the physiotherapist has clear, ongoing responsibilities to both the supervisee and the patient. Below, we consider each of these requirements in greater detail.
All supervisor-supervisee relationships must begin with a period of direct supervision to enable the supervisor to assess technical and non-technical competencies, performance, and behavior of the supervisee in the clinical setting.
During the direct assessment phase, the supervisor must be physically present and able to directly observe/assess competence, provide input into the supervisee’s performance, and intervene if a safety concern arises.
Through this period of direct supervision, the supervisor will determine if the supervisee is able to perform some patient care assignments with indirect supervision and what form of indirect supervision is appropriate for the skills and competence of the supervisee, practice context and patient population.
Developing a Supervision Plan
At this point, the supervisor formulates a plan for how they will fulfill their supervision obligations. The College of Physiotherapists of Alberta recommends that supervisors create a written plan outlining:
- The supervision methods that will be employed with each identified task or patient population.
- The frequency of monitoring of supervisee performance and anticipated dates of review and updating of the supervision plan.
- The mechanisms that will be used for ongoing re-assessment of the supervisee’s performance and patient care assignments.
- Any limits the supervisor has imposed on the supervisee’s practice, based on the supervisee’s current performance.
- For example, the supervisor may require ongoing direct supervision when the supervisee is working with a designated patient population or when the supervisee is engaged in specific patient care tasks.
- Any specific concerns or issues identified by the supervisor that the supervisee needs to address and resources available to the supervisee to further their skills and competencies/address areas of concern.
The purpose of this plan is to facilitate and formalize the processes that will be used to meet supervisor’s responsibilities on an ongoing basis, enabling the transition from direct to indirect supervision as appropriate. The supervisor must discuss the supervision plan with the supervisee.
Supervisors are also encouraged to create a supervision log to track their completion of supervision activities identified in the supervision plan, such as periods of direct supervisee observation, case discussions, chart audits.
When assigning tasks to supervisees, the sole consideration must be the interests of the patient. The supervisor must identify the activities to be assigned. When doing so, they must only assign and supervise activities which they themselves are competent to perform.
Within the clinical environment, it is realistic that a supervisee may have skills and competencies that differ from those of their supervisor. For example, in cases where the supervisor is a physiotherapist intern working with an experienced physiotherapist support worker, or where the physiotherapist support worker’s background includes training that differs from that of their supervisor. If a supervisee were to perform a task or activity that the supervisor was not competent in, the supervisor would not be able to evaluate the appropriateness of the task, nor assure the quality and safety of the services provided. For this reason, the supervisor may only assign those tasks and activities that they, themselves, are competent to perform.
The tasks and activities assigned, and the method used to monitor the performance of that assignment should become part of the supervision plan. This documentation, which pertains to the supervisee, is in addition to the documentation which must be included in the patient record regarding the treatment plan established by the physiotherapist and the tasks assigned to other members of the health-care team.
The assignment and supervision plan should include parameters and protocols to direct supervisees’ actions regarding when guidance or patient re-assessment from the supervisor is required. These parameters and protocols may include both critical events that would necessitate a re-evaluation and anticipated milestones that may require a revision to the care plan. These parameters and protocols will differ depending on the group to which the supervisee belongs (e.g., physiotherapist support worker vs. physiotherapist intern), as well as the individual competencies of the supervisee.
The ethical principle of patient autonomy, a core value of physiotherapists, naturally leads to the requirement that patients be aware of the role and skills of individuals involved in the provision of their care and that this information be provided to patients in a clear and transparent manner. This is imminently important when working with supervisees.
The patient must be aware of and consent to the involvement of supervisees in the provision of their physiotherapy care. Further, the respective roles and responsibilities of different providers involved in the provision of physiotherapy services must be explained to the patient. How is the quality of their care assured through effective supervision by the physiotherapist? Who can they speak to if they have a concern or complaint, (up to and including contacting the College of Physiotherapists of Alberta)? What are the implications of declining physiotherapy services provided by a supervisee, and what other options are available to the patient if they choose to do so?
The requirement to provide supervision continues after the period of supervisee assessment and mandatory direct supervision comes to an end.
Supervisees require ongoing monitoring of their performance to ensure that safe, quality physiotherapy services are provided and that those services meet the patient’s needs. Monitoring enables the supervisor to comply with the expectations articulated in the Supervision Standard of Practice.
Ongoing monitoring may include both direct and indirect forms of supervision, employing different supervision strategies, as indicated by the practice context, patient needs, and skills and competencies of the supervisee.
The supervisor bears the ultimate accountability for the appropriateness of the supervision provided, and as such they alone have the authority and responsibility to impose ongoing supervision requirements. The supervisor should be prepared to explain how they determined the appropriate supervision approach for a given supervisee, patient population and treatment technique.
It is anticipated that supervisees will require progressively less direct supervision over time. However, it is not anticipated that a supervisee will transition to entirely indirect supervision for all assignments immediately following the assessment phase.
The pace of the transition from direct to indirect supervision will depend on the context of the practice, and the supervisee’s past experiences and individual competence, the tasks assigned and relevant regulatory requirements.
Reassessment refers both to the necessity of reviewing the supervisee’s performance and the need for an alternate approach to supervision, as well as to the imperative to reassess the patient and the outcomes of care to assure that the physiotherapy services provided are addressing the patient’s needs.
With regards to care provided by physiotherapist support workers, physiotherapists must not assign a patient’s care to a supervisee, with the patient never to be seen again by a physiotherapist. The frequency of patient reassessment by the supervisor must reflect the anticipated trajectory of patient progress or change. As such, the frequency of patient reassessment will be different depending on the patient’s condition and the sector in which the physiotherapist works. At a minimum, the physiotherapist is responsible for the decision that physiotherapy services are no longer required and for discharge planning.
Similarly, the frequency of reassessment of the supervisee’s skills and the supervision plan must take into account:
- The skills and training of the supervisee
- The initial supervision plan
- The tasks assigned to the supervisee, legislative regulatory considerations
- The context of practice
There are a range of risks encountered in physiotherapy service provision. These range from common, minor risks to rare but foreseeable and potentially serious risks. The nature, severity, and potential consequences of both common and rare but foreseeable risks encountered in a given practice setting must inform the approach a supervisor takes when assigning physiotherapy services to supervisees.
Aspects of physiotherapy practice which may affect the risks encountered by supervisors and supervisees include:
- Practice setting (e.g., critical care, private clinic, extended care facility) and patient population/acuity
- Proximity to peers and other practitioners
- Supervisee’s ability to show insight or reflect on their skills and abilities
- Requirements of the position description
- Whether supervised practice is required due to a conduct decision, or registration requirement (e.g., supervision required when learning a restricted activity)
Other factors that also affect the risk of assigning tasks to a supervisee include:
- Qualifications of the supervisor and supervisee
- Skills, knowledge, and competence of both parties
- Years of practice and clinical experience with the designated population or in a specific practice setting
The identified risks relevant in a specific practice setting and in relation to a supervisor/supervisee must be used to inform:
- Level and method of supervision
- The need for a formal written supervision plan
- Frequency of monitoring of patient response to assigned care and of the supervisee’s performance
- Parameters for progression of the supervision plan
- The minimum required experience of the supervisor assigned the task of providing supervision
As a general principle, if the supervised practice is assessed as higher risk, the supervision will be more direct, and the monitoring will be more frequent and extensive.
Many physiotherapists may already, intuitively employ a risk-based approach to their supervision and assignment of physiotherapy services. The College of Physiotherapists of Alberta encourages an intentional approach to identifying and mitigating practice risks to make both risks and mitigation strategies apparent to all parties involved, and to facilitate a consistent approach to risk management in supervision and assignment of physiotherapy services across sectors and settings.
Levels of Supervision
Levels of supervision exist along a continuum and can be described by the level of access to and oversight by the supervisor available to the supervisee. It is anticipated that supervisees will travel back and forth along this continuum as they gain experience, refine their skills, and encounter patients with unfamiliar conditions or those with increasingly complex care needs.
Levels of supervision can be described as:
- Direct supervision
- The supervisor is present, in the treatment room, observing the actions of the supervisee.
2. Indirect, but present
- The supervisor is present on site but is on a different unit or in a different treatment room. Supervision using audio or video conferencing technology can also be considered indirect but present supervision.
3. Indirect, but accessible.
- The supervisor is available by phone or other communication means and can attend the workplace if needed.
- The supervisor is not present at the worksite and cannot readily attend the workplace if contacted by the supervisee.
Direct supervision means that the supervisor is present, and able to directly observe/assess competence, provide input into the supervisee’s performance and intervene if a safety concern arises. Direct supervision means that the physiotherapist is not simply “on-site” but that they are in the treatment room* and actively engaged in the process of supervision.
*Historically, the College of Physiotherapists of Alberta has defined the “treatment room” to be the treatment cubicle, room, or gym. However, within telerehabilitation practice, the treatment room is seen to be the virtual treatment environment, and direct supervision can be achieved when all three parties (patient, supervisee, and supervisor) attend the treatment session virtually.
As already discussed, all supervisor-supervisee relationships begin with a period of direct supervision. Following the assessment period, the supervisor may continue to employ direct supervision techniques for certain interventions or patient care groups. The need for ongoing direct supervision is determined by the supervisees’ competence, the supervisor’s confidence in their performance of assigned activities, the nature of the activities assigned, and patient factors.
In some instances, direct supervision is mandated under existing legislation:
- When a physiotherapist intern on the Provisional Register is engaged in wound debridement or care, performing suctioning, or performing a pelvic health internal examination.
- When a physiotherapist on the General Register is enrolled in an education program to learn a restricted activity that requires additional authorization (spinal manipulation, needling, pelvic health internal examinations) and is performing the activity but is not yet authorized by the College of Physiotherapists of Alberta to do so independently.
Direct supervision of the supervisee’s performance enables the supervisor to meet legislative and regulatory requirements and ensures the supervisor has direct knowledge of the supervisee’s performance.
Indirect or Remote
When a supervisee has demonstrated a reasonable level of competence in a particular practice context and with a specific patient population, the supervisor may opt to monitor their practice indirectly. There is a range of supervision methods available to assess and monitor performance of supervisees on an ongoing basis; however, not all methods will be appropriate for all supervisees or practice settings. The supervisor must take a risk-based approach, consider patient factors, as well as supervisor and supervisee preferences to determine which strategies are appropriate.
Remote Audio or Video Conferencing
Remote monitoring of supervisee performance using audio or video conferencing to observe patient care interactions is an acceptable method of indirect supervision. Audio or video conferencing may be an appropriate method for ongoing monitoring of patient care, enabling the supervisor to fulfill their supervision requirements from a distance. When used to enable the supervisor to remotely attend a patient care intervention, this method may provide a significant level of oversight; however, this method may not be used in instances where direct supervision is required (e.g., when a supervisee on the General Register is learning a restricted activity).
If using this method of supervision, the patient, supervisor, and supervisee must all consent to the use of audio or video conferencing. Supervisors who are considering employing this method of supervision are directed to review the Telerehabilitation Resource Guide for Alberta Physiotherapists in full to ensure that other regulatory requirements are addressed.
Chart-stimulated recall assesses the clinical reasoning and judgment applied to a real-life situation and helps to determine the supervisee’s thought process. In preparation for the discussion, the supervisor advises the supervisee that they plan to review a patient chart, provide feedback about the contents of the chart, and then discuss the case with the supervisee.
Following review of the patient record, the supervisor asks the supervisee standardized questions related to patient care assessment, diagnosis, treatment and decision making. See Appendix 1 for sample questions.
Ongoing dialogue should be part of all supervision plans. Discussions should occur regularly (e.g., weekly caseload review) to discuss patient cases, monitor clinical reasoning and patient care, and to inform the need for formal evaluation. This form of supervision is also important for addressing supervisee questions when faced with unfamiliar situations or unexpected outcomes.
Discussions can be held in person, using audio or videoconferencing, or by email.
Chart audits provide supervisors with information about the completeness, quality and appropriateness of care provided by a supervisee. A chart audit can also be used to determine if the supervisee is adhering to the College of Physiotherapists of Alberta’s Documentation and Record Keeping Standard of Practice. Finally, chart audits can be employed to monitor patient progress and identify when a change to the plan of care is required, as in the case where care is being delivered by a physiotherapist support worker.
Multi-source feedback helps to evaluate professionalism and non-technical competencies. Gathering input from patients or from other members of the multidisciplinary team helps to assess the supervisee’s communication and collaboration skills. This type of feedback should be used to inform discussions with the supervisee and may also help to identify concerns regarding technical skills that the supervisor should monitor or reassess in greater detail.
Purpose of Supervision
Physiotherapists frequently work with unregulated health-care providers working in physiotherapist assistant or support worker roles, and with students enrolled in physiotherapist assistant education programs. The use of physiotherapist support workers enables increased patient access to physiotherapy services and aids in efforts to deliver the right care, at the right time, by the right person.
Supervising physiotherapist support workers, including both physiotherapist assistants with formal post-secondary education and those who have received their training on the job enables more extensive physiotherapy service delivery while providing oversight to assure the quality and safety of the services delivered.
What’s Unique About This Group of Supervisees?
This is perhaps the most diverse group of health-care providers that physiotherapists are called on to supervise. Some physiotherapist support workers will have extensive on the job training but limited or no formal education in the provision of physiotherapy services, others 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 physiotherapist support workers.
This range of skills and training will directly influence the activities that the supervisee is competent to perform and those that the physiotherapist may assign while remaining compliant with the expectations established by the College of Physiotherapists of Alberta’s Standards of Practice. This range of skills and training will also directly affect the level and method of supervision employed to ensure safe and effective services are provided.
However, regardless of the supervisee’s education, experience, and competence, there are some tasks that must never be assigned to this group of supervisees. These include:
- Any aspect of a restricted activity
- Any intervention that requires continuous judgment
- Interpretation of assessment findings
- Initial discussions regarding the treatment plan
The complete list of activities that must not be assigned to this group of supervisees is found in the Supervision Standard of Practice.
This group of supervisees is also unique in that in some patient care contexts, the physiotherapist support worker may also perform tasks assigned by another individual, whether that individual is another regulated health professional assigning patient care tasks, or a manager or supervisor assigning tasks. When a support worker is performing tasks that are not assigned by the physiotherapist, the tasks are not considered physiotherapy and the support worker is accountable to the other regulated health professional or supervisor who assigned the tasks. It is imperative that all parties are clear regarding the individual responsible for the tasks assigned and for the supervision of those tasks.
Supervision Requirements Specific to Support Workers
The supervisor must:
- Be familiar with the Essential Competency Profile for Physiotherapy Assistants in Canada.
- Consider the individual support worker’s skills and competencies when deciding which activities to assign.
- Ensure that supervisors, care managers and other health professionals within the practice environment are aware of the College of Physiotherapists of Alberta’s requirements regarding supervision of physiotherapist support workers.
- Retain responsibility and accountability for the activities they assign to physiotherapist support workers.
- Assign only those activities that the physiotherapist themselves is competent to perform.
- Never assign restricted activities or any component thereof.
- Never assign patient 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 when the support worker is acting under the supervision of the physiotherapist. The physiotherapist supervisor and support worker must both be aware of who the support worker is accountable to when not working under the supervision of the physiotherapist.
- Ensure that in instances when the support worker is providing health-care services without the supervision of the physiotherapist, these services are not represented to patients or payers as physiotherapy.
The supervisee must:
- Retain responsibility for their performance of the activities assigned and their adherence to the patient care assignment and parameters to that assignment provided by the supervisor.
- Identify situations where an assignment is not within their individual skills and competence, declining the assignment and notifying the supervisor of their self-assessment.
Who is Responsible?
When considering this question related to support workers, it is imperative to remember that support workers are not regulated health professionals, and although many support workers have formal training, there are no formal education requirements that this group of health-care providers must meet prior to entry to practice. Further, accreditation of physiotherapist assistant education programs is relatively new, and graduates of these programs are not required to successfully complete a summative evaluation comparable to the Physiotherapy Competence Examination (PCE) prior to entering practice. Therefore, the knowledge, skills and competencies of physiotherapist support workers cannot be assumed to be uniform.
For these reasons, the supervising physiotherapist always retains responsibility for the physiotherapy services that they assign to physiotherapist support workers, the appropriateness of that assignment, and for the provision of ongoing supervision of both the care provided and the patient’s progress.
Purpose of Supervision
Clinical placements are an integral part of the student experience and enable consolidation of skills and integration of theoretical knowledge into clinical practice. The purpose of supervision in this context is to assure the public interest is met and that patients receive safe, quality physiotherapy services when treated by students, while simultaneously enabling students to practice and refine their clinical skills.
What’s Unique About This Group of Supervisees?
Clinical placements are a period of rapid skill development for the supervisee. In some ways the supervising physiotherapist is also an instructor whose role is to aide in the student’s skill attainment and the development of professional identity and autonomy.
However, there is a need to balance student learning and the development of autonomy with the provision of sufficient oversight to ensure patient safety. Supervisors must be aware that skill attainment and consolidation is not always uniform over time nor between students of the same level, and that although a student nearing the end of their program would typically be performing at close to an entry to practice level, that is not always the case.
Supervision Requirements Specific to Students
The supervisor must:
- Be aware of the entry to practice program’s curriculum plan and expectations of students at different points in the program.
- Address concerns regarding student performance with the student and educational institution in a timely manner.
The supervisee must:
- Adhere to the requirements of the educational institution.
- Adhere to the Code of Ethical Conduct and Standards of Practice of the College of Physiotherapists of Alberta when providing physiotherapy services.
Who is Responsible?
When considering this question, it is imperative to remember that physiotherapist students are not regulated health professionals. Therefore, the supervising physiotherapist is responsible for the physiotherapy services provided and for ensuring that the Standards of Practice are met. The supervisor is responsible for the care assigned, the appropriateness of that assignment, the effective provision of physiotherapy services and to ensure appropriate monitoring of the supervisee’s performance of that assignment.
Purpose of Supervision
Physiotherapist interns are regulated members of the College of Physiotherapists of Alberta who have been admitted to the Provisional Register, pending completion of all registration requirements. As regulated members, physiotherapist interns are subject to the same Standards of Practice and Code of Ethical Conduct as regulated members on the General Register.
In most cases, physiotherapist interns are recent graduates of Canadian entry to practice education programs or recent applicants who were internationally educated. By the time a recent Canadian graduate or internationally educated individual is admitted to the Provisional Register they have:
- Completed their entry to practice education in physiotherapy from an accredited Canadian university program or demonstrated that their education completed in another jurisdiction is not substantively different.
- Successfully completed the written component of the PCE.
- Provided evidence of good character and reputation.
- Obtained personal professional liability insurance.
The only outstanding registration requirement for this group is the successful completion of the clinical component of the PCE.
In other cases, previously registered physiotherapists who are returning to practice may be admitted to the Provisional Register until they have met the requirements for re-admission to the General Register. For this group, the outstanding requirements for admission to the General Register may vary and do not necessarily include completion of the clinical component of the PCE.
The College of Physiotherapists of Alberta’s perspective is that by enabling these individuals to practice under supervision before all registration requirements are fulfilled, a balance is struck between public protection and public access to physiotherapy services. Without the ability to practice under supervision, a physiotherapist intern would be required to wait several weeks or months before successfully fulfilling all registration requirements and entering practice.
However, the fact remains that physiotherapist interns have not yet fully demonstrated their competence for independent practice through the successful completion of the clinical component of the PCE, and that a subset of candidates - both Canadian trained and internationally educated - are unsuccessful in their PCE attempts each year. As such, successful completion of the clinical component of the PCE cannot be assumed for any candidate and supervision is required to provide oversight of the services provided and ensure the quality and safety of those services.
What’s Unique About This Group of Supervisees?
The population of individuals on the Provisional Register is diverse, representing graduates from physiotherapy programs across the country and internationally educated physiotherapists from around the world. Among internationally educated physiotherapist interns, some may have moved to Canada immediately upon completion of their education, some may have worked for an extended period in their country of origin, and some may have been unable to practice physiotherapy for an extended period for a variety of reasons. In addition, the health system context in which internationally educated physiotherapists completed their training can vary widely, from health systems that are substantively similar to the Canadian health system, to those with considerable differences in terms of the provision of primary care and professional autonomy.
Supervised practice plays an essential role in assuring safe and effective physiotherapy service delivery during the time when the physiotherapist intern is awaiting completion of the clinical component of the PCE. Supervised practice also facilitates the enculturation and transition process from student or internationally educated physiotherapist into clinical practice in Canada, regardless of their specifics of their situation.
Another key difference between this and other supervisee groups is in regard to assignment of physiotherapy services. the College of Physiotherapists of Alberta frequently hears from supervisors of physiotherapist interns who question whether they assign patients to these supervisees.
Admittedly, assignment to a physiotherapist intern looks different from assignment to a student or a physiotherapist support worker. However, the supervisor still has the responsibility to assess which patient groups and which patient care tasks the intern can manage with indirect or remote supervision and which patient groups or care tasks require direct supervision.
For example, a supervisor of a physiotherapist intern working in a private practice setting may determine that the intern can safely and effectively see a patient with knee OA with minimal indirect supervision but decide that the same intern requires more frequent indirect supervision when seeing a patient following a rotator cuff repair and direct supervision when treating a patient with whiplash post-MVA.
From the College of Physiotherapists of Alberta’s perspective, this constitutes a patient care assignment. It is up to the supervising physiotherapist to ensure that appropriate supervision is provided, and that patient safety is assured. This means that it is up to the supervising physiotherapist to assign patients and care tasks according to the supervision needed and available, to support quality, safe patient care.
Supervision Requirements Specific to Physiotherapist Interns
The supervisor must:
- Be employed at the same location as the physiotherapist intern, even if that employment is for the purpose of providing supervision only.
- Sign a supervision agreement specific to the practice location in which the supervisor and the intern work, and the area of practice, when required (e.g., pelvic health (internal exams)).
- Confirm the intern has been admitted to the Provisional Register before beginning to supervise.
- Be familiar with and comply with the Standards of Practice related to Supervision and Restricted Activities.
- Inform the College of Physiotherapists of Alberta immediately if they are no longer able/willing to continue to provide supervision.
Physiotherapist interns must:
- Uphold applicable regulatory responsibilities.
- Submit a supervision agreement for each practice location in which they work and gain approval of the supervision agreement from the College of Physiotherapists of Alberta prior to practicing.
- Notify the College of Physiotherapists of Alberta when/if supervision arrangements change.
Who is Responsible?
Within the physiotherapist intern-physiotherapist relationship, the physiotherapist intern is responsible for their patient’s care. The supervising physiotherapist provides oversight and monitors the quality and safety of the care provided, but the physiotherapist intern is expected to assess the patient, determine the plan of care, provide patient care services, and modify the plan of care as appropriate. As a regulated member of the College of Physiotherapists of Alberta, the physiotherapist intern is accountable for complying with the Standards of Practice.
The supervisor is responsible and accountable for providing supervision appropriate for the physiotherapist intern’s individual skills and competencies, the practice context, legislative requirements, and patient factors. If a complaint were received about a physiotherapist intern’s practice, the supervisor would be questioned regarding how supervision was provided and how they had determined that the supervision approach in use was appropriate for the intern and patient in question.
Purpose of Supervision
From a regulatory perspective, physiotherapists on the General Register may be required to practice under supervision for a few reasons:
- Learning a restricted activity.
- To fulfill a regulatory requirement (conduct or registration).
In these instances, the supervisor has a regulatory responsibility to supervise, monitor and evaluate the performance of another regulated member, ensuring safe delivery of quality physiotherapy services to the public.
Note: This is separate and distinct from the support that regulated members may be asked to provide to a colleague who has recently transitioned to work in a new service area. The College of Physiotherapists of Alberta’s perspective is that such situations are better classified as mentorship, as the evaluative aspect of supervision is typically lacking from these situations.
What’s Unique About This Group of Supervisees?
This is a group where the rationale for supervision will drive the expectations of supervision and any requirements established by the College of Physiotherapists of Alberta.
In the case of supervision to fulfill a regulatory requirement, the College of Physiotherapists of Alberta may establish conditions for the supervisor-supervisee pair. If approached to provide supervision in these circumstances, supervisors should ensure that they understand what is being asked of them and why supervision is required before agreeing to provide supervision.
In the case of a physiotherapist being supervised while learning a restricted activity, the requirement of supervision is established in the Physical Therapists Profession Regulation. The legislation specifies that until a regulated member on the General Register has gained the authority to perform a restricted activity which requires additional authorization from the College of Physiotherapists of Alberta independently, they must be directly supervised. This includes both clinical practice settings where the learner is supervised in their provision of care to a patient, and practice on peers in a learning environment.
Supervision Requirements Specific to Physiotherapists on the General Register
The supervisor must:
- Agree to provide supervision.
- Understand the purpose of the supervision.
- Regarding supervision related to re-entry to practice or a conduct finding:
- Be aware of any formal requirements established by the College of Physiotherapists of Alberta.
- Submit any required documentation to the College of Physiotherapists of Alberta.
- Notify the College of Physiotherapists of Alberta if they are no longer able or willing to provide supervision.
- Regarding supervision related to restricted activities, the supervisor must:
- Be competent and authorized by the College of Physiotherapists of Alberta to perform the restricted activity themselves.
- Be trained in the same method or approach to the performance of the restricted activity as that which the supervisee is learning.
- Provide direct supervision of the restricted activity and be able to observe and promptly intervene to stop or change the actions of the supervisee under supervision.
The supervisee must:
- Uphold applicable regulatory responsibilities.
- Comply with the restrictions on their independent practice and the requirement for supervised practice.
Before You Begin
Whether you are a new supervisor, new to supervised practice, or are simply entering a new supervision relationship, the following questions should be considered before you begin.
Questions for Supervisors
Before agreeing to take on the role of supervisor, physiotherapists should consider the following questions and seek additional information and resources as necessary to support them in this role.
- Does a supervision relationship exist?
- Am I competent to provide supervision?
- Am I competent in the tasks I am assigning to my supervisee?
- Am I the best person for the role?
- What’s my plan for providing supervision to my supervisee and do I have the resources and supports that I need in order to be able to provide supervision effectively?
Questions for Supervisees
- Do I understand the supervision plan and the parameters my supervisor has placed around my practice?
- Do I understand what I can do with indirect supervision?
- Do I understand when direct supervision is required?
- Do I understand the activities I cannot perform and why?
- Do I know what to do if something unexpected happens and the parameters for when I need to seek assistance from my supervisor?
- For regulated members of the College who are supervisees - do I understand my responsibilities to the College?
The purpose of supervision is to ensure the delivery of safe, quality physiotherapy service. Some aspects of effective supervision require that the supervising physiotherapist be on-site and accessible. For example, the Supervisor must be on-site:
- Initially, to observe the supervisee’s performance and determine their level of competence
- When the supervisee is learning a new skill
- To conduct supervisee evaluations
- Anytime you have concerns about the supervisee’s performance
- Any time a supervisee is performing an activity for which direct supervision is required
Supervisors must ask themselves this: How will I know if the supervisee is competent to do the tasks I have assigned?
Once the supervisor has determined the supervisee is competent and performing at an acceptable level, they may be able to provide indirect or remote supervision for interventions other than restricted activities.