The practice advice team occasionally gets questions like the following:
Q: How do you develop and prove competence in a restricted activity like suctioning or reducing a dislocated joint?
Q: How about in a non-restricted activity like blood flow restriction training?
Q: If you were trained in acupuncture, can you also perform trigger point dry needling?
Q: If you want to pick up new acupuncture points that you didn’t learn or weren’t tested on in a course, can you?
This article will highlight the questions we commonly get asked about competence and more specifically competence in regard to restricted activities.
“Everybody’s got a different circle of competence. The important thing is not how big the circle is. The important thing is staying inside the circle.” - Warren Buffet
The College of Physiotherapists of Alberta expects its registrants to practice within their level of competence as well as maintain competence in existing and emerging areas of their practice by actively pursuing continuous lifelong learning. With respect to restricted activities, physiotherapists should not only be competent in performing them but must also be authorized or supervised to perform them in accordance with the Standards of Practice.
Q: I was looking at using blood-flow restriction (BFR) cuffs in my practice, would I be able to use it?
A: Great question. The use of BFR cuffs is not a restricted activity so there are no specific authorizations granted around its use in physiotherapy practice. However, there are risks to its use in practice and you must consider these as you build and document your competence. Physiotherapists must be competent in the techniques they use in practice. As a regulated professional, physiotherapists are responsible for ensuring they have the competence to provide the interventions to the populations they serve and for pursuing appropriate education/training to obtain and maintain this competence.
The College does not require you to take a specific course or certificate to implement BFR into your practice, but a course would be a great place to start as this is not an entry to practice skill. You could also list out articles you read, instructional videos you watched, the precautions or contraindications you considered, and the safety measures you put in place. Having a record of the things you did to learn about and safely implement BFR would help to demonstrate you took the time to learn this properly before implementing it into your practice.
Q: I work in a remote setting and we lack access to professionals who fit pessaries. I am authorized to do pelvic health internal exams, can I add pessary fittings to my practice? If so, what do I need to do?
A: This is a restricted activity so yes, you would have to be competent and authorized to perform pelvic health internal examinations. Ideally, you would have worked in the pelvic health setting for some time and gained experience prior to pursuing additional training in pessary fitting. You also need to provide the service in the context of the provision of physiotherapy and in accordance with the Standards of Practice.
With less common areas of practice such as pessary fitting, best practice would be to have a strong, multi-disciplinary or interprofessional team with good support and collaboration. Often the development of competence in these additional skills of pelvic health practice involves mentored practice, and specific knowledge and skill development through several means as already discussed.
Q: I have my sport physiotherapy diploma and there have been instances in training and competition where fingers have been dislocated.
My colleagues have taught me/supervised me when it comes to reducing these injuries, and I see on the website that there is no application or approval required to perform this skill.
Do I need to include on my registration/license that I am able to perform joint reductions? Is there a specific course or some form of proof that I can do so adequately? I just want to make sure I am able to do so in practice, under my current license.
A: The reduction of a joint is a restricted activity that is similar to wound debridement and suctioning. None of these restricted activities require additional authorization; however, you do need to be competent to perform that activity as there are increased levels of risk, which is why it is a restricted activity.
You should view the process of gaining competence as similar to when you were doing mentorship hours for your sports certification. In order to demonstrate competence in the reduction of dislocations you could list out what you did to become competent in a way that most physiotherapists would deem reasonable. This may include actions such as:
- Theoretical knowledge: listing the videos, articles or texts you read to get the knowledge required (how to do it, relative risks, contraindications, etc).
- Practical skill development: listing clinical experiences (e.g., mentorship hours) and document what your focus of learning was in those hours and how your competence was assessed.
- Practical experience: keeping track of the dislocations you have watched, assisted with or reduced yourself and reflect on them (continuing competence).
This can be a challenging restricted activity to gain competence in as it is not often that physiotherapists are working in an area of practice where acute dislocations are seen. Even in contact sports you usually have to work quite a bit to see several dislocations. It may be worthwhile to look at potential practice sites that have sport medicine doctors or opportunities for on-field coverage that may allow you to gain more practical experience. As with all restricted activities, if you are going to pursue this restricted activity it is important to ensure that you have the competence to do so and that you limit your practice to activities that you are competent in, to ensure your clients get safe, quality, and effective care.
If you are performing any restricted activity granted to physiotherapists you must report that on your member profile.
It is important to keep in mind that restricted activities are restricted because they come with higher risk. If a complaint or client safety incident arises it is likely that there would be questions asked about your training, how your skills were assessed, and the work you’ve done on an ongoing basis to maintain your skill. You can look at the Standard of Practice – Continuing Competence for more information.
Q: I am looking at working in wound care and was wondering what course would be best. There seems to be a couple that are offered that I can take but what do you think would be appropriate?
A: Thanks for your email but the College of Physiotherapists of Alberta does not endorse any specific courses regarding wound care or any other areas of practice. Registrants are encouraged to evaluate course offerings to determine if the course will provide them with the necessary knowledge and skills to be able to competently adopt treatment techniques and safely apply their knowledge to address the needs of their patients.
Q: I recently completed my acupuncture course and have authorization from the College to perform acupuncture on clients. I was wondering if I can start doing trigger point dry needling since I am authorized to use needles in practice.
A: Acupuncture and trigger point dry needling or IMS involve different foundations of knowledge, assessment systems, and needling techniques so to learn one system does not make you safe to practice the other. To apply for authorization to perform dry needling, you must provide evidence of meeting several conditions one of which is to have
“Completed a post entry-level needling education program that includes as part of the curriculum: theory, practice, safety instruction, and final (summative) evaluation conducted by the course instructor which resulted in a passing grade.”
If a physiotherapist in Alberta who is authorized to use needles in practice wishes to learn a new needling technique or use needling points or techniques that they were not trained and tested on in their course, they are expected to complete the same steps in order to develop their knowledge and demonstrate competence with the new needling technique. They would also need to continue to be aware of and practice in accordance with the Standards of Practice (especially Competence and Performance of Restricted Activities).
Action Items
Reflect on your practice.
How can you gain competence to perform a restricted activity?
- What education/training do you need?
- Is it realistic and possible that you can gain competence in your current practice site/environment?
- Are you able to get the support and mentorship needed to meet the College’s requirements and to ensure you can provide safe quality care?
- How will you know if you are competent to perform the restricted activity independently?
- If you had to defend your competence in front of a group of your peers, what would you point to as evidence?
