Good Practice: Is There a Supervision Relationship?
June 7, 2021
Throughout their careers, most physiotherapists find themselves in the position of having to supervise another individual providing physiotherapy services. The Merriam Webster dictionary defines supervision as “the action, process, or occupation of supervising; especially a critical watching and directing (as of activities or a course of action).”1
Any health-care provider who delivers services to an individual patient owes a duty of care to that patient and is responsible for the care they provide, as well as their acts, errors, and omissions. When a physiotherapist is supervising another health provider, they have additional responsibilities related to their role. These are described in the Standard of Practice and include:
Assessment of the knowledge and skills of supervisees to determine competence
Assignment of tasks/activities that fall within the supervisee’s personal competence and that the supervisor is also competent to provide
Assessment of patients to identify those that are appropriate to receive services from the supervisee
Employment of appropriate supervision strategies to maintain client safety and quality care provision
Monitoring and evaluation of services delivered by the supervisee
Intervention if there are patient safety concerns or risk of harm arising from the supervisee’s care
Monitoring patient outcomes to ensure safe, effective, and appropriate care is being provided by the supervisee, and that patient needs are addressed and outcomes achieved.
In some instances, it is clear that a supervision relationship exists between the physiotherapist and the other health-care provider. This includes situations where the supervisor has offered a clinical placement to a physiotherapy or physiotherapist assistant student, or when a physiotherapist on the General Register has signed a supervision agreement with a physiotherapist intern.
There are other situations, where the existence of a supervisory relationship may not be as clear. Have you ever felt unsure if you were responsible for supervising another provider or whether you would be accountable for their actions? Although challenging in some situations, it is important to clarify if a supervision relationship exists.
Some examples that can lead to confusion include:
When a physiotherapist provides consultation services in a group home environment, school system or other setting, providing 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 case.
When a physiotherapist works as part of a multidisciplinary team that includes both regulated health professionals and unregulated health providers to provide care to an identified patient population in a facility-based setting.
When a physiotherapist works collaboratively with personal trainers or kinesiologists in a community recreation centre, exercise facility, or multidisciplinary clinic.
While each situation is unique, the table below presents some characteristics of professional relationships that make it more or less likely you are in a supervisory relationship. Be aware that this is not an exhaustive or definitive list, and the absence of any single factor does not necessarily indicate that a supervisory relationship does not exist.
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 Physiotherapy Alberta registration number.
Exception: Registered members of Physiotherapy Alberta (e.g., PT interns) always bill for their services using their own registration number, regardless of the supervisory relationship.
Services of physiotherapist and the other party are billed separately.
The other party’s invoices do not make use of the physiotherapist’s registration number.
To help illustrate the point, let’s look at these characteristics as they relate to working relationships between physiotherapists and unregulated providers more closely.
Scenario #1: Single Discipline Community Practice
One of the most common scenarios occurs within a physiotherapy clinic that employs both physiotherapists and unregulated physiotherapist assistants. When both the physiotherapist and the unregulated worker are employed by the same organization and their job descriptions describe a relationship in which the physiotherapist assigns tasks, supervises activities, and monitors, or evaluates the performance of the physiotherapist assistant, a supervisor/supervisee relationship exists.
Scenario #2: School or Group Home Consultations
Every year, Physiotherapy Alberta receives questions from registrants working in these environments who are uncertain about their responsibilities when they leave a set of recommendations with a school, teacher, or group home operator following the assessment of a specific patient.
These recommendations are often implemented by a non-regulated health professional, or someone who is not a health professional at all. To what extent is the physiotherapist responsible to ensure the plan is followed correctly, that the individuals providing the recommended services are competent and properly trained, and is the physiotherapist responsible in the event of an injury or adverse event?
In this scenario, the physiotherapist is providing a consultation service to another organization, using their assessment findings to create recommendations to the other organization. The consultant’s report, including recommendations for action, is provided to the school or group home, and in a consultative model of care and the consultant’s responsibilities are complete. The patient is discharged from the physiotherapist’s active caseload. In some cases, the physiotherapist’s contract may include training of staff to deliver the recommended services. However, at the end of the consultation there is no expectation for the physiotherapist to monitor the performance of the staff providing services, evaluate their performance or provide follow-up assessments until they are contacted again for a new consultation. There is no supervisor/supervisee relationship, and though responsible for the recommendations made, the physiotherapist is not responsible for the care provided by the employees of the other organization (e.g., the education assistant or personal support worker). Most importantly, all parties – the physiotherapist, the patient and family, and the other organization (school or group home) understand the roles and responsibilities of the physiotherapist and the school or group home staff.
Scenario #3: Multidisciplinary Community Practice
In some situations, organizations hire or contract both regulated physiotherapists and unregulated kinesiologists and athletic trainers.
If a kinesiologist or athletic trainer have been hired to support physiotherapists in the provision of physiotherapy, then a supervisory relationship exists and the physiotherapist must fulfill the responsibilities of supervision. The physiotherapist retains responsibility for the assignment of services, oversight of the delivery of services, and ultimately for the care provided. The physiotherapist explains to the patient that the kinesiologist or athletic trainer is providing care under the supervision of the physiotherapist, and the patient must consent to this.
However, in these settings an unregulated kinesiologist or trainer could be hired to be an independent service provider. In this scenario they would complete their own assessments and develop/monitor/modify the patient’s programs independent of the physiotherapist. In this instance there is no supervisory relationship. The patient must understand that this is not physiotherapy, and the sessions cannot be billed as physiotherapy under the physiotherapist’s registration number.
In some situations, the physiotherapist may complete an assessment and determine that the patient’s needs can be best addressed by the kinesiologist or athletic trainer in which case they may refer the individual to the kinesiologist or athletic trainer. This would be no different than referring the patient to another health professional. The referral results in the patient being discharged by the physiotherapist and the ongoing care is assumed by the unregulated provider. Care is no longer physiotherapy, there is no supervisory relationship, and the ongoing sessions cannot be billed as physiotherapy.
One of the most challenging situations that can arise is if a kinesiologist or athletic trainer works at times as a physiotherapist support worker and at other times as an independent health provider. These situations can lead to a great deal of confusion on the part of patients and others in the practice environment. The physiotherapist needs to take appropriate steps to avoid confusion on the part of patients and payers in such a situation.
Scenario #4: Multidisciplinary Public Practice
This scenario involves multidisciplinary teams composed of more than one regulated health-care professional and unregulated support personnel. This situation can lead to confusion on the part of the support worker and the regulated health professionals as to who is responsible for supervising and monitoring the care provided by the support worker.
Physiotherapists in this scenario are responsible for the activities and tasks they assign to support workers as part of the patient’s treatment plan. Physiotherapists are not responsible for tasks and activities assigned by other health professionals or managers. It is vital that all members of the team understand this concept and recognize when they are responsible for supervising unregulated health providers tasked with implementing the care plan. Good communication among team members is key to ensuring that the needs of the patient are met by the most appropriate members of the team and that appropriate oversight of services is provided. When services are provided by an unregulated health provider without the supervision and assignment by a physiotherapist, the services cannot be referred to as physiotherapy.
Defining when a supervisory relationship exists can be challenging. It is imperative that all parties, including the supervisee, other regulated team members, and managers/owners/employers are aware of their roles and responsibilities.
If you are unsure, discuss the relationship and expectations with your employer and co-workers. Ensure all parties understand who is expected to develop, implement, and monitor the treatment plan, who is responsible for the assignment of services, and who is responsible to supervise the unregulated health provider. If you are assigning tasks to the unregulated health provider this is a supervisory relationship, and you are responsible to provide appropriate supervision.
Ensure any services that are provided by unregulated team members which are not supervised by a physiotherapist are not referred to, presented as, billed as, or otherwise implied to be physiotherapy.
If you are unsure whether a supervisory relationship exists in your situation, contact Physiotherapy Alberta’s Practice Advisor who can walk through the scenario with you and provide support and guidance.