As the health-care environment becomes more interprofessional in how care is delivered, the boundaries between the roles of different health professions can become less clear and distinct. Although current legislation identifies regulated health professions and restricted activities, it does not define professional scopes of practice. It is important for physiotherapists to understand how physiotherapy practice is described in the Health Professions Act (HPA), and the boundaries to practice imposed by the Government Organization Act (GOA), and the Physical Therapists Profession Regulation (PTPR). Although specific definitions of scope are not included in the HPA, the Act describes physiotherapy practice in the following way:
In their practice, physiotherapists do one or more of the following:
(a) assess physical function,
(b) diagnose and treat dysfunction caused by a pain, injury, disease, or condition to develop, maintain, and maximize independence and prevent dysfunction,
(b.1) engage in research, education, and administration with respect to health services delivery and the science, techniques, and practice of physiotherapy, and
(c) provide restricted activities authorized by the regulations.1(Schedule 20, Section 3)
The absence of legislated scopes of practice does not mean that anyone or everyone is competent (has the requisite knowledge, skills, and attitudes) to safely engage in a specific activity. As the profession evolves and grows in new directions, physiotherapists and the College must consider not only the legislation, but also entry-to-practice education and current evidence to support the role of physiotherapy in the delivery of a new or expanded service.
The role and boundaries of scope of practice of physiotherapists in the provision of medication management-related services has been a source of questions from physiotherapists and managers. Although the definition provided by the HPA does not expressly allow or prohibit physiotherapists having a role in medication management, it is doubtful that the intent of the legislation was to support significant involvement in medication management. This is particularly the case when the restrictions imposed by the GOA and the PTPR, which restrict physiotherapists from prescribing medications, are considered.
This article will look at the entry-to-practice education and training physiotherapists receive, what on the job knowledge they may gain, and the role physiotherapists may play in medication management activities.
Pharmacology education and training
The term medication management encompasses the provision of medication assistance, involvement in medication reconciliation, and furnishing medication advice to patients (regarding both prescribed and over the counter (OTC) medications).
Within the current physiotherapy curriculum, education about medications is often presented alongside other information and is related to the assessment and management of common conditions treated by physiotherapists. For example, a physiotherapy student may learn which medications are commonly used to manage Parkinson’s disease or the increased tone experienced by a patient with a spinal cord injury. They may also develop a basic understanding of how specific medications may affect a patient’s balance, memory, or general function. However, a review of the Entry-to-Practice Physiotherapy Curriculum Guidelines from the Canadian Council of Physiotherapy Programs2 includes no reference to curriculum content related to pharmaceuticals, pharmacology, or pharmacokinetics. There is also no formal instruction or training in the administration of medications. There is no background education to provide physiotherapy students with the competency to identify drug errors or omissions, know or recognize when there is a potential for an adverse reaction to a specific drug, or when a combination of medications may result in an unwanted drug interaction and negative results. This means that physiotherapists do not have the entry-to-practice knowledge to counsel patients on which medications to take, which ones to discontinue, and how/when to take them.
Over time and with experience, physiotherapists may gain a working knowledge of medications commonly used within their practice setting and with the patient populations they interact with on a regular basis. Knowledge gained through personal experience is considered tacit knowledge.3 Although valuable, this type of knowledge does not replace that which is gained through formal education. Working on the spasticity team, rheumatology unit, or with orthopedic surgeons may give physiotherapists an increased awareness of the usefulness and risks of regularly prescribed medications but does not provide them with the competency to offer advice on the use of these medications, or the knowledge to determine the appropriate dosage, duration, or risks associated with these medications.
Why is relying on tacit knowledge dangerous?
Consider the adage “you don’t know what you don’t know.” This is very true in this discussion. Even without formal training and education in pharmacology, physiotherapists may have gathered some knowledge about a specific drug and its usefulness in certain situations. However, a physiotherapist may not have access to the patient’s complete medical and medication history, know which other medications the patient is taking and how a new medication may affect their health either positively or negatively. Furthermore, the pace of change in the pharmaceutical industry is rapid, with new medications introduced weekly, and updates to prescribing guidelines and adverse reaction profiles published all the time. This continually growing base of knowledge is difficult for health professionals who are constantly involved in medication advising or prescription to keep up with. Authorized prescribers also have readily available resources and databases to support safe practice which physiotherapists do not typically have access to. Providing medication advice without this knowledge and access to these supports creates risk for the patient.
Providing medication advice about a prescribed or over the counter drug without the knowledge to do so competently puts the physiotherapist at risk as well. As a health-care professional in a patient-provider relationship, physiotherapists are in a position of a power. The patient would inherently tend to trust what the physiotherapist is saying and may take the physiotherapist’s advice without seeking an opinion from a more appropriate professional. If this led to an adverse event, whether minor or life-threatening, the physiotherapist could be held accountable for their actions and the subsequent results. Again, it is important for physiotherapists to remember that you don’t know what you don’t know and that this presents significant risks to both the patient and the physiotherapist.
Medication reconciliation and the role of physiotherapists
One aspect of medication management in which physiotherapists may play a limited role, is in medication reconciliation.
Medication reconciliation is more than simply asking a patient for a list of medications they are taking. It is a systematic process used to review a patient’s prescribed medications (over the counter and non-prescription medications) and substance use, therefore, requiring in-depth knowledge of pharmacology to facilitate the safe use of medications and mitigate against adverse drug events.4,5
The purpose of completing medication reconciliation is to:
Identify any errors or changes in prescription medications and how medications are being taken
Identify any concerns with medications prescribed or patient adherence with prescribed medications
Counsel patients about their medications
Resolve any discrepancies between the patient report and the last known medication list4
There are several steps involved in the process of medication reconciliation, so it is essential that physiotherapists understand the components of the process, and where they might be able to contribute. Medication reconciliation includes:
Generating a Best Possible Medication History (BPMH)
Reviewing medications being taken to ensure they are appropriate, identifying any errors or discrepancies and notifying the prescriber
Making required changes to the medication orders and reconciling this in the medication record to ensure the final medication list is accurate4,6
Some aspects of the medication reconciliation process require knowledge and competence in pharmaceuticals, pharmacology, or pharmacokinetics or are activities that are restricted under the GOA that physiotherapists are not authorized to perform.7 Steps 2 and 3 in the process identified above are not within the competence or scope of practice for physiotherapists.
Best possible medication history
There is some question as to whether a physiotherapist can complete step 1 in the process – the completion of a BPMH. When deciding if a physiotherapist can complete a BPMH, it is important for the physiotherapist to understand what a BPMH is, and what it is not. A BPMH requires a more thorough medication history be taken than that which physiotherapists typically obtain as part of their patent history. The BPMH includes a detailed review of all the medications being taken, including the dose, frequency, timing and mode of delivery.6 The individual gathering the BPMH must also obtain information related to missed doses or other signs related to poor or non-adherence with prescribed medications.6
Physiotherapists are trained to gather relevant information from patients and/or caregivers as part of their initial history taking process. This may give them the required education and competence to collect the information required in step 1 of the BPMH. However, the ability to identify discrepancies or where clinical judgment is required regarding the appropriateness of medication use is not within the competence of a physiotherapist.
Where a BPMH constitutes more than a simple clerical review, and particularly where judgment is required, the physiotherapist’s participation in the activity creates risk for both the patient and the physiotherapist and is not recommended. If a physiotherapist were assigned the task of performing a BPMH by their employer or by virtue of their work role, they must have supports in place, in the form of duly trained health professionals assigned to provide assistance when required and formal policies and procedures to address situations where clinical judgment is required to ensure patient safety.
Adverse events and even deaths related to medication errors remain common and are an ongoing patient safety concern. Therefore, it is vital that the individuals who are involved in performing a BPMH have the knowledge, skills and experience to do so competently and understand the limits of their ability to contribute safely to the task.
So, what does this all mean for physiotherapists?
Physiotherapist involvement in medication management activities poses risk to both the patient and the physiotherapist. Due to their lack of formal training, the tasks of medication reconciliation, providing medication administration and providing advice about medication use are generally outside of the scope and competence of physiotherapists.
If a physiotherapist is asked to perform duties related to medication management, they need to consider the risks to both the patient and themselves. Physiotherapists must also reflect on their personal competence, and employer supports in place to ensure they provide safe and effective care that is in the patient’s best interest and should limit their involvement in these activities accordingly.
Although this article has focused on medication reconciliation, Physiotherapy Alberta’s newly published Medications Guide also discusses the risks of physiotherapist involvement in medication administration and medication advising in detail and provides advice to the profession regarding the performance of these activities.
For more information related to the role of physiotherapists in medication management activities, please refer to the Medications Guide.