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 Physiotherapy Alberta’s practice standards are met.

View the Supervision Resource Guide for Alberta Physiotherapists in PDF.

Purpose

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 Physiotherapy 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.

What is supervision?

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.

Who requires supervision?

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.

Why supervise?

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.

Managing the Supervisor-Supervisee Relationship

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, Physiotherapy 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

Physiotherapy 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.

Does a Supervision Relationship Exist?

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 Physiotherapy 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 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.

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.   

Who is Responsible?

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.  

General Principles of Supervision

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.

Supervisors

  • 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, Physiotherapy 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.

Supervisees

  • 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).

What Does Supervision Entail?

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.

Assessment

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. Physiotherapy 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.

Assignment

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.

Consent

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 Physiotherapy 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?

Monitoring

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

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

Taking a Risk-Based Approach to Supervision and Assignment

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. Physiotherapy 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.

How to Provide Supervision and Meet College Requirements

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.
  • 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.
  • Indirect, but accessible.
    • The supervisor is available by phone or other communication means and can attend the workplace if needed.
  • Remote.
    • The supervisor is not present at the worksite and cannot readily attend the workplace if contacted by the supervisee.

Methods of Supervision

Direct

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, Physiotherapy 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 Physiotherapy 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

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.
Supervisee discussions

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

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 Physiotherapy 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.  

Patient/colleague discussions

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.

In this section we will discuss how supervision expectations may vary depending on who is being supervised.

Unregulated Providers: Physiotherapist Support Workers (Physiotherapist Assistants, Therapist Assistants, Therapy Assistants, Physiotherapist Assistant Students)

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 Physiotherapy 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 Physiotherapy 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.  

Unregulated Providers: Physiotherapy Students

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 Physiotherapy 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.

Regulated Members: Provisional Register

Purpose of Supervision

Physiotherapist interns are regulated members of Physiotherapy 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.

Physiotherapy 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. Physiotherapy 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 Physiotherapy 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 Physiotherapy 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 Physiotherapy Alberta prior to practicing.
  • Notify Physiotherapy 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 Physiotherapy 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.

Regulated Members: General Register

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. Physiotherapy 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 Physiotherapy Alberta.

In the case of supervision to fulfill a regulatory requirement, Physiotherapy 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 Physiotherapy 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 Physiotherapy Alberta.
  • Submit any required documentation to Physiotherapy Alberta.
  • Notify Physiotherapy 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 Physiotherapy 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?

Q. When does the supervisor need to be on-site when providing supervision?

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.

Q. Do the supervisor and supervisee need to be employed by the same employer?

The issue is that the supervisor must be able to fulfill their supervision obligations. They need to be able, for example, to have unimpeded access to the supervisee’s work site so that they can observe the supervisee and access patient records whenever they wish or see the need to do so. The supervisor also needs to have sufficient authority within a worksite that they can establish and enforce any parameters around the supervisee’s patient care assignments, particularly when the supervisee is not yet ready to work with specific patient populations, perform specific interventions, or is only safely able to do so with direct supervision.

It is Physiotherapy Alberta’s expectation that supervisors and supervisees be employed at the same physical location, even if the supervisor does not treat patients at that location and their employment at the location is for the sole purpose of providing supervision. It may be feasible for a physiotherapist supervisor to be an independent contractor and provide supervision to a physiotherapist intern within a private practice clinic at which both individuals work.

Q. Can a supervising physiotherapist bill for treatment provided by a physiotherapist support worker or student under their registration number?

Physiotherapy Alberta’s Fees and Billing Standard of Practice states that all billing records need to be transparent and verifiable.

Physiotherapy Alberta’s Supervision Standard of Practice outlines multiple requirements that the supervisor must fulfill, including providing appropriate monitoring and reassessment of the patient condition and progress, communicating the role of supervisees, and obtaining consent for the supervisee’s involvement in the patient’s care.

Physiotherapy Alberta’s perspective is that when appropriate supervision is provided and the requirements of both standards are met, the physiotherapist may bill care provided by a support worker or student as physiotherapy 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.

Q. How should services provided by a physiotherapist intern be billed?

Physiotherapist interns are regulated members and therefore should submit bills using their own registration numbers. 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; however, if physiotherapist interns are experiencing difficulties gaining reimbursement from third party payers for services provided, they are encouraged to contact Physiotherapy Alberta’s Registrar to discuss the issue.

Q. Can physiotherapist support workers complete documentation for services they provide under supervision?

Yes. The clinical record needs to identify who provided the physiotherapy services received and the details of those services. The best individual to document the services provided is the individual who delivered the services. Depending on their training, physiotherapist support workers may have received training in how to complete documentation for services provided. If the physiotherapist support worker has not received formal training in documentation, the supervising physiotherapist will need to provide training in how to document in a manner consistent with the Documentation and Record Keeping Standard. The supervising physiotherapist also needs to provide ongoing monitoring to ensure that the physiotherapist support worker’s documentation adheres to Physiotherapy Alberta’s documentation standards.

Q. Are supervisors required to co-sign patient records of the individuals they supervise?

Historically, physiotherapists may have co-signed records as a means of demonstrating that they had fulfilled their supervision responsibilities. However, there is no legislated requirement to co-sign patient records, and doing so may not be appropriate depending on the circumstances.

If a physiotherapist co-signs notes, it can be interpreted to signify that they agree with the accuracy of the assessment and diagnosis and other details contained in the chart note. Simply reading a chart note is insufficient to satisfy the duty of confirming the accuracy of these details. The expectation in such a situation would be that the supervisor had confirmed the findings through independent or concurrent assessment of the patient.
Before co-signing a chart, the physiotherapist must be sure that they can verify the assessment findings and, therefore, the appropriateness of the treatment plan. If they were not present throughout the assessment or treatment session, they may not be able to do so, and are advised not to co-sign the patient record.

Q. How should a supervisor document that they completed a chart audit, if not providing a co-signature?

Physiotherapy Alberta recommends that if a supervisor is using chart auditing as the means of supervision, they should enter a separate note either in the patient record or in a separate supervision log, indicating the date of the chart audit, that a chart audit was completed, and the name of the individual who conducted the audit. If a chart audit is employed for the sole purpose of fulfilling the supervisor’s supervision duty, it is appropriate to document the audit in a supervision log, if one exists. If the audit is employed as part of the decision-making process for determining a change in the patient’s plan of care, or if a separate supervision log does not exist, the audit should be documented in the patient record.

Q. Can physiotherapist support workers complete outcome measures?

It is up to the supervisor to determine what is assigned. This task assignment can include the completion of measurement or rating activities if the supervisee has been determined to be competent to complete the task accurately. However, activities that require continuous clinical judgment must not be assigned to physiotherapist support workers. As such, testing protocols which depending upon such judgment may not be assigned to a physiotherapist support worker. Furthermore, it is the supervisor’s responsibility to interpret the findings of the outcome measure and determine how treatment will be modified in light of the findings.

Q. Which restricted activities can be assigned to supervisees?

It depends on the supervisee in question.
Physiotherapists on the General Register may be assigned the task of performing a restricted activity that they are in the process of learning but are not yet authorized to perform independently, provided:

  • The supervisor is present and providing direct supervision of the task
  • The supervisor is competent and authorized in the performance of the activity
  • Other regulatory requirements are met

Physiotherapist interns may be assigned tasks such as wound debridement and care, suctioning, and pelvic health internal examinations, provided:

  • The supervisor is present and providing direct supervision of the task
  • The supervisor is competent and authorized in the performance of the activity (if required)
  • Other regulatory requirements are met

Physiotherapist interns may not perform spinal manipulation or needling on another person under any circumstances.

Physiotherapist students may perform restricted activities under direct supervision while on a clinical placement if their program has included in its curriculum instruction in the performance of the restricted activity, and provided:

  • The supervisor is present and providing direct supervision of the task
  • The supervisor is competent and authorized in the performance of the activity (if required)
  • Other regulatory requirements are met

Physiotherapist support workers must not be assigned any aspect or component of any restricted activity.

Q. I am on the General Register and am currently doing a medical acupuncture course. My colleague is authorized to use needles in practice but is trained in IMS, can they supervise me while I am learning how to use needles but not yet authorized?

No. The supervising physiotherapist must be a member on the General Register and must be authorized to use needles in practice. They also need to be familiar with the approach to needling you are learning, the philosophy of care, and the correct way to perform the restricted activity based on that approach or philosophy. They need to know not only that your practice is safe, but also that it is technically correct. If you are learning medical acupuncture you need to be supervised by a physiotherapist who is trained and authorized in the performance of medical acupuncture as well.

Q. How many physiotherapist interns, support workers or physiotherapist students am I allowed to supervise at one time?

Physiotherapy Alberta does not specify the number of students/interns/support workers a physiotherapist can supervise at one time. However, it is the supervisor’s responsibility to provide adequate supervision to meet Physiotherapy Alberta’s Supervision Standard of Practice. Failure to properly supervise can put the public at risk and may have implications for the supervisor if a complaint were filed regarding the care provided by one of their supervisees.

Physiotherapists must only agree to supervise the number of students, physiotherapist interns or support workers that they can reasonably and feasibly provide adequate supervision to. This number will vary depending on the sector, practice setting, patient population and other contextual factors. If physiotherapists are pressured to supervise more individuals than they are able, it is important that they remember that Physiotherapy Alberta’s standards for supervision must take priority over the demands of employers.

Q. Who is responsible if a physiotherapist intern is supervising a physiotherapist support worker? If a physiotherapist support worker is supervising a student enrolled in a therapist assistant program?

In both cases, the supervising physiotherapist is ultimately responsible.

The physiotherapist intern is accountable for the assignments they make to support workers, but the supervising physiotherapist still has an oversight responsibility. If an assignment provided by a physiotherapist intern to a support worker is inappropriate for the support worker’s competencies or relevant regulatory rules, the supervising physiotherapist has a responsibility to address and correct the situation with the physiotherapist intern.

In the case where a support worker is supervising a student enrolled in a formal therapist assistant education program, the supervising physiotherapist’s responsibilities are more direct and include evaluating the skills of the therapist assistant student and ensuring that the assignments made to both student and support worker are appropriate. Typically, the physiotherapist and the physiotherapist support worker would share student supervisory duties, though the support worker may spend more time directly engaging with the therapist assistant student in their daily tasks.

Q. What are the physiotherapist’s responsibilities when supervising a support worker who provides both physiotherapy and occupational therapy functions for a shared patient?

The physiotherapists is responsible for supervising support workers if and when they are performing physiotherapy tasks that the physiotherapists has assigned to them. Because physiotherapists and occupational therapists have overlapping scopes of practice and competencies, it is prudent that both support workers and patients clearly understand which part of their overall treatment plan is physiotherapy (for which the physiotherapist is responsible) and which aspects of the treatment plan are not physiotherapy.
In addition, the Collaborative Practice Standard of Practice requires that the physiotherapist collaborates with the occupational therapist to coordinate the support worker’s assignment and the care provided to the patient.

Q. What are the physiotherapist’s responsibilities when working with someone who is trained as a kinesiologist, Pilates instructor or similar?

This depends entirely on whether a supervision relationship exists between the physiotherapist and the other individual. It is imperative that all parties, the physiotherapist, the other health-care provider, and the patient all understand the working relationship between the physiotherapist and the other health-care provider.
If there is a supervision relationship, then the physiotherapist must fulfill all the responsibilities identified in the standard and in this guide.

If an unregulated health-care provider is operating as an independent health-care provider, the physiotherapist does not have a supervision obligation. In this case, the other party is operating independently of the physiotherapist and is responsible for all aspects of the services they provide. In this situation, the services provided by the other individual must not be billed as physiotherapy.

Q. Do the requirements to supervise support workers differ in different patient care settings?

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

Q. What are the physiotherapist’s responsibilities if they work as a consultant?

In a consultative model of care, the physiotherapist is providing consulting services (such as education, recommendations, or programming) that will then be carried out by staff employed by a facility or organization, rather than active treatment. In this instance, the physiotherapist is not acting as a supervisor of the facility’s/organization’s staff and the staff are not acting as physiotherapist support workers.

In this model of care, the physiotherapist is accountable for the consultation and the recommendations made, but not for the services provided by the staff of the facility/organization to whom the consultation was provided.
The physiotherapist is accountable to ensure that both the patient and the facility/organization are aware of this.

An example would be if a physiotherapist provided consultation to a group home regarding a stretching program for a client with spasticity and taught the group home staff how to perform the stretches with the client. The physiotherapist would be 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, but not for the supervision of the group home staff.

Q. What about consent? Who needs to obtain consent for a supervisee to see a patient?

This depends on the supervisee in question. In the case of a physiotherapist support worker, the supervisor is responsible to obtain patient consent for the support worker’s involvement in the physiotherapy services. The support worker then obtains ongoing consent for services they have been assigned prior to providing the service.
A physiotherapy student may be assigned the task of obtaining patient consent as this is an important skill for the student to master as part of their clinical placements. The supervisor is responsible to ensure that informed consent has been obtained.

Physiotherapist interns and physiotherapists on the General Register who are working under supervision, as regulated members of Physiotherapy Alberta are subject to the standards of practice and are responsible to obtain patient informed consent for the services they provide.

Q. What are the physiotherapist’s responsibilities when they share supervision duties with another physiotherapist?

When two or more physiotherapists share supervision responsibilities, it is ideal that they communicate and collaborate in developing and refining the supervision plan with the supervisee. A clear understanding of the working relationships and responsibilities, understood by all parties, will not only provide clear direction for the supervisee but will support effective supervision.

In the case of physiotherapist interns, the supervisee must have formal, signed supervisory agreements with both supervisors.

Q. What if a physiotherapist intern’s supervisor is going to be away for a brief period, unexpectedly or otherwise?

The answer varies depending on many factors, including the phase of supervision, the supervisor’s assessment of the intern’s competence, the practice setting, and patient population served, and the duration of the absence.
The general principle is that physiotherapy services must be performed by or supervised by a member who is on the General Register.

Once the direct supervision phase has been completed, there are many ways for a supervisor to fulfill their supervision responsibilities and some may enable a supervisor to be away for a brief period or for the intern to be assigned to work on some days when the supervisor is not scheduled. For example, the supervisor could complete a caseload review discussion with the supervisee and discuss the supervisee’s care plan for patients prior to and following a brief planned absence. This may or may not be appropriate depending on the practice setting, population served, and typical patient acuity.

The supervisor must also identify a regulated member whom the supervisee could contact in the event of an unanticipated situation.

However, if there are supervisee performance concerns or the supervisor will be away for a prolonged absence, an alternate supervision arrangement is required, and the physiotherapist intern will need to submit a new supervision agreement for approval. Depending on the situation, the supervisor may also need to notify Physiotherapy Alberta that they are unable to continue the supervision agreement.

Q. What if a physiotherapist support worker’s supervisor is going to be away for a brief period, unexpectedly or otherwise?

The answer varies depending on the supervisor’s assessment of the support worker’s competence, the practice setting, and patient population served, patient acuity, and the duration of the absence.

In the case of a brief absence, the supervisor may provide indirect supervision (e.g., through a case discussion prior to and following the absence), paired with clear parameters on the treatment plan and when to seek assistance or defer care, and the identification of a regulated member whom the supervisee could contact in the event of an unanticipated situation.  

In some instances, it may be appropriate to alter the support worker’s assignment to ensure patient safety while also ensuring that the patient receives some physiotherapy services.

In other cases, the only appropriate course of action is to transfer supervision to another physiotherapist or reschedule the physiotherapy services for another day.  

Q. If a physiotherapist supervisor is going to be away for a brief period, and has assigned services to a supervisee, do they retain supervisory responsibility for the services assigned?

It depends. If the supervising physiotherapist has assigned the service to a supervisee and is willing to provide indirect supervision, they can retain responsibility for the assignment and for the treatment provided by the supervisee.

Supervisors are advised to provide clear parameters to the supervisee regarding when treatment plans should be discontinued and re-assessment by the supervisor or an alternate physiotherapist initiated (e.g., in the case of a change in the patient’s medical status, patient discharge, or need for another intervention that only a supervising physiotherapist can provide).

Supervisors should only contemplate this course of action if the supervisee has demonstrated sound clinical competence and sufficient judgement to enable safe remote supervision.

If the supervisee requires closer supervision, the supervisor is unwilling to take on the risks inherent with remote supervision, there are performance concerns, or the supervisor is concerned with the supervisee’s ability to adhere to the treatment plan and parameters established, supervision responsibilities should be transferred to another physiotherapist available to provide supervision during the original supervisor’s absence.

All parties must be aware of the supervision expectations and which parties are responsible to provide supervision.

Q. Am I the supervisor or is my unit manager the supervisor?

Again, that depends.

There is nothing that would prevent a unit manager from being the direct supervisor of an individual or group of supervisees. However, all parties must be aware of their responsibilities.

Furthermore, there is no rule that says that only a physiotherapist assistant may engage in activities such as mobilization or therapeutic exercise; however, if a physiotherapist is not involved in the provision or supervision of an activity, it must not be described as physiotherapy.

Q. What if a supervisor is going to be away for an extended period?

Patient safety and the quality and effectiveness of physiotherapy services received are of paramount concern. Using indirect forms of supervision may be appropriate for a brief absence, but if a supervisor is going to be away for an extended period, whether due to an unexpected situation or a planned absence, the responsibilities of supervision must be transferred to another physiotherapist willing and able to provide supervision. In some instances, this may be done informally; however, in the case of a physiotherapist intern the transfer of supervision responsibilities for an extended period will necessitate that the intern submit a new supervision agreement to Physiotherapy Alberta for approval.

Q. What aspects of supervision should be documented in the patient record?

In addition to having a supervision plan that describes how supervision will be provided and the anticipated progression of that supervision, certain aspects of the supervised practice should be documented on the patient record. For example, when a patient provides consent to be treated by a supervisee, the consent should be documented. In addition, when a physiotherapist assigns tasks to a support worker or physiotherapy student the tasks assigned and parameters of treatment must be documented in the patient record.

Q: When is a telerehabilitation a form of supervision, and when is it not?

In some instances, audio or video conferencing may be employed by a physiotherapist so that they may virtually attend a treatment session and observe the actions of another health provider. This can take many forms including a physiotherapist consulting with a peer, a physiotherapist remotely supervising a physiotherapist intern or a physiotherapist directing the actions of and co-treating a patient with a physiotherapist support worker who is co-located with the patient. It is important to identify what the specific responsibilities of the individual attending virtually are, to determine if a supervision responsibility exists.

In the instance where the physiotherapist is providing a remote consultation to a fellow regulated member, the virtual attendee is providing a consultation service, not supervision.

In the case where the physiotherapist is supervising a physiotherapist intern using video or audio conferencing, the supervision responsibility is established by the supervision agreement between the two individuals, and the supervisor is using telerehabilitation technologies to fulfill their responsibilities.

In the final instance, the physiotherapist-physiotherapist support worker team are delivering physiotherapy services with the physiotherapist located at a distance and the support worker co-located with patient. In this case, the services provided by the physiotherapist could be described as telerehabilitation services with the support worker acting as an extension of the physiotherapist to enable physiotherapy care. However, the physiotherapist could also use telerehabilitation technologies to fulfill their supervision responsibilities remotely. When doing so, the physiotherapist support worker would be leading the patient care session, with the supervising physiotherapist using technology to enable an observation of the services provided.

The Chart Stimulated Recall Interview is an activity in which the physiotherapist supervisor interviews a supervisee about the care delivered to a patient. The selected patient chart is used to help guide recall about the details of the patient’s case.

  • The supervisee uses the experience to reflect on and improve their practice.
  • The supervisor uses the experience to evaluate the supervisee’s clinical decision making.

Instructions:

  • One chart is selected to be used for the interview.
  • The supervisor reviews the chart prior to the interview.
  • It is anticipated that the interview will last approximately 45 minutes to one hour.
  • The questions on the Chart Stimulated Recall form are the basis of the interview; however, every question may not be applicable to every chart. Areas described on the form may be explored in further detail. Areas not specifically addressed on the form may be explored, as appropriate.
  • The supervisor records key information in the space provided.
  • Both the supervisor and the supervisee may refer back to the patient’s chart, as needed, during the interview, to assist with recalling details about the case.
  • The intended outcome of the Chart Stimulated Recall is improved patient care in the future through reflective review of care provided in the past.

Overview

Briefly summarize this patient, their presenting condition and the reason for them seeking/you providing physiotherapy intervention.

 

Consent

Describe how you obtained informed consent from the patient for the assessment and the treatment plan.

 

Describe what was discussed with the patient in obtaining informed consent.

 

 

Describe how you documented the informed consent.

 

 

Assessment

You collected subjective information (history/background) information. Describe why you collected the information you did.

 

Describe the impact of the information you collected on the subsequent assessment and treatment provided.

 

On reflection, is there any information you did not collect, that would have been helpful in the treatment of this patient?

 

Describe the physical/objective assessment you undertook with this patient; please explain/describe the relevance of the assessment techniques chosen.

 

How did the results of each procedure potentially affect your physiotherapy care?

 

Is the clinical record a reasonable reflection of the assessment process you undertook with the patient?

 

On reflection, are there assessment techniques that you would include or delete if given the same scenario?

 

Diagnosis

What was your clinical diagnosis?

 

What led you to this conclusion?

 

Did you consider any differential diagnosis? Please describe.

 

Goals

Did you identify the patient’s expectations/goals of physiotherapy? How?

 

Describe how you documented the patient’s goals.

 

Treatment Plan

Describe the treatment interventions you chose to use over the course of care and why you chose them.

 

Describe how you decided how often to see this patient and for what duration.

 

Describe any other alternative courses of action or treatments considered.

 

Describe any of the following that may have been provided to the patient over the course of treatment:

  • Education
  • Home programming
  • Functional status

How were these interventions documented?

 

Objective Evaluation/Re-evaluation

How did you determine whether your treatment interventions were having a positive impact on the patient? What measures did you use to monitor this patient’s condition?

 

Did the patient’s condition progress as you had expected? What factors were considered?

 

Treatment Progression

Describe how and why you progressed the patient’s treatment plan over the course of care.

 

Discharge Planning

Did you instruct the patient regarding recommendations for post discharge or self-management? What did you communicate? When and how did you communicate this component of care?

 

How did you document this component of care?

 

Please describe the discharge criteria regarding why this patient was discharged from/discontinued treatment.

 

Risk Evaluation

Describe how you assessed and then identified any possible risks of the proposed treatment plan.

 

Describe any adverse consequences that may arise in your practice related to the performance of the techniques used during the course of care.

 

Collaborative Care

Were other health-care professionals involved in the patient’s care? Describe how you facilitated a coordinated approach to care.

 

Conclusion

Following review of this patient’s treatment file, is there anything you would do differently, in a similar situation, in the future?

 

Strengths/Positives in This Case:

 

 

 

 

Areas for Improvement in Future Cases: