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.
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.
- 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.
- 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.
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.
When assigning tasks to supervisees, the sole consideration must be the interests of the patient. The supervisor must identify the activities to be assigned. When doing so, they must only assign and supervise activities which they themselves are competent to perform.
Within the clinical environment, it is realistic that a supervisee may have skills and competencies that differ from those of their supervisor. For example, in cases where the supervisor is a physiotherapist intern working with an experienced physiotherapist support worker, or where the physiotherapist support worker’s background includes training that differs from that of their supervisor. If a supervisee were to perform a task or activity that the supervisor was not competent in, the supervisor would not be able to evaluate the appropriateness of the task, nor assure the quality and safety of the services provided. For this reason, the supervisor may only assign those tasks and activities that they, themselves, are competent to perform.
The tasks and activities assigned, and the method used to monitor the performance of that assignment should become part of the supervision plan. This documentation, which pertains to the supervisee, is in addition to the documentation which must be included in the patient record regarding the treatment plan established by the physiotherapist and the tasks assigned to other members of the health-care team.
The assignment and supervision plan should include parameters and protocols to direct supervisees’ actions regarding when guidance or patient re-assessment from the supervisor is required. These parameters and protocols may include both critical events that would necessitate a re-evaluation and anticipated milestones that may require a revision to the care plan. These parameters and protocols will differ depending on the group to which the supervisee belongs (e.g., physiotherapist support worker vs. physiotherapist intern), as well as the individual competencies of the supervisee.
The ethical principle of patient autonomy, a core value of physiotherapists, naturally leads to the requirement that patients be aware of the role and skills of individuals involved in the provision of their care and that this information be provided to patients in a clear and transparent manner. This is imminently important when working with supervisees.
The patient must be aware of and consent to the involvement of supervisees in the provision of their physiotherapy care. Further, the respective roles and responsibilities of different providers involved in the provision of physiotherapy services must be explained to the patient. How is the quality of their care assured through effective supervision by the physiotherapist? Who can they speak to if they have a concern or complaint, (up to and including contacting 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?
The requirement to provide supervision continues after the period of supervisee assessment and mandatory direct supervision comes to an end.
Supervisees require ongoing monitoring of their performance to ensure that safe, quality physiotherapy services are provided and that those services meet the patient’s needs. Monitoring enables the supervisor to comply with the expectations articulated in the Supervision Standard of Practice.
Ongoing monitoring may include both direct and indirect forms of supervision, employing different supervision strategies, as indicated by the practice context, patient needs, and skills and competencies of the supervisee.
The supervisor bears the ultimate accountability for the appropriateness of the supervision provided, and as such they alone have the authority and responsibility to impose ongoing supervision requirements. The supervisor should be prepared to explain how they determined the appropriate supervision approach for a given supervisee, patient population and treatment technique.
It is anticipated that supervisees will require progressively less direct supervision over time. However, it is not anticipated that a supervisee will transition to entirely indirect supervision for all assignments immediately following the assessment phase.
The pace of the transition from direct to indirect supervision will depend on the context of the practice, and the supervisee’s past experiences and individual competence, the tasks assigned and relevant regulatory requirements.
Reassessment refers both to the necessity of reviewing the supervisee’s performance and the need for an alternate approach to supervision, as well as to the imperative to reassess the patient and the outcomes of care to assure that the physiotherapy services provided are addressing the patient’s needs.
With regards to care provided by physiotherapist support workers, physiotherapists must not assign a patient’s care to a supervisee, with the patient never to be seen again by a physiotherapist. The frequency of patient reassessment by the supervisor must reflect the anticipated trajectory of patient progress or change. As such, the frequency of patient reassessment will be different depending on the patient’s condition and the sector in which the physiotherapist works. At a minimum, the physiotherapist is responsible for the decision that physiotherapy services are no longer required and for discharge planning.
Similarly, the frequency of reassessment of the supervisee’s skills and the supervision plan must take into account:
- The skills and training of the supervisee
- The initial supervision plan
- The tasks assigned to the supervisee, legislative regulatory considerations
- The context of practice
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.
- The supervisor is not present at the worksite and cannot readily attend the workplace if contacted by the supervisee.
Methods of Supervision
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 assesses the clinical reasoning and judgment applied to a real-life situation and helps to determine the supervisee’s thought process. In preparation for the discussion, the supervisor advises the supervisee that they plan to review a patient chart, provide feedback about the contents of the chart, and then discuss the case with the supervisee.
Following review of the patient record, the supervisor asks the supervisee standardized questions related to patient care assessment, diagnosis, treatment and decision making. See Appendix 1 for sample questions.
Ongoing dialogue should be part of all supervision plans. Discussions should occur regularly (e.g., weekly caseload review) to discuss patient cases, monitor clinical reasoning and patient care, and to inform the need for formal evaluation. This form of supervision is also important for addressing supervisee questions when faced with unfamiliar situations or unexpected outcomes.
Discussions can be held in person, using audio or videoconferencing, or by email.
Chart audits provide supervisors with information about the completeness, quality and appropriateness of care provided by a supervisee. A chart audit can also be used to determine if the supervisee is adhering to 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.
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.