The role of a Practice Advisor is sometimes misunderstood, but they serve an important function and the information they glean from close contact with registrants can help inform regulatory activities. This article is a summary of a presentation by Leanne Loranger and Susan Paul at the 2019 FSBPT Annual Meeting.
It is difficult for physical therapy practitioners to have a healthy practice if they do not understand the rules of that practice. Practice advisors (PAs) offer a valuable service to both practitioners and to regulators by helping practitioners understand the jurisdiction’s regulatory rules. Additionally, by keeping such a strong pulse on issues facing practitioners on a daily basis, PAs offer a wealth of information that is directly applicable to policymaking and college decisions.
Some regulators may be uncomfortable with the term “practice advice” because it conjures the idea of giving direct advice on how to practice physical therapy. However, it is more accurate to view the role as a vehicle for communications and outreach to practitioners. The role of the PA is to help practitioners understand what regulation might apply to the practice scenario the practitioner is bringing forward.
Please note, as Canadians, the speakers of the presentation use different terms. For example, the “college” is the equivalent of a state board. Similar to the US system, physical therapists must be licensed by a college.
We all want physical therapists to deliver effective, quality, competent care. That is the shared goal for protection of the public. Practice advisors help achieve that goal.
PAs need to be critical thinkers in order to discern what questions are appropriate for the college to answer and which questions would be best to direct to other entities. For example, some practitioners are really asking about clinical advice, such as what intervention to use. It is not the mandate of the college to answer this type of question. PAs routinely redirect these inquiries to clinical experts or other organizations.
Another common misconception is that PAs give legal advice. The college is very clear that they do not supply legal advice. Instead, the PA directs the practitioner to relevant statutes and standards and helps them to understand what the statute says and how it applies to a specific situation. All practice advice is grounded in the standards, legislation, and regulations. If a scenario is not explicitly addressed in the standards, the PA clearly identifies this and provides recommendations instead. At times the PA may suggest the registrant seek a legal opinion. In Canada, many malpractice insurance policies include limited access to free legal advice.
The PA also needs to consider whether a query is connected to the college mandate: public protection. For example, some practitioners want regulators to be more involved in advocacy (e.g., how much insurers will reimburse for particular physical therapy services or the number of sessions funded). While these topics are sometimes creatively framed as public interest issues, there is typically a profession interest that is equal or greater than the public interest. The college is not the right organization to address these issues.
Practice advice questions are rarely simple, such as “How long do I have to keep my clinical records?” Practitioners can find these answers themselves easily online. The PA usually deals with scenarios that are more complicated. For example, a patient who has gone abroad to have an experimental procedure. They return to Canada and want their physical therapist to provide the rehabilitation that goes with this procedure. However, the physical therapist did not feel competent to deliver the care, but was wrestling with their ethical obligations and duty of care to the patient. What did the college recommend?
The PA combed through the standards, leveraged existing resources, and discussed the scenario with their colleagues. The discussion with the clinician focused on the requirements for competent practice, competence development, and evidence-based practice as outlined in the standards of practice, and options to meet these requirements.
Another example was a call from a practitioner who picked up the caseload of a physical therapist who was under investigation for multiple counts of sexual assault. Many of the patients had questions for her about their former physical therapist and if the physical therapist had acted inappropriately with them. Therefore, she called to get clarity on her role. The conversation with the PA focused on the Health Professions Act requirement to report it to the college if a physical therapist has reason to believe that sexual misconduct occurred.
Those are just a couple of examples of some of the interesting, complex, high-stakes conversations PAs have every day.
Practitioners are busy trying to stay competent with the clinical care they are providing. They are trying to figure out what is wrong with their patient, not exactly what statue applies in a given situation. Because of this, they may call with a question they think is connected to one standard. However, the PA may realize that two other standards or a different piece of legislation entirely actually applies to the situation. PAs ensure that practitioners are looking at the right information. PAs are not supplying answers so much as they are raising awareness as to what is in the standards and having a thoughtful conversation as to how those standards apply to certain situations.
PAs document every conversation, email, etc. in a database. This documentation serves multiple purposes. Practice advice is not without risks and the documentation serves as a form of risk management. Even the chronology of when the college was contacted can be important. Additionally, the PA may not always get the full story. If the PA documents the information received, that documentation can help explain or defend the response provided.
Finally, documentation can simply increase efficiency. When the college receives a question that is familiar, the PA can easily look up how they addressed that question previously.
Detailed documentation is essential. Though a rare occurrence, PA records have been used in college proceedings, hearing tribunals, and complaints. Therefore, there is some a risk to giving this advice. However, the benefits outweigh the risks.
There are multiple benefits to having a PA. A PA can aid in harm reduction, help inform evidence-based policies, and foster stronger relationships between the college and practitioners and the public.
Practice advice gets right at the heart of risks and supports. PAs are a support that help create the best conditions for a healthy practice.
PAs hear from physical therapists across the experience spectrum. Novices need help with understanding the context of their situations, more experienced physical therapists may know they are brushing up against a boundary and they want to ensure they do not cross it, and mid-career practitioners know they may be working on old information, so they want to get confirmation on things they think they know.
However, the most valuable situations are with the outliers: physical therapists who work through a situation and come to conclusions that most practitioners would not come to. Sometimes it is because they are isolated practitioners and PAs can help by providing vital education and a different perspective to encourage them to rethink the way they are applying the college standards. PAs try to establish relationships with these practitioners, knowing that they may not have a network to reach out to for support. The PA is there as a resource, spending time building bridges with the registrant to ensure they have the resources they need and understanding of the college standards.
Consider this, if practitioners cannot ask the college about these complicated scenarios, who are they asking? If they are not asking the college, what risks come with that? Maybe they are asking their insurers or their association. If so, what is the focus of the person or group responding? Is the focus on public protection? Additionally, these situation-specific questions can be urgent. Practitioners might be asking about a patient who they will see the next day. Are other parties going to be responsive enough to provide appropriate guidance?
PAs play a role in harm reduction. Once practitioners have all the information they need about regulatory requirements, they may make different choices and have different interactions that ultimately protect the public.
The information PAs document can help inform data-driven regulatory decisions. The college receives thousands of requests every year. These requests can be mined for trends and reoccurring issues that perhaps the college or legislators need to address or clarify in the statutes. For example, there has been a significant uptick in social media use, telerehabilitation, and conflict of interest issues in recent years. Additionally, in Alberta, concerns about sexual abuse and sexual misconduct have seen increased attention due to recent legislative change.
Legislation is a slow process. Having the data to show how necessary and timely a change is can be vital. It can help colleges address real problems, not perceived problems.
PAs are valued. Registrants often list this service as one of the things they value most from the college, which in turn encourages a more positive dynamic.
When the PA answers a question for one contact, the recipient is not the only beneficiary. Frequent questions are categorized, time is invested in providing answers and resources are developed to share that information more broadly. Many practitioners may have the same issue but may not think to contact the college; however, they still need guidance. PAs write guides and articles addressing common issues and frequently asked questions and distribute those through multiple communications vehicles, including newsletters, social media, and the college’s website to address this need.
The college’s mandate is to protect the public, and the best way to do that is to be a proactive regulator.
Leanne Loranger, PT, MHM
Manager, Policy + Practice, Physiotherapy Alberta – College + Association
Leanne Loranger is the Manager, Policy + Practice at Physiotherapy Alberta and is involved in practice and quality improvement related activities, including policy and resource development and continuing education planning. She served as Physiotherapy Alberta’s Practice Advisor from 2014 to 2017. Leanne graduated from McMaster University’s Master of Health Management program in 2016. She currently serves as a volunteer accreditor for Physiotherapy Education Accreditation Canada and is a member of the Board of Examiners of the Canadian Alliance of Physiotherapy Regulators. Prior to her employment with Physiotherapy Alberta, Leanne worked as a physiotherapist for nineteen years in clinical practice.
Susan Paul
Manager, Professional Practice, College of Physical Therapists of British Columbia
Susan has worked at the College answering practice questions since 2002 in her role as Manager, Professional Practice. She assists with teaching the first year Masters of Physical Therapy students’ professional issues course at the University of British Columbia, where she is a Clinical Associate Professor with the Department of Physical Therapy. Susan practices clinically in an acute care cardiorespiratory setting.