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Physiotherapy Thresholds

Background to the Physiotherapy practice thresholds

The Physiotherapy Board of Australia (PhysioBA) and the Physiotherapy Board of New Zealand (PBNZ) worked together between 2012 and 2015 to develop and publish the Physiotherapy practice thresholds in Australia and Aotearoa New Zealand (referred to here as “Physiotherapy practice thresholds”).

The PhysioBA and PBNZ will regularly review the published Physiotherapy practice thresholds to maintain their relevance to the expectations of threshold competence required for contemporary physiotherapy practice in Australia and Aotearoa New Zealand.

 

Purpose of the Physiotherapy practice thresholds

The Physiotherapy practice thresholds describe the threshold competence required for initial and continuing registration as a physiotherapist in both Australia and Aotearoa New Zealand.

 

Format of the Physiotherapy practice thresholds

The format of the Physiotherapy practice thresholds draws on a competency framework, the CanMEDS framework, developed by the Royal College of Physicians and Surgeons of Canada (Royal College). The CanMEDS framework “describes the abilities physicians

require to effectively meet the needs of the people they serve” (Frank, Snell, Sherbino et al, 2014, p 1). The CanMEDS framework emerged in the 1990s and was first launched by the Royal College in 1996 and subsequently updated in 2005. The Royal College will publish a third version in late 2015.

 

The main feature of the CanMEDS framework is the thematic arrangement of competencies based on seven integrated roles of physicians in practice. The thematic arrangement

of competencies based on roles of practitioners in practice, drawing on the CanMEDS framework, has gained acceptance in several other countries. The medical profession in Australia, Aotearoa New Zealand, Denmark and the Netherlands has adapted the CanMEDS framework for entry to medical practice. Other professions, including the physiotherapy profession in Canada and the Netherlands, have drawn on the CanMEDS framework to describe the competencies that are “essential” at the beginning of, and throughout, a practitioner’s career.

In applying the CanMEDS approach, the Physiotherapy practice thresholds arrange key competencies within seven integrated and thematic roles: Physiotherapy practitioner, Professional and ethical practitioner, Communicator, Reflective practitioner and self- directed learner, Collaborative practitioner, Educator and Manager/leader. Although the Physiotherapy practice thresholds arrange key competencies within separate roles, the Physiotherapy practitioner role is central to physiotherapy practice in any context, and,  as practitioners, physiotherapists integrate the other roles in the Physiotherapy practice thresholds with that central role as they apply to the context of the physiotherapist’s practice.1

The Physiotherapy practice thresholds expand on each of the seven roles at three levels:

 

“Role definition” describes the essential characteristics of physiotherapy practice encompassed by the corresponding key competencies. When combined, the seven role definitions describe the essential characteristics of a competent registered physiotherapist in both Australia and Aotearoa New Zealand.

“Key competencies” are described for each role. The key competencies are the practices necessary for a physiotherapist to safely and effectively perform the central role of physiotherapy practitioner in a range of contexts and situations of varying levels of complexity, ambiguity and uncertainty.2 An individual should demonstrate threshold competence for all key competencies relevant to their field of practice.

“Enabling components” describe the essential and measureable characteristics of threshold competence for the corresponding key competency. Threshold competence requires an individual’s practice to comprise all the enabling components for the corresponding key competency

Practice thresholds describes behaviours that characterise threshold competence in practice. Each key competency and enabling component is prefaced by the words “Registered physiotherapists in Australia and Aotearoa New Zealand are able to”.

The key competencies and enabling components embed the complex conceptual, analytical and behavioural elements that integrate foundational abilities, such as the knowledge,

skills, attitudes, values and judgements, that may be learnt in entry-level programmes. The Physiotherapy practice thresholds do not explicitly identify the corresponding foundational abilities (knowledge, skills, attitudes, values and judgements) that may be learnt in entry- level programmes at the level of task-oriented elements that, in isolation, do not assure threshold competence in practice.3

 

Uses of the Physiotherapy practice thresholds

The PhysioBA and PBNZ each have statutory functions as regulators of the physiotherapy profession in Australia and Aotearoa New Zealand respectively. One statutory function

of the PhysioBA is “to register suitably qualified and competent persons in the health profession”.4 One of the statutory functions of the PBNZ is “to set standards of clinical competence, cultural competence and ethical conduct to be observed by the profession”.5

The PhysioBA and PBNZ use the Physiotherapy practice thresholds as a reference point of threshold competence when exercising their statutory functions, including for:

  • registration of individuals who completed an approved physiotherapy programme in Australia or a prescribed physiotherapy qualification in Aotearoa New Zealand (see section headed “Physiotherapy practice thresholds and accreditation of physiotherapy education in Australia and Aotearoa New Zealand” for more details)
  • registration of individuals who complete their initial physiotherapy qualifications in other countries
  • re-registration of individuals who were previously registered as a physiotherapist in Australia or Aotearoa New Zealand, and
  • evaluation of a registrant whose level of competence to practise may pose a risk of harm to the public, for example, if the PBNZ or PhysioBA receives a complaint or notification about that registrant.

 

The PhysioBA and PBNZ recognise that other organisations and individuals may use the Physiotherapy practice thresholds as a reference point of threshold competence for other purposes. This could include registrants’ self-assessment of their competence, employers’ performance evaluation and management of physiotherapists in the workplace, and the development of health policy and health workforce strategy by agencies responsible for such work.

 

Physiotherapy practice thresholds and accreditation of physiotherapy education in Australia and Aotearoa New Zealand

The PhysioBA and PBNZ do not generally directly examine or assess the competence of applicants for registration who completed their physiotherapy studies in Australia

or Aotearoa New Zealand, if the programme of study is approved (Australia) or their qualification is prescribed (Aotearoa New Zealand). Instead, the PhysioBA and PBNZ have approved accreditation and/or audit arrangements that enable them to consider these applicants suitably competent for registration as a physiotherapist in the respective country.

As part of the accreditation/audit arrangements, the PhysioBA and PBNZ appoint an accreditation and/or audit body to assess if the physiotherapy programme, and the university that delivers it, provides students with the knowledge, skills and professional attributes to practise physiotherapy. In Australia, the PhysioBA has approved the accreditation standards developed and used by its accreditation body – the Australian Physiotherapy Council.

The Physiotherapy practice thresholds are not accreditation standards but are, as noted, a reference point for the threshold competence required for initial and continuing registration as a physiotherapist in both Australia and Aotearoa New Zealand. The language used in the Physiotherapy practice thresholds describes abilities in practice. The Physiotherapy practice thresholds do not explicitly identify the corresponding foundational abilities (knowledge, skills, attitudes, values and judgements) that may be learnt in entry-level programmes.

 

 

 

 

 

Concept of threshold competence

“Threshold competence” is used here to describe the competence level required to practise as a registered physiotherapist in Australia and Aotearoa New Zealand. This is based on the premise that competence levels can be described on a continuum. The threshold represents the point on the continuum that delineates a minimum acceptable level of competence to practise as a physiotherapist. This level is described as “threshold competence”.

 

Figure 1 illustrates the concept of a line on the competence continuum delineating “threshold competence”. The purple arrow represents the competence on the continuum above the threshold. The red area represents gradations of competence on the  continuum below the threshold. The line labelled “Physiotherapy practice thresholds” is the lower margin of the purple arrow – that is, the minimum level of competence required to practise as a registered physiotherapist in Australia and Aotearoa New Zealand.

Threshold competence is often referred to as “entry-level” competence and is described from the perspective of an individual wishing to enter practice from below the line representing threshold competence. This approach often describes competence in the context of the current requirements for graduates of education programmes in Australia and Aotearoa New Zealand to enter practice. Entry-level competence described from this perspective frequently comprises task-oriented statements that identify the foundational abilities (knowledge, skills, attitudes, values and judgements) acquired in entry-level programmes during development of the key competencies necessary to practise as a registered physiotherapist at the time the competencies are written.

Rather than describing competence from the perspective of an individual wishing to enter practice from below the line representing threshold competence, the Physiotherapy practice thresholds describe physiotherapy practice at the line representing threshold competence. This perspective defines competence in the context of practice as a physiotherapist and is applicable to a range of contexts including individuals entering from education programmes in Australia and Aotearoa New Zealand. These contexts include physiotherapy practice across various settings and different chosen fields of practice.

The Physiotherapy practice thresholds use key  competencies and enabling components   to describe threshold competence. The key competencies and enabling components take into account the complex conceptual, analytical and behavioural elements that integrate competent performance of observable abilities into physiotherapy practice relevant to the key competency. The foundational abilities, such as the knowledge, skills, attitudes, values

and judgements, that may be learnt in entry-level programmes are integrated in the abilities described by the key competencies and enabling components of the Physiotherapy practice thresholds.

 

Maintenance of competence

The Physiotherapy practice thresholds are relevant throughout a registered  physiotherapist’s career. They describe the minimum level of competence that all registered physiotherapists in Australia and Aotearoa New Zealand must maintain for continuing registration.

The PBNZ and PhysioBA recognise that each physiotherapist’s level of competence and chosen field of practice may change over time. Physiotherapists may focus on a particular client group or area of physiotherapy specialisation, or work in roles that do not involve direct client care, such as research, education or management. The fields of physiotherapy practice will also change as new roles emerge in an evolving health-care environment.

Each registered physiotherapist must continue to demonstrate at least the minimum level of competence described by the Physiotherapy practice thresholds in the context of their chosen field of practice. If a physiotherapist wants to change their chosen field of practice, they need to first ensure they can demonstrate at least the minimum level of competence described by the Physiotherapy practice thresholds in the context of their changed field of practice.

A physiotherapist practising below threshold competence may pose a risk to the public. The PhysioBA and PBNZ recognise that many physiotherapists will seek to ensure they excel and maintain a higher level of competence than the threshold.

 

Essential components of threshold competence

The behaviours listed below are essential components of threshold competence for initial and continuing registration as a physiotherapist in Australia and Aotearoa New Zealand.

These behaviours apply across the key competencies and enabling components but are described below to avoid repetition. Physiotherapists in Australia and Aotearoa New Zealand always:

  • behave professionally and ethically
  • consider each client as a whole, adopt client-centred and family/whanau focused (where relevant) approaches and prioritise cultural safety and cultural respect
  • obtain the client’s informed consent before acting and acknowledge the inherent power imbalance in the physiotherapist–client therapeutic relationship
  • reflect on their practice, recognise the limits of their clinical expertise and competence and take timely action to effectively manage risk in their practice
  • use evidence-based practice to support clinical  decision-making
  • integrate knowledge of pathology, anatomy, physiology and other core biomedical sciences relevant to human health and function, encompassing cardiorespiratory, musculoskeletal, neurological and other body systems, within the context of physiotherapy and the client’s needs.

Physiotherapy practice thresholds and assessment of competence

The PhysioBA and PBNZ use the Physiotherapy practice thresholds as a reference point of threshold competence, including for:

  • registration of individuals who completed an approved physiotherapy programme in Australia or a prescribed physiotherapy qualification in Aotearoa New Zealand (see section headed “Physiotherapy practice thresholds and accreditation of physiotherapy education in Australia and Aotearoa New Zealand” for more details)
  • registration of individuals who complete their initial physiotherapy qualifications in other countries
  • re-registration of individuals who were previously registered as a physiotherapist in Australia or Aotearoa New Zealand, and
  • evaluation of a registrant whose level of competence to practise may pose a risk of harm to the public, for example, if the PBNZ or PhysioBA receives a complaint or notification about that registrant.

The Physiotherapy practice thresholds provide a consistent reference point for assessing an individual’s performance in the relevant context of physiotherapy practice. This includes assessment of:

  • a physiotherapist’s performance in the context of the workplace or a simulated setting for maintenance of registration
  • a physiotherapy student’s performance in the context of a clinical placement or simulated setting for education purposes
  • individuals who were previously registered as a physiotherapist in Australia or Aotearoa New Zealand in the context of a competence assessment for re-registration
  • individuals who qualify as physiotherapists in other countries in the context of a competence assessment for initial registration in Australia or Aotearoa New Zealand.

The Physiotherapy practice thresholds also provide a consistent reference point for threshold competence in the context of practice relevant to each of these assessments.

The key competencies and enabling components describe abilities that can be assessed in practice and provide a reference point of threshold competence that can be applied across   a range of contexts of practice. Unlike the Australian Standards for Physiotherapy (2006) and the Physiotherapy Competencies for Physiotherapy Practice in New Zealand (2009), the Physiotherapy practice thresholds framework does not “deconstruct” the key competencies  or enabling components into task-oriented performance criteria or examples of evidence   that reflect the context of current education in Australia or Aotearoa New Zealand. In an educational context, these abilities may be “deconstructed” into task-oriented performance criteria relevant to the foundational abilities integrated at the threshold competence level.

The Assessment of Physiotherapy Practice (APP) instrument established performance indicators and a rating scale for valid measurement of physiotherapy students’ level of professional competence in workplace practice (Dalton, Davidson & Keating, 2011). The APP was developed after the Australian Standards for Physiotherapy (2006) and the Physiotherapy Competencies for Physiotherapy Practice in New Zealand (2009) were published and embedded in the accreditation standards for physiotherapy programmes in Australia.

Like the Australian Standards for Physiotherapy (2006) and Physiotherapy Competencies for Physiotherapy Practice in New Zealand (2009), the Physiotherapy practice thresholds framework is not designed as a “stand-alone” means of measuring competence.

The framework supports the establishment of additional performance indicators and rating scales for valid measurement of physiotherapists’ competence for different purposes, in different settings and across different chosen fields of practice.

The context of a physiotherapist’s practice may not be limited to (and may not include) direct clinical care. Many of the abilities described in the key competencies are required in direct non-clinical relationships with clients. The abilities are also required when registered physiotherapists work in management, administration, education, research, policy development, advisory contexts, regulatory or other contexts that have an impact on safe, effective delivery of health services in physiotherapy. The performance indicators and rating scales for valid measurement of physiotherapists’ competence will depend upon the purpose of the assessment of an individual’s competence and the context of physiotherapy practice in which the assessment is taking place.

 

Terms used in this document

A glossary of terms is provided at the end of this document to help the reader’s understanding of the content covered here.

Physiotherapy practice in Australia and Aotearoa New Zealand

Physiotherapists in Australia and Aotearoa New Zealand practise within a legislated regulatory framework (see Appendix 2). Only individuals who hold current registration with the PhysioBA (in Australia) and PBNZ (in Aotearoa New Zealand) are permitted to use the professional title “physiotherapist”. In Australia and Aotearoa New Zealand, individuals   are generally able to consult a physiotherapist without a third-party referral. This is often referred to as “primary contact” or “direct access” physiotherapy practice. If a third party, such as a government department or an insurer, is paying for a client’s physiotherapy,

the payment arrangement may require the client to consult another professional before attending physiotherapy.

It is relevant to describe physiotherapy practice in Australia and Aotearoa New Zealand because the Physiotherapy practice thresholds describe the threshold competence required for initial and continuing registration as a physiotherapist in each country.

 

Description of physiotherapy

The PBNZ has published the following description of the general scope of practice for physiotherapists in Aotearoa New Zealand.6

Physiotherapy provides services to individuals and populations to develop, maintain, restore and optimise health and function throughout the lifespan. This includes providing services to people compromised by ageing, injury, disease or environmental factors. Physiotherapy identifies and maximises quality of life and movement potential by using the principles of promotion, prevention, treatment/intervention, habilitation  and rehabilitation. This encompasses physical, psychological, emotional, and social well being.

Physiotherapy involves the interaction between physiotherapists, patients/clients, other health professionals, families/whanau, care givers, and communities. This is a people-centred process where needs are assessed and goals are agreed using the knowledge and skills of physiotherapists.

Physiotherapists are registered health practitioners who are educated to practise autonomously by applying scientific knowledge and clinical reasoning to assess, diagnose and manage human function.

The practice of physiotherapy is not confined to clinical practice, and encompasses   all roles that a physiotherapist may assume such as patient/client care, health management, research, policy making, educating and consulting, wherever there may be an issue of public health and safety.

In Australia, general registration allows unrestricted clinical practice within a practitioner’s scope of practice. Unlike Aotearoa New Zealand, there is no defined scope of practice for physiotherapists in Australia. Scopes of practice vary according to different roles; for

example, practitioners, researchers and managers will all have quite different competence and scopes of practice. The PhysioBA has published a definition of “practice”.7 The following description is based on that definition:

Physiotherapy practice is any role, whether remunerated or not, in which the individual uses their skills and knowledge as a physiotherapist … practice is not restricted to

the provision of direct clinical care. It also includes using professional knowledge in a direct non-clinical relationship with patients or clients, working in management, administration, education, research, advisory, regulatory or policy development roles and any other roles that have an impact on safe, effective delivery of health services in physiotherapy.

 

Key features of physiotherapy in Australia and Aotearoa New Zealand

Physiotherapists in Australia and Aotearoa New Zealand share a culture of professionalism and ethical practice and are generally regarded by the community as socially responsible, trustworthy and credible. Throughout their careers, physiotherapists engage in professional development and practice to continuously maintain competence within their chosen field of practice.

Some physiotherapists in Australia and Aotearoa New Zealand further develop their chosen field of practice and work in roles that require advanced levels of competence. Many physiotherapists take on responsibilities other than direct client care. They may work in management, administration, education, research, advisory, regulatory or policy development roles and many other roles that have an impact on safe, effective delivery of health services. Physiotherapists are well suited to roles that require critical thinking, reasoned decision-making, advanced communication skills, problem-solving skills, leadership and intellectual capacity for innovative and lateral thinking.

Physiotherapists in Australia and Aotearoa New Zealand work in partnership with individuals and populations to optimise their function and quality of life. Physiotherapists promote health and implement strategies to prevent and minimise impairments, activity limitations and participation restrictions including those associated with complex and  chronic conditions. Physiotherapists consider each client as a whole and facilitate each client’s self-management. They evaluate each client’s environment and recognise personal factors that may that client’s functioning, disability and health. Physiotherapists in Australia and Aotearoa New Zealand consider these factors and client preferences as part of their evidence-based practice.

 

Cultural competence

Physiotherapists in Australia and Aotearoa New Zealand must be able to work effectively with people whose cultural realities are different from their own. Culture may include, but is not limited to, age, gender, sexual orientation, race, socio-economic status (including occupation), religion, physical, mental or other impairments, ethnicity and organisational culture. A holistic, client-centred approach to practice requires cultural competence.

Cultural competence is a commonly used term that encompasses client-centred concepts focused on demonstrating cultural safety and cultural respect and that interact effectively with and respond to each client at all times. Culturally responsive practice requires physiotherapists to reflect not only on their own culture but that of their client and to engage in new and ongoing learning relevant to cultural safety.

Physiotherapists in Australia and Aotearoa New Zealand require a working knowledge of factors that contribute to and influence the health and well-being of Aboriginal and Torres Strait Islander and Maori communities respectively. These factors include history, spirituality and relationship to land, and other determinants of health in Aboriginal and Torres Strait Islander and Maori peoples.

 

Te Tiriti o Waitangi / the Treaty of Waitangi

Te Tiriti o Waitangi / the Treaty of Waitangi is a founding document of Aotearoa New Zealand and informs legislation, policy and practice. Government health policy aims   to reduce health inequalities between Maori and non-Maori. Alongside this, the Health

Practitioners Competence Assurance Act 2003 (NZ) requires health regulatory authorities, such as the PBNZ, to ensure registered health professionals meet set competencies (including cultural competencies).

To practise effectively in Aotearoa New Zealand, a physiotherapist therefore needs, in addition to meeting cultural competence, to understand the relevance and be able to demonstrate contemporary application of Te Tiriti o Waitangi / the Treaty of Waitangi’s three principles of partnership, participation and protection and incorporate the four cornerstones of Maori health, which are whanau (family health), tinana (physical health), hinengaro (mental health) and wairua (spiritual health).

Partnership involves working together with iwi, hapu, whanau and Maori communities

to develop strategies for Maori health gain and appropriate health and disability services.

Participation requires Maori to be involved at all levels of the health and disability sector, including in decision-making, planning, development and delivery of health and disability services.

Protection involves the Government working to ensure Maori have at least the same level of health as non-Maori, and safeguarding Maori cultural concepts, values and practices.

 

Contexts of physiotherapy in Australia and Aotearoa New Zealand

Physiotherapists work across a diverse range of clinical and non-clinical settings in urban as well as regional, rural and remote geographical locations.

Contexts of physiotherapy practice and the ways physiotherapists work in Australia and Aotearoa New Zealand will change as health workforce roles evolve and new roles and technologies emerge.

The key competencies in the Physiotherapy practice thresholds apply to all contexts of physiotherapy practice, irrespective of setting, location, environment, use of technology, field of practice or workforce role.

 

Assumptions applying to the Physiotherapy practice thresholds

The Physiotherapy practice thresholds assume that, in addition to demonstrating threshold competence for initial and continuing registration, all physiotherapists in Australia

and Aotearoa New Zealand have completed a professional entry-level physiotherapy programme leading to a higher education qualification in physiotherapy.

Successful completion of the physiotherapy programme should generally include learning and assessment of all the following foundational abilities:

  • knowledge of relevant anatomy, physiology, pathology, other biomedical sciences relevant to human health and function, and psychosocial and other determinants of health encompassing cardiorespiratory, musculoskeletal, neurological and other body systems within the context of physiotherapy and best available research evidence,  and
  • knowledge and understanding of theoretical concepts and principles relevant to physiotherapy practice including evidence-based practice, and
  • knowledge and understanding of theoretical concepts and principles relevant to physiotherapy practice with clients across the lifespan, from birth to end of life care, who present with one or more problems such as pain and/or impairment  or dysfunction contributing to impairment, activity limitations and participation restrictions, and
  • knowledge and understanding of theoretical concepts and principles relevant to physiotherapy practice across acute, rehabilitation and community practice in a range of environments and settings, and
  • competence to practise as a physiotherapist autonomously as well as a member of an interprofessional team in relevant clinical situations, and
  • knowledge and understanding of theoretical concepts and principles relevant to physiotherapy practice in health promotion and facilitation of client self-management strategies to enhance their health and well-being.

If a physiotherapist’s studies led to a higher education qualification in physiotherapy but did not address the matters listed above, it is assumed the individual subsequently completed an examination or assessment to measure their competence before initial registration as a physiotherapist in Australia or Aotearoa New Zealand.

Footnotes:

  1. The integration of the central role of the Physiotherapy practitioner with the other roles is best illustrated by the CanMEDS diagram.
  2. The context of a physiotherapist’s practice may not be limited to (and may not include) direct clinical Many of the abilities described in the key competencies are required in direct non-clinical relationships with patients or clients. The abilities are also required when registered physiotherapists work in management, administration, education, research, policy development, advisory contexts, regulatory contexts or other contexts impacting on public health and safety.
  3. Unlike the Australian Standards for Physiotherapy (2006) and the Physiotherapy Competencies for Physiotherapy Practice in New Zealand (2009), the Physiotherapy practice thresholds do not “deconstruct” the key competencies or enabling components into task-oriented performance criteria or examples of
  4. Section 35(1)(a) of the Health Practitioner Regulation National Law Act as in force in each state and territory in
  5. Section 118 of the Health Practitioners Competence Assurance Act 2003 (NZ).
  6. New Zealand Government Gazette, 11 December 2008, No. 192, p5105
  7. Physiotherapy Board of Australia, March 2014, Code of Conduct.