Scope of practice...are you working within yours?
Internal Pelvic Examinations (IPE) are a daily occurrence in a Pelvic Floor Physiotherapy practice. They are an extremely intimate procedure and can be associated with some of the most personal and debilitating symptoms patients’ experience. This places a Pelvic Floor Physiotherapist in a highly privileged and trusted position.
Despite the sensitivity and complexity of pelvic floor assessment and practice, there are currently no formal guidelines or rules that govern exactly what type of training is required for this nor is there an agreed standard to determine competence in this area.
The Australian Physiotherapist Association (APA) recommends that Physiotherapists should self assess whether IPE’s are within their ‘scope of practice (SOP)’. In essence, this self assessment asks the Physiotherapist to evaluate whether or not they are appropriately educated, competent and authorised to perform the roles, activities and functions required for an IPE within their day to day clinical work. This self assessment may be flippantly misinterpreted by physiotherapists and their employers to be something that can be easily proven, i.e. If I personally feel I have adequate training and skills to work in this area, then I do.
Where the ability to define your ‘SOP’ and show clinical competence becomes very important is if a legal claim were to arise and you were required to prove to your professional body, insurer and possibly a court, that you were adequately trained and experienced. Furthermore, you may be called upon to justify that your actions were appropriate. How then does one prove their practice was/is within their SOP?
In 2019, Frawley, Neumann and Delany produced a detailed article highlighting the need for a robust competency framework to guide and inform pelvic floor physiotherapy training and practice. In their article, they suggested four key elements to achieving this end. This essentially defines ‘SOP’ and they are outlined in the figure below.
Performing IPE’s is not taught as part of undergraduate physiotherapy training. Therefore, post-graduate training is required to be undertaken by a Physiotherapist wanting to work in the pelvic floor field. Attending a formal training/education course is often the first step in showing proof of training. However not all courses assess competency as part of their curriculum. Therefore, while they still may be beneficial to attend, they cannot prove competency.
Alternatively, a University level post-grad certificate (or equivalent) where skills are examined against a detailed assessment rubric can prove that a standard of competency was met. This kind of assessment however, while rigorous, only proves competency at that point in time (often early in a physiotherapist’s career) and may not be adequate to prove your ongoing competence to treat patients or more complex cases.
To show ongoing competency to assess, diagnose and treat pelvic floor disorders, two key elements are proposed: (i) frequency of practice (ie. regularly seeing pelvic health clients) and (ii)supervised practice.
Frawley, Neumann and Delany (2018) propose that there should be a requirement to demonstrate ‘supervised practice’. This should / may include observation and/or shadowing of experienced pelvic floor clinicians and reviewing cases collaboratively.
While some Pelvic Floor Physiotherapists are lucky enough to have access to supervised practice within their workplace, many do not. In the absence of this outsourced specific clinical mentoring helps to ensure skills, ideas and practice remain current and safe. It can, if necessary, also contribute as evidence that you are within the ‘SOP’. Frawley, Neumann and Delany (2018) further suggested that the development and application of skills cannot be assumed without “expert mentoring and feedback”.
Mentoring is key to developing one's skills over time. Initially, mentoring focuses on the development, understanding and implementation of basic technical skills and clinical reasoning. Additionally, a huge part of mentoring is helping the clinician to understand when they have the appropriate skill level to treat a particular case, essentially exploring SOP. Over time, SOP changes for a clinician, as their skill set and clinical reasoning develops. Ongoing mentoring, can however, help to coach the Physiotherapist to ensure they remain working within their scope.
As physios, we all want to help people and provide optimal care. For many of us, the idea of having a legal claim against us can be the cause of great anxiety. However, rather than leaving things to chance and hoping something untoward never happens, why not ensure you and/ or your staff are doing everything they can to prove they are not only effective clinicians but competent ones too?
References
Frawley, H. C., Neumann, P., & Delany, C. (2019). An argument for competency-based training in pelvic floor physiotherapy practice. Physiotherapy theory and practice, 35(12), 1117-1130.
NB: We highly recommend you read of the above article to deepen your knowledge around scope of practice (SOP) and clinical competency in pelvic health physiotherapy.