COTO
PROMOTING QUALITY PRACTICE

Working With Support Personnel

College of Occupational Therapists of Ontario
February 1997

Practice Scenarios:

During a recent telephone conversation with the College's Director of Professional Practice, an occupational therapist noted that her facility was undergoing re-organization and that she would no longer be responsible for providing 'direct' care to patients on a long term care unit. The care would now be provided by a support worker and the occupational therapist was to supervise this individual. The occupational therapy support worker had worked on the unit for many years and had been responsible for many of the "day-to-day" activities with the patients. With the new organizational structure, the support worker's responsibilities were to increase to include seating, positioning, activities of daily living (i.e., dressing, toiletting and feeding assessments and training) and group activities (i.e., cognitive stimulation, reality orientation). The occupational therapist asked specifically about the amount and type of supervision required and whether it mattered if the occupational therapy support worker was a member of another regulatory body in Ontario.

Probing Questions

  • What responsibilities can be assigned to an occupational therapy support worker?
  • What is an adequate level of supervision? Do factors such as the setting, caseload, or support worker educational qualifications make a difference? How can the occupational therapist demonstrate that she has adequately supervised a support worker?
  • Can another regulated health care practitioner supervise the occupational therapy support worker?
  • What client information should be shared with the support worker? Is client confidentiality an issue?
  • Is the occupational therapy support worker's status as a member of a regulatory body an issue? Does this mean the occupational therapist does not have to supervise the individual?
  • Is the occupational therapist responsible if the occupational therapy support worker commits an illegal act (e.g., stealing from a patient), or an act that could be considered malpractice or sexual abuse? Could a complaint be laid with the College against the occupational therapist?
College Quality Practice Analysis:

The College of Occupational Therapists of Ontario recognizes that, as a result of the reorganization of health care in this province, the use of support workers to provide occupational therapy services is increasing. Adequate supervision of support personnel, to ensure that occupational therapy services continue to be offered in a safe, effective and efficient manner, is a growing issue. To emphasize the accountability of the occupational therapist for the supervision of the support worker, the College included in the Professional Misconduct Regulation (section 35) that:

"failing to supervise an auxiliary appropriately or in accordance with the regulations"

is considered an act of professional misconduct. As well, the College has published a Briefing Note on Delegation and the Assigning of Service Components, a Practice Guideline on Assigning of Service Components to Non-Registrants, and a position statement on the Role and Use of Support Personnel in the Rehabilitation Disciplines.

Key to these documents is the need for the occupational therapist to use his/her professional judgment to determine whether the support worker has the knowledge, skills and abilities – i.e., the competency – to provide the assigned service components safely and effectively, and to determine what amount of supervision is required.

The support worker's proven abilities, experience, and education; the setting; and the severity of the illness of the client are all factors the occupational therapist must consider when deciding on the services to be assigned and the amount of supervision that is required.

For example, in a situation where the occupational therapist is working with a support worker that he or she has not previously worked with, to provide service to an acutely ill patient, in an acute care setting, the occupational therapist should assign service components to the support worker only with clear and complete instructions and ensuring maximum supervision is provided. This may involve not leaving the support worker alone with the patient.

However, in cases, where the support worker has demonstrated her or his competence and where patient care risk factors are reduced (e.g. stable condition; maintenance intervention) and where explicit assessment protocols and intervention strategies have been established by the occupational therapist, all service components may be assigned to the support worker and minimal supervision may be required.

Supervision of the support worker for assigned occupational therapy care should be provided only by an occupational therapist. In the event of an emergency occurring during working hours, arrangements should be in place for the support worker to be able to contact an occupational therapist. Supervision can be accomplished through regularly scheduled meetings between the occupational therapist and the support worker, with or without the client present; chart reviews; observation of the support worker; review of client logs completed by the support worker; and so forth. Support personnel can chart on the patient record; the College does not require the occupational therapist to co-sign support personnel notes. However, in all situations, facility policy must be followed. It is essential for the occupational therapist to be knowledgeable of all occupational therapy care provided by the support worker to the patient.

In this scenario the support worker is an employee of the facility, and is therefore bound by employee policies. Client information relevant to client care can be shared keeping in mind the principle of "need to know". Support workers who are members of another regulated health care body are accountable to their College, but must still function within the job description of the position that they have accepted.

To support the occupational therapist's decisions regarding the support worker, written facility-approved documents setting out support personnel orientation, and criteria/guidelines for determining support worker responsibilities and amount of supervision are recommended. The orientation program should highlight issues related to client confidentiality, unacceptableness of sexual abuse, structured assessments, and explicit client interventions. Support worker accomplishment of each component of the orientation program and occupational therapist use of criteria/guidelines should be noted in writing.

In the event a complaint was laid against an occupational therapist because of the actions of a support worker, the College would investigate to determine whether the support worker was adequately prepared for the assigned responsibilities, had the required knowledge, skills and abilities, and was appropriately supervised. Documentation of the above suggested process or a similar approach would provide support that the occupational therapist had implemented procedures to ensure the support personnel would provide safe effective care.



References:
1. COTO Professional Misconduct Regulation, 1993.

2. COTO Briefing Note on Delegation and the Assigning of Service Components, 1997.

3. COTO Practice Guideline on Assigning of Service Components to Non-Registrants, 1996.

4. COTO Response to the Report on the Role and Use of Support Personnel in the Rehabilitation Disciplines, 1993.