Advanced Musculoskeletal Physiotherapy in The

Advanced musculoskeletal physiotherapy in the Post-arthroplasty review clinic (PAR) Workbook Prepared by Alfred Health on behalf of the Department of Health, Victoria. © 20142 ContentsBackground...... 3 Scope of practice – PAR clinic...... 4 Competency standard – delivering advanced musculoskeletal physiotherapy in the PAR clinic...... 5 Learning needs analysis Part A and B: PAR clinic...... 25 Competency standard self-assessment tool (Part A of the Learning needs analysis): PAR clinic....26 Knowledge and skills self-assessment – Part B of the Learning needs analysis: PAR clinic...... 32 Learning and assessment plan: PAR clinic (example only)...... 50 Workplace learning program...... 57 Competency-based assessment and related tools...... 60 Advanced musculoskeletal physiotherapy – clinical and record keeping audit guideline...... 81 Curriculum overview...... 99 Glossary...... 102 References...... 102 Bibliography...... 103 Appendix 1...... 1053 Background This workbook contains the resources for the competency-based learning and assessment program for advanced musculoskeletal physiotherapists commencing work in the post-arthroplasty review (PAR) clinic. It should be read in conjunction with each individual organisation’s policy and procedures for delivering advanced musculoskeletal physiotherapy services and, in particular, with the operational guidelines and clinical governance policy for the PAR service. The competency-based learning and assessment program is designed to be flexible and tailored to suit the needs of individual physiotherapists and the needs of the organisation. Therefore decisions regarding the detail of the program need to be made for each organisation by the clinical lead physiotherapist in collaboration with the orthopaedic department. This workbook provides the framework to be used along with examples of the learning and assessment program. Organisations may choose to include additional tasks, or do away with some of the proposed tasks depending on the experience and skills of the individual, the resources available and the requirements of the orthopaedic and physiotherapy departments and the organisation as a whole.A summary of the key components of the competency-based learning and assessment program contained in this workbook specifically written for the PAR clinic are as follows: the scope of practice definition  the competency standard  Competency standard self-assessment tool (Part A of the Learning needs analysis) Learning needs analysis (Part A and B) Learning and assessment plan assessment and related tools.4 Scope of practice – PAR clinicThe scope of practice for advanced musculoskeletal physiotherapists working in the PAR clinic includes management of patients requiring routine post-operative orthopaedic reviews following uncomplicated primary hip and knee joint arthroplasty surgery. These review appointments are scheduled as determined by the director of orthopaedics (refer to the PAR clinic operational guidelines for further detail). The PAR physiotherapist is responsible for assessing, diagnosing, requesting and interpreting plain-film imaging, and comprehensively managing patients according to their post-operative needs following hip and knee arthroplasty. The physiotherapist will liaise with the orthopaedic surgeon regarding any patient who, on assessment, presents with red flags and/or fails to achieve their expected post-operative milestones and, when indicated, will ensure that a timely referral back to orthopaedics occurs.The physiotherapist is responsible for working collaboratively with orthopaedic surgeons regarding the review of imaging. Where indicated, the physiotherapist is responsible for referring patients on to other medical services (for example, rheumatology, GP), specialty services (for example, OAHKS) and community health services.The physiotherapist will commence working under the guidance of the orthopaedic consultants in the outpatient clinics until work-based competency standards have been met. Once competency has been achieved, the physiotherapist will be deemed to work autonomously with patients presenting with primary, hip and knee arthroplasty who, on assessment:  present with no red flags  do not need further investigations other than plain film (with plain film to be reviewed at a later scheduled time with an orthopaedic consultant)  do not require medication other than paracetamol and ibuprofen  do not require acute medical management.If, on assessment, a patient is identified with any of the above findings, input from an orthopaedic surgeon is required. Regardless of being deemed competent, a collaborative, team-based approach to patient care is strongly encouraged at all times while working in the outpatient clinic, and the physiotherapist should remain in close consultation with the orthopaedic consultant regarding any patient concerns. Competency standard – delivering advanced musculoskeletal physiotherapy in the PAR clinic Refer to the Advanced musculoskeletal physiotherapy clinical education framework manual for details regarding the background and development of the competency standard for advanced musculoskeletal physiotherapists delivering services in the PAR clinic. In addition the pathway to competence in the workplace that provides the steps involved to achieving competence is detailed in the manual. The diagram on the next page provides an overview of the competency standard for the PAR clinic.There are variations across Victoria in the model of care for PAR clinics; therefore it may be that some of the domains and performance criteria described in the competency standard may not apply to every organisation. For example, if two- and six-week post-operative reviews are not being conducted then the performance criteria relating to wound care is not required. In addition, the prevalence of diabetes varies across different demographics. If the prevalence of diabetes is high in the patient population the organisation services, it is recommended the diabetes section of the competency-based learning and assessment program be included, otherwise it may not be a high priority for learning and assessment, and there may be other chronic illnesses more prevalent that warrant further knowledge. 7 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard elementProfessional behaviours1. Operate within scope 1.1 Identify and act within own knowledge base and scope of  Confer with expert colleagues for a second opinion when of practice practice unsure or exposed to uncommon presentations  Refrain from procedures outside scope 1.2 Work towards the full extent of the role  Demonstrate a desire to acquire further knowledge and extend practice to achieve full potential within scope of practice  Extend the range of patient conditions/profile over time  Identify features and appearances of different prostheses from imaging  Apply advanced knowledge regarding arthroplasty procedures, imaging and clinical assessment findings to recognise when orthopaedics need to be consulted2. Display accountability 2.1 Demonstrate responsibility for own actions, as it applies  Identify the additional responsibilities resulting from working in to the practice context advanced roles  Identify the impact own decision making has on patient outcomes and act to minimise risks  Choose to take responsibility for ensuring patients referred back to orthopaedics for review are followed upLifelong learning8 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element3. Demonstrate a 3.1 Engage in lifelong learning practices to maintain and commitment to lifelong extend professional competence learning  Use methods to self-assess own knowledge and clinical skills; for example, engage in a Learning needs analysis and/or 3.2 Identify own professional development needs, and performance appraisal process implement strategies for achieving them  Design a plan to appropriately address identified learning needs3.3 Engage in both self-directed and practice-based learning  Maintain a comprehensive professional portfolio, including evidence supporting achievement of identified needs 3.4 Reflect on clinical practice to identify strengths and areas  Actively participate in ongoing continued education programs, requiring further development both in-house and external Prepare in advance for work-based assessment and/or continuing education sessions Initiate and create own learning opportunities, for example: o follow up on uncommon or complex cases o obtain and act on advice from other professionals to improve own practice o follow up on outcome of referrals made to orthopaedics Share clinical experiences that provide learning opportunities for othersCommunication9 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element4. Communicate with 4.1 Use concise, systematic communication at the colleagues appropriate level when conversing with a range of colleagues in the practice context  Verbally present patients to consultant with appropriate brevity and pre-considered purpose, using a systematic approach such as the ISBAR format (to assist with diagnosis and confirm 4.2 Present all relevant information to expert colleagues management plan) when acting to obtain their involvement  When presenting cases, consistently include essential information while excluding what is extraneous  Write referral letters that are concise, accurate and contain all required information to accepted practice standards and are appropriate to the audienceProvision and coordination of care5. Evaluate referrals 5.1 Discern patients who are appropriate for advanced  Consistently discern patients who are appropriate for physiotherapy management in accordance with individual management in the PAR clinic strengths or limitations, any legal or organisational restrictions on practice, the environment, the patient  Consistently discern patients who are not appropriate for the profile/needs and within defined work roles PAR clinic10 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element5.2 Discern patients who are appropriate for management  Engage in timely discussion and referral to expert colleagues in a shared-care arrangement in accordance with individual for appropriate cases strengths or limitations, any legal or organisational restrictions on practice, the environment, the patient  Consistently apply local organisational requirements of patient profile/needs and within defined work roles flow in work prioritisation for the PAR clinic5.3 Defer patient referrals to relevant health professionals  Ensure relevant health professionals receive an accurate and (including other physiotherapists) when limitations of skill or timely handover when transferring patient care, and that job role prevent the patient’s needs from being adequately urgency of care is understood addressed or when indicated by local triage procedure  Document referral/handover clearly with all necessary information 5.4 Prioritise referrals based on patient profile/need, organisational procedure or targets and any local factors  Where relevant, and if required, follow the organisation’s policy regarding the prioritising of patients 5.5 Communicate action taken on referrals using established organisational processes6. Perform health 6.1 Design and perform an individualised, culturally The following has been adapted from the work of Suckley (2012): assessment/examination appropriate and effective patient interview for common History-taking skills and/or complex conditions/presentations  Ensure a thorough knowledge of the patient’s past medical and 6.2 Formulate a preliminary hypothesis and differential surgical history, comorbidities, smoking and alcohol use, diagnoses for a patient with common and/or complex surgical details of joint arthroplasty (including any complications conditions, as relevant to the practice context or deviations from the expected pathway), rehabilitation program and any events since the time of surgery11 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element6.3 Perform complex modifications to routine  Establish an accurate understanding of the patient’s condition, musculoskeletal assessment in recognition of factors that limitations and physical function prior to surgery may impact on the process, such as the patient profile/needs and the practice context  Obtain a history of the presenting condition. This should include details on severity, irritability, nature of problem, 24-hour behaviour, agg/eases, special questions and functional level 6.4 Design and conduct an individualised, culturally appropriate and effective clinical assessment that:  Include past and current medication, allergies and previous adverse drug reactions, complementary medicines and over-  is systems-based the-counter medications includes relevant clinical tests  Assess current analgesia needs and efficacy (visual analogue scale pain score)  selects and measures relevant health indicators  Obtain a social and family history substantiates the provisional diagnosis  Enquire about patient’s goals following surgery  Where indicated, asks questions relevant for wound 6.5 Identify when input is required from expert colleagues assessment such as recent discharge, redness, swelling, pain, and act to obtain their involvement fevers, sweats, lethargy, use of antibiotics Be able to make a working diagnosis after taking a history 6.6 Act to ensure all red flags are identified in the assessment process, link red flags to diagnoses not to be  Use history-making skills to direct an appropriate physical missed and take appropriate action in a timely manner examination12 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element6.7 Act to ensure yellow flags are identified in the Physical examination skills assessment process and take appropriate action in a timely manner  Demonstrate advanced skills in examination of the musculoskeletal system as it applies in the context, and as directed by information obtained in the history taking, including: o routine musculoskeletal clinical examination of hip, knee and lumbar spine o regional-specific special tests o neurological and vascular examination as required o wound assessment and skin integrity o assessment of radiographic imaging of prosthesis to assess for modes of joint arthroplasty failureDemonstrate the ability to use a detailed health assessment and examination to identify the following conditions or presentations Exclude ‘red flags’ or possible serious underlying pathology (special questions – fevers, sweats, weight loss, night pain, etc) Screening for ‘yellow flags’ to identify psychosocial factors exacerbating presenting condition Post-operative complications relating to surgery such as: o prosthesis failure or infection or reaction to prosthesis o inadequate pain management13 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element o failure to regain satisfactory range of motion post-knee joint arthroplasty, which needs a timely medical opinion on manipulation under anaesthetic o delays or problems with wound healing Common secondary musculoskeletal conditions – for example, trochanteric bursitis, patellofemoral joint dysfunction, back pain with referred symptoms, exacerbation of other osteoarthritis (OA)-affected joints  A more complex musculoskeletal cause of a musculoskeletal presentation that requires a medical opinion Possible non-musculoskeletal cause of a musculoskeletal presentation – for example, deep vein thrombosis Chronic widespread pain Regional pain7. Apply the use of 7.1 Anticipate and minimise risks associated with  Apply the principles of assessing the risk:benefit ratio of radiological radiological investigations ionising radiations to decision making investigations in advanced  Determine the latest date of imaging before requesting musculoskeletal 7.2 Determine the indication for imaging based on investigation physiotherapy services assessment findings and clinical decision-making rules  Apply the indications, advantages and disadvantages, precautions and contraindications of different imaging 7.3 Select the appropriate modality consistently and act to modalities to decision making, for a variety of presentations gain authorisation as required14 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element7.4 Convey all required information on the imaging request  Follow the clinical decision-making rules to determine imaging consistently applicable to PAR clinic imaging guidelines  Follow the local organisation’s policies and procedures 7.5 Interpret plain-film images accurately using a regarding the referral and requesting of imaging by systematic approach for patients with common and/or physiotherapists complex conditions, as relevant to the practice context  Describe the recommended imaging pathways following arthroplasty 7.6 Identify when input is required from expert colleagues and act to obtain their involvement  Determine when imaging other than plain film may be indicated and liaise effectively with consultant/medical specialist 7.7 Meet threshold credentials and/or external learning and regarding this, ensuring all precautions and contraindications assessment processes set by the organisation, governing have been identified prior to discussion body or state/territory legislation  As per organisational guideline, include all essential information on the imaging referral consistently, including: o correct patient information and side o clinical findings, such as site of injury and mechanism if relevant o radiological series/view required o preliminary diagnosis o other relevant information such as previous fracture/injury to region Consistently use a systematic approach to x-ray interpretation, including:15 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element o routine check of name, date, side and site of injury o correct patient positioning, view and exposure o ABCS (alignment, bone, cartilage, soft tissue) o common sites of injury or pathology o common sites for missed injuries o prosthesis to be imaged in its entirety o imaging compared with previous imaging o alignment and positioning of prosthesis o assessing for evidence of lucency, lytic areas or wear and debris of the prosthesis suggesting prosthesis failure Consistently interpret plain x-rays accurately, and seek expert opinion routinely to check results Immediately seek medical review when concerned about imaging findings, or in cases where results may be inconclusive8. Apply the use of 8.1 Anticipate and minimise risks associated with pathology  Consistently identify patients infected with HIV or a blood- pathology tests in tests transmissible virus, and notify staff involved in the procedure advanced about handling of specimens according to local procedure musculoskeletal physiotherapy services 8.2 Determine the indication for pathology testing based on  Identify the common indications for pathology and microbiology (under direction and assessment findings and clinical decision-making rules testing in patients following arthroplasty16 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element supervision of a 8.3 Identify the appropriate test(s) consistently and act to  Follow the local organisation’s policies and procedures consultant) gain authorisation as required regarding the referral and requesting of pathology; that is, consult with the medical team and:8.4 Convey all required information to appropriate o convey accurate and relevant patient assessment personnel initiating pathology tests findings to the consultant to ensure the pathology request form includes full and accurate information 8.5 Interpret routine pathology test results for patients with o ensure the right test is conducted for the right indication common and/or complex conditions, as relevant to the for the right patient practice context and in consultation with expert colleagues when required o provide accurate clinical details record details of drug therapy that may affect test or 8.6 Meet threshold credentials and/or external learning and o assessment processes set by the organisation, governing interpretation body or state/territory legislation  Describe procedures and tests to the patient accurately and in a manner they can understand and consent to Understand the results of pathology and microbiology tests relevant to the practice context, as discussed with the orthopaedic consultant – for example, ESR and CRP9. Apply the use of 9.1 Determine the indication and appropriate medication  Use objective measures to assess and reassess analgesic therapeutic medicines in requirements from information obtained from the history requirements advanced taking and clinical examination, and liaise with relevant musculoskeletal health professionals regarding this  Establish time and dosage of medication used on day of 17 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element physiotherapy services 9.2 Demonstrate knowledge of pharmacokinetics, presentation to outpatients (under direction and indications, contraindications, precautions, adverse effects, supervision of a interactions, dosage and administration of medications  Acknowledge and follow the legislative barriers to consultant) commonly used to treat musculoskeletal conditions, physiotherapists prescribing therapeutic medicine, as well as applicable to the practice context local policy and procedures for providing medicines Accurately record patient’s current medication regimen for their 9.3 Apply knowledge of the legal and professional condition and other pre-existing medical conditions, and current responsibilities relevant to recommending, administering, patient compliance with prescribed medication using, supplying and/or prescribing medicines under the current legislation, as relevant to the practice context  Consistently record allergies and adverse drug reactions in medical history 9.4 Comply with national and state/territory drugs and  Effectively convey essential information obtained from the poisons legislation patient history and physical examination to the medical team/GP to facilitate timely, safe and efficacious prescribing 9.5 Identify when input is required from expert colleagues  Apply the requirements of being a competent prescriber to and act to obtain their involvement decision making within the practice context (refer to NPS competency framework at <http://www.nps.org.au/health- 9.6 Apply relevant knowledge of the medicine involved professionals/professional-development/prescribing- when recommending and informing patients of the risks and competencies-framework>) benefits of use  Provide the patient with adequate information to ensure safe medicine use (within the physiotherapist’s scope of practice and 9.7 Exercise due care including assessing properly the legislative requirements) and ascertain the that patient implications for individual patients receiving therapeutic understands prior to leaving medicine, as relevant to the practice context  Provide written information for other health professionals involved in the patient’s care regarding any changes to the 9.8 Maintain proper clinical records as they relate to patient’s medication regimen initiated during their outpatient therapeutic medicine appointment18 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element9.9 Meet threshold credentials and/or external learning and  Demonstrate an understanding regarding the use of antibiotics assessment processes set by the organisation, governing and the significance of this in managing wound and joint body and national state/territory legislation infections post-arthroplasty Demonstrate an understanding regarding the use of antibiotics prophylactically for patients following arthroplasty who are undergoing other procedures (such as dental work) and educate the patient accordingly10. Apply advanced 10.1 Synthesise and interpret findings from clinical  Ensure the diagnosis and management plan proposed by the clinical decision making assessment and diagnostic tests to confirm the diagnosis physiotherapist is consistently verified by expert colleagues Display an awareness of the diagnostic accuracy of physical 10.2 Demonstrate well-developed judgement in tests performed and discuss the effect of a positive or negative implementing and coordinating a patient management plan test finding on pre/post-test probabilities that synthesises all relevant factors  Demonstrate flexible thinking and revisit other subjective or objective examination findings when presented with new information, either from the patient or as a result of diagnostic investigations Link radiological findings to the presenting complaint, demonstrating awareness of aberrant pathology, incidental findings, anatomical variants and normal images Link assessment findings with expected level of progress, identify patients not achieving milestones and liaise with orthopaedic consultant accordingly Identify patients at risk of requiring manipulation under anaesthetic following knee arthroplasty, and implement an appropriate management plan that includes earlier review, 19 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element discussion with orthopaedic consultant and close monitoring of their progress Discuss the relevance of findings of pathology and microbiology results, and decide on further assessment or management, in conjunction with the orthopaedic consultant Incorporate the patient/caregiver in formulating a management plan Identify the appropriate management plan post-arthroplasty and discuss with medical colleagues as necessary Determine appropriate additional diagnostic imaging in line with local policies/procedures/practice, in conjunction with the orthopaedic consultant as required Refer patients on to specialist clinics in line with local policies/procedures/practice context, in consultation with orthopaedic consultant as required Identify precautions and contraindications for medications appropriate to the patient10.3 Use finite healthcare resources wisely to achieve best  Modify practice to accommodate changing demands in the outcomes availability of local resources – for example, high demands on radiology, availability of appointments Educate patients regarding expectations of services that may not be available, indicated or realistic in an outpatient setting – for example, a patient requesting an MRI scan for low back pain20 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element on the day of their appointment11. Formulate and 11.1 Formulate complex, evidence-based management  Ensure availability of local resources are integrated into implement a plans/interventions as determined by patient diagnosis, decision making – for example, local community health services management/interventio relevant to the practice context and in collaboration with the n plan patient  Formulate management plans using best available evidence Involve the patient in formulating management plans 11.2 Identify when guidance is required from expert colleagues and act to obtain their involvement  Seek a medical opinion when serious underlying pathology or non-musculoskeletal pathology is suspected11.3 Facilitate all prerequisite investigations/procedures  Engage other health professionals to complement care – for prior to consultation, referral or follow-up, as relevant to the example, occupational therapy for home assessment, nursing practice context for removal of stitches at two-week review  Complete WorkCover/sick certificates 11.4 Assess the need for referral or follow-up and arrange if necessary  Communicate with patient’s GP/community services Provide education and advice to the patient/caregiver, including 11.5 Identify when input to complementary care is required diagnosis, treatment plan, self-management strategies (where from other healthcare professionals and act to obtain their indicated), advice when to seek further help, medication usage, involvement vocational advice, timelines regarding recovery, referrals for ongoing management, activity modification following 11.6 Provide appropriate education and advice to patients arthroplasty, advice regarding restrictions and gait aids, and with common and/or complex conditions, as relevant to the information on local community resources and health promotion practice context  Use written information for patients where available11.7 Conduct a thorough handover to ensure patient care is  Confirm patient’s understanding of information provided maintained21 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element Communicate effectively using written and verbal methods when handing over patient care to the orthopaedic consultant. Handover of care is given to the operating surgeon where possible Inform patients of the handover12. Monitoring and 12.1 Monitor the patient response and progress throughout  Perform routine neurovascular assessment when indicated, escalation the intervention using appropriate visual, verbal and reassessing and acting on the findings when clinically indicated physiological observations  Identify and act on verbal and non-verbal cues that indicate worsening pain levels or symptoms – for example, signs of a 12.2 Identify and respond to atypical situations that arise deep venous thrombosis when implementing the management plan/intervention  Identify difficult and challenging behaviours – for example, aggression, intoxication, expressed desire to self-harm. Use appropriate de-escalation strategies and seek involvement of other team members where required – for example, security, pysch team Monitor for side effects of any medications given – for example, nausea and vomiting, and inform relevant staff Identify a wound that is not healing as expected and discuss this with the orthopaedic consultant Identify when the patient is not achieving expected milestones and discuss this with the orthopaedic consultant  Identify changes to likely differential diagnosis throughout the assessment and management of patients, and change to a 22 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element‘joint management’ model of care Identify which patients no longer require physiotherapy input and need to be handed over to medical colleagues for all ongoing care Identify issues around continuing consent to treatment with involvement of other colleagues as necessary 13. Obtain patient 13.1 Explain own activity to the patient as it specifically  Clearly inform the patient that their care is being managed by a consent relates to the practice context and check that the patient physiotherapist and address any issues relating to patient agrees before proceeding expectation of being managed by medical staff in the outpatient setting13.2 Consider the patient’s capacity for decision making  Educate the patient and confirm their understanding of relevant and consent risks and benefits of investigations and procedures while under the care of the physiotherapist but not limited to those performed by the physiotherapist 13.3 Inform the patient of any additional risks specific to advanced practice, proposed treatments and ongoing  Consistently identify factors compromising the patient’s service delivery, and confirm their understanding capacity to consent – for example, intoxication, shock, patient duress/stress, substance abuse, non-English speaking 13.4 Employ strategies for overcoming barriers to informed background, mental health conditions consent as relevant to the practice context  Liaise with expert colleagues (for example, an orthopaedic consultant) when presented with barriers to consent  Arrange interpreters where indicated23 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element14. Document patient 14.1 Document in the patient health record, fully capturing  Consistently include all aspects of the patient’s assessment and information the entire intervention and consultation process, addressing management by the physiotherapist in the documentation areas of risk and consent, and including any referral or follow-up plans  Ensure documentation is consistent with standards defined by the local healthcare network Demonstrate a working knowledge of local processes for documentation  Consistently complete all documentation related to outpatient attendance – for example, referrals, sick leave certificates, discharge letters Consistently meet the standards outlined by APRHA’s code of conduct for maintaining a health recordSpecific to practice context (PAR clinic)15. Perform an 15.1 Describe the surgical procedures for hip and knee  Describe the different surgical approaches, features and appropriate arthroplasty, the components of a THA or TKA, and be able indications for different prostheses, cement or uncemented musculoskeletal to identify different prosthesis assessment and  Describe OA and associated pathologies that are indications for implement a arthroplasty and explain the significance of these pathologies management plan for 15.2 Demonstrate an in-depth knowledge of the aetiology, on post-operative outcomes and management patients following total pathology and indications for arthroplasty surgery hip or knee arthroplasty  Outline the typical post-operative management and milestones that patients are expected to achieve following THA or TKA (THA, TKA) 15.3 Demonstrate an in-depth knowledge of the post- operative management and complications following  Identify post-operative complications following THA or TKA arthroplasty (such as excessive pain, wound infection, deep vein thrombosis24 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element15.4 Modify assessment to identify any post-operative (DVT), joint stiffness) and act appropriately complications following arthroplasty  Use appropriate outcome measures post-arthroplasty to monitor progress 15.5 Interpret plain-film imaging post-arthroplasty accurately, using a systematic approach to identify signs of  Delineate which post-operative complications need to be prosthesis failure escalated in a timely manner and seek out medical review Demonstrate competency in the interpretation of normal and 15.6 Identify when referral to orthopaedics is required and abnormal findings on plain-film imaging post-THA or TKA act to obtain their involvement  Identify signs of loosening, wear, infection, osteolysis, loss of fixation, peri-prosthetic fracture, etc. on plain-film imaging Provide evidence-based management to patients following THA and TKA, including advice about weight management, physical activity, functional activities, joint longevity, pain management, joint strengthening and other physiotherapy management as indicated Delineate which patients require referral back to orthopaedics or to other health professionals as indicated16. Provide basic wound 16.3 Monitor the healing of surgical wounds  Describe the key principles of history taking in relation to wound care assessment and management Describe the wound-healing process in a surgical patient25 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element16.5. Identify when input is required from expert colleagues  Perform a wound assessment and identify potential problems to assess and manage surgical wounds, and act to obtain related to the wound, such as infection their involvement  Identify high-risk groups for delayed wound healing, such as patients with diabetes or a history of smoking, and seek medical review when indicated Describe and document wound characteristics accurately, and effectively communicate with medical and nursing staff when their involvement is required Identify clinical indications for imaging and laboratory tests for wounds, and organise as appropriate in consultation with the medical team  Demonstrate a basic level of understanding of antibiotic choice for different wound and joint infections as prescribed by the orthopaedic consultant  Demonstrate a basic level of understanding of wound-care dressing products as applied by nursing staff Apply the principles of standard precautions and additional precautions to the wound when conducting a joint assessment17. Perform an 17.1 Demonstrate an in-depth knowledge of the aetiology,  Describe modifiable and non-modifiable risk factors associated appropriate pathology and clinical findings of OA with OA musculoskeletal assessment and  Distinguish key features of OA from other inflammatory implement a conditions, such as rheumatoid arthritis (RA) management plan for  Describe the prevalence of OA within the community, and the 26 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element patients presenting with impact of the disease on the population and healthcare system osteoarthritis (OA) of the hip or knee  Demonstrate an understanding of the stages and progression of OA and the implications on assessment and management Use recognised published guidelines on managing OA to guide practice17.2 Perform a complex assessment for patients presenting  Perform a musculoskeletal examination of the knee or hip with for musculoskeletal assessment of hip or knee pain appropriate testing of active and passive range of movement, ligamentous structures, muscle length, gait, balance, leg length/alignment, special tests and functional abilities as 17.3 Ensure all red flags are identified in the assessment required to determine a problem list relevant to the individual process, link red flags to diagnoses not to be missed and take appropriate action in a timely manner  As appropriate, demonstrate a complex assessment of other joints and the spine, including neurological testing Demonstrate advanced clinical reasoning in analysing findings Be able to demonstrate an advanced knowledge about possible differential diagnoses. These should include septic arthritis, inflammatory arthritis, gout, ACL/ligamentous injuries, tumour and spinal conditions17.4 Determine the indication for imaging based on assessment findings and decision-making rules  Describe the recommended imaging pathways for OA of the hip and knee17.5 Interpret plain films accurately using a systematic  Follow the local organisation’s policies and procedures approach to diagnose OA regarding the referral and request of imaging27 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element Apply knowledge of Kellgren-Lawrence scale for reporting severity of OA Demonstrate and apply an advanced understanding of the 17.6 Demonstrate an in-depth knowledge of the evidence evidence base for conservative management of OA. This for managing OA includes corticosteroid injections, physiotherapy, orthotics and braces, exercise, hydrotherapy, weight loss and pharmacology 17.7 Formulate an appropriate management plan in  Provide appropriate education and advice to patients collaboration with the patient  Demonstrate an advanced understanding of when surgery is 17.8 Identify when input is required from expert colleagues indicated in managing OA of hip and knee and act to obtain their involvement  Clearly identify and prioritise patients presenting with urgent surgical requirements and liaise effectively with orthopaedic 17.9 Assess need for referral or follow-up and arrange if team necessary  Use appropriate outcome measurement to monitor progress or deterioration and to help make ongoing management decisions18. Implement care of 18.1 Modify routine musculoskeletal assessment in  State the normal blood glucose range musculoskeletal recognition of a patient’s diabetic condition, as relevant to conditions in patients the practice context  Identify situations when blood glucose should be tested with diabetes 18.2 Modify routine musculoskeletal interventions in  Interpret the results of blood glucose testing and report recognition of a patient’s diabetic condition, as relevant to readings outside the acceptable range to the appropriate the practice context person18.3 Provide patients with diabetic conditions, with  Identify the signs of hypoglycaemia or hyperglycaemia and act information relevant to altering their health behaviours and in a timely way to involve nursing and medical staff improving their health status  Identify the need for, and carry out, foot screening for people 28 Element Performance criteria Performance cues Elements describe the The performance criteria specify the level of the Performance cues provide practical examples of what an essential outcome of the performance required to demonstrate achievement of the independent performer may look like, in action competency standard element18.4 Identify when input is required from expert colleagues to assess and manage musculoskeletal conditions in with diabetes, including a thorough neurovascular assessment patients with diabetes, and act to obtain their involvement  Demonstrate awareness of complications and prevention of 18.5 Apply evidence-based practice to managing neuropathy musculoskeletal condition in patients with diabetes  Describe measures to prevent tissue damage in people with diabetes Demonstrate awareness that all people with diabetes are at risk of nephropathy and the implications of this on medication use Demonstrate awareness that all people with diabetes are at risk of retinopathy, and consider the impact of this in the management and follow-up plan Ensure health professionals involved in the care of patient’s diabetes are informed of diagnosis, changes to medications, management and follow-up plan As part of their recovery process encourage people with diabetes to participate in safe, healthy and active lifestyle behaviours that complements their management following joint arthroplasty29 Learning needs analysis Part A and B: PAR clinic The Learning needs analysis is a self-assessment using the Competency standard self-assessment tool (Part A) and the underpinning Knowledge and skills self- assessment tool (Part B). Part B includes an extensive list that varies from having a basic awareness to advanced knowledge of the different skills and knowledge an advanced musculoskeletal physiotherapist may require. It should be completed with Part A prior to developing the Learning and assessment plan.Both Part A and B of the Learning needs analysis should first be completed by the individual (approximately no more than half an hour should be spent doing this – it is a tool designed to identify gaps in knowledge). Part A and B are then reviewed jointly with the physiotherapists and clinical lead or mentor. The key areas for development to be addressed in the learning program should be prioritised with help from the clinical lead or mentor according to relevance to the role and most common conditions that are likely to present to the organisation. The non-clinical time available to the physiotherapist also needs to be considered when prioritising what areas need to be addressed first.It is not expected that ALL of what is listed in Part B needs to be addressed in order to achieve competency. Part B is merely a tool to help identify what the physiotherapist does not know and direct learning accordingly. A tailored Learning and assessment plan should then be developed to direct the use of the learning modules.Additionally, the Learning needs analysis Part A and B, once completed, can also be used as evidence as having met the performance criteria (2.1, 3.1–3) of the competency standard by the method of self-assessment. Competency standard self-assessment tool (Part A of the Learning needs analysis): PAR clinic Clinicians use self-assessment to help them reflect meaningfully and identify both their strengths and their own learning needs. This allows tailoring of the training and assessment program to meet that identified learning need. The Competency standard self-assessment tool is a self- assessment against the elements and performance criteria listed in the competency standard. It also is Part A of the Learning needs analysis. If needed refer to the performance cues on the competency standard to assist with this self-assessment process.Candidate’s name: Date of self- assessment: INDICATE YOUR LEVEL OF CONFIDENCE AGAINST THE FOLLOWING PERFORMANCE CRITERIA 1. I require training and development in most or all of this area 2. I require further training in some aspects of this area 3. I am confident I already do this competently R RELEMENTS AND PERFORMANCE CRITERIA E O Confidence o If 1 or 2 on the confidence rating scale L L E Refer to the competency standard for further detail. E rating scale document action plan VA o If 3 on the confidence rating scale NC provide/document evidence of competencyE 1 2 3PROFESSIONAL BEHAVIOURS 1. Operate within scope of practice 1.1 Identify and act within own knowledge base and scope of practice 1.2 Work towards the full extent of the role 2. Display accountability 2.1 Take responsibility for own actions, as it applies to the practice context LIFELONG LEARNING 3. Demonstrate a commitment to lifelong learning 3.1 Engage in lifelong learning practices to maintain and extend professional competence 3.2 Identify own professional development needs and implement strategies for achieving them 3.3 Engage in both self-directed and practice-based learning 3.4 Reflect on clinical practice to identify strengths and areas requiring further development COMMUNICATION 4. Communicate with colleagues 4.1 Use concise, systematic communication at the appropriate level when conversing with a 31 range of colleagues in the practice context 4.2 Present all relevant information to expert colleagues when acting to obtain their involvement PROVISION AND COORDINATION OF CARE 5. Evaluate referrals 5.1 Discern patients who are appropriate for advanced physiotherapy management in accordance with individual strengths or limitations, any legal or organisational restrictions on practice, the environment, the patient profile/needs and within defined work roles 5.2 Discern patients who are appropriate for management in a shared care arrangement in accordance with individual strengths or limitations, any legal or organisational restrictions on practice, the environment, the patient profile/needs and within defined work roles 5.3 Defer patient referrals to relevant professionals (including other physiotherapists) when limitations of skill or job role prevent the client’s needs from being adequately addressed, or when indicated by local triage procedure 5.4 Prioritise referrals based on patient profile/need, organisational procedure or targets and any local factors 5.5 Communicate action taken on referrals using established organisational processes 6. Perform health assessment/examination 6.1 Design and perform an individualised, culturally appropriate and effective patient interview with common and/or complex conditions/presentations 6.2 Formulate a preliminary hypothesis and differential diagnoses for a patient with common and/or complex conditions, as relevant to the practice context 6.3 Perform complex modifications to routine musculoskeletal assessment in recognition of factors that may impact on the process such as the patient profile/needs and the practice context 6.4 Design and conduct an individualised, culturally appropriate and effective clinical assessment that:  is systems-based  includes relevant clinical tests  selects and measures relevant health indicators  substantiates the provisional diagnosis 6.5 Identify when input is required from expert colleagues and act to obtain their involvement 6.6 Ensure all ‘red flags’ are identified in the assessment process, link ‘red flags’ to diagnoses not to be missed and take appropriate action in a timely manner 6.7 Ensure ‘yellow flags’ are identified in the assessment process and take timely appropriate action32 7. Apply the use of radiological investigations 7.1 Anticipate and minimise risks associated with radiological investigations 7.2 Determine the indication for imaging based on assessment findings and clinical decision- making rules 7.3 Select the appropriate modality consistently and act to gain authorisation as required 7.4 Convey all required information on the imaging request consistently 7.5 Interpret plain-film images using a systematic approach for patients with common and/or complex conditions, as relevant to the practice context 7.6 Identify when input is required from expert colleagues and act to obtain their involvement 7.7 Meet threshold credentials and/or external learning and assessment processes set by the organisation, governing body or state/territory legislation 8. Apply the use pathology tests in advanced musculoskeletal physiotherapy (under the direction and supervision of a consultant) 8.1 Anticipate and minimise risks associated with pathology tests 8.2 Determine the indication for pathology testing based on assessment findings and clinical decision-making rules 8.3 Identify the appropriate test(s) consistently and act to gain authorisation as required 8.4 Convey all required information to appropriate personnel when initiating pathology tests 8.5 Interpret pathology test results for patients with common and/or complex conditions, as relevant to the practice context and in consultation with expert colleagues when required 8.6 Meet threshold credentials and/or external learning and assessment processes set by the organisation, governing body or state/territory legislation 9. Use therapeutic medicines in advanced practice 9.1 Determine the indication and appropriate medication requirements from information obtained from the history taking and clinical examination and liaise with relevant health professionals regarding this 9.2 Demonstrate knowledge of pharmacokinetics, indications, contraindications and precautions, adverse effects, interactions, dosage and administration of medications commonly used to treat musculoskeletal conditions, applicable to the practice context 9.3 Apply knowledge of the legal and professional responsibilities relevant to recommending, administering, using, supplying and/or prescribing medicines under the current legislation, as relevant to the practice context 9.4 Comply with national and state/territory drugs and poisons legislation 9.5 Identify when input is required from expert colleagues and act to obtain their involvement 9.6 Apply relevant knowledge of the medicine involved when recommending and informing patients of the risks and benefits of use 9.7 Exercise due care including properly assessing the implications for individual patients receiving therapeutic medicine, as relevant to the practice context 9.8 Maintain proper clinical records as they relate to therapeutic medicine 33 9.9 Meet threshold credentials and/or external learning and assessment processes set by the organisation, governing body and national and state/territory legislation 10. Advanced clinical decision making 10.1 Synthesise and interpret findings from clinical assessment and diagnostic tests to confirm the diagnosis 10.2 Demonstrate well-developed judgement in implementing and coordinating a patient management plan that synthesises all relevant factors 10.3 Use finite healthcare resources wisely to achieve best outcomes 11. Formulate and implement a management/intervention plan 11.1 Formulate complex, evidence-based management plans/interventions as determined by patient diagnosis, relevant to the practice context and in collaboration with the patient 11.2 Identify when guidance is required from expert colleagues and act to obtain their involvement 11.3 Facilitate all prerequisite investigations/procedures prior to consultation, referral or follow-up, as relevant to the practice context 11.4 Assess the need for referral or follow-up and arrange if necessary 11.5 Identify when input to complement care is required from other health professionals and act to obtain their involvement 11.6 Provide appropriate education and advice to patients with common and/or complex conditions, as relevant to the practice context 11.7 Conduct a thorough handover to ensure patient care is maintained 12. Monitoring and escalation 12.1 Monitor the patient response and progress throughout the intervention using appropriate visual, verbal and physiological observations 12.2 Identify and respond to atypical situations that arise when implementing the management plan/intervention 13. Obtain patient consent 13.1 Explain own activity to the patient as it specifically relates to the practice context and check that the patient agrees before proceeding 13.2 Consider the patient’s capacity for decision making and consent 13.3 Inform the patient of any additional risks specific to advanced practice proposed treatments and ongoing service delivery and confirm their understanding 13.4 Employ strategies for overcoming barriers to informed consent as relevant to the practice context 14. Document patient information 14.1 Document in the patient health record, fully capturing the entire intervention, consultation process, addressing areas of risk and consent and including any referral or follow-up plans 34 ADDITIONAL ADVANCED PRACTICE CLINICAL TASKS SPECIFIC TO PRACTICE CONTEXT 15. Perform an appropriate musculoskeletal assessment and implement a management plan for patients following total hip or knee arthroplasty (THA, TKA) 15.1 Describe the surgical procedures for hip and knee arthroplasty, the components of a THA or TKA, and is able to identify different prosthesis 15.2 Demonstrate an in-depth knowledge of the aetiology and pathology and indications for arthroplasty surgery 15.3 Demonstrate an in-depth knowledge of the post-operative management and complications following arthroplasty 15.4 Modify assessment to identify if post-operative complications following arthroplasty 15.5 Interpret plain-film imaging post-arthroplasty accurately, using a systematic approach to identify signs of prosthesis failure 15.6. Identify when referral to orthopaedics is required and act to obtain their involvement 16. Provide basic wound care 16.1 Determine acute traumatic wounds appropriate for care by an advanced x musculoskeletal physiotherapist, excluding wounds requiring debridement or suturing 16.2 Safely and effectively assess and manage acute traumatic wounds appropriate for care x by an advanced musculoskeletal physiotherapist 16.3 Monitor the healing of surgical wounds 16.4 Identify when input is required from expert colleagues to assess and manage acute x traumatic wounds and act to obtain their involvement 16.5 Identify when input is required from expert colleagues to assess and manage surgical wounds and act to obtain their involvement 17. Perform an appropriate musculoskeletal assessment and implement a management plan for patients presenting with osteoarthritis (OA) of the hip or knee 17.1 Demonstrate an in-depth knowledge of the aetiology, pathology and clinical findings of OA 17.2. Perform a complex assessment for patients presenting for musculoskeletal assessment of hip or knee pain 17.3. Ensure all red flags are identified in the assessment process, link red flags to diagnoses not to be missed and take appropriate action in a timely manner 17.4. Determine the indication for imaging based on assessment findings and decision- making rules 17.5. Interpret plain-films accurately using a systematic approach to diagnose OA 17.6. Demonstrate an in-depth knowledge of the evidence for management of OA 17.7. Formulate an appropriate management plan in collaboration with the patient 18. Implement care of musculoskeletal conditions in patients with diabetes 18.1 Modify routine musculoskeletal assessment in recognition of a patient’s diabetic condition, as relevant to the practice context 18.2 Modify routine musculoskeletal interventions in recognition of a patient’s diabetic 35 condition, as relevant to the practice context 18.3 Provide patients with diabetic conditions with information relevant to altering their health behaviours and improving their health status 18.4 Identify when input is required from expert colleagues to assess and manage musculoskeletal conditions in patients with diabetes and act to obtain their involvement 18.5 Apply evidence-based practice to managing musculoskeletal condition in patients with diabetes Identified learning needs, action plan and timeframe36 Knowledge and skills self-assessment – Part B of the Learning needs analysis: PAR clinicThis Learning needs analysis has been modified and adapted with written permission from Symes G 2009, Resource manual and competencies for extended musculoskeletal roles: chartered physiotherapists with an extended scope of practice, Scotland.Candidate’s name: Date of self-assessment: INDICATE YOUR LEVEL OF CONFIDENCE AGAINST THE FOLLOWING PERFORMANCE CRITERIA 1. I require training and development in most or all of this area 2. I require further training in some aspects of this area 3. I am confident I already do this competently R R E SKILLS AND KNOWLEDGE O Confidence rating Learning strategies L L E E V scale A N CE 1 2 31. Musculoskeletal presentations Background knowledge The advanced  Anatomy of the neuromusculoskeletal systems musculoskeletal  Surface anatomy physiotherapist (AMP) has  Neurovascular supply advanced knowledge in:  Functional anatomy  Physiology of the neuromusculoskeletal systems  Biomechanics of the neuromusculoskeletal systems  Pain mechanisms  Hip and knee joint prostheses, arthroplasty surgical procedures and post-operative management  Risk factors for early prosthesis failure  Osteoarthritis, avascular necrosis (AVN) and RA History taking The AMP is able to obtain an  Allergies 37 accurate clinical history from  Presenting complaint patient’s presenting with  Chronological relevant sequence of events and signs and symptoms symptoms  Severity, irritability and nature of problem  Current and past medications – medications taken that dayThe AMP identifies the  Medical history using a systems-based following: approach  Special questions: recent illness, fevers, weight loss, etc.  Family history  Personal, work and social history, physical activity  Alcohol, smoking, drug taking  The presenting complaint is referred (spinal or visceral) or of non-musculoskeletal origin  Red flags – the symptoms indicate possible serious pathology such as tumour or fracture  Yellow flags – psychosocial factors are exacerbating the presenting complaintClinical assessment To perform an accurate Observation of posture and any associated spinal clinical assessment of problem, gait, limb alignment, muscle wasting, skin patients, the AMP describes integrity (wound) or absence or presence of accurately and includes the deformity or swelling and takes circumferential following: measurements if indicatedConducts a neurovascular assessment (where indicated) inclusive of peripheral nerve assessment and/or thorough neurological assessment Examination techniques as appropriate, for example:  Palpation38  Functional tests  Range of motion tests  Muscle strength tests  Joint stability testsHip / sacroiliac joint (SI) pain provocation tests  Trendelenburg’s test  Leg length test  Hamstring contracture test  Sign of the buttock (straight leg raising) test  Squeeze test  Thomas test (modified)KNEE  Lachman’s test The AMP is capable of  Joint line palpation describing and performing  Anterior and posterior drawer additional tests as  Medial collateral ligament (MCL) or lateral appropriate and relevant to collateral ligament (LCL) tests the practice context, for  Tibial sag sign example:  McMurray’s test  Loomer’s (dial) test for posterolateral instability  Wipe/tap test for effusion  Janda’s muscle length of quadriceps, iliotibial band (ITB) and hip flexors The AMP applies the  Patella tests such as: relevant precautions and o Waldron test contraindications to the o McConnell’s critical test operated hip following o passive patellar tilt arthroplasty when o lateral pull test conducting the clinical o Zohler’s sign assessment o patella inhibition test o tracking test o Homans’ sign (DVT) 39 SPINE  Upper and lower limb reflexes  Babinski sign  Straight leg raise  Femoral nerve stretch test  Upper limb tension tests  Thoracic outlet test  Cranial nerves tests  SI pain provocation tests  Segmental instability test  One-leg lumbar extension test  Spurling’s test  Coordination tests  Tests for clonus and upper motor neurone lesions  Slump test Investigations The AMP is aware of the  Blood tests role, indications, risks and  Biochemistry and microbiology – urine analysis clinical decision pathways and joint aspirations related to listed  X-rays investigations for the  MRI diagnosis and management  CT  Nerve conduction studies (NCS) of patients following  Ultrasound arthroplasty  Bone scans Differential diagnosis The AMP shows awareness  Referred pain from visceral organs of and can identify the  Infection following differential  Malignancy and tumour diagnoses:  Osteomyelitis  Rheumatological inflammatory conditions40 HIP  Femoral acetabular impingement (Cam and Pincer)  Labral pathology  Chondral damage  AVN  Congenital hip dislocation  Slipped upper femoral epiphysis  Loose bodies  Stress fracture  Atypical fracture (bisphosphonates)  Insufficiency fracture  Snapping hip  Gluteus medius tendonopathy  Adductor tendonopathy  Hamstring tendonopathy  Psoas tendonopathy  Bursitis  Osteonecrosis  Osteoid osteoma  Nerve entrapment  Osteitus pubis  Short-leg syndrome  Gynaecological and pelvic disorders  Hernia  Lumbar spine / SI joint referred  Monarticular synovitisKNEE  Meniscal tears  Chondral damage  Loose bodies  Ligamentous injury  Patella tendon injury/rupture 41  Quads tendon injury/rupture  Patellofemoral dysfunction  Pes anserius bursitis  Prepatellar bursitis  Infrapatellar bursitis  Fat pad impingement  Baker’s cyst  Medial plica syndrome  Meniscal cysts  Nail patella syndrome  Gout  Calcium pyrophosphate deposition disease (CPPD)/pseudogout  Osteochondromas  Ollier’s disease  Hip lesions (referred)  Monoarticular arthritis/synovitisSPINE  Radiculopathy  Somatic referred pain  Canal stenosis  Spondylolithesis  Spondylolysis  Ankylosing spondylitis  Cauda equina  Pyrogenic and TB infections  Upper motor neurone lesions (UMNL)  Vascular/metabolic/visceral  Paget’s disease of the bone  Osteoporosis  Scoliosis Poorly controlled post-operative pain 42  Wound infections – superficial and deep  Joint stiffness The AMP demonstrates an  Joint instability ability to assess for the  Haemarthrosis following post-operative  Loss of fixation complications following  Periprosthetic fractures arthroplasty  Suboptimal positioning or size of prosthesis  Synovial hypertrophy and patella clunk syndrome  DVT/thrombosis  Joint infection  Dislocation  Tendon rupture  Patella alta or baja  Heterotrophic ossification  Histolytic response  Delayed posterior cruciate ligament (PCL) insufficiency Congenital problems The AMP shows / is aware  Congenital hip dislocations of the following:  Hip dysplasia  Lateral femoral dysplasia  Bipartitie patella  Congenital scoliosis  Spina bifida occulta Management The AMP is able to diagnose  Make a sound diagnosis of the clinical condition and formulate a based upon the above history, examination and management plan following investigations hip and knee arthroplasty  Identify conditions that are outside of scope of practice and need to be managed or referred to a doctor, specialist, other health professional or to hospital The AMP is able to diagnose  Manage according to organisational guidelines and formulate a and protocols regarding best practice such as management plan for the 43 musculoskeletal hip and the Australian Orthopaedic Association knee conditions identified recommendations regarding the follow-up after above in the differential arthroplasty diagnosis conditions in  Educate patients regrading risk factors for prosthesis failure and prophylactic antibiotic patients following management to reduce infection risk arthroplasty:  Educate patients regarding return to activity/work/function following arthroplasty  Identify patients who require monitoring and non routine follow-up2. Differential diagnosis of non-musculoskeletal conditions Rheumatology The AMP has awareness of  The longevity of problem (acute vs chronic) the importance of:  Recurring problems  Additional symptom development  Other areas becoming symptomaticThe AMP is able to discuss  Osteoarthritis the signs and symptoms  Ankylosing spondylitis associated with the  Diffuse idiopathic skeletal hyperostosis (DISH) following:  Reactive arthritis  Systemic lupus erythematosus (SLE)  RA  Psoriatic arthritis  Enteropathic arthropathies  Gout  Polymyalgia rheumatica  Fibromyalgia  Avascular necrosis Endocrinology The AMP demonstrates  The interrelation between ‘neuromuscular’ awareness of: problems and endocrine problems  The interrelation of other factors such as alcoholism and obesity with endocrine problems The AMP is able to discuss  Chondrocalcinosis 44 the basic neuromuscular and  Hypothyroidism systemic signs and  Diabetes mellitus symptoms associated with  Metabolic alkalosis/acidosis endocrine dysfunction, for  Osteoporosis example:  Osteomalacia  Paget’s diseaseOncology The AMP demonstrates  The AMP demonstrates knowledge of referred awareness of the possible pain patterns from oncological conditions red flags associated with oncological conditionsThe AMP is able to discuss at a basic level signs and  Musculoskeletal system symptoms commonly associated with cancer of  Neurological system the:Visceral/vascular The AMP demonstrates  Heart ( and vessels) knowledge of referred pain  Lung patterns from visceral  Kidney organs, for example:  Liver  Stomach  Intestines  Gall bladder The AMP demonstrates knowledge of vascular  DVT conditions that may present  Vascular claudication as musculoskeletal  Abdominal aortic aneurysm conditions, for example:Neurology45 The AMP is able to discuss  Multiple sclerosis at a basic level signs and  Motor neurone disease symptoms commonly  Parkinson’s disease associated with neurological  Cerebral vascular disease problems, for example:  Neurofibromatosis3. Radiology Radiation safety The AMP demonstrates  Principles of ionising and non-ionising radiation awareness of radiation  Risks and contraindications of each modality: safety that includes: o plain film o CT o MRI o ultrasound o nuclear medicine o interventional radiology o bone scans  Pregnancy and protection of the fetus Indications for imagingThe AMP can describe the  Hip and pelvis clinical decision-making  Knee rules to determine the need  Spine for imaging post-arthroplasty surgery of the:The AMP can describe the  Hip and pelvis indications, advantages and  Knee disadvantages of the  Lumbar spine imaging modalities – plain  In the presence of a prosthesis film, CT, MRI, ultrasound, nuclear medicine – in the following regions:46 The AMP describes the  Prosthesis loosening – septic and aseptic imaging pathway for the  Prosthesis failure following suspected  Prosthesis debris/wear conditions:  Patella clunk syndrome  Prosthesis malalignment or malpositioning Fractures and dislocations  Cartilage and osteochondral lesions  Tendon and muscle ruptures  Ligamentous injuries  Degenerative joint conditions  Avascular necrosis  Stress fractures  Acute osteomyelitis  Bony metastases  Soft tissue mass  Multiple myeloma  DVT (outline Wells’ criteria) Requesting imaging When requesting imaging  Describe the principles of requesting imaging the AMP should be able to:  Define the ALARA principle  Discuss the responsibilities of the referrer  Understand informed consent and how this may be documented  Describe the principles in assessing risk:benefit ratiosInterpretation of imaging (PAR) When requesting imaging  Routine check of name, date, side and site of the AMP should be able to injury interpret plain films using a  Correct patient positioning, view and exposure systematic approach that  ABCS (alignment, bone, cartilage, soft tissue) includes the following:  Common sites of injury or pathology  Common sites for missed injuries  Ability to compare with previous imaging  Recognise failure patterns of prosthesis on x-ray The AMP has advanced  Technical problems regarding prosthesis 47 knowledge in interpreting alignment on x-ray plain-film imaging post-  Associated complications post-arthroplasty such arthroplasty and can identify as peri-prosthetic fractures  Assess limb alignment The AMP has the ability to HIP AND PELVIS recognise the musculoskeletal conditions  Fractures o neck of femur, acetabular from plain-film imaging, for o avulsion example: o AVN o OA, Cam deformitiesKNEE  Fractures o patella, tibial plateau, fibula o avulsion – Segond  Effusion  Tendon ruptures – patella alta  OA  CPPD SPINE  Fractures  Degeneration  Spondylolisthesis The AMP has the ability to  Acute osteomyelitis identify abnormal findings on  Bony metastases plain film of non-  Multiple myeloma musculoskeletal cause that  Foreign bodies require a medical review and  Soft tissue mass may be diagnosed by the medical team such as:5. Pharmacology The AMP demonstrates  Clinical pharmacology knowledge of relevant state/  Pharmacotherapeutics territory legislation regarding  Pharmacokinetics and pharmacodynamics use of medicines  Special considerations for certain populations 48 The AMP demonstrates an (for example, post-arthroplasty, older adults) awareness of pharmacology  International, national and organisational clinical relevant to managing guidelines in relation to medicine use musculoskeletal conditions including:  Analgesics The AMP demonstrates  Antibiotics knowledge about mode of  Anti-inflammatories action, indications,  Disease-modifying antirheumatic drugs precaution, (DMARDs) contraindications, drug  Neuropathic medications interactions, adverse  Corticosteroids reactions and side effects  Opioids and dosage of the following  Diabetic medications drug classes: 6. Pathology The AMP demonstrates a  The red blood cell basic understanding of three  The white blood cell main areas relating to  Coagulation haematology and problems associated with these areas:The AMP can interpret  Anaemia simple haematological  Infection/neoplasia  Thrombosis/haemorrhage results and identifies when medical involvement is required  Fluid and electrolyte balance  Sodium and potassium The AMP demonstrates a  The kidney basic understanding of the  Liver function tests and plasma protein key areas of biochemistry  Calcium and problems associated  Thyroid function with these areas:  Dehydration  Renal and liver failure  Diabetes49 The AMP can interpret  Joint aspiration and microbiology simple biochemistry results and identifies when medical involvement is required7. Wound management History taking The AMP will have the  Presence of discharge, pain, swelling, redness knowledge of the key and warmth principles of history taking in  Risk factors for delayed wound healing relation to wounds, for  Stages of wound healing example:  Signs of wound infectionClinical assessment and investigations The AMP can demonstrate a  Wound characteristics focused clinical wound  Wound complications assessment that includes:  Documentation of wound assessmentManagement of wounds The AMP identifies wounds that require referral to medical and nursing staffThe AMP has a basic understanding of the  Antibiotics for commons superficial and deep management of wounds and wound infections includes knowledge of the  Indications for surgery of wound infections following:  Further investigations required for wound infections The AMP has a basic 50 understanding of dressings and products wound management9. Diabetes The AMP will have basic  Normal glucose and fat metabolism knowledge that includes an  Pathophysiology of diabetes understanding of the  Definition of diabetes mellitus and common following: comorbid conditions  How diabetes is diagnosed  Differences between type 1, type 2 and gestational diabetes  Impaired glucose tolerance and impaired fasting glucose  Risk factors and preventative measures for type 2 diabetes  Self-managed of diabetes with the assistance of a healthcare team  Role of the physiotherapist in supporting individuals with diabetes  Need for good diabetes control – blood glucose, lipids and blood pressure to limit diabetes complications and maintain quality of life  Role of medication in management of diabetes  Complications associated with diabetes o cardiovascular risk o macrovascular complications o microvascular complications – retinopathy, nephropathy and neuropathy  Hypoglycaemia and hyperglycaemia The AMP will have a  Take a history that includes all relevant 51 demonstrated ability to: information required for assessment of a patient with diabetes  Identify when blood glucose should be tested  Interpret results and if outside normal range make the appropriate referral  Recognise signs and symptoms of hypoglycaemia and hyperglycaemia and know how to act appropriately  Conduct a foot screening assessment  Assess for neuropathy and modify management accordingly identify patients at risk of nephropathy and implications of this on management  Identify patients at risk of retinopathy and implications of this on management  Minimise tissue damage  Promote healthy lifestyle behaviours to patients with diabetes who have had arthroplasty surgery 10. Communication Verbal communication The AMP demonstrates  Use concise, systematic approach to verbally advanced skills in presenting cases to expert colleagues communicating at all levels  Acknowledge time restraints and competing and in particular demands on expert colleagues and approaches only when appropriate demonstrates the ability to:  Follows ISBAR approach when indicated and appropriate Documentation The AMP will have a  Correctly document in the medical record by demonstrated ability to: following all: o local policies and procedures o national standards o professional standards  Record accurate and complete clinical notes that are either electronic or legibly hand written  Document clinical notes that are relevant, objective, accurate and concise 52 Consent The AMP will have a  Legislation regarding patient rights and consent demonstrated knowledge of: to treatment  Local organisational guidelines for consenting patients  The barriers that limit a patient’s capacity to The AMP will have a consent demonstrated ability to:  Clearly educate patients of the risks and benefits of investigations or procedures prior to gaining consent  Identify patients that are not able to consent  Troubleshoot when unable to obtain consent53 Learning and assessment plan: PAR clinic (example only) The Learning and assessment plan is separated into two sections: (1) the learning plan and (2) the assessment plan. The learning plan outlines learning resources and describes various learning activities to be undertaken as directed by the Learning needs analysis and as set by the organisation. The assessment plan outlines the methods in which the competency assessment will occur – for example, work-based observed sessions, case-based presentations and oral appraisals. The assessment is mapped back to the performance criteria of the competency standard and recorded on the Learning and assessment plan. This is a flexible, adaptable document that may vary between organisations and individuals. Each organisation should set and clearly document the minimum acceptable method of assessment to determine competency as agreed with the relevant stakeholders (for example, physiotherapy manager, orthopaedic director, radiology). The physiotherapist should keep all documentation regarding the learning activities and assessment undertaken and develop a professional practice portfolio that can then be used as evidence of prior learning should they transfer their employment to another organisation in the future.To develop the Learning and assessment plan the minimum acceptable method of assessment for each performance criteria should be determined by first reviewing the Cumulative assessment tool. This is a copy of the competency standard with recommended methods of assessment allocated to each performance criteria. For some performance criteria there may be more than one method of assessment recommended on the Cumulative assessment tool. This Cumulative assessment tool may vary between organisations and is dependent on the agreed method of assessment between the physiotherapy and orthopaedic departments. There is an option to select and record the preferred method of assessment indicated and many performance criteria may be assessed more than once and additionally by more than one different method of assessment. The Learning and assessment plan should document the method of assessment and the performance criteria and address all performance criteria that are relevant to the role and are yet to be met. Refer to the Learning and assessment plan for the AMP in the orthopaedic department as an example of a completed Learning and assessment plan for a trainee engaging in the whole learning and assessment program. The clinical lead physiotherapist is responsible for developing the assessment component of the Learning and assessment plan in collaboration with the physiotherapist undertaking the assessment and in accordance with the requirements of the organisation.An example Learning and assessment plan can be found on the following pages. A template Learning and assessment plan can be found in the Appendix. COMPETENCY STANDARD Deliver advanced musculoskeletal physiotherapy in the post-arthroplasty review (PAR) clinic ASSESSMENT TIMEFRAME To be negotiated with clinical lead, assessor and/or line manager. WORKPLACE LEARNING A combination of the following will be implemented:  self-directed learning DELIVERY OVERVIEW  observation, coaching or mentoring  workplace application  internal learning. LEARNING ACTIVITIES/RESOURCES (example) TASK DESCRIPTION (add/delete according to individual and organisational needs) Completed  X 1. Complete self-assessment Complete self-assessment using the Learning needs analysis tool(s) Part A and B and discuss learning for the work role needs and assessment/verification processes with clinical supervisor or line manager. 2. Complete site-specific Complete orientation with the clinical lead or line manager, covering all details outlined in the site- orientation to PAR clinic specific orientation guideline. 3. Complete learning  Arthroplasty modules as required from o Hip the Learning needs o Knee analysis  Radiology # must be completed prior to o Radiation safety# requesting imaging o Indications for imaging (learning objectives 2, 3, 9–13) Not all learning modules have o Requesting imaging to be completed prior to o Radiology interpretation PAR commencing competency  Osteoarthritis assessment  Surgical wound management  Pharmacology Learning modules and other learning  Pathology resources can be accessed from the  Differential diagnosis of non-musculoskeletal presentations Victorian Department of Health  Diabetes (APA diabetes e-module or equivalent in-house training) website: http://www.learningseat.com/servlet/ShopLearning?categoryName=Browse+ www.health.vic.gov.au/workforce/amp %BB+Physiotherapy/Clinical+Content+%BB+Diabetes+For+Physiotherapists+- +8+CPD+Hours&learningId=38954 or 55  Communication (ISBAR)/consent/documentation 4. Complete further individual Complete further individualised learning as discussed with and directed by clinical supervisor or line learning as required from manager in the initial self-assessment. This may include material beyond what is covered in the learning the Learning needs modules above. In-service training provided by colleagues from departments such as pharmacy, analysis radiology and pathology can support the learning program. 5. Undertake supervised  Physiotherapists new to the work role who are undertaking the full learning and assessment clinical practice and pathway will engage in a structured/timetabled work program as advised and negotiated with their feedback sessions clinical supervisor/assessor.  Access to senior staff (physiotherapist/consultant) via telephone or in person will be maintained during clinic times, until an individual is deemed competent to practice independently within the outpatient setting.  A formative assessment should be conducted early into commencing the role and throughout the supervision period to help the physiotherapist prepare for workplace observation assessment(s) and oral appraisal. The formative assessment may be conducted by the clinical lead physiotherapist; however, the workplace observation should be conducted by an orthopaedic consultant familiar with the competency standard.6. Review the following  Australian physiotherapy standards documents http://www.physiocouncil.com.au/files/the-australian-standards-for-physiotherapy • APA scope of practice http://www.physiotherapy.asn.au/DocumentsFolder/Advocacy_Position_Scope_of_Practice_20 09.pdf • APRHA code of conduct / registration requirements http://www.physiotherapyboard.gov.au/Codes-Guidelines.aspx • Processes for issuing of sick leave certificates/WorkCover • Local organisational guidelines / clinical governance structure  Australian Orthopaedic Association position statements and documents http://www.aoa.org.au/subspecialties/arthroplasty  Recommendations for patients with hip or knee joint replacements who require dental treatment  Position statement on driving after total hip and knee replacement surgery  Position statement on long-term follow-up of hip and knee arthroplasty - revised and updated 20 August 2012  Guidelines for VTE prophylaxis for hip and knee arthroplasty – revised and updated 14 September 2010, 22 September56 Add/delete7. Other activities to be Attend theatre to observe a total hip and knee arthroplasty being conducted. advised (document other activities organised to assist learning – for example, Lightbox radiology course, Add/delete orthopaedic case conferences)57 ASSESSMENT DETAILS AND LINKAGE (example) ASSESSMENT TASK Due date Elements and performance criteria 1. Complete self-assessment tool – Learning needs analysis Part A and B (SA) 1.1, 2.1, 3.1–2 Self-assessment will include the physiotherapist completing the Learning needs analysis Part A and B: I. prior to commencing in the PAR clinic II. prior to undergoing competency assessment. The physiotherapist should discuss the completed self-assessment tool with their clinical lead, experienced physio or mentor, and develop an individualised Learning and assessment plan.2. Complete written responses (WR) 7.1, 7.5, 15.5, 17.5 Physiotherapists may be required to complete assigned written tasks – for example, multiple choice, short answer, online quizzes. I. WA imaging guidelines radiation safety online module (minimum of 80% correct). This module must be completed during the orientation process before any imaging is requested http://www.imagingpathways.health.wa.gov.au/includes/RadiationQuiz/quiz.html. II. Interpretation of radiology case series (post-arthroplasty and OA)(Refer to PowerPoint presentation available on CD).3. Participate in direct workplace observation (WO) 4.1–2, 5.1–3, 6.1–7, For an agreed period of time the physiotherapist will work under supervision. When deemed ready by self and 7.1–3, 7.5–6, 10.1– supervisor, the physiotherapist will undergo formal observation in orthopaedic outpatients. Refer to the Direct 2, 11.1–7, 12.1, workplace observation assessment checklist. 13.1–3, 15.4, 15.5, 15.6  The physiotherapist’s level of performance will be rated against the standard by the designated assessor using assessment tool(s) during a formal assessment process.  Occasions of direct workplace observation will be negotiated by the assessor (with the physiotherapist).  It is recommended these observations are to include a minimum of two patient presentations following: i. total hip arthroplasty ii. total knee arthroplasty.  Additional observed sessions may be required to fulfil the competency standard requirements such as interpretation of imaging and use of medications if not encountered in the observed sessions  The assessor can be an orthopaedic consultant familiar with the assessment process and competency standard requirements or the clinical lead physiotherapist (as agreed with the orthopaedic department).4. Maintain a professional practice portfolio (PF) 1.2, 3.1–3.3 The professional practice portfolio required is consistent with the requirements of the APA’s requirements and should include relevant information regarding attendance and participation in formal and informal education and 58 learning opportunities specific to advanced musculoskeletal physiotherapy in the PAR clinic. This may include:  self-reflective journal/diaries  in-services, lectures, journal clubs, continuing education programs attended or given  quality assurance projects  presentations provided  research activities – publications  conference attendance  mentoring/supervision sessions. Please refer to:  APA continuing development guidelines: www.physiotherapy.asn.au/APAWCM/Learning_and_Development/CPD_Overview/APAWCM/LearningDev elopment/CPD_Overview.aspx  APHRA guidelines for continuing education: www. physiotherapy board.gov.au/documents/default.aspx 5. Provide documentary evidence (DE) 5.5, 7.4, 9.8, 11.7, I. Complete a documentation audit – It is recommended physiotherapists produce documentary evidence 14.1 of health record entries and of imaging requests. The level of performance will be rated against the standard by the designated assessor (clinical lead physiotherapist) using the assessment tool(s). Documentation audits of clinical notes and imaging requests will be conducted http://www.physiotherapy.asn.au/DocumentsFolder/Advocacy_Position_Health_Records_2010.pdf II. Maintain an electronic clinical log – records of type and nature of patient encounters. The physiotherapist should keep an electronic record of the patients seen and information as indicated on the 1.2 Access electronic database throughout the supervision period.6. Give case-based presentations (CBP) 3.4, 5.2–3, 6.1–7, Physiotherapists will present a minimum of four cases to colleagues at a frequency designated by the assessor or 7.2–3, 7.5, 8.2–3, clinical lead or supervisor – Case based presentation assessment tool. 8.5, 9.1–2, 9.5–7 10.1–2, 11.1–2,  It will be supported by verbal questioning by the assessor, centring on advanced clinical decision making. 11.4, 12.2, 15.1–6,  The level of performance will be rated against the standard by the designated assessor, using assessment 16.3, 16.5, 17.1–7, tool(s). 18.1–5 The presentations must address all areas identified in the standard assessment tool that include the following:  reflection of clinical practice  examples of patients requiring a shared model of care or that required transfer of care to orthopaedics  history and examination findings of patients with conditions across the domains of different arthroplasty procedures (THA, TKA)  examples of cases with imaging, pathology and pharmacological requirements  evidence of advanced clinical decision making and formulation of complex management plans  an example of an atypical situation or a situation requiring escalation o prosthesis failure 59 o complication post-arthroplasty o infection post-arthroplasty  a case that required wound assessment and management  a case of a patient with diabetes post-arthroplasty. 7. Participate in performance appraisal (PA) 1.2, 2.1, 4.1–2, 5.4, A performance appraisal should be conducted at the completion of an agreed timeframe by an allocated 6.1–7, 7.6, 8.4, 8.5, orthopaedic consultant who has worked regularly with the physiotherapist. This appraisal is based on an informal 10.3, 11.3–7, 15.6 observation of clinical practice over a period of time. This appraisal will include the following areas:  working to full potential of the role  accountability  ability to work within limitations  overall clinical practice  communication with colleagues including o presentation of cases o recognition of when to involve colleagues  management of workload  use of resources. Refer to the Performance appraisal assessment tool. 8. Undertake external qualification/training (Q/T) 7.7, 8.6, 9.9, 15.5, The physiotherapist may undertake external training and formal assessment to achieve independent practice. 18.1–5 Examples include:  APA diabetes learning modules 1–4 / in-house equivalent  The University of Melbourne single subject – ‘Radiology for Physiotherapists’  The University of Melbourne single subject – ‘Pharmacology’9. Participate in oral appraisal (OA) 1.1, 5.1, 5.4 Oral appraisal will be used to assess aspects of workplace performance, as required and at the discretion of the 9.3–4, 10.1–2 assessor (orthopaedic consultant or clinical lead physiotherapist). Refer to the Oral appraisal assessment tool . The 12.2, 13.4, 15.1 physiotherapist should be required to verbally demonstrate knowledge regarding:  scope of practice  knowledge about surgical procedures  prioritisation of workload and use of resources  clinical reasoning and decision-making processes regarding use of investigations and medications  indications for making referrals to specialists  risk management  relevant policies and procedures, legislation and health standards.60 Workplace learning program One aspect of the workplace learning program includes self-directed learning modules that apply the adult learning principles.1 These principles support the self-directed approach rather than the traditional didactic teaching method. The learning modules can be accessed on the Victorian Department of Health website. Ideally the modules should be accompanied by other learning activities such as in-services provided by other specialty departments within the organisation such as orthopaedics, pharmacy, pathology, radiology and the diabetes educators. All learning activities undertaken should be documented in the professional practice portfolio. Other examples of learning activities are included in the Learning and assessment plan and include attendance at orthopaedic case conferences, external courses and lectures and conferences. Learning modules The learning modules for the ‘Advanced musculoskeletal physiotherapy services – PAR clinic’ are divided into key areas relevant to practice. All of these modules do not need to be completed prior to starting in these roles however the section on radiation safety in the radiology module should be completed during the initial orientation process and prior to commencing the requesting of imaging.How to use the learning modules It is presumed a combination of team-based and individual learning approaches will be applied. The gaps identified in Learning needs analysis (Part A and B) should direct the focus for the learning modules. The learning modules can be divided up among the team to complete and present back to the musculoskeletal physiotherapy team at professional development sessions. Some elements of the module may need to be completed individually as per the individualised Learning and assessment plan agreed jointly with the clinical lead or mentor. There may be some learning objectives in the modules that are not relevant to all organisations (for example, wound management) and/or some learning objectives previously achieved and therefore do not need to be completed. Additionally there is repetition and overlap in learning objectives across the modules. This is deliberate to allow the learning modules to be a stand-alone document. It is not expected that every question in the learning modules, particularly questions already addressed in other modules, need to be answered – time should be spent on the areas identified as needing development and areas of high priority and most likely presentations relevant to the practice context. How much time should it take? Non-clinical time must be allocated to complete the learning modules and this should be protected time away from a clinical workload. The amount of time for learning should be negotiated as early as possible and be dependent on the needs of the individual. The timeframe to complete the training program will be dependent on the number of hours working in the role (full time or part time) and should be determined in consultation with the clinical lead. The physiotherapist is responsible for ensuring the modules are completed in a timely way in preparation for the work-based competency assessment. The learning modules assume a level of musculoskeletal skills and knowledge equivalent to that of clinicians working at an APA titled master’s level. Hence, physiotherapists who have not completed their master’s, or have gone through the APA experiential titling pathway, may be required to undergo additional competency assessment to address performance gaps that cannot be addressed within the scope of this clinical education framework.It is important to note that not all parts of all the learning modules are required to successfully complete the competency assessment. Some of the learning modules are for more experienced 1 Knowles M S 1975, ‘Adult education: new dimensions’, Educational Leadership, 75, retrieved 26 November 2013, <http://www.ascd.org/ASCD/pdf/journals/ed_lead/el_197511_knowles.pdf>.61 advanced musculoskeletal physiotherapists (for example, the differential diagnosis module) and can be left to a later stage. The modules can be used as an ongoing tool to support learning in the future even after competency has been achieved.62 Example of learning modules for the ‘Advanced musculoskeletal physiotherapy service – PAR clinic’Module Domain1 Arthroplasty Post hip arthroplasty Post knee arthroplasty2 Radiology Radiation safety# Indications for imaging (learning objectives 2, 3, 9–13) Requesting imaging Radiology interpretation (PAR)3 Osteoarthritis4 Wound management – surgical 5 Pharmacology6 Pathology7 Differential diagnosis8 *9 Diabetes – APA diabetes module^ or in-house equivalent10 Communication (ISBAR)/consent/documentation # must be completed before ordering of imaging commences* Module 8 is paediatrics which is not required for PAR clinic^APA diabetes module is located at: http://www.learningseat.com/servlet/ShopLearning? learningId=38954&categoryName=Diabetes+For+Physiotherapists+-+8+CPD+Hours63 Competency-based assessment and related toolsBackground ‘Competency based assessment is a purposeful process of systematically gathering, interpreting, recording and communicating to stakeholders, information on candidate performance against industry competency standards and/or learning programs’ (National Quality Council 2009)Assessment is an important part of any training system, not only for the learner but for the clinical educator and for stakeholders.For the learner, assessment provides feedback to guide their future learning and monitor their own progress. For clinical educators, assessment allows them to verify that learning is taking place in line with the required standard of performance and to determine their success in facilitating the learning process. For stakeholders, assessment provides a way of knowing if people have the required knowledge, skills and behaviours for the job. In this instance, the key stakeholders would include employers and clinical supervisors from a variety of professions. As it stands now, competence assessment of AMPs is not required to satisfy any professional association or legal requirements but is broadly applied in some shape or form across the health sector. Providing proof of competency achievement involves a process of gathering information (evidence), matching it against the requirements of the competency standard and applying it in the workplace using sound assessment principles. This process is assisted by using a variety of assessment tools and instructions listed under the assessment resources section. Assessing competence in the workplace using evidence The type and amount of evidence required to support decisions of competence is not prescribed here; however, recommendations regarding assessment methods mapped against the competency standard are made to provide some guidance on how this might be done. These recommendations are outlined in the Cumulative assessment tool and the Learning and assessment plan and are supported by a number of other assessment checklists and tools, listed below. They provide a guide only. Ultimately the amount and type of evidence to support decisions of competence for AMPs is at the discretion of the organisation.64 Principles of assessment The principles of validity, reliability, flexibility, fairness and sufficiency, should be applied to assessment processes and decisions. Principles of competency-based assessment as it applies to advanced musculoskeletal physiotherapists Principle Key ideas Validity (assessing  The assessor’s knowledge and skill is crucial to enhancing the validity of what it claims to the assessment process – this is enhanced by ensuring workplace assess) assessors meet specific criteria  The assessor gathers evidence about performance to justify assessment judgements  Assessment includes the range of knowledge and skills needed to demonstrate competency with their practical application  Where possible, includes judgements based on evidence from a number of sources, occasions and across a number of contexts Reliability (consistent  Clear instruction for the assessor as to what must be identified and what and accurate constitutes the required performance level – this is enhanced by the decisions) competency standard, performance cues and use of assessment tools and instructions  This is also enhanced by ensuring workplace assessors meet specific criteria and that consistent conduct is used during assessments  Consideration is given to the amount of error included in the evidence Flexibility (when it can  Assessment should reflect the candidate’s needs accommodate the  It must provide for recognition of knowledge, skills and attitudes, needs of learners, a regardless of how they have been acquired variety of delivery  Assessment must be accessible to learners through a variety of methods modes and delivery appropriate to context and the candidate sites ) Fairness (when it  Assessor considers the needs and characteristics of the candidate and places all learners on includes reasonable adjustment where applicable equal terms)  Assessment is based on a participative and collaborative relationship between the assessor and the candidate  Assessment procedure is clear to all learners before assessment – this is enhanced by learners having access to instructions and tools prior to assessment  Assessor is open and transparent about all assessment decision making and maintains impartiality and confidentiality throughout the assessment process  Assessment decisions can be challenged and appropriate mechanisms are made for reassessment as a result of the challenge Sufficiency (relates to  Refers to evidence as well as assessment methods the quantity and quality  Enough appropriate evidence needs to be collected and assessed to of the evidence ensure all aspects of the competency standard have been satisfied – this assessed) is enhanced by a well-developed assessment plan that includes evidence recommended by subject matter experts  Evidence should accurately reflect real workplace requirements and include the range and complexity of patient presentations found in the practice context  Includes a range of methods mapped to the competency standard  Provides evidence from the assessment process that is acceptable to stakeholders Adapted from: National Quality Council 2009, Guide for developing assessment tools, DEEWR, Canberra, pp. 24–28. © Commonwealth of Australia65 Assessment resources A number of assessment resources have been developed to support implementation in the workplace. Some tools relate to establishing the suitability of the assessor and some can be used as a recording tool during occasions of assessment; others help to ensure consistent processes are used and that candidates are aware of how the assessment task will be conducted. Not all assessment tools will be used in the competence assessment of individual candidates. The tools used will depend on what assessment methods have been decided on by the organisation and mapped in the Learning and assessment plan, the competences specific to the practice context and the individual needs of the candidate. The assessment resources and a description of purpose and use are included below.Assessment resources No. Name Purpose How to use the resource Assessment tools to assess candidates 1.1 Cumulative assessment To inform recommended Use this tool as a starting and tool assessment methods for endpoint. performance criteria At the beginning, the Cumulative assessment and collate assessment tool provides a guide to all evidence to enable a the assessment methods final decision on recommended for specific workplace competence performance criteria, as relevant to the work role. By using these recommendations, the Learning and assessment plan for the individual can be refined. At the endpoint this tool is used to collate all the evidence collected from assessment processes and indicate the overall outcome of assessment made by the assessor.1.2 Competency standard To help clinicians reflect Use this tool as a self-assessment self-assessment tool: meaningfully and to against the elements and Part A, Learning needs identify strengths and performance criteria at the beginning analysis of the program to assist in their own learning needs establishing the learning needs of as they relate to the the individual to allow tailoring of the standards Learning and assessment plan. 1.3 Knowledge and skills To help clinicians reflect Use this tool as a self-assessment self-assessment tool: meaningfully and to against the underpinning knowledge Part B, Learning needs identify strengths and and skills at the beginning of the analysis program to assist in establishing the their own learning needs learning needs of the individual to as they relate to allow tailoring of the Learning and underpinning knowledge assessment plan. and skills 1.4 Direct workplace To record performance After adequate preparation of the observation (WO) during a direct learner and due consideration of the (adult): assessment observation assessment assessment context and conditions checklist against designated (see additional resources below) the performance criteria for tool is used to record performance Includes a modified an adult patient during a WO assessment. The checklist number of WO assessments is not 66 fixed and may vary depending on the range of clinical presentations relevant to the practice context, the level of performance of an individual in earlier assessments or prior work experience and training of an individual. See the Learning and assessment plan for details. One tool should be used for each WO. Ratings against all performance criteria may not be possible on the one assessment occasion, but for each occasion an overall rating should be given and effective performance feedback given. 1.5 Direct workplace To provide consistent Assessors can select from this list of observation (WO): questions that can be questions to target performance follow-up questions used to clarify criteria that may not have been performance against observed in the WO, or to clarify the specific performance candidate’s understanding in criteria performance criteria where performance may fall short of the expected standard. 1.6 Case-based To help candidates and Candidates use the tool to collate presentation (CBP): assessors collate the evidence across a number of focus assessment evidence collected by areas and assessment occasions. instructions and case presentations and summary inform learners on assessment requirements using this method1.7 Case-based To record performance The assessment tool is used to presentation (CBP): during a case-based record performance during a CBP assessment checklist presentation assessment assessment. As per the application against designated in the adult population, the number of performance criteria WO assessments is not fixed and may vary. See the Learning and assessment plan for details. One tool should be used for each WO. Ratings against all performance criteria may not be possible on the one assessment occasion, but for each occasion an overall rating should be given and recorded and constructive feedback given. 1.8 Record-keeping audit: To record performance of This assessment tool is used by the assessment tool a candidate’s record assessor to collate evidence over a keeping against number of health record entries and designated criteria provide feedback to target areas for improvement.1.9 Clinical audit: recording To record feedback by This recording tool is used by peers tool peers given during a to record feedback after reviewing clinical audit of random the content of medical record entries health records against evidence-based practice and best practice. Constructive feedback will be provided to the physiotherapist and recommendations for improvement 67 documented with a plan to ensure recommendations are implemented.1.10 Performance appraisal To capture the overall A performance appraisal should be (PA): assessment tool performance of a conducted at agreed times by a candidate over an agreed consultant who has worked regularly timeframe as rated by a alongside the physiotherapist. This consultant who has appraisal is based on an informal worked regularly with the observation of clinical practice and candidate against addresses designated criteria not designated criteria easily captured elsewhere. It may provide supplementary evidence in instances where engagement of consultants in formal assessment processes is difficult, such as a WO, and is designed to promote collaborative working relationships. 1.11 Oral appraisal (OA): To record a candidate’s An oral appraisal takes place assessment tool performance against between the candidate and the designated criteria not clinical lead or consultant in a covered by other methods question and answer format and of assessment addresses areas such as legislation and scope of practice. The assessor rates the answers on the assessment tool. 1.12 Radiological To record performance The assessment tool is used to interpretation of a plain- during radiological record the candidate’s interpretation film case series: interpretation of a plain- of plain-film imaging case series as assessment tool for the film case series, against relevant to the practice context. The candidate (Refer to designated criteria assessor will rate the performance of powerpoint the candidate as directed by the tool. presentation) Additional resources for assessment preparation 2.1 Pre-assessment To establish the suitability All workplace assessors should checklist for workplace of the workplace assessor complete the checklist to establish assessors: self- in accordance with their suitability as a workplace assessment tool recommended minimum assessor prior to assessing the criteria competency of candidates. This is to be used as a guide only where there are no legislated requirements or additional organisational requirements to be applied. 2.2 Conditions and context To inform candidates and These instructions can be adapted for assessment: assessors of the contexts as needed but in their current format instructions and conditions required provide general principles and for workplace assessment instructions to guide the assessment process. The candidate should have access to these instructions and any assessment tool(s) prior to the assessment task. An opportunity for clarification of these instructions prior to assessment would also be given to the candidate. 2.3 Assessment To promote consistent This checklist is to be used by the preparation checklist conduct and adequate assessor prior to the assessment of preparation of the the candidate to promote adequate preparation for the ensuing candidate prior to assessment and to ensure the 68 assessment candidate has been fully informed. It is particularly applicable for direct WO assessments. 2.4 Guidelines for To promote consistent This provides a guide to how an assessors conduct conduct by assessors assessor should conduct themselves during a direct during direct observation during a direct observation workplace observation assessment. It is particularly assessment assessment applicable for direct WO assessments but the principles can and should be applied to other forms of assessment.69 Cumulative assessment tool – PAR clinic Candidate’s name: Assessment timeframe: Name(s) of assessor(s): R E R V ELEMENTS AND PERFORMANCE CRITERIA O Performance E Source of evidence gathered I C L DDid the candidate provide evidence of the following? E rating scale O E  Self-assessment (SA)  Case-based presentation D M A S I M N R n  Written responses (WR) (CBP) u e s a d C M E p s p r e  Oral appraisal (OA)  Qualification/training E L E g i e e p s E i record (Q/T) n r N  Documentary evidence n e t v V e d D n a i (DE)  RPL evidence (RPL) d A e s l d E n eN  Portfolio (PF) e  Workplace observation D d t n C(WO)  Performance appraisal t E (PA)  Other … PROFESSIONAL BEHAVIOURS 1. Operate within scope of practice 1.1 Identify and act within own knowledge base and scope of practice SA, OA 1.2 Work towards the full extent of the role PF, PA, DE 2. Display accountability 2.1 Demonstrate responsibility for own actions, as it applies to the practice context SA, PA LIFE LONG LEARNING 3. Demonstrate a commitment to lifelong learning 3.1 Engage in lifelong learning practices to maintain and extend professional PF, SA competence 3.2 Identify own professional development needs and implement strategies for PF, SA achieving them 3.3 Engage in both self-directed and practice-based learning PF 3.4 Reflect on clinical practice to identify strengths and areas requiring further CBP development COMMUNICATION 4. Communicate with colleagues 4.1 Use concise, systematic communication at the appropriate level when WO, PA conversing with a range of colleagues in the practice context 4.2 Present all relevant information to expert colleagues when acting to obtain their involvement 70 PROVISION AND COORDINATION OF CARE 5. Evaluate referrals 5.1 Discern patients who are appropriate for advanced physiotherapy management OA, WO in accordance with individual strengths or limitations, any legal or organisational restrictions on practice, the environment, the patient profile/needs and within defined work roles 5.2 Discern patients who are appropriate for management in a shared care CBP, arrangement in accordance with individual strengths or limitations, any legal or WO organisational restrictions on practice, the environment, the patient profile/needs and within defined work roles 5.3 Defer patient referrals to relevant professionals (including other physiotherapists) when limitations of skill or job role prevent the client’s needs from being adequately addressed, or when indicated by local triage procedure 5.4 Prioritise referrals based on patient profile/need, organisational procedure or PA, OA targets and any local factors 5.5 Communicate action taken on referrals using established organisational DE processes 6. Perform health assessment/examination 6.1 Design and perform an individualised, culturally appropriate and effective WO, patient interview with common and/or complex conditions/presentations CBP, PA 6.2 Formulate a preliminary hypothesis and differential diagnoses for a patient with common and/or complex conditions, as relevant to the practice context 6.3 Perform complex modifications to routine musculoskeletal assessment in recognition of factors that may impact on the process such as the patient profile/needs and the practice context 6.4 Design and conduct an individualised, culturally appropriate and effective clinical assessment that:  is systems-based  includes relevant clinical tests  selects and measures relevant health indicators  substantiates the provisional diagnosis 6.5 Identify when input is required from expert colleagues and act to obtain their involvement 6.6 Act to ensure all ‘red flags’ are identified in the assessment process, link ‘red flags’ to diagnoses not to be missed and take appropriate action in a timely manner 6.7 Act to ensure ‘yellow flags’ are identified in the assessment process and take 71 appropriate action in a timely manner 7. Apply the use of radiological investigations 7.1 Anticipate and minimise risks associated with radiological investigations WR, WO 7.2 Determine the indication for imaging based on assessment findings and clinical CBP, Other – as determined by local radiology decision-making rules WO department 7.3 Select the appropriate modality consistently and act to gain authorisation as required 7.4 Convey all required information on the imaging request consistently DE 7.5 Interpret plain-film imaging accurately using a systematic approach for patients CBP, with common and/or complex conditions, as relevant to the practice context WO, WR 7.6 Identify when input is required from expert colleagues and act to obtain their WO, PA involvement 7.7 Meet threshold credentials and/or external learning and assessment processes set by the organisation, governing body or state/territory legislation 8. Apply the use of routine pathology tests in advanced musculoskeletal physiotherapy (under direction and supervision of a consultant) 8.1 Anticipate and minimise risks associated with pathology tests CBP 8.2 Determine the indication for pathology testing based on assessment findings and clinical decision-making rules 8.3 Identify the appropriate test(s) consistently and act to gain authorisation as required 8.4 Convey all required information to appropriate personnel initiating pathology PA tests 8.5 Interpret basic pathology test results for patients with common and/or complex CBP, PA conditions, as relevant to the practice context and in consultation with expert colleagues 8.6 Meet threshold credentials and/or external learning and assessment processes Not presently available set by the organisation, governing body or state/territory legislation 9. Apply the use of therapeutic medicines in advanced musculoskeletal physiotherapy (under the direction and supervision of a consultant) 9.1 Determine the indication and appropriate medication requirements from CBP information obtained from the history taking and clinical examination and liaise with relevant health professionals regarding this 9.2 Demonstrate knowledge of pharmacokinetics, indications, contraindications and precautions, adverse effects, interactions, dosage and administration of medications commonly used to treat musculoskeletal conditions, applicable to the practice context 9.3 Apply knowledge of the legal and professional responsibilities relevant to OA recommending, administering, using, supplying and/or prescribing medicines under 72 the current legislation, as relevant to the practice context 9.4 Comply with national and state/territory drugs and poisons legislation OA 9.5 Identify when input is required from expert colleagues and act to obtain their CBP involvement 9.6 Apply relevant knowledge of the medicine involved when recommending and informing patients of the risks and benefits of use 9.7 Exercise due care including assessing properly the implications for individual patients receiving therapeutic medicine, as relevant to the practice context 9.8 Maintain proper clinical records as they relate to therapeutic medicine DE 9.9 Meet threshold credentials and/or external learning and assessment processes Q/T The University of Melbourne pharmacology set by the organisation, governing body and national and state/territory legislation subject (optional) 10. Apply advanced clinical decision making 10.1 Synthesise and interpret findings from clinical assessment and diagnostic tests WO, to confirm the diagnosis CBP, OA 10.2 Demonstrate well-developed judgement in implementing and coordinating a patient management plan that synthesises all relevant factors 10.3 Use finite healthcare resources wisely to achieve best outcomes PA 11. Formulate and implement a management/intervention plan 11.1 Formulate complex, evidence-based management plans/interventions as WO, determined by patient diagnosis, relevant to the practice context and in CBP collaboration with the patient 11.2 Identify when guidance is required from expert colleagues and act to obtain their involvement 11.3 Facilitate all prerequisite investigations/procedures prior to consultation, WO, PA referral or follow-up, as relevant to the practice context 11.4 Assess the need for referral or follow-up and arrange if necessary 11.5 Identify when input to complement care is required from other health professionals and act to obtain their involvement 11.6 Provide appropriate education and advice to patients with common and/or complex conditions, as relevant to the practice context 11.7 Conduct a thorough handover to ensure patient care is maintained WO, DE, PA 12. Monitoring and escalation 12.1 Monitor the patient response and progress throughout the intervention using WO appropriate visual, verbal and physiological observations 12.2 Identify and respond to atypical situations that arise when implementing the CBP, OA management plan/intervention73 13. Obtain patient consent 13.1 Explain own activity to the patient as it specifically relates to the practice WO context and check that the patient agrees before proceeding 13.2 Consider the patient’s capacity for decision making and consent 13.3 Inform the patient of any additional risks specific to advanced practice proposed treatments and ongoing service delivery and confirm their understanding 13.4 Employ strategies for overcoming barriers to informed consent as relevant to OA the practice context 14. Document patient information 14.1 Document in the patient health record, fully capturing the entire intervention, DE consultation process, addressing areas of risk, consent and including referral or follow-up plans ADDITIONAL ADVANCED PRACTICE CLINICAL SKILLS SPECIFIC TO PRACTICE CONTEXT 15. Perform an appropriate musculoskeletal assessment and implement a management plan for patients following total hip or knee arthroplasty (THA, TKA) 15.1 Describe the surgical procedures for hip and knee arthroplasty, the OA, CBP components of a THA or TKA, and is able to identify different prosthesis 15.2 Demonstrate an in-depth knowledge of the aetiology and pathology and CBP indications for arthroplasty surgery 15.3 Demonstrate an in-depth knowledge of the post-operative management and CBP complications following arthroplasty 15.4 Modify assessment to identify if post-operative complications following CBP, arthroplasty WO 15.5 Interpret plain-film imaging post-arthroplasty accurately using a systematic WO, approach to identify signs of prosthesis failure WR, CBP 15.6 Identify when referral to orthopaedics is required and act to obtain their WO, PA, involvement CBP 16. Provide basic wound care 16.1 Determine acute traumatic wounds appropriate for care by an advanced x practice musculoskeletal physiotherapist, excluding wounds requiring debridement or suturing 16.2 Assess and manage acute traumatic wounds appropriate for care by an x advanced practice musculoskeletal physiotherapist, safely and effectively 16.3 Monitor the healing of surgical wounds CBP 16.4 Identify when input is required from expert colleagues to assess and manage x74 acute traumatic wounds and act to obtain their involvement 16.5 Identify when input is required from expert colleagues to assess and manage surgical wounds and act to obtain their involvement 17. Perform an appropriate musculoskeletal assessment and implement a management plan for patients presenting with osteoarthritis of the hip or knee 17.1 Demonstrate an in-depth knowledge of the aetiology, pathology and clinical CBP findings of OA 17.2. Perform a complex assessment for patients presenting for musculoskeletal assessment of hip or knee pain 17.3. Ensure all red flags are identified in the assessment process, link red flags to diagnoses not to be missed and take appropriate action in a timely manner 17.4. Determine the indication for imaging based on assessment findings and decision-making rules 17.5. Interpret plain films accurately using a systematic approach to diagnose OA WR, CBP 17.6. Demonstrate an in-depth knowledge of the evidence for management of OA CBP 17.7. Formulate an appropriate management plan in collaboration with the patient 18. Implement care of musculoskeletal conditions in patients with diabetes 18.1 Modify routine musculoskeletal assessment in recognition of a patient’s CBP, diabetic condition, as relevant to the practice context Q/T 18.2 Modify routine musculoskeletal interventions in recognition of a patient’s diabetic condition, as relevant to the practice context 18.3 Provide patients with diabetic conditions, with information relevant to altering their health behaviours and improving their health status 18.4 Identify when input is required from expert colleagues to assess and manage musculoskeletal conditions in patients with diabetes and act to obtain their involvement 18.5 Apply evidence-based practice to managing musculoskeletal condition in patients with diabetesOVERALL COMPETENCY RESULT achieved in assessment timeframe Date: Signature of candidate: (*Independent rating required in all performance criteria to achieve competency) Competent  Not yet competent Date: Signature of assessor(s):If competency NOT achieved, document performance criteria to be addressed and action plan 75 BONDY RATING SCALE Scale label Standard of procedure Quality of performance Level of assistance required Independent Safe Achieved intended outcome Proficient No supporting cues required (I) Accurate Behaviour is appropriate to context Confident Expedient Supervised Safe Achieved intended outcome Proficient Occasional supportive cues (S) Accurate Behaviour is appropriate to context Confident Reasonably expedient Assisted (A) Safe Achieved most objectives for intended outcome Proficient throughout most of the performance Frequent verbal and occasional physical Accurate Behaviour generally appropriate to context when assisted directives in addition to supportive cues Marginal (M) Safe only with guidance Incomplete achievement of intended outcome Unskilled Continuous verbal and frequent physical Not completely accurate Inefficient directive cues Dependent (D) Unsafe Unable to demonstrate behaviour Unskilled Continuous verbal and physical directive cues Lack of insight into behaviour appropriate to context Unable to demonstrate behaviour/procedure X Not observed Reference: Bondy K N 1983, ‘Criterion-referenced definitions for rating scales and clinical evaluation’, Journal of Nursing Education, 22(9):376–381.76 Direct workplace observation (WO) (adult): modified assessment checklist (PAR)Candidate’s name: Date:Assessment linkage to competency standard: 4.1–2, 5.1–3, 6.1–7, 7.1–3, 7.5–6, 10.1–2, 11.1–7, 12.1, 13.1–3, 15.4–6  Within each workplace observation not all performance criteria may be appropriate to be assessed.  Performance criteria may be carried over for assessment in the next workplace observation.  Once all performance criteria have been assessed as independent no further workplace observations will be required. Workplace observation no. ( circle): 1 2 Additional as required Assessor’s name and designation:Candidate to indicate the type of patient presentation included in this workplace observation:  Hip arthroplasty  Knee arthroplastyBONDY RATING SCALE Scale label Standard of procedure Quality of Level of performance assistance required Independent (I) Safe Achieved intended outcome Proficient No supporting cues Accurate Behaviour is appropriate to context Confident required Expedient Supervised (S) Safe Achieved intended outcome Proficient Occasional Accurate Behaviour is appropriate to context Confident supportive cues Reasonably expedient Assisted (A) Safe Achieved most objectives for Proficient throughout Frequent verbal Accurate intended outcome most of the and occasional Behaviour generally appropriate to performance when physical directives context assisted in addition to supportive cues Marginal (M) Safe only with Incomplete achievement of Unskilled Continuous verbal guidance intended outcome Inefficient and frequent Not completely physical directive accurate cues Dependent (D) Unsafe Unable to demonstrate behaviour Unskilled Continuous verbal Lack of insight into behaviour Unable to and physical appropriate to context demonstrate directive cues behaviour/procedure X Not observed Reference: Bondy K N 1983, ‘Criterion-referenced definitions for rating scales and clinical evaluation’, Journal of Nursing Education, 22(9):376–381.77 s c L Performance rating scale  o t i a n m D M A S I n n k u e s p a d ELEMENTS AND PERFORMANCE CRITERIA d t p s p r a e o e g i e e t r p s eDid the candidate provide evidence of the following? i d n r n t e v n e d n a i c d e s d l y n i e X o t n or n t N/ACommunication Communication with expert colleagues is concise, systematic, at 4.1, appropriate level and includes liaising regarding: 6.5, 7.6,  assessment and management plan 11.2,  differential diagnosis 15.6  use of medicines and imaging All relevant information presented to expert colleagues 4.2 Provision and coordination of care Appropriate patients allocated from theatre list 5.1 Shared care management instigated appropriately 5.2 Patients deferred to other professionals appropriately and a 5.3, thorough handover is conducted as required 11.5, 11.7 Perform health assessment/ examination An individualised, culturally appropriate and effective patient 6.1 interview conducted Preliminary hypothesis formed 6.2 Differential diagnoses identified 6.2 An individualised, appropriate and effective musculoskeletal 6.3 assessment conducted 6.4 ‘Red flags’ and ‘yellow flags’ are identified, and appropriate action 6.6–7 taken 15.4 Apply the use of radiological investigations in advanced musculoskeletal physiotherapy Imaging selected is indicated, risks are minimised and appropriate 7.1-3 modality selected Radiological plain-film images are interpreted systematically and 7.5 accurately 15.5 Advanced clinical decision making Findings interpreted and synthesised to confirm the diagnosis 10.1 Management plan shows well-developed judgement, with synthesis 10.2 of all relevant factors Formulate and implement a management/intervention plan Plan is evidence-based, appropriate and made in collaboration with 11.1 patient All prerequisite investigations and information facilitated prior to 11.3 consultation/referral Referral and follow-up arranged appropriately 11.4 Provided appropriate education and advice to patient 11.6 Monitor and escalate care Monitored the patient response and progress throughout the 12.1 intervention appropriately Obtain patient consent Own activity as it specifically relates to the practice context 13.1 explained and checked that the patient agreed before proceeding The patient’s capacity for decision making and consent considered; 13.2– informed of risks and understanding confirmed 3ELEMENTS AND PERFORMANCE CRITERIA i L Performance rating scale78 I n y c n D M A n S d o k uDid the candidate provide evidence of the following? e s e s a m p s p p t r t a o g i e e e p s n i n r n e X n t v d e d d t a i a e d e s or e l r n n i n d o c N/A t tOPTIONAL FOLLOW-UP QUESTIONS FOR THE ASSESSOR TO CONSIDER What are the risks associated with ordering plain x-rays? 7.1 What are the key principles to apply to minimise risk associated with plain x-rays? What are the risks associated with pathology tests and what do 8.1 clinicians requesting pathology tests need to do to minimise risks? Provide an example of what and when pathology tests be indicated. 8.2 What tests can be initiated by a physiotherapist? What is the process when pathology tests are indicated but can’t be 8.3 initiated by a physiotherapist? In what situations should expert colleagues be consulted and what 9.5 important information needs to be conveyed? 12.2 When is over-the-counter analgesia indicated and what is the 9.3,9. relevant information to inform patients of when recommending over- 6, 9.7 the-counter analgesia? Demonstrate your knowledge of pharmacokinetics, indications, 9.2 contraindications, precautions, adverse effects, interactions, dosage 9.6 9.7 and administration of medications commonly used post-arthroplasty surgery (for example, paracetamol, NSAIDs, opioids). Explain how your clinical decision making underpins your 10.1-2 management plan. Provide an example of a situation where you have faced an atypical 12.2 situation and discuss how you managed the situation. What are common surgical procedures for THA and TKA, and how 15.1 would you identify different prosthesis? What are the possible barriers to informed consent you might face in 13.4 this practice context and what strategy would you use to deal with it? OVERALL COMPETENCY/RESULT PERFORMANCE LEVEL Date: Signature of assessor(s): Dependent Marginal Assisted Supervised Signature of candidate: IndependentSPECIAL QUESTIONS / COMMENTS / FURTHER ACTIONASSESSMENT ADDED TO ASSESSMENT RECORD  Yes  No  N/A79 Case-based presentation (CBP): assessment checklist (PAR) Case-based presentation (CBP): assessment instructions and summary (PAR) Candidate’s name: Date: Assessment linkage to competency standard: 3.4, 5.2–3, 6.1–7, 7.2–3, 7.5, 8.1–3, 8.5, 9.1–2, 9.5–7, 10.1–2, 11.1–2, 11.4, 12.2, 15.1–6,Candidate’s 16.3, name:16.5, 17.1–7, 18.1–5 Assessment linkage to competency standard: 3.4, 5.2–3, 6.1–7, 7.2–3, 7.5, 8.1–3, 8.5, 9.1–2, 9.5–7, 10.1–2, 11.1–2, 11.4, 12.2, Case presentation no. (circle): 1 2 3 4 Assessor’s15.1–6, 16.3, name 16.5, and17.1-7, designation: 18.1–5 Audience: CandidateAssessment to instructions:indicate the patient profile/condition(s) or assessment focus included in this presentation: History and examination findings of patients with Management/intervention required conditions1. Candidates of: must satisfactorily complete a minimum of four case-basedSurgical procedure presentations, which when tracked on the table belowTHA cover the full range of assessment focus areas.  Imaging  TKA  Pathology 2. The frequencyEither THA/TKA and timing of the CBP will be designated by thePharmacological assessor, clinical requirements lead or supervisor. Patient profile/condition Patient care required 3. PleaseDiabetes confirm (18.1–5) any additional requirements with the assessor Shared such as model access of tocare patient’s / transfer medical of care number, (circle) access to patient’sSurgical imaging, wound de-identified issue (16.3, notes 16.5)  Escalation in response to an atypical situation  Complication post-surgery (15.3–4)  Reflection on clinical practice 4. EachOsteoarthritis presentation /should indication attempt for surgery to address as manyEvidence of the of performance advanced clinical criteria decision listed on making the CBP and assessment formulation tool, of as possible.(17.1–7) complex management plans Did the candidate provide evidence of the Link to S N N/ Comments: Areas performed well, areas for following?5. In the table below, the candidate needs to track performancecomp. criteriaS yetA to beimprovement, observed or satisfactorily criteria still completed. requiring Satisfactory = S Not standar or evidence, for example, N/A or NS satisfactory6. At the =completion NS of the four CBPs, all performanced criteria need to haveX been observed and satisfactorily completed these Not applicablecan be = N/Atracked in the table below. Not (delete observed = X if N/A) 7. CBPs will be supported with oral appraisal by the assessor, centring on advanced clinical decision making. Referrals SharedCBP no. care arrangement applied appropriately 5.2, 11.2CBP 1 CBP 2 CBP 3 CBP 4 PatientsDate of completiondeferred to other professionals appropriately 5.3, 7.6, Result S / NS 11.7, List performance criteria yet to be observed or 15.6, satisfactorily completed 16.5 Health assessment/examination Appropriate and effective patient interview evident 6.1 PreliminaryAssessor’s hypothesis name and formeddesignation and differential 6.2 diagnosis identified Did the candidate provide evidence of the LinkTrack to the contentS N of theN/ CBPComments: by ticking Areas the assessment performed focus well, areas areas for following? comp. S A improvement, criteria still requiring Assessment focus area below. Satisfactory = S Not satisfactory = NS standar or evidence, for example, NA or NS Not applicable = N/A Not observed = X d CBP 1  XCBP 2  CBP 3  CBP 4  Complex modifications to routine musculoskeletal 6.3, assessmentHistory and examination are evident findings, of patients with conditions15.4, of: (for example: THA 16.3 wound; 15.4 complications; 17.2 OA; 16.3, 18.1 diabetes) TKA 17.2,  Either THA or TKA 18.1 Appropriate,Patient profile/condition effective, individualised musculoskeletal 6.4, assessment is evident and is:  Diabetes 17.1–2 o systems-based Surgical wound issues o includes Post-arthroplasty relevant clinical complications tests o selects Osteoarthritis/indication/pathology and measures relevant health indicators and o substantiatesindication the for provisionalsurgery diagnosis InputManagement/intervention from expert colleagues obtained required appropriately in 6.5 assessment Surgicalphase procedures ‘Red flags’ areImaging identified, with appropriate action taken 6.6, 17.3 ‘Yellow flags’ Pathology are identified, with appropriate action 6.7 taken  Pharmacological requirements RadiologicalPatient care investigations required Imaging selectedShared is indicatedmodel of careand appropriate/ transfer of care 7.2–3,  Escalation in response to an atypical situation 17.4 Radiologicalo imagesprosthesis accurately failure and systematically 7.5, interpreted 15.5, o post-op complications 17.5 Reflection on clinical practice Identify when input from colleagues is required in time 7.6 appropriateEvidence of manneradvanced clinical decision making and Pathologyformulation testsof complex management plans 80 PathologyOVERALL tests PERFORMANCE and results are for applied all assessed and interpreted case- 8.1–3/5Signature of assessor(s) and designation: Date: based presentations (circleappropriately to indicate) Input on pathology tests sought from colleagues and 8.3/5Signature of candidate: Date: physiotherapistSatisfactory acts appropriately Not satisfactory ADVANCED MUSCULOSKELETAL PHYSIOTHERAPY – CLINICAL AND RECORD KEEPING AUDIT GUIDELINETARGET AUDIENCE Musculoskeletal physiotherapists Physiotherapy manager Medical directors of relevant unit (emergency, orthopaedics and neurosurgery)PURPOSE The purpose of this guideline is to provide a tool to audit the performance of advanced musculoskeletal physiotherapists to ensure patient safety and quality of care is maintained at the highest level.GUIDELINEAudits have been identified as a clinical governance activity in the Advanced musculoskeletal physiotherapy clinical governance guideline to assist in the process of demonstrating clinical effectiveness of advanced musculoskeletal physiotherapists. Two different audit activities that will be undertaken will be described in this guideline.DefinitionsRecord-keeping auditA record-keeping audit is a process that establishes whether physiotherapy documentation, within the medical record, referral or handover, meets accepted legal, professional and statutory requirements.For both audit activities medical records will be used; however, for the clinical audit the relevance of the clinical content documented in the medical record will be discussed against clinical standards and evidence-based practice (whether what was done or not done was appropriate for the context). The record-keeping audit will assess the way it was recorded in terms of health record-keeping standards.Clinical auditClinical audit is a systematic, critical analysis of the quality of clinical care that is reviewed by peers against explicit criteria or recognised standards, and then used to further inform and improve clinical practice. Its ultimate goal is improving quality of care for patients. Its purpose is to examine whether what you think is happening really is, and whether current performance meets existing standards. The environment in which audit and peer review takes place should be one of open discussion, based on accurate data and an understanding of the role of systems issues.AUDIT METHODSRecord-keeping auditThis involves a random sample of 10 records (medical records of patients will be selected by the clinical lead physiotherapist for each advanced musculoskeletal physiotherapist). The medical UR number will be selected from the electronic clinical log (Access database). The patient’s history and their corresponding UR numbers will be accessed on PowerChart by the clinical lead. The record- keeping audit assessment form can be completed by the clinical lead or an allocated peer (Tool 1) for three patients. The results of this assessment will be discussed with the advanced musculoskeletal 81 physiotherapist and recommendations of areas for improvement will be made with a plan to address the recommendations. If the results of the record-keeping audit are not satisfactory further medical records may be accessed and/or the record-keeping audit repeated again after a period of time once the recommendations to the physiotherapist have be implemented.Self-assessmentThe advanced musculoskeletal physiotherapist should conduct a self-assessment of record-keeping using the assessment form throughout the training period and on a regular basis using the record- keeping assessment tool.Clinical audit (peer reviewed)From the sample of 10 records used in the record-keeping audit or from any other cases identified, the clinical lead physiotherapist will select up to three medical records to be used for the clinical audit (they may be the same records used for the record-keeping audit or be a different three patients – this will be up to the discretion of the clinical lead). The clinical lead will review the content of the medical records and be rated according to evidence-based practice and best practice standards. The clinical audit assessment form will be completed (Tool 2). A medical consultant may also be involved in this process as determined by the relevant individual medical units. A peer review process with feedback to the advanced musculoskeletal physiotherapist will be scheduled with the clinical lead (with or without a medical consultant). The peer review process should be documented with recommendations of actions to address areas requiring improvement and the plan to evaluate and monitor the implemented actions. The advanced musculoskeletal physiotherapist should keep a copy of the documentation for their professional practice portfolio, which will contribute to their work-based competency assessment and the ongoing assessment of competency.The clinical lead may decide to present the case to the team of advanced musculoskeletal physiotherapist to share the opportunity for learning at a scheduled continuing education session. This must be done with the permission of the advanced musculoskeletal physiotherapist and with the identities of the people involved removed to protect patient and staff privacy. Further audits may be required at the discretion of the clinical lead.ReportingThe clinical lead physiotherapist for the advanced musculoskeletal physiotherapy service will be responsible for reporting the results of the clinical audit and record-keeping audit to the physiotherapy manager and medical director annually. Advanced musculoskeletal physiotherapy trainees will be expected to complete the clinical audit and record-keeping audit requirements prior to undertaking their work-based competency assessment. Once deemed competent all advanced musculoskeletal physiotherapist will be expected to participate in the clinical and record-keeping audit annually.KEY RELATED DOCUMENTS Advanced musculoskeletal physiotherapy clinical governance guidelineAdvanced musculoskeletal physiotherapy clinical education framework – work-based competency standard and assessmentAllied health clinical governance guideline82 Australian Physiotherapy Association documentation standards http://www.physiotherapy.asn.au/DocumentsFolder/Advocacy_Position_Health_Records_2010.pdfKey legislation, Acts and standards:Charter of Human Rights and Responsibilities Act 2006 (Vic)2RESOURCES Guild Insurance Record-keeping self-test: retrieved 18 March 2013, <http://www.riskequip.com.au/surveys/records-in-physiotherapy>.Centre for Clinical Governance Research in Health, UNSW (2009) Clinical audit: a comprehensive view of the literature; retrieved 18 March 2013, <http://clingov.med.unsw.edu.ai>.Australian Medicare Locals Alliance (2013) Guidelines for conducting clinical audits, ATAPS clinical governance implementation resource kit, retrieved 18 March 2013, <http://www.amlalliance.com.au/medicare-local-support/primary-mental-health/ataps-clinical- governance-framework/ataps-clinical-governance-resource-kit>.AUTHOR/CONTRIBUTORS* denotes key contactName Position Service/program* Grade 4 musculoskeletal Physiotherapy physiotherapist2 Reminder: Charter of Human Rights and Responsibilities Act 2006 – All those involved in decisions based on this guideline have an obligation to ensure all decisions and actions are compatible with relevant human rights.83 TOOL 1: ADVANCED MUSCULOSKELETAL PHYSIOTHERAPY RECORD-KEEPING AUDIT ASSESSMENT TOOL Audit date: Mark as appropriate below, each health record entry against each criteria 1–40:  X N/A Physiotherapist:Health record entry number: 1 2 3Assessor’s name (role) for each entry:UR number:GeneralConsent requirements metLegibleDate of consultTime of consultPhysiotherapy headingSignaturePrinted namePage has UR stickerBlack or blue penAll notations and abbreviations used are meaningful to those other than physiotherapistsAre personable comments excluded from all recordsSingle line through errorsReason for alterations statedAlterations initialledSubjective assessment Allergies noted84 HOPCSpecial questions – red flags, yellow flags, population-specific questions assessedPast medical and surgical historyCurrent health statusMedications taken on the day and usual regimenSocial historySmoker/alcohol/drugsObjective assessmentNeurovascular statusSkin integrityOther observationsVital signs if indicatedPalpation findingsFunctional statusRange of movementSpecial tests / neuroInvestigations – referral information adequate, outcome documented Reviewed by consultant?Working diagnosis/impressionManagementTreatmentWarningsReassessment / action taken85 Written information providedConsultationsName, position, outcome of consultationFollow-up planReferralsDischarge letterEducation and advice to patientOVERALL RESULT: S= satisfactory; NS = not satisfactory (80% correct of applicable criteria, required for satisfactory result) S NS S NS S NSSignature of assessor:Main areas identified for improvement (overall) Action plan and timeframe GeneralSubjective assessment86 Objective assessmentManagement/consultationsFollow-up plan87 Date: Signature of clinical lead or consultant: Signature of physiotherapist:88 TOOL 2: ADVANCED MUSCULOSKELETAL PHYSIOTHERAPY CLINICAL AUDIT ASSESSMENT TOOL Assessor (role): Physiotherapist: Date:UR number: Presenting condition:Main areas identified for improvement Evidence-based practice / best practice Action plan (as agreed with physiotherapist)Subjective assessmentObjective assessmentDiagnosis/impression (clinical reasoning)89 Management/consultationsFollow-up planDate: Signature of assessor: Signature of physiotherapist:90 Advanced musculoskeletal physiotherapist – performance appraisal (PAR) Please circle the response that indicates the physiotherapist’s performance.Physiotherapist’s name: Date: Please circle: Designs and performs an individualised, culturally appropriate and effective patient Yes No 6.1 interview Acts to ensure all ‘red flags’ and ‘yellow flags’ are identified in the assessment process Yes No 6.6 6.7 and takes appropriate action in a timely manner Performs complex modifications to routine musculoskeletal assessment in recognition of Yes No 6.3 factors that may impact on the process such as the patient profile/needs Designs and conducts an individualised, culturally appropriate and effective clinical assessment that:  is systems-based Yes No 6.4  includes relevant clinical tests  selects and measures relevant health indicators  substantiates the provisional diagnosis Formulates a preliminary hypothesis and differential diagnoses for a patient with common Yes No 6.2 and/or complex conditions Identifies when input is required from expert colleagues, acts to obtain their involvement, 5.4 Yes No 6.5 7.6 refers patients appropriately and escalates referral appropriately when indicated 11.5Uses concise, systematic communication at the appropriate level when conversing with 4.1 Yes No colleagues Presents all relevant information to expert colleagues when acting to obtain their 4.2, Yes No 8.4, involvement 11.3 Identifies when input to complement care is required from other health professionals and Yes No 11..5 acts to obtain their involvement Uses finite healthcare resources wisely to achieve best outcomes Yes No 10..3 Provides appropriate education and advice to patients with common and/or complex Yes No 11.6 conditions Conducts a thorough handover to ensure patient care is maintained and identifies 11.4, Yes No 11.7 appropriate referrals when required 15.6 Works towards the full extent of their role (PAR clinic) Yes No 1.2 Takes responsibility for own actions Yes No 2.1 Comments:Consultant’s name:Consultant’s signature: Date:91 Oral appraisal (OA) assessment tool (PAR)Candidate’s name: Date:Assessment linkage to competency standard: 1.1, 5.1, 5.4, 9.3, 9.4, 13.4, 15.1Assessor’s name and designation: s c L t o i a n Performance Comments ELEMENTS AND PERFORMANCE CRITERIA m n k d p t rating scale  a e o r t e d nDid the candidate satisfactorily answer the following questions? c y S NSSatisfactory = S Not satisfactory = NS PROFESSIONAL BEHAVIOURS1. Operate within scope of practice Can you describe the scope of practice relevant for the role and provide 1.1 an example of what you might encounter that would be outside scope of practice?What is the definition of advanced scope of practice and how does it differ from extended scope of practice?PROVISION AND COORDINATION OF CARE5. Evaluate referrals Can you describe the patients who are appropriate for this advanced 5.1 musculoskeletal physiotherapy role in the context of the individual physiotherapist?Can you prioritise from the attached list of referrals who should be seen to 5.4 first? (this will be different for each advanced musculoskeletal 92 physiotherapy service)9. Apply the use of therapeutic medicines in advanced musculoskeletal physiotherapy What legislation and registration requirements relating to medicines apply 9.3 to physiotherapists working in advanced physiotherapy roles?What responsibilities apply to physiotherapists in relation to the 9.4 recommending the use of medicines to patients?13. Obtain patient consent What is the process if a patient refuses to be seen by a physiotherapist 13.4 and requests to be seen by a doctor?15. Assessment and management post-arthroplasty Describe the standard surgical procedures for hip and knee arthroplasty, 15.1 different types of prosthesis and how the type of prosthesis might influence outcomes.OVERALL COMPETENCE RESULT Date: Signature of assessor(s): Satisfactory / unsatisfactory Date: Signature of candidate:SPECIAL QUESTIONS / COMMENTS / FURTHER ACTIONORGANISATIONAL RECORDING PROCESSES COMPLETED  Yes  No Author: Last review date:93 Radiological interpretation of a plain-film case series: PAR assessment tool (for the candidate) Candidate’s name: Date:Assessment linkage to competency standard: Area of advanced musculoskeletal 7.5, 15.5 physiotherapy: PAR clinicAssessor’s name and designation:ELEMENTS AND PERFORMANCE Link to Plain-film case series marking criteria CRITERIA competency instructions standardPROVISION AND COORDINATION OF CARE7. Apply the use of radiological investigations in advanced musculoskeletal physiotherapy7.5 Interpret plain-film images 7.5 Candidate’s answers will be matched against accurately using a systematic the actual radiology report approach for patients with common and/or complex conditions, as Total marks available for each question will relevant to the practice context vary depending on whether an abnormality is present or not and number of abnormalitiesCandidate correctly identifies if image is normal or abnormal = 1 markIf abnormal, candidate correctly identifies the anatomical site of abnormality = ½ mark for each site and correctly describes each abnormality to the satisfaction of the assessor = ½ markScore from each section should be total and added together for final score15. Perform appropriate musculoskeletal assessment and implement a management plan for patients following total hip or knee arthroplasty (THA, TKA)15.5 Interprets plain-film imaging 15.5 post-arthroplasty accurately using a systematic approach to identify signs of prosthesis failureScore of plain-film case series Satisfactory / not satisfactory Comments / action plan94 PRE-ASSESSMENT CHECKLIST FOR WORKPLACE ASSESSORS: SELF- ASSESSMENT TOOL  Tacit knowledge of assessment areaRecent and broad experience in the area being assessedExpertise in performance assessment processesWorking knowledge of the competency standard content Working knowledge of the assessment plan and toolWorking knowledge of the responsibilities as an assessor including: Ensures assessment takes part in the practice setting Ensures the candidate has appropriate preparation for and information about the assessment process Conducts assessments fairly Provides effective performance feedback  Records results, maintaining confidentiality in accordance with organisational requirementsHas relevant clinical competencies at least to the level being delivered or assessed by virtue of a qualification, training or experience95 CONDITIONS AND CONTEXT FOR ASSESSMENT: INSTRUCTIONS Self-assessment using the Learning needs analysis tools is recommended for the candidate prior to engaging in a work-based learning and assessment program. (Self-assessment will not be used as a stand-alone method to make a decision of competence.)Assessment tasks will be planned throughout the timeframe negotiated between the candidate and the assessor. A combination of assessment occasions and methods will be used and are mapped on the Learning and assessment plan. The Cumulative assessment tool collates all of the evidence gathered through the assessment and, based on this evidence, the assessor makes and records an overall assessment about the learner’s competence.The assessment(s) will be conducted at a time that is mutually agreeable to both the assessor and the candidate (making allowances for the impact access to appropriate patients may have on this).When the assessment task requires direct workplace observation, this will be conducted in reality, with patient(s) appropriate for advanced musculoskeletal physiotherapy and within the practice context setting. (The use of simulated contexts is discouraged and will only be implemented when there is no other available, appropriate and timely method of assessment.)Access to relevant guidelines, standards and procedures will be given during the assessment task.To achieve competency, the candidate will provide sufficient evidence through planned assessment activities, as determined by the assessor.All competency elements and performance criteria must be satisfactorily met for the candidate to be deemed competent. The assessment must be conducted by a workplace assessor who meets the recommended minimum criteria for assessors.It is implicit that the candidate demonstrates appropriate knowledge during the whole assessment task.If the candidate does not meet the expected standard of performance:  A plan will be made to address the performance gap. This may include opportunity for additional teaching and supervised clinical practice. This will be made available prior to subsequent assessments.  An additional assessment will be rescheduled at a time negotiated between the assessor and candidate.  The candidate is permitted to engage another assessor if available/appropriate.96 ASSESSMENT PREPARATION CHECKLIST:  Have you prepared all necessary equipment/assessment tools prior to the assessment?Have you introduced yourself?Have you verified the candidate is ready for assessment?Have you informed the candidate about confidentiality issues regarding the assessment?Have you provided an explanation of the parameters of the assessment (including the method and context)?Have you explained that in the event of unsafe practices the assessment will be terminated?Have you invited the candidate to ask questions before the assessment begins?Have you described the assessment scenario in a clear and non-ambiguous manner?97 GUIDELINES FOR ASSESSORS DURING A DIRECT WORKPLACE OBSERVATION ASSESSMENT Use ‘non-prompting’ and ‘non-involvement’ behaviour.Provide succinct clarification on request, without suggestive prompting. Use follow-up questioning at the conclusion of the direct observation to clarify or address outstanding performance criteria (a list of potential clarifying questions has been included with the direct work observation tool).Inform the candidate of the outcome of the assessment in a timely manner.Provide effective feedback at the completion of the assessment. Be concise. Focus on behaviour (not personality) and engage the candidate in a discussion of performance. Discuss areas performed well. Discuss areas requiring improvement. Document the outcome of the assessment on the tool.Communicate effectively with a candidate who is ‘not yet competent’ about the performance rating given. Communicate objective reasons for non-competence / the rating. Negotiate an action plan with the candidate to develop skills for successful completion / performance improvement. Agree on a timeframe for an ongoing learning and assessment plan. If applicable/available, offer an alternate assessor.98 Curriculum overviewOrientation program One of the requirements in the Learning and assessment plan is to complete an orientation program for the role. All new staff to the organisation should undergo the routine staff orientation process in addition to the specific orientation program developed for the role of advanced musculoskeletal physiotherapist (refer to orientation manual developed at local site and included in the operational guidelines). An orientation program will be specific to the advanced musculoskeletal physiotherapy service. For example, several sessions of observing/shadowing with either an experienced physiotherapist already working in the role prior to seeing patients in the PAR clinics is recommended. For a physiotherapist new to the advanced practice role a reduced clinical load with direct access to the clinical lead physiotherapist during the clinic may be recommended for the first few weeks. Prior to observing a session the physiotherapist should achieve the following objectives: Complete the organisation’s staff orientation process. Complete an orientation specific to the PAR clinic and advanced practice role. Complete an orientation to the physiotherapy department (if new to the department). Complete an orientation and introduction to the orthopaedic or neurosurgical team as appropriate including consultants and registrars where practicable.  Get familiar with the hospital and clinic IT system(s) and acquire the necessary IT access. Complete the online radiation safety module: http://www.imagingpathways.health.wa.gov.au/index.php/radiation-training-module  Complete Learning needs analysis Part A and B, and meet with a mentor to discuss Learning and assessment plan. Complete module 10 on communication (ISBAR).Curriculum development An example of how the curriculum might look is provided below. Not all the self-directed learning modules may be applicable depending on the model of care being implemented; for example, wounds may not be required and some self-directed learning modules may be considered for more advanced learning and experience, and therefore used at a later stage such as differential diagnosis, pharmacology and diabetes. The focus of the learning program should be directed at assisting the physiotherapist to acquire the necessary underpinning skills and knowledge to perform as per the performance criteria described in the competency standard. 99 Example of a possible curriculum timeline (for a physiotherapist who has met the selection criteria working as an advanced musculoskeletal physiotherapist in the PAR clinic)ORIENTATION Block 1 Block 2 Block 3 Block 4 Orientation program SELF-DIRECTED SELF-DIRECTED SELF-DIRECTED SELF-DIRECTED LEARNING MODULES LEARNING MODULES LEARNING MODULES LEARNING MODULES Complete Learning needs analysis Part A and B and Arthroplasty Arthroplasty Surgical wounds (if Pharmacology discuss in collaboration with applicable) clinical lead to develop Radiology Radiology individualised Learning and OA assessment plan  Indications for imaging  Interpreting plain-film  Requesting imaging imaging (PAR) SELF-DIRECTED LEARNING MODULES Radiology IN-SERVICE: IN-SERVICE: IN-SERVICE: Radiology IN-SERVICE:  Radiation safety Orthopaedic surgeon on Pharmacy/anaesthetics surgical approaches? Interpreting plain film? Wound nurse  Complete quiz (80% Analgesics pass) Surgical wound assessment – indications for referral CommunicationMEET WITH MENTOR OBSERVE/SHADOW REDUCED CLINICAL LOAD MEET WITH MENTOR Case-based presentation 1 Discuss Learning needs CLINIC WITH ACCESS TO Formative assessment Workplace observation analysis Part A and B CLINICAL LEAD 100 Block 5 Block 6 Block 7 Block 8 Block 9 Competency assessment SELF-DIRECTED SELF-DIRECTED SELF-DIRECTED REVISION REVISION  Oral appraisal LEARNING LEARNING MODULES LEARNING MODULES MODULES  Performance Differential diagnosis appraisal Pathology Diabetes  Further case-based IN-SERVICE: presentations as IN-SERVICE: Rheumatologist required IN-SERVICE: Pathologist OA vs other inflammatory Diabetes educator  Present clinical log Interpreting routine disorders? and professional bloods? practice portfolio and all completed MEET WITH Case-based presentation MEET WITH Case-based presentation MEET WITH MENTOR assessment tasks MENTOR 2 MENTOR 3 Formative assessment Formative Repeat Competency  Any other assessment Complete radiology standard self- documented interpretation case base assessment tool (Part A) Record-keeping audit assessment tasks Workplace series observation Case-based presentation 4101 Glossary Refer to the manual of the Advanced musculoskeletal physiotherapy clinical education framework.References Bondy K N 1983, ‘Criterion-referenced definitions for rating scales and clinical evaluation’, Journal of Nursing Education, 22(9):376–381.Knowles MS 1975, ‘Adult education: new dimensions’, Educational Leadership, 75, retrieved 26 November 2013, <http://www.ascd.org/ASCD/pdf/journals/ed_lead/el_197511_knowles.pdf>.National Prescribing Service: Better choices, Better health 2012, Competencies required to prescribe medicines: putting quality use of medicines into practice, National Prescribing Service Limited, retrieved 6 February 2013, <http://www.nps.org.au/__data/assets/pdf_file/0004/149719/Prescribing_Competencies_Framework.p df>National Quality Council 2009, Guide for developing assessment tools, National Quality Council, retrieved 1 December 2012, <http://www.nssc.natese.gov.au/__data/assets/pdf_file/0011/51023/Validation_and_Moderation_- _Guide_for_developing_assessment_tools.pdf>.Suckley, J 2012, ‘Core clinical competencies for extended-scope physiotherapists working in musculoskeletal interface clinics based in primary care: a delphi consensus study’, Professional Doctorate thesis, University of Salford.Symes, G 2009, Resource manual and competencies for extended musculoskeletal roles: chartered physiotherapists with an extended scope of practice, Scotland, UK 102 BibliographyACT Health 2008, Physiotherapy extended scope of practice: Phase 1 final report, ACT Health, Canberra.Australian Commission on Safety and Quality in Health Care 2011, National safety and quality health service standards, Sydney.Australian Confederation of Paediatric and Child Health Nurses 2006, Competencies for the specialist paediatric and child health nurse, Australian Confederation of Paediatric and Child Health Nurses, retrieved 6 February 2013, <http://www.accypn.org.au/downloads/competencies.pdf>.Australian Diabetes Educators Association 2008, National core competencies for credentialed diabetes educators, Australian Diabetes Educators Association, Holder, ACT, retrieved 6 February 2013, <http://www.adea.com.au/asset/view_document/979315967>.Australian Medicare Locals Alliance 2013, Guidelines for conducting clinical audits: ATAPS clinical governance implementation resource kit, retrieved 18 March 2013, <http://www.amlalliance.com.au/medicare-local-support/primary-mental-health/ataps-clinical- governance-framework/ataps-clinical-governance-resource-kit>.Australian Nursing Council 2002, Principals for the assessment of national competency standards for registered and enrolled nurses, Australian Nursing Council.Australian Physiotherapy Association 2009, Position statement: scope of practice, Australian Physiotherapy Association, retrieved 1 December 2012, <http://www.physiotherapy.asn.au/DocumentsFolder/Advocacy_Position_Scope_of_Practice_2009.pd f>.Australian Physiotherapy Association 2010, Position statement: health records, Australian Physiotherapy Association, retrieved 1 December 2012, <http://www.physiotherapy.asn.au/DocumentsFolder/Advocacy_Position_Health_Records_2010.pdf>.Australian Physiotherapy Council 2006, Australian standards for physiotherapy, Australian Physiotherapy Council, South Yarra.Centre for Clinical Governance Research in Health, UNSW 2009, Clinical audit: a comprehensive view of the literature, retrieved 18 March 2013, <http://clingov.med.unsw.edu.ai>.Delany C, Molloy E 2009, Clinical education in the health professions, Churchill Livingstone, Edinburgh.Guild Insurance 2013, Record-keeping self-test, retrieved 18 March 2013, <http://www.riskequip.com.au/surveys/records-in-physiotherapy>.Health Workforce Australia 2013, National common health capability resource: shared activities and behaviours of the Australian health workforce, Health Workforce Australia, Adelaide.103 Heartfield M, Gibson T, Nasel D 2005, Mentoring fact sheets for nursing in general practice, Australian Government: Department of Health and Ageing, Canberra.Lawlor, D 2011, Training in Australia, Pearson, Frenchs Forest.Lin I, Beattie N, Spitz S, Ellis A, Spitz S, Ellis A 2009, 'Developing competencies for remote and rural senior allied health professionals in Western Australia', Rural and Remote Health, vol. 9, no. 2, Article No. 1115.Mills J, Francis K, Bonner A 2005, ‘Mentoring, clinical supervision and preceptoring: clarifying the conceptual definitions for Australian rural nurses. A review of the literature’, Rural and remote health, vol. 5, no. 410, pp. 1–10.National Quality Council 2009, Guide for developing assessment tools, National Quality Council, retrieved 1 December 2012, <http://www.nssc.natese.gov.au/__data/assets/pdf_file/0011/51023/Validation_and_Moderation_- _Guide_for_developing_assessment_tools.pdf>.National Skills Standards Council 2012, Standards for training packages, National Skills Standards Council (NSSC), retrieved 1 December 2012, <http://nssc.natese.gov.au/__data/assets/pdf_file/0014/71510/NSSC_- _Standards_for_Training_Packages_v1.0.pdf>.Pearce, A 2013, Monash Health competency framework: working draft May 2013, Monash Health, Victoria.Physiotherapy Board of Australia 2010, Physiotherapy guidelines on continuing professional development, Physiotherapy Board of Australia, retrieved 4 December 2012, <http://www.physiotherapyboard.gov.au/documents/default.aspx? record=WD10%2f1308&dbid=AP&chksum=QScN2VUhX8%2fvv%2bXYmZyPEQ%3d%3d>.Skills for Health 2010, EUSC34 Provide musculo-skeletal support, Skills for Health, UK, retrieved 21 February 2013, <https://tools.skillsforhealth.org.uk/competence/show/html/id/980/>.Spencer C 2004, Mentoring made easy, a practical guide, NSW Government, Sydney.Training Research and Education for Nurses in Diabetes, UK 2010, An Integrated Career and Competency Framework for Diabetes Nursing, SB Communications Group, London, retrieved 6 February 2013, <http://www.trend-uk.org/TREND-UK_Feb%202010.pdf>.Victorian Department of Human Services 2009, Health workforce competency principles: a Victorian discussion paper, Melbourne..104 Appendix 1Learning and assessment plan template TITLE OF COMPETENCY Deliver Advanced Musculoskeletal Physiotherapy in the insert area of practice STANDARD(S) TO BE ACHIEVED ASSESSMENT TIMEFRAME To be negotiated with clinical lead physiotherapist, assessor &/or line manager WORKPLACE LEARNING A combination of the following will be implemented DELIVERY OVERVIEW  Self-directed learning  In-house in-services  Coaching or Mentoring  Workplace application  Formal external learning 1. LEARNING ACTIVITIES / RESOURCES TASK DESCRIPTION Completed  X 1. Complete Learning Needs Complete Learning Needs Analysis Part A and B, and discuss learning needs, evidence of Analysis for the work role prior learning, and assessment/ verification processes with clinical lead physiotherapist/supervisor/ mentor 2. Complete site specific Complete orientation covering all details outlined in the site specific orientation guideline orientation to ED 3. Complete self-directed Select self-directed learning modules to complete (delete or add additional learning learning modules as required modules relevant to area of practice): from the Learning Needs 1. Musculoskeletal conditions/presentations Analysis. 2. Radiology 3. Modules specific to area of practice 4. Wounds 5. Pharmacology 6. Pathology 7. Differential Diagnosis105 8. Paediatrics 9. Diabetes (APA diabetes e module) 10. Communication(ISBAR)/Consent/Documentation 4. Complete formal training e.g. (add or delete) Radiology, Pharmacology and  University of Melbourne Radiology single subject Diabetes Subject Code: RADI90001 Radiology for Physiotherapists  University of Melbourne Pharmacology single subject (TBC) APA e modules Diabetes for Physiotherapists http://www.learningseat.com/servlet/ShopLearning?categoryName=Browse+ %BB+Physiotherapy/Clinical+Content+%BB+Diabetes+For+Physiotherapists+- +8+CPD+Hours&learningId=38954  Other 5. Complete further individual Complete further individualised learning as discussed with and directed by clinical learning as required from the supervisor/ line manager. This may include material beyond what is covered in the learning Learning Needs Analysis modules above. List below:6. Undertake supervised clinical  Physiotherapists new to the work role who are undertaking the full learning & practice & feedback sessions assessment pathway our encouraged to engage in a structured/timetabled work program as advised and negotiated with their clinical supervisor/assessor.  Physiotherapists new to the role should complete an orientation program which includes shadowing and observation  Until an individual is deemed competent to practice independently within the setting it is recommended they have access to senior medical /physiotherapy staff for clinical supervision.  A graduated process from direct to indirect clinical supervision should be maintained during this period until performance is at an independent standard and physiotherapists will be supported by specific targeted feedback during this time, to 106 address learning needs  A formative assessment should be conducted early into commencing the role and throughout the supervision period to help the physiotherapist prepare for work place observation assessment(s) and oral appraisal. The formative assessment may be conducted by the clinical lead physiotherapist however the work place observation could be conducted by an ED consultant familiar with the Competency Standard.7. Review the following  Australian Physiotherapy Standards documents and become familiar http://www.physiocouncil.com.au/files/the-australian-standards-for-physiotherapy with the content in relation to • APA scope of practice advanced musculoskeletal http://www.physiotherapy.asn.au/DocumentsFolder/Advocacy_Position_Scope_of_ physiotherapy Practice_2009.pdf • AHPRA Code of conduct/registration requirements http://www.physiotherapyboard.gov.au/Codes-Guidelines.aspx • Processes for issuing of sick leave certificates/WC • Local organisational guidelines /clinical governance structure  State Drugs and Poisons act : http://www.health.vic.gov.au/dpcs/reqhealth.htm  Poisons Standard 2010: http://www.comlaw.gov.au/Details/F2010L02386 • Paediatric legislation/standards8. Other activities to be advised 1. It is recommended the trainee conduct a self-assessment of their clinical record- keeping at intervals during the training program, in preparation for the record keeping audit and using the record-keeping audit assessment tool.Insert other learning activities.2. ASSESSMENT DETAILS & LINKAGE107 ASSESSMENT TASK Due date Performance Criteria **Add Performance Criteria from Competency Standard to assessment task 1. Complete written responses (WR) 7.1, 7.5 Provide details of assessment task2. Participate in direct workplace observation (WO) 6.1-6.7, 7.1-2, 7.5, For an agreed period of time the physiotherapist will work under supervision, and the physiotherapist when 9.1, 10.1-2, 11.1-4, deemed ready by self and supervisor, will undergo formal observation in the workplace. 13.1-3, 17.1-6, 17.9-10  The physiotherapist’s level of performance will be rated against the standard by the designated assessor, using assessment tool(s) during a formal assessment process. Add performance  Occasions of direct workplace observation will be negotiated by the assessor with the criteria where physiotherapist. required  It is recommended that these observations of clinical practice are to include patient presentations with signs and symptoms most common in presentation to area of practice  Who the assessor is will vary depending upon the local organisation’s requirements. The assessor could be a consultant or an experience physiotherapists who is familiar with the assessment process and competency standard requirements. Provide details of assessment task3. Maintain a professional practice portfolio (PF) 3.3 The professional practice portfolio required is consistent with the requirements of the APA’s requirements and should include relevant information regarding attendance and participation in formal and informal education and learning opportunities specific to advanced musculoskeletal physiotherapy area of practice.This may include:  self-reflective journal/diaries  in-services, lectures, journal clubs, continuing education programs attended or given108  quality projects  research activities and publications  conference attendance  mentoring/supervision sessions  an electronic clinical log of types of conditions seen Please refer to:  APA continuing development guidelines www.physiotherapy.asn.au/APAWCM/Learning_and_Development/CPD_Overview/APAWCM/Learn ingDevelopment/CPD_Overview.aspx  APHRA guidelines for continuing education www. physiotherapy board.gov.au/documents/default.aspx 4. Provide documentary evidence (DE) For Example: Participation in a record keeping audit – It is recommended that physiotherapists are required to provide documentary evidence of pre-determined number of health record entries, which will be audited using an audit assessment tool, by an assessor such as the clinical lead Physiotherapist or a peer. Performance will 7.4, 9.8, 14.1 be rated as satisfactory if at least 80% of the applicable criteria are included in the samples. Feedback will be provided to the physiotherapist and recommendations for improvement documented with a plan to ensure recommendations are implemented. Record keeping practice should be in line with the local organisation’s policies and the APA Position Statement on health records.5. Give case based presentations (CBP) 6.1-7, 8.1, 8.5, 9.1, It is recommended that physiotherapists present a predetermined number of cases (insert number) to 10.1-2, 11.1-4, colleagues at a frequency designated by the assessor/clinical lead/supervisor 16.1-5, 17.1-3, 17.5-6  It will be supported by verbal questioning by the assessor, centring on advanced clinical decision making. Add performance  The level of performance will be rated against the standard by the designated assessor, using the criteria where appropriate case based presentation assessment tool(s). required The presentations should address the required performance criteria as identified in this learning and assessment plan. Additional performance criteria may be added and addressed in case based presentations. 6. Participate in performance appraisal (PA)109 It is recommended that a performance appraisal should be conducted at the completion of an agreed Insert performance timeframe by an allocated consultant or experienced physiotherapist who has worked regularly with the criteria physiotherapists being assessed. This appraisal is based on an informal observation of clinical practice over a period of time. 7. Undertake external qualification/training (Q/T) It is recommended the physiotherapist undertakes further external training. Examples of this may include: Insert performance criteria  University of Melbourne single subject in Radiology  APA Diabetes learning modules 1-4 To be guided by local organisation policies and guidelines.8. Participate in oral appraisal (OA) An oral appraisal can be conducted to assess aspects of workplace performance, as required and at the Insert performance discretion of the assessor (Consultant or Clinical Lead physiotherapist) in relation to the relevant criteria performance criteria. Refer to the OA assessment tool. It is recommended that this oral appraisal is conducted when the physiotherapist is ready to submit all forms of evidence for a final assessment of competency to the designated assessor who maybe the Clinical Lead physiotherapist or nominated Consultant.110

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