Practice Committee members (J.C., H.H., G.P.-Z.); Clinician guests (D.G., J.H., C.M., K.P.)
As the profession of physical therapy continues to move toward the fulfillment of APTA Vision 2020,1 it is important for individual physical therapists to understand its elements. Moreover, it is critical that physical therapists practice in a manner that is consistent with APTA Vision 2020. One of the elements of APTA Vision 20201 is autonomous practice. The document Working Operational Definitions of Elements of Vision 2020 From the Task Force on Strategic Plan to Achieve Vision 2020 states the following about autonomous practice: “Physical therapists accept the responsibility to practice autonomously and collaboratively in all practice environments to provide best practice to the patient/client [italics added]. Autonomous physical therapist practice is characterized by independent, self-determined, professional judgment and action.”2(p2) Autonomous practice is not synonymous with direct access, described as follows: “Every consumer has the legal right to directly access a physical therapist throughout his/her lifespan for the diagnosis of, interventions for, and prevention of: impairments, functional limitations, and disabilities related to movement, function and health.”2(p2) Thus, autonomous practice is a characteristic of the practitioner, while direct access is a benefit to the consumer.
In preparing the annual Neurology Section Practice Issues Forum, “Defining Autonomous Practice across Various Neurological Settings,” for Combined Sections Meeting 2008, we asked ourselves, “What is really meant by autonomous practice, and is it setting specific?” After reviewing the definitions of the elements of APTA Vision 2020,2 we undertook an iterative process to arrive at consensus-based answers to these questions. We concluded that autonomous physical therapist practice is self-determined, entry-level actions that are based on sound professional judgment and best practice in all settings. Inherent in this definition are 3 key concepts: excellence, communication and collaboration, and advocacy and caring. These concepts all appear in the definition of professionalism from Working Operational Definitions of Elements of Vision 2020 From the Task Force on Strategic Plan to Achieve Vision 2020: “Physical therapists and physical therapist assistants consistently demonstrate core values by aspiring to and wisely applying principles of altruism, excellence, caring, ethics, respect, communication and accountability, and by working together with other professionals to achieve optimal health and wellness in individuals and communities.”2(p2) Autonomous practice and professionalism are interwoven. While features of the practice setting may impact these components (eg, face-to-face communication with physicians and other practitioners may be easier in some settings), autonomous practice is not setting-specific.
Excellence is one of the core values of professionalism. Excellence is practice in which the clinician “consistently uses current knowledge and theory while understanding personal limits, integrates judgment and the patient/client perspective, embraces advancement, challenges mediocrity, and works toward development of new knowledge.”3(p5) Excellence relates to autonomous practice in terms of professional judgment and action,2(p2) which, in turn, encompass the concepts of differential diagnosis and clinical decision making. Differential diagnosis and sound clinical decision making reflect practitioner excellence and are components of autonomous practice. Furthermore, they are inherent to best-practice physical therapy and occur in every practice setting. Excellence also occurs when a physical therapist demonstrates an ongoing commitment to lifelong learning, including an active plan for professional development.
Autonomous practice does not mean practice in isolation from other practitioners; rather, it means practice that is collaborative with other practitioners without a supervisory relationship. An autonomous physical therapist practices independently but within a patient/client-centered multidisciplinary team, including patients, family members and other caregivers, other physical therapists, support staff, and other types of healthcare professionals. This independence means engaging in self-determined, professional judgment and action as opposed to relying on another provider to give explicit instructions. The neurologic physical therapist offers valuable, pertinent, precise information to the healthcare team to ensure patient/client safety and optimal outcomes. Collaboration also encompasses the mentoring of a less experienced physical therapist by a more experienced physical therapist. Communication is intrinsic to collaboration. Professional communication is concise, informative, timely, and confident and is a skill that, like all skills, requires practice. Often, communication is the vehicle for action that follows from professional judgment (eg, for communicating the findings of the differential diagnosis process to the physician). Communication is also often the vehicle for patient/client advocacy.
Autonomous practice occurs when a physical therapist accepts accountability for his or her practice. Accountability to and advocacy for our patients/clients are needed for optimal outcomes. An autonomous physical therapist recognizes that he or she may be the only healthcare provider in touch with a patient/client on any given day, necessitating well-developed clinical decision-making skills that are applied at every patient/client visit (or other form of contact) to ensure best patient/client care, including safety. An autonomous physical therapist also recognizes that multiple visits with a patient/client permit the ongoing opportunity to provide differential diagnosis and refer to other providers as needed for changes in health status and that this referral process, beyond timely communication and coordination, may necessitate advocacy. As stated previously, accountability is a component of the definition of professionalism as an element of APTA Vision 2020.2(p2) In Professionalism in Physical Therapy: Core Values, accountability is defined as “active acceptance of the responsibility for the diverse roles, obligations, and actions of the physical therapist including self-regulation and other behaviors that positively influence patient/client outcomes, the profession and the health needs of society.”3(p4)
The answer to the question, “Is autonomous practice in neurologic physical therapy defined differently based on the type of practice setting?” is no. Autonomous practice is a characteristic of the physical therapist, embodying excellence, communication and collaboration, and advocacy and caring. It is our belief that many physical therapists already practice autonomously, even though they may not recognize their practice as being autonomous; and it is our hope that physical therapists who are functioning as autonomous practitioners will provide peer mentoring to help bring their colleagues to the same level of practice and the same recognition. The full position statement on autonomous practice is available on the Neurology Section Web site at http://www.neuropt.org/go/healthcare-professionals/autonomous-practice.