PCE Cancellation - FAQ

The NSCP was informed of the cancellation of the examination on the morning of March 20th. Details regarding what exactly occurred remain limited; however, the information we have received to date is that the cancellation was necessary due to severe technical challenges with the platform used to administer the examination. The Canadian Alliance of Physiotherapy Regulators (CAPR) continues to investigate the problem, and NSCP anticipates further communication from them in the coming days regarding the source of the problem and potential solutions.

While it may be tempting to simply set aside the clinical component of the PCE, and that certainly is a suggestion that we have heard, NSCP cannot opt to do so without careful consideration of the implications.

The requirement that candidates complete an examination prior to registration is written into our legislation. The examination approved by the Board is the Physiotherapy Competency Examination (PCE) administered by CAPR. This includes both Written and Practical Components.

Deviating from use of the CAPR examinations, while potentially possible, would need to be done with considerable caution to ensure that a comparable, objective, reliable, and valid assessment process was completed prior to registration. An exam review initiative started by CAPR in Feb 2020 is still underway and we are looking at alternate styles of meeting needs of stakeholders in today’s environment.

It is correct that in some jurisdictions, physiotherapy residents / interns have been unable to practice as they await their opportunity to take the clinical component of the PCE. That is not the case in NS. Candidates who have passed the qualifying (QE) written exam are able to work under a provisional license as a Physiotherapy Resident with an assigned sponsor / mentor for up to 12 months or two unsuccessful attempts at the clinical component of the examination.

While individuals are granted three attempts at the examination, after two unsuccessful attempts the risk of having the candidate remain in clinical practice outweighs the potential benefit.

In response to COVID-19 and disruptions to the clinical exam, the NSCP extended all provisional licenses until an exam is available. This means that in NS, exam candidates are currently working as physiotherapy Residents providing essential physiotherapy services to Nova Scotians under the supervision of a physiotherapist, with a range of health concerns and across sectors, including in acute care, ICU, rehabilitation, home care, continuing care, and outpatient orthopedics.

We are glad that you noticed the difference between the messaging of NSCP and that of the Canadian Physiotherapy Association (CPA)!

The NSCP has a government-issued mandate to serve the public interest. Our primary role is to register competent individuals who meet the specified registration requirements to practice physiotherapy in NS. We protect the public interest and assure their confidence in the quality of service provided by physiotherapists in NS. We must place public interest ahead of that of the physiotherapy profession.

Physiotherapy regulators from across the country are charged with the same responsibility. Advocating for the profession, including PCE candidates is the role of the CPA.

As already stated, making such a significant change from currently established registration requirements is not something done lightly, nor should it be. To do so represents a marked deviation from our governing legislation. The CPA can advocate on behalf of PCE candidates, but it has limited influence in changing legislated registration requirements established at the provincial level. Again, these requirements are put in place by provincial governments with the public interest as the ultimate consideration, not the profession’s interest.

No, although the NSCP maintains a collaborative working relationship with the CPA we are not, nor have we ever been, a branch of the CPA. The mandate of NSCP is incompatible with that of the CPA. The NSCP is a provincial regulatory licensing body in which registration is mandatory for practice of physiotherapy in NS and for use of title and is mandated to always work from the perspective of public interest. The CPA is a voluntary membership professional association representing the interest of the profession, and their advocacy may, but is not required to, align with the public interest.

It is correct that two prior attempts to offer the in-person clinical component of the PCE, in June and November 2020, were cancelled. The cancellation of the March 2021 virtual examination marks the third disruption in the clinical examination process.

Both the June and November 2020 examinations were cancelled due to COVID-19, the public health measures in effect, and the closure of testing centers which precluded offering an in-person clinical examination. Early in the pandemic, CAPR began to investigate the idea of a virtual examination, and with the 2020 cancellations, plans were made to transition to a virtual examination in March 2021.

The NSCP is currently in discussions with our stakeholders including NSCP’s Council, the Ministry of Health, and regulatory legal advisors to review available options to address our legislative requirements for registration given the ongoing issues.

People have been questioning the competence of CAPR to deliver the National licensing examination a lot on social media. CAPR has long been a leader nationally, and internationally, in the provision of examination services. Their inability to deliver an in-person examination in the context of COVID-19 and the challenges faced in 2020 is not a reflection of their competence any more than a candidate’s inability to complete the examination in 2020 reflects their competence. The circumstances of 2020 can be referred to, in legal terms as a “force majeure", meaning that the circumstances are beyond anyone's control. While it is true that the platform that CAPR used to provide the virtual clinical examination in March 2021 did not perform as expected, despite rigorous pre-exam testing, and ultimately failed, the circumstances contributing to the failure are not yet clear.

As a physiotherapy regulatory body in Canada, the NSCP is a founding member of the Alliance and will continue to work with our peers in physiotherapy regulation in the interest of assuring the public that all physiotherapists practicing in Canada, including nationally and internationally trained physiotherapists, meet the same minimum standard for competence and that the public interest is assured.

It is true that not all regulated health professionals are required to complete a clinical examination prior to registration. Each regulated health profession develops licensure requirements consistent with the needs and responsibilities of that profession.

The PCE was developed in the late 1980s and early 1990s to address the following issues:

• The need for a consistent, equitable and fair entry to practice standard for all applicants for registration to practice physiotherapy, including those who did not receive their physiotherapy education in Canada.

• The need to develop a system of checks and balances to address the public interest and assure confidence, by having an independent organization, separate from those that specify the physiotherapy entry to practice curriculum or conduct accreditation, verify that the education programs were successful in their efforts to develop competent clinicians.

The clinical component of the PCE has existed since the examination’s inception and reflects the general scope of physiotherapists’ daily work. While some forms of knowledge can be tested using a written or multiple-choice examination format, technical skills such as patient handling and treatment techniques, and non-technical skills such as patient education and communication have long been thought to require a clinical examination to provide an accurate evaluation of a candidate’s skills and competence.

Physiotherapists have long advocated for their role as primary care providers and have sought to have the same standing in the health system as physicians. If they wish to fulfill the role of primary care provider and autonomous practitioner, physiotherapists will need to hold themselves to comparably high standards of competence assessment and demonstration.

The reliability, validity, and psychometric properties of the examination have been studied since the examination’s inception. The exam blueprint is developed and modified based on foundational documents such as the national curriculum guidelines, the Physiotherapist Competence Profile, and the Analysis of Practice.

Examination questions are developed by a team of Physiotherapist subject matter experts from across the country, and the question’s performance on each exam is carefully studied to ensure its reliability and validity. Questions that perform poorly are removed from the question bank. New questions are added to the bank as practice changes.

Each exam question is accompanied by a checklist that examiners use to score a candidate’s performance. Examiners also receive training regarding how to score the station they are assigned. These measures help to ensure that candidates’ performance is scored consistently, despite being tested by different examiners in different locations.

CAPR invests considerable resources into assuring the reliability and validity of the examination.

During the transition to the virtual examination, CAPR has taken steps to ensure that the same psychometric reliability and validity is achieved through the new examination process. More details about the exam blueprint and psychometric properties of the exam can be found on CAPR’s website.

There are pros and cons of a virtual exam. Perhaps the most significant detractor is the common perception that one cannot assess clinical skills using a virtual or simulated environment.

Prior to the COVID-19 pandemic, CAPR, like other pre-licensure examination providers that typically include a clinical examination component in their examination process, was working to innovate examination processes. These organizations have all been challenged to accelerate the process of innovation process and re-think their exam processes due to the pandemic.

The Medical Council of Canada and Pharmacy Examining Board of Canada are two comparable Canadian organizations which have also been challenged by this issue. The Medical Council of Canada announced in February its plan to transition to a virtual examination in 2021 after postponing examinations in May and October 2020, and February 2021.

The shift to a virtual exam has an obvious short-term benefit of limiting the risk of COVID-19 exposure during the examination for candidates, examiners, and standardized patients alike. This change is partly in response to safety concerns raised by examination candidates as CAPR prepared to run the November in-person clinical examination, which was ultimately cancelled.

In the long-term, the virtual examination may also result in increased ease of access to the exam for candidates.

Many questions arise when discussing any such change including:

• How would internationally educated physiotherapists access the examination, or be vetted for inclusion as examination candidates?
• Which organizations have the necessary psychometricians and other technical skills to ensure a reliable, valid, and sound examination?
• Which organizations have the clinical and technical skills to deliver a rigorous examination under usual circumstances?
• Which organizations, if any, could deliver a reliable, valid, and sound examination in the context of current COVID-19 restrictions?
• If provinces opt to employ a local approach to meeting the clinical competency examination requirement, what implications could this have on future labour mobility between provinces? Interprovincial labour mobility was one of the drivers behind the development of the PCE to begin with.

Importantly, if the NSCP were to develop an examination of its own, it would require a significant investment of time, human, and financial resources. The NSCP does not have the technical capacity to develop an examination on its own and would require the services of external contractors to complete this work.

If we were to “go it alone” there would be considerable costs attached to developing the examination, and those costs would be passed on to current regulated members and exam candidates. A new examination would also take considerable time to develop and validate so it is not likely to be a quick solution to the current situation.

While some people may think of the PCE as the last two hurdles in a race, it is more accurate to think of the exam as two strands of rope in a large safety net, like the net that protects a trapeze artist.

The Canadian physiotherapy programs are, accredited by Physiotherapy Education Accreditation Canada (PEAC), and that accreditation signifies that the program has met the expectations established in PEAC’s accreditation standards. The programs deliver instruction and conduct student performance assessments, including the OSCE, as part of its work to address the accreditation standards. While Canadian educational programs may complete a mid or end of term OSCE there is no requirement for them to.

Similarly, all Canadian physiotherapy programs follow the National Physiotherapy Entry-to-Practice Curriculum Guidelines, established by the Canadian Council of Physiotherapy University Programs. Finally, all physiotherapy regulators, including the NSCP have similar registration requirements such as good character and reputation requirements, and requirements that registrants graduate from accredited Canadian programs or demonstrate that their education is substantively equivalent.

Together, these different groups and requirements form the safety net that ensures that all physiotherapists practicing in Canada meet a shared, minimum expectation for knowledge and performance of the practice of physiotherapy. This protects the public interest in that when receiving physiotherapy care they can be assured that a certain level of competent care can be expected.

No one document, organization or set of standards or requirements alone can achieve this objective. Removing any strand of rope from the safety net weakens the protection it offers, eroding public safety and confidence in physiotherapists.

Download the PEAC statement on the role of accreditation for more information on the role of accreditation in the preparation of Canadian-educated physiotherapists for entry to practice.

The registration requirements were established in the Physiotherapy Act S.N.S. 1998, C. 22. Implementing change to our governing legislation is not a nimble process. Making such a change has the potential to take years.

More importantly, practice hours or a sponsor reference alone, lack the rigor, objectivity, reliability, and validity of an examination process.

As a regulatory organization we accept that there is not always consistency with all sponsor/supervision arrangements. Although physiotherapy residents and their sponsors have worked hard to fulfill their obligations, particularly during this challenging time, the NSCP understands that the normal scope of any particular clinical practice does not include the entire breadth of the scope of the profession and would allow for a relatively narrow slice of scope that could be observed, supervised and vouched for.

Having sponsors and supervised practice hours serve in place of the clinical competency examination also has the potential to place the sponsors in a conflict of interest. This would be problematic not only for the sponsor, but also from the perspective of assuring the public of the validity of the registration process.

There may also be equity and fairness considerations as some physiotherapy residents may not have secured and maintained full-time employment through the pandemic, impacting their ability to meet a practice hours requirement or secure a sponsor reference.

Finally, most clinical environments do not encompass the breadth and depth of the Clinical Component of the PCE, which is designed to ensure that all physiotherapists entering practice do so with a shared, basic knowledge of the profession, regardless of where they anticipate their career path will lead.

The PCE is a comprehensive, entry-to-practice examination that determines if candidates have met the entry-to-practice milestones set out in the Competency Profile for Physiotherapists in Canada. While the NSCP certainly would expect students to study in preparation for the examination, we would not expect that students who have received the extensive education they describe from Canadian physiotherapy programs would need to take time off from work to prepare. We concede that the same may not be true of physiotherapists who received their entry-to-practice education outside of Canada.

While it is true that some employers pay a lower rate (either hourly or percentage of billings) for physiotherapy residents, that is a matter between the physiotherapist and their employer and should be addressed directly between the two parties. The NSCP has long held the perspective that physiotherapy residents are regulated members subject to the same Standards as any other regulated member and should be afforded the same rights and privileges.

All registered members of the NSCP have received a message regarding the exam cancellation. Therefore, your sponsors should be aware of the situation. The same message is posted on the NSCP’s website.

New messages and important updates are being sent directly to all Physiotherapists registered in Nova Scotia and posted on the website as well.

Under normal circumstances, physiotherapy residents in Nova Scotia have a 12-month time window in which to successfully complete the examination. After this time expires, they are no longer eligible to remain on the Provisional Register. Although the time frame for completion of the clinical examination has been extended in the wake of exam disruptions, it is not infinite.

Once examination services are resumed, physiotherapy residents will need to fulfill the requirements for registration within a defined period of time. Failure to do so will result in suspension or revocation of provisional registration.

Any person practicing Physiotherapy without a license is committing an offence under the Physiotherapy Act and subject to significant fines and/or imprisonment. These significant enforcement provisions underscore the importance of ensuring that only those who are appropriately qualified and licensed engage in the practice of physiotherapy in this province and hold themselves out as physiotherapists.

Designing, testing, and implementing a Nova Scotia made exam that would be similar enough to the PCE is not feasible for the NSCP. Below are the reasons:

• CAPR is working on providing a solution and will beat any timeline that NSCP could meet in designing its own.
• CAPR has in-house knowledge and 20+ years of experience designing and delivering competency exams for the Physiotherapy profession in Canada.
• NSCP does not have the expertise in house, nor the resources to hire external consultants to design a similar exam. This is a fundamental reason for NSCPs membership in CAPR, as the resource sharing with other provinces allows for a more robust credentialling and certification process than if it were sole sourced by NSCP.
• Despite the recent cancellations of the PCE exam NSCP continues to have confidence in CAPR as an organization that has consistently provided valuable services to the NSCP including administration of the national competency exam.
• NSCP does not agree with the approach taken in BC and Alberta and have expressed that to those regulators. NSCP is committed to a national standard for qualification and competency. While we understand the context and rationale for provinces designing their own exams, we feel doing so weakens the national process by providing potential “backdoors” to credentialling that undermines public confidence in the regulatory system.
• NSCP continues to believe in the importance of a national standard for entry to practice, and that the PCE continues to be recognized as a leader in evaluation services both nationally and internationally.

This decision will be determined based on the Canadian Free Trade Agreement (CFTA) at the government level.

Right now, alternate exams are only being offered in AB and BC to those who have been registered since before March 11, 2020, in that specific province and are still waiting for the clinical exam. Nova Scotia does not plan to design and run its own exam.

It is possible that regulators may have to accept transfers through CFTA once they have practiced in their home province under a full license, but as stated above will be determined at the government level.

The NSCP does not agree with fracturing the entry level competency evaluation process by having individual provinces administer exams. The NSCP is advocating for national entry level standards to be maintained.

These are up to CAPR and will be posted on their website. They are providing weekly updates found at https://www.alliancept.org/whatsnew/.

NSCP has extended provisional license durations until the exam is available to be taken. This means that if there are further cancellations/delays in delivery or an extended period required to catch up on backlogged exams, provisional licenses will be extended provided the provisional registrant is registered for the next available exam that has space. Once the exam is available you will have the same two attempts in 12 months as before unless you have already failed one attempt. If that is the case, the next available exam would be your last attempt for your provisional license in NS.

The goal of the university is to provide students with the opportunity to obtain the educational requirements (Entry Level Master’s Degree) that provides eligibility to challenge a licensing examination. In Canada, this eligibility is automatic if the required accreditation status through PEAC is upheld. Below are some considerations for this question.

• University exams are not intended to be competency evaluations. They are designed to provide evidence that students have met the learning objectives of the course for which they are delivered.
• The OSCE is not an accreditation requirement, and therefore schools may or may not choose to use these evaluation methods to examine student learning or may choose modified OSCE’s that better match course objectives than those used for national licensing.
• Third party evaluation is considered the gold standard for OSCEs to limit the possible bias that may be introduced by having individuals that know and teach the students run the OSCE.
• The evaluation of clinical placements is not based on metrics that have been validated for the purpose of establishing a threshold for competent practice and national licensing. Tools used for evaluations in clinical placements are designed to capture the objectives of the course and the learning trajectory of the student through their education.
• It is not expected that a student be at the level of “entry-to-practice” in all of their placement evaluations, particularly those preceding their final placement as students have not yet completed the educational requirements of the MScPT.

The situations are different. The Medical Council of Canada has an accepted and established minimum 12 month post graduate medical training requirement that must be completed in order to get the Licentiate of the Medical Council of Canada (LMCC). This allows the MCC more flexibility in cancelling the practical exam while considering other options. Physiotherapy does not have a standardized, effective, and mandatory 12-month post graduate training requirement in physiotherapy to fall back on.

Physiotherapy does have mentorship; however, this is quite different from the post graduate training requirements of the MCC. Mentorship is non-standardized and therefore subjective. Mentorship was set up to develop a mentoring and learning relationship for entering practice. It is not a validated evaluation tool but an indicator of areas to further develop. Not all provinces have it and it is different from province to province. Each school has slightly different programs and clinical experiences and that is why a non-biased national exam run by a third party is so important.

It is important to realize that CAPR has been looking at alternative ways to evaluate competency since before the pandemic. However, the research, development and psychometric validation takes many months to complete. CAPR’s current immediate focus is running an exam that is valid and will clear the backlog as soon as possible. When the pandemic first hit CAPR’s focus was on developing a virtual written exam to get new graduates qualified for provisional licensure so they could enter the work force and begin consolidating their knowledge and skills. Unlike the MCC, Physiotherapy does not have a 12-month post graduate training program to fall back on for evaluation of competency that would enable us to drop the clinical as it is and work on a new innovative plan.