Managing Inappropriate Behaviour: What are the Limits?

Case Scenario:

The patient becomes upset and starts using offensive and abusive language with the clinic staff. The patient requires treatment, but the physiotherapist is so concerned with their behaviour that they do not want to treat the patient again. The physiotherapist considers telling the patient that they can no longer see them for physiotherapy treatment. Is this allowed?

Physiotherapists are responsible for setting professional boundaries with patients when it comes to appropriate behaviour in the clinical setting. Boundaries help patients feel safe, but they also help protect the physiotherapist and other clinic staff.

While physiotherapists must always maintain professional boundaries with their patients, they should not tolerate verbal abuse or threats of physical violence.

The Professional Misconduct Regulation outlines when it would appropriate for a physiotherapist to discharge a patient, and having reasonable grounds to believe that a patient will become abusive is included as one of the reasons.

(Important note: Sometimes disruptive behaviour may be explained by a patient’s cognitive condition. To manage those situations, the PT may need to take extra steps to understand what is causing the patient to act inappropriately. This article does not address those circumstances.)

When a patient behaves in a way that threatens the safety of the PT or clinic staff, the physiotherapist should take appropriate steps to manage the unwanted behaviour. If the physiotherapist is unable to mitigate the behaviour, they can refuse care.

The Providing or Refusing Care Standard states that a physiotherapist can discontinue care if a professional boundary has been breached and all reasonable steps have been taken to manage the behaviour. Abuse towards the PT or other staff can ultimately create a lack of trust that would negatively impact the therapeutic relationship.

If a physiotherapist finds themselves in a similar situation to what is outlined above, they should consider the following actions:

1. Discuss the inappropriate behavior with the patient. If a patient is behaving in an unacceptable way, the PT must communicate with them professionally to explain which behaviours must change.

   This discussion should ideally happen before discharging the patient. The patient should have an opportunity to change their behaviour, unless there is reason to believe there is a significant risk to anyone’s safety. When the safety of the PT or other staff is at risk, the patient can be discharged immediately without an explanation of why.

   2. There may be other situations where the therapeutic relationship is broken beyond repair, and it’s in everyone’s best interest that the patient does not return. The physiotherapist should develop a plan to address the issue. If the patient needs ongoing care, the physiotherapist should take reasonable steps to provide alternatives for the patient to manage their care. This could include a home exercise plan, a list of other clinics where they could continue their care, or a direct referral to another physiotherapist.

   The plan should be communicated to everyone involved. The patient may feel abandoned if they are told they are being discharged from physiotherapy care without a clear plan about next steps for them to continue their care elsewhere.

   3. As stated in the Providing or Refusing Care Standard, a PT cannot refuse to assess or treat a person for ethnic, racial, or religious reasons. Additionally, physiotherapists cannot discriminate against a patient based on their sex (biological sex), gender identity or gender expression, or sexual orientation. The only exception would be if a PT lacks a competency related to the treatment that the patient is seeking. For example, a PT cannot provide pelvic floor treatment if they are not qualified and trained to do so. In this case, the physiotherapist should assist with a referral.

   4. The physiotherapist must document any communication with the patient in the patient’s record. The Record Keeping Standard emphasizes that physiotherapists must maintain clinical records about their patients, and other records that are required by the College, by law, or by other organizations. If the patient were to submit a complaint to the college about the discontinuation of care, the clinical records would be reviewed as part of the investigation.

Choosing effective and appropriate responses to a patient acting inappropriately may be complicated by ethical considerations within the therapeutic relationship. Physiotherapists should remember that any response to patient behaviours must be balanced against the right to a safe workplace free of abuse. Any actions by the physiotherapist should consider the needs of the patient, the PT themself, and other clinic staff.

If you find yourself in a similar situation, consider calling the Practice Advisors for guidance. They can help you understand your professional obligations and chat through ethical considerations. Call 1-800-583-5885 (extension 241) or email advice@collegept.org.

Additional Resources:

Providing or Refusing Care Standard

Boundaries and Sexual Abuse Standard

Boundaries and Sexual Abuse Standard E-Learning Module

Record Keeping Standard

Communication Skills Resource