Case of the Month
The Cases
In recent years the College has seen a noticeable increase in complaints related to boundary breaches. Often these complaints have an underlying issue of poor communication by the physiotherapist. A boundary breach may be unintentional, but it can have a lasting impact on the therapeutic relationship if it’s not properly addressed.
Here are some examples of boundary breaches that have led to complaints:
- A physiotherapist was treating a patient’s wrist. The patient was lying supine with their arm off the table, and the PT was using their lap to rest the forearm while performing carpal mobilizations. The patient felt something hard beneath their forearm and interpreted it as an erect penis. The physiotherapist was shocked by the complaint but admitted to working with their cell phone in their front pocket.
- A patient consented to having a TENS machine on their upper back. The physiotherapist stood behind the patient and, without any verbal warning, put their hands up the patient’s shirt to attach the electrodes. The patient was shocked and upset that the physiotherapist didn’t provide an explanation for the touch or seek consent to put their hands up the patient’s shirt.
- A physiotherapist assessed a patient and determined that they had reduced thoracic rotation bilaterally. The PT decided that the patient would benefit from some mobilizations with movement (MWMs) and asked the patient to sit up on the bed. The physiotherapist then straddled the bed beside the patient and asked the patient to cross their arms in front of their chest. The PT reached around the patient and performed the technique. The patient was very surprised to find the physiotherapist straddling the bed and sitting so close to them. The patient was uncomfortable and unable to relax. The patient reported feeling like this was a violation of their physical safety as the physiotherapist did not explain the treatment fully or provide alternatives if the patient was uncomfortable.
- A patient attended physiotherapy to help address a sprained ankle. The physiotherapist obtained consent, discussed the assessment, and diagnosed a grade 2 anterior talofibular ligament sprain, with significant limitations in dorsiflexion at the talocrural joint. The PT included mobilization of the talocrural joint as part of the treatment plan. They asked the patient to sit on the table with their lower leg off the table. The PT then placed the patient’s foot directly on their inner thigh and proceeded to stabilize the talus and lean forward using their bodyweight to mobilize the ankle into dorsiflexion. The patient didn’t understand why their foot was placed so close to the physiotherapist’s groin and reported feeling something hard under their foot. The PT was surprised by the complaint but realized that they should have had a more fulsome discussion with the patient around the placement of the foot on their thigh. The PT also acknowledged that they were practicing with their keys in their front pocket.
The Standards
As noted in the Boundaries and Sexual Abuse Standard: “Boundaries in patient care are physical and emotional limits of the therapeutic relationship between the patient and the physiotherapist. The physiotherapist’s responsibility is always to act in the patient’s best interest and to manage the boundaries within the therapeutic relationship.”
PTs must also respond appropriately when a professional boundary is breached. This involves identifying the breach, correcting the inappropriate behaviour, and documenting the actions taken to address the breach in the patient’s record.
Physiotherapists must communicate clearly to ensure patients understand the nature of the treatment including benefits, risks, side effects, the alternative courses of action, and any possible consequences of not having the treatment. The patient must have this information to provide consent. Patients should always be given the opportunity to ask questions about treatment, and PT should regularly check in with the patient to make sure they’re comfortable.
How to Prevent a Similar Situation
- Use clear and direct communication with patients – provide information before and during the appointment.
- Always provide an explanation for treatment and get permission from patients before touching them or working in close physical proximity.
- Talk about what you’re doing during treatment and always seek ongoing feedback from patients.
- Use draping and allow the patient to adjust or move the drape as required.
- Consider placing a barrier, like a pillow, between yourself and the patient when working in close proximity.
- Always be mindful of the position of your body in relation to the patient. You may need to adjust your approach depending on the patient.
- Don’t practice with a cell phone or anything else in your front pocket, as it might accidentally touch the patient and can easily be mistaken for part of your body.
- Acknowledge any accidental touch and apologize. It’s far better for you to address the incident in the moment. Be sure to document the incident and discussion in the patient’s chart.
- Ask the patient to tell you when they feel uncomfortable. Remind them that they can stop the treatment at any time.
Be sure to review and bookmark these two-minute video resources for additional learning:
a signed consent forms is not enough throughout the treatment. I used to tell patient what I am gonna do and ask consent again. I was told by my patient on why I kept asking if I could hold any of their body parts and told me to just do what needs to done. I explain nicely that I have to do that to show respect.