Resources:
Boundaries and Sexual Abuse

Under the law (RHPA, Sched. 2, s.1 (3,4)) it is considered to be sexual abuse when a health care provider touches, behaves or makes remarks of a sexual nature towards a patient—as well as having physical sexual relations.

If a physiotherapist is dating a patient and doing any of these things it constitutes sexual abuse, and there is a zero tolerance policy. It does not matter if the patient starts the relationship or consents to the relationship.

Being found guilty of sexual abuse can result in the loss of your ability to practice as a physiotherapist. Colleges are required to revoke (take away) the registration of members found guilty of sexual abuse. It really is a big deal. The Regulated Health Professions Act states:

(5) If a panel finds a member has committed an act of professional misconduct by sexually abusing a patient, the panel shall do the following in addition to anything else the panel may do under subsection (2):1. Reprimand the member.2. Revoke the member’s certificate of registration if the sexual abuse consisted of, or included, any of the following,i. sexual intercourse,ii. genital to genital, genital to anal, oral to genital, or oral to anal contact,iii. masturbation of the member by, or in the presence of, the patient,iv. masturbation of the patient by the member,v. encouragement of the patient by the member to masturbate in the presence of the member. 1993, c. 37, s. 14 (3).

You should contact the College and make a mandatory report. The College Practice Advisor can also assist you. The name of a patient who may have been sexually abused must not be included in a report unless the patient, or if the patient is incapable, the patient’s representative, consents in writing to including the patient’s name. 1993, c. 37, s. 23.Under the Regulated Health Professional Act (RHPA) it is considered to be sexual abuse when a health care provider touches, behaves or makes remarks of a sexual nature towards a patient—as well as having physical sexual relations.The RHPA also requires health care providers to report to the College when they have reasonable grounds to suspect the sexual abuse of a patient. There can be a $25,000 fine for anyone who does not report.

You are correct, it is against the law to date a current patient. You must wait at least one year and there are other things you must think about in this situation. Dating a past patient is often not a good idea. Given the role a physiotherapist plays in a person’s recovery and the therapeutic relationship shared, a power imbalance exists between the patient and the PT. There is a risk that a patient may become dependent on their physiotherapist. However, it is possible to date a former patient if all the following apply:- at least one year has passed since the patient was discharged from your physiotherapy care- there is no power imbalance between the physiotherapist and the patient, and – the patient is no longer dependent on the physiotherapist.Still not sure? Why not contact the Practice Advisor and talk it through. advice@collegept.org or 647-484-8800 or 1-800-583-5885 ext. 241.

Physiotherapists are expected to maintain professional boundaries in all circumstances. This includes recognizing signs of a potentially inappropriate interaction and taking steps to deal with it—even when initiated by a patient.These expectations exist to protect the patient but they can also protect you.The definition of sexual abuse, in the context of providing healthcare to patients, includes behaviour, remarks or touching of a sexual nature as well as having physical sexual relations. Anyone overhearing the interaction could interpret the behaviour as sexual abuse and by not addressing the behaviour you are participating and could be found guilty of sexual abuse.More importantly, the patient could interpret your actions or even your silence as a willingness to begin a relationship.Even though it may be uncomfortable, you cannot ignore the situation. Consider talking to a colleague or the College Practice Advisor before having a respectful conversation with the patient.

Video Resources: Redirecting Inappropriate Patient Behaviour: Verbal Techniques

• I Think, I Feel, I Want
• Active Listening and Broken Record
• The Positive/Negative Warning

You are the supervising PT and need to intervene. Explain to the student why having coffee with a patient may be a problem. Find out if the student can understand the differences between a therapeutic relationship and a personal one. There is a power imbalance in favor of the PT (“student”).  The PT (“student”) has knowledge and skills and may hold private knowledge about the patient. The PT and the PT student are responsible for setting professional boundaries to maintain a safe therapeutic environment for the patients.

Use your best efforts to tell the patient about your obligation as a health care provider. Explain that you must report the sexual abuse to the college to which the alleged abuser belongs — it’s the law.Before making the report, you must get the patient’s written permission to include their name in the report. Patients do have the option to remain anonymous, but it is preferable to have their name. 

The Registrar (CEO) will forward the report to the Inquiries, Complaints and Reports Committee. The Committee will review the report and any supporting documentation (the member’s response for example) and decide if there are grounds to request a formal investigation.

The Committee can make the following decisions:- Refer allegations of professional misconduct or incompetence to the Discipline Committee – Refer allegations of incapacity to the Fitness to Practise Committee – Issue a Caution to the member – Provide advice to the member – Negotiate an Undertaking agreement with the member – Take no action

A physiotherapist must maintain professional boundaries with each patient. Seeing a patient socially moves the relationship from a professional to a personal relationship. Consider some of the challenges that may arise with attending these social gatherings:There are no simple yes or no answers to these questions but a PT should carefully consider the impact that attending such a function might have on their professional relationship with a patient.

The answer to this depends on the circumstance. Sometimes it will be OK and other times not.Some of it depends on the gift itself and some of it depends on the patient and whether there is an expectation that you do something in return. Always consider it from the patient’s point of view. Occasionally it might do more harm than good to refuse the gift.Some examples:On their last visit, a patient gives you a card with a $50 gift card. This is probably OK. The patient has completed their treatment and expects nothing in return.A patient’s mom is grateful for the care you are providing her son and wants to make sure you don’t discharge him. She wants to give you $50. You should decline this offer. 

Sometimes a physiotherapist will find themselves in a social situation that involves their patients. As a PT, your children may attend the same school as your patient, your patient might live in your neighbourhood, or attend the same gym that you do. In these circumstances socializing may be unavoidable. What is important is how you manage the situation and the potential for a boundary crossing. Physiotherapists must set limits (boundaries) when they see a person both inside and outside of the clinical environment. This creates a safe place for the patient and prioritizes their care.

Boundaries are limits that establish identity, maintain privacy, avoid entanglement and allow for safe and professional interactions. Boundaries are the invisible lines that are drawn to help define roles and interactions in relationships. When these lines are crossed, negative consequences may result. According to the College’s Boundaries and Sexual Abuse Standard, the physiotherapist’s responsibility is to always act in the patient’s best interest and manage the boundaries within the therapeutic relationship.

One of the important risks to note when providing services to a person you interact with both professionally and in-person is that your clinical objectivity may be affected when you assess or treat that person. In this case, knowing this person’s family for example may make the patient feel less comfortable sharing sensitive information with you. Or because of your familiarity with them, you could be tempted to take shortcuts with record keeping or discussing consent for example.  Patient confidentiality must be carefully protected as there is risk of accidently breaking confidentiality is higher when you interact with someone both personally and professionally. 

Tips:

• Do not discuss patient care topics in non-clinical settings
• Develop strategies to redirect treatment-related questions to the clinic setting and social questions to a personal setting.

For example:

If the patient’s injury or condition comes up at the park or a party, be prepared to say something like “I am happy to look at the injury in the clinic at our next treatment session.” And if a patient starts to discuss something personal when you are treating them, be prepared to say something like “Let’s chat more about that when I see you at the hockey game on the weekend.” 

“I know exactly where my professional boundaries are; they are the four walls of my clinic, and outside of them, I don’t discuss client care, and inside of them, I don’t have personal conversations.”

Reference “Where’s the Line” Professional Boundaries in a Therapeutic Relationship.