Resources:
Boundary Violations

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.

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.

Example:

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 Boundary Violations 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.”