Guide:
Boundary Violations Standard

A boundary violation in physiotherapy is when someone — whether it’s the therapist, the patient, a caregiver, or another person — crosses the line of what’s appropriate in a health care relationship.

The Boundary Violations Standard explains what physiotherapists must do to keep and manage professional boundaries. A boundary violation happens when someone acts in a way that is not acceptable in a professional relationship. This can affect patient care or the workplace environment. Boundary violations could involve touch, words, or behavior that crosses the line, and they can damage trust, safety, and fairness in care.

Common Examples of Boundary Violations:

Physical:

• Not offering draping or privacy when treating sensitive areas
• Touching without clear, informed consent
• Standing or getting too close to someone in a way that feels uncomfortable or isn’t needed for care
• A patient touching the physiotherapist or making movements that are not acceptable with the care being provided

Psychological: 

• Saying things that pressure, criticize, or play with someone’s emotions to get a certain reaction
• Sharing personal beliefs (e.g., political, religious, or spiritual) during treatment
• Purposely overlooking, or not fully considering, a patient’s trauma-related history
• Continuing care when professional judgement is biased or unfair
• Comments that are too personal and do not match the care being provided

Social: 

• Starting personal friendships with current patients, unless it’s unavoidable given your practice context
• Accepting gifts with favours attached, that are too personal, or have unclear motivation
• Having romantic or sexual relationships with patients, caregivers, or people you supervise. Initiating, pursuing, or engaging in a romantic or sexual relationship with a patient is sexual abuse.
• A patient trying to start a personal, romantic, or social relationship with the physiotherapist
• Using personal social media accounts to have private conversations or sending/accepting friend requests with patients

Note: Physiotherapists may use social media professionally for education, advertising, or public engagement. However, using social media to talk with patients personally can blur professional boundaries. 

A power imbalance happens when one person has more authority, influence, or control in a relationship than the other. In physiotherapy, this exists because patients depend on physiotherapists for their expertise, clinical judgement, and decisions about their care. This places the therapist in a position of power, responsibility, and trust. Power imbalances are present in all health-care interactions.

Power imbalances are not automatically harmful, but they carry risk if they are misused and not properly managed. As a physiotherapist, you must use your authority, and the trust placed in you, to support the patient’s health and wellbeing and never for personal benefit. Maintaining professional boundaries helps ensure the natural power imbalance does not compromise a patient’s care.

Please see the blog post on power imbalances for more information about how to identify and manage them.

Physiotherapists are not strictly prohibited from treating people they know, but doing so creates a “dual relationship” where personal and professional roles overlap. These overlaps carry significant risks to objectivity, patient safety, and professional boundaries.

For example, patients who are close to you may hold back important information, expect special treatment, or feel uncomfortable giving honest feedback. It is your responsibility as the physiotherapist to make sure the personal relationship does not compromise their care. Because of these risks, physiotherapists should refrain from treating people they have close personal relationships with (like friends and family) if an alternative provider is available.

If no reasonable alternative exists, like in a remote community or where no other providers are available to treat the patient’s condition, taking the following steps can help manage the risks associated with treating people close to you:

• Recognize and disclose any situation that could prevent you from putting the needs and interests of the patient first. Explain to the patient and other members of the care team how you will manage the dynamic.
  • For example, if you work in a small community and your patient is also your child’s teacher, you should indicate this in the chart and have a conversation with the patient about how you will manage the relationship.
• Promptly and clearly document the situation and the plan for managing it, updating the record if the plan or level of risk changes.
• Be sure that your clinical judgement and objectivity are not compromised throughout the treatment plan.
• Meet all professional obligations in line with the standards, as well as regulatory requirements. This includes but is not limited to:
  • Performing comprehensive assessments
  • Obtaining informed consent
  • Treatment planning
  • Thorough record keeping
  • Ensuring the patient’s privacy and confidentiality
  • Appropriate billing practices

If at any point the personal relationship compromises your ability to meet these obligations and safe care can no longer be provided, you must not proceed with treatment.

Finally, you must not treat a spouse or anyone with whom you have a current or past sexual relationship. This is sexual abuse under the law. Please see the guide for the Sexual Abuse Standard for more information.

Living and working in a small community means physiotherapists will often know their patients outside of the clinic. In these dual relationships, socializing may be unavoidable, and it may be harder to separate personal and professional roles. How you manage the situation and the potential for a boundary violation is important. Physiotherapists must set boundaries when they see a person both inside and outside of the clinical environment, and they are responsible for ensuring those boundaries are maintained. This creates a safe place for the patient and prioritizes their care.

Treating people you know personally is allowed if there are no reasonable alternatives available, such as in communities with limited treatment options.

Here are some other ways to ensure boundaries are maintained for those who live and work in small communities:

• Don’t give clinical advice outside of the clinic. For example, if a patient approaches you in a grocery store, gym or community event, it’s not the right time or place to talk about their physiotherapy care. Without an assessment or documentation, a physiotherapist cannot provide safe care. Instead, use polite, consistent phrases to redirect the person back to the clinic for proper treatment.
  • Example: “I’m happy to look at this in the clinic at our next session.”
  • Example: “I can’t give advice here, but if you book an appointment, we can look at it properly.”
• If a patient approaches you in public, remember that others may overhear. Do not share or discuss sensitive health information outside of the clinic. Always protect confidentiality and redirect conversations to a private, professional setting.
• If a patient begins discussing something personal during treatment, gently redirect the conversation to a more appropriate setting.
  • Example: “Let’s chat more about that when I see you at the hockey game on the weekend.”
• Friends, family, or acquaintances may ask about a patient’s condition. Information cannot be shared without the patient’s consent. Maintaining confidentiality builds trust in the community.
• In clinics with shared spaces, respect the patient’s cues about privacy. Offer a more private area when sensitive issues need to be discussed, and be aware of situations where patients might know each other.

Do not discuss patient care in non-clinical settings and develop strategies to separate treatment-related questions from social conversations.

Being part of a small community does not change your professional responsibilities. Boundaries, privacy, and confidentiality must always be maintained.

It depends on the circumstances. Sometimes it is OK to accept a gift from a patient, other times it is not.

The gift may be acceptable if: The gift is modest, freely given, and without expectation. “Modest” means that you could keep gifts that are small (cards, thank you notes, etc.), while declining expensive items.

Decline the gift if: It could influence care, feels too personal, has an unclear motivation, creates pressure to continue treatment, or feels like it comes with favours attached.

Examples:

• On their last visit, a patient gives you a card with a $50 gift card. This is likely acceptable, since 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 cash. You should decline this offer.

If you believe that you should decline the gift, it is also important to consider how to approach that conversation with the patient. Be transparent with the patient and always consider the situation from their point of view. If you think that refusing the gift could harm the relationship, thank them for the gesture while making clear that care is not dependent on gifts.

Beyond the potential for gifts to violate professional boundaries, accepting them may also create a conflict of interest. According to the Conflict of Interest Standard, physiotherapists must not enter into any agreement, arrangement, or activity that could interfere with their ability to prioritize the needs and interests of the patient. Please refer to the standard for more information.

Regardless of who crossed a professional boundary (the physiotherapist or the patient), the physiotherapist is expected to notice and address boundary violations. These violations can compromise trust, safety, and objectivity in the therapeutic relationship if not handled appropriately. In these situations, it is your responsibility to respond professionally and protect the therapeutic relationship.

According to the Boundary Violations Standard, physiotherapists must take the following steps in response to a boundary violation:

• Address the concern directly with the patient. Identify the boundary violation. Use clear and respectful language to name the behaviour and explain why it is not appropriate in a professional setting.
• Take steps to resolve the situation while maintaining professionalism. This may include redirecting the conversation back to the treatment, setting clear expectations for future interactions, or arranging for another staff member to be present.
  
  If the violation was started by you as the physiotherapist, you must acknowledge your mistake, apologize sincerely, clearly outline the facts, and take corrective action. 
  
  If a patient shows inappropriate or unwanted behaviour, respectfully explain what behaviour is acceptable and potential consequences if the behaviour does not change. The patient should have a chance to change their behaviour, unless there is reason to believe there is a significant risk to anyone’s safety.
• Document the incident and your response in the patient record. Accurate documentation protects you and the patient. Record what happened, how it was handled, and any steps taken. 
• End the therapeutic relationship if needed. If boundaries cannot be re-established or objectivity is compromised, you must discontinue treatment or transfer care in a safe and appropriate way. The Duty of Care Standard sets out the requirements for appropriate patient discharge.

Respond early and communicate clearly so that boundaries are reinforced and the therapeutic relationship is kept safe and effective. For more guidance, please see the Patient-Centred Communication Learning Module.

Because every patient is different, there is no “right way” to drape. You should apply consistent principles that balance the patient’s privacy, safety, and clinical need.

Here are some key principles to keep in mind:

• Consent. Explain why draping is necessary and ask permission before starting.
• Privacy. Only uncover the area being treated and keep the rest of the body covered. Adjust draping promptly if it slips. Encourage patients to bring their own t-shirt, sleeveless shirt, or shorts to avoid using towels or sheets that slip.
• Autonomy. Help patients feel safe and in control by involving them in the draping. For example, let them hold the drape. Never unclip a patient’s bra unless they are physically unable and you have their clear consent to do so.
• Cultural sensitivity. Don’t assume that every patient’s comfort levels are the same. Ask respectfully about modesty or privacy needs and adapt your approach.
• Comfort. Watch the patient’s body language, adjust draping for mobility needs, and use extra sheets or blankets if the patient is cold.
• Clear communication. Let patients know each step in the process, including when to re-dress. Offer help if needed. Check in if the patient seems uncomfortable.

Draping is a skill that improves with confidence and experience. When handled well, it supports both treatment and the therapeutic relationship by showing patients that their comfort and dignity matter.

Cultural safety means creating an environment free from discrimination where patients feel respected and heard. You must recognize that what feels professional or appropriate to you may not feel the same for the patient. Boundaries must protect the patient’s dignity and safety, while also respecting cultural values, beliefs, and practices.

According to the Boundary Violations Standard, boundaries protect patients from harm and preserve trust in the therapeutic relationship.

The following practices can be applied to cultural safety:

• Ask, don’t assume. Patients may have specific expectations related to their culture, including touch, modesty, or decision-making roles. Invite them to share what feels comfortable and who they may want to be present or involved.
• Communicate clearly. Explain why a boundary exists or why certain care is needed. Ask if the patient understands or has concerns about how care will be delivered.
• Adapt within safe limits. Where possible, adjust your approach to respect cultural needs without compromising patient safety or your professional responsibilities.
• Reflect on your own biases. Be aware of how your background or assumptions could influence boundary decisions.

Remember that cultural safety does not change your professional boundaries. It changes how boundaries are explained and managed in ways that build mutual trust and respect.

Social media can blur the line between personal and professional roles. Physiotherapists must be careful when using social media. Remember that patients, colleagues, and people you supervise may see what you post on social media, even if it was not intended for them.

Practical steps for using social media while maintaining boundaries:

• Keep professional and personal accounts separate. Use professional channels for clinic information, education, or physiotherapy-related updates, and keep personal accounts private.
• Do not friend, follow, or direct message patients or caregivers from a personal account. This risks crossing into a personal relationship and may undermine the therapeutic one.
• Be mindful of the content you post. Avoid posting anything that could be perceived as unprofessional, discriminatory, or overly personal for patients or colleagues to see.
• Protect patient confidentiality. Never post identifiable patient information, images, or stories without their explicit consent.
• Think before you post. Ask yourself: “Would this be acceptable if I said or did it in the clinic?”

For more guidance on using social media responsibly, please see the resource on Social Media — Principles for Physiotherapists.