Good Practice: Sensitive Practice as a Universal Precaution

  •   September 5, 2017
  •  Nancy Littke, PT, Practice Advisor

As physiotherapists, we are familiar with the term therapeutic relationships and have a basic understanding of what that means in the realm of providing patient care: the need to separate personal from professional relationships and the need to identify and manage professional boundaries. The topic of “sensitive practice” may require more investigation.

Sensitive practice is practicing in a manner that is sensitive to the needs of adult survivors of sexual abuse and other types of interpersonal violence. Statistics related to the occurrence of childhood sexual abuse indicate that as many as 1/3 of women and 14% of men in Canada are survivors of sexual abuse and therefore all health-care providers knowingly or unknowingly encounter individuals who are survivors of interpersonal violence.1 These stats reinforce the need for all of us to have an awareness and better understanding of this issue.

A valuable resource I found is the "Handbook on Sensitive Practice for Health-Care Practitioners" published by the Government of Canada. This handbook identifies the need for all health-care providers to adopt a policy of utilizing “universal precautions” for all patients to ensure vulnerable patients are not further traumatized and that the success of the patient-physiotherapist interaction is not unknowingly jeopardized or negatively influenced.

I found it very interesting, as I read through the handbook, to see the nine principles of sensitive practice1 identified and to reflect on their similarity to both Physiotherapy Alberta’s Standards of Practice and Code of Ethical Conduct. The nine principles are:

  1. Respect
  2. Taking time
  3. Rapport
  4. Sharing information
  5. Sharing control
  6. Respecting boundaries
  7. Fostering mutual learning
  8. Understanding non-linear healing
  9. Demonstrating awareness and knowledge of interpersonal violence

As I read the nine principles, it became clear that these are principles we should apply to each person we enter a therapeutic relationship with. Showing respect for the uniqueness of each client is one of the foundations of our Code of Ethical Conduct and the Standard of Practice related to client-centered care. The principles of taking time to listen, developing rapport, sharing information or communicating honestly, fostering mutual learning and sharing control of the relationship, and the treatment processes are all included in several of our Standards of Practice including Communication, Client-Centered Care and Consent and are crucial to providing quality care to all individuals we interact with as health-care professionals.

As physiotherapists, we must always understand and be aware of the need to respect therapeutic boundaries and ensure our clients clearly understand when, what and why personal boundaries may be crossed or impacted by the needs of the care to be provided. They must be constantly in the know and must provide ongoing informed consent throughout the relationship. This consent or lack of consent may be demonstrated through actions and non-verbal communication and we must be constantly monitoring the client’s reactions, body language and responses to our treatment to ensure we are picking up some of the subtle clues to their comfort level with what we are asking or doing. This is where the "sensitive" part comes in. Many of our clients, regardless of their past, struggle with voicing their preferences, discomfort, or reluctance when they feel less empowered to do so.

The understanding of non-linear healing is important. The Handbook on Sensitive Practice describes in the following way. "Survivor participants reminded us repeatedly that healing/recovery from childhood sexual abuse is not a linear process. As a result, the degree to which a survivor is able to tolerate or participate in treatment may vary from one health-care encounter to the next. This variability may occur over the short term (day-to-day) or over longer periods of time. In recognition of this reality, health-care practitioners must check in with their clients throughout each encounter and adjust their behavior accordingly. The practitioner who responds with understanding and compassion in these circumstances contributes to the survivor’s feeling of safety and to a stronger therapeutic alliance."1 This to me sounds a lot like something we should do with all our clients.

 The ninth principle of demonstrating an awareness and knowledge of interpersonal violence speaks directly to the principles of providing safe, ethical, and quality client care and ensuring that we are providing care that is specific to the individual and their health care and life story.

The Handbook identifies several tough questions that we can ask ourselves about the service and care we provide and to guide our reflection on whether our service delivery is sensitive to the needs of all clients.

  • Might any of my current practices be interpreted as insensitive by survivors? What needs to change?
  • In what ways might I adapt my own practice to incorporate specific guidelines discussed in the Handbook?
  • Do any of these guidelines seem unrealistic or unworkable in my practice? What are some alternate ways of following such guidelines?
  • How committed am I to incorporating these guidelines into my routine practice and into the routine practice of those who assist me in my work? What does this level of commitment mean to my clients?
  • How aware am I of nonverbal communication of discomfort? Do I follow up on these indicators with my clients?
  • Am I aware of resources in my community to which I can refer survivors for care outside my scope of practice? Is this information readily available?1

Physiotherapy Alberta has recently developed and posted the new Therapeutic Relationships Resource Guide on the website. This guide reinforces the importance of establishing and maintaining ethical, safe and effective therapeutic relationships and is intended to assist in answering questions, developing policies and procedures, and guiding interactions to prevent conflicts or complaints.

A list of precautions that we should employ with all our clients to ensure we do not re-victimize these individuals is present. These precautions include:

  • Investing adequate time to develop rapport with the patient.
  • Letting patients know they can bring someone with them to their treatments.
  • Explaining what the subjective and objective assessment involves before proceeding.
  • Providing the patient with the opportunity to ask and have questions answered before proceeding.
  • Completing the subjective exam before asking the patient to remove their clothing for the objective exam.
  • Ensuring privacy for undressing and dressing.
  • Re-visiting consent as the assessment and treatment progresses.

By reflecting on our current practice using the questions above and the nine principles described in the Handbook and by implementing a policy of using Universal Precautions outlined in the Therapeutic Relationships resource, we will decrease the likelihood of causing undo harm and increased stress for all our clients and improve the overall success of our patient care delivery.


  1. Schachter CL, Stalker CA, Teram E, Lasiuk GC, Danilkewich A. Handbook on sensitive practice for health care practitioners: Lessons from adult survivors of childhood sexual abuse. Ottawa: Public Health Agency of Canada, 2008. Available at: http://publications.gc.ca/collections/collection_2010/aspc-phac/HP20-11-2009-eng.pdf Accessed on August 24, 2017.