Defining professional boundaries
Professional boundaries set limits to define the parameters of a safe, therapeutic connection between physiotherapists and their patients. Rather than a clear, consistent dividing line, physiotherapists must be aware of the grey zone which lies in between clearly acceptable and clearly unacceptable behavior. In this zone, behavior may or may not be appropriate depending on aspects of the patient-provider relationship and the treatment provided. In this way, professional boundaries are dynamic in nature.
Inherent to establishing therapeutic relationships is knowing where to draw the line between a professional relationship and a personal one, and how to avoid crossing that line.
To do so, you must acknowledge:
- The power imbalance inherent in the relationship.
- The profession’s expectations for appropriate behavior.
- Your duty of care.
Blurring the line
Given that there is a grey zone of behaviours that may or may not be appropriate, it can sometimes be difficult to know if you have crossed the line.
|May be appropriate
||Probably not appropriate
|Giving or accepting gifts.
||Social relationships with current patients.
||Physical, verbal, sexual or emotional abuse.
|Romantic relationships with former patients.
||Treating family or friends.
||Sexual relationships with a current patient.
|Hugging/touching for non-treatment reasons.
Warning signs for boundary crossings
“The crossing of boundaries usually begins with seemingly innocent comments or disclosure and escalates from there.”11
Some examples of warning signs include:
- Thinking of the patient when away from work.
- Sharing too much personal information with the patient.
- Providing personal contact information to the patient, for non-clinical reasons.
- Dressing differently when booked to see the patient.
- Acting or feeling possessive of the patient.
- Giving special attention or preferential treatment to the patient, different from normal practices, including scheduling more time or more sessions than required to meet therapeutic goals.
- Being defensive, embarrassed or making excuses when someone comments on, or questions your interactions with the patient.
- Giving or accepting gifts that may cause a sense of obligation or convey a special relationship.
What puts me at risk of crossing the line?
Personal and professional factors can increase your risk of engaging in questionable or inappropriate behavior.
Personal factors can include:
- Physical and mental health issues,12 including stress or burnout.
- Social isolation at work.12
- Belief that the rules “don’t apply to me” or to the situation at hand.12
- Lack of awareness and insight regarding the culture of the population served, and failure to apply culturally aware care.
Professional factors can include:12
- Working in isolation (either as sole charge practitioner or due to team dysfunction resulting in isolation).
- Lack of knowledge or respect for the Standards of Practice and other professional obligations.
- Lack of clinical knowledge or experience (new to the area of practice, or failing to maintain currency of knowledge).
- Workload or other system factors.
Blurring of boundaries often occurs gradually and unintentionally; however, minor transgressions tend to lead to more significant ones if left unchecked.
“Boundary violations result from a deliberate action or choice that is recognizably inappropriate and in violation of the nature of a therapeutic relationship.”11
Inappropriate behaviours include:
- Sarcasm, offensive language, intimidation, teasing.
- Cultural slurs and discrimination.
- Tones of voice and body language that express impatience, condescension, or exasperation.
Prohibited behaviours include:
- Discrimination based on race, religion, ethnic origin, age, gender, sexual orientation, social, or health status.
- Verbal or physical abuse.
- Sexual relations including flirtations, suggestive jokes, and sexual innuendos.
In general, accepting gifts is part of a personal relationship, not a professional relationship. Accepting a gift from a patient always carries some degree of risk. Context is everything.
- What motivated my patient to give this gift? A desire for a “special relationship,” or future preferential treatment increases the risk of accepting a gift.
- Did my self-disclosure (i.e., my upcoming birthday) make the patient feel obligated to bring the gift?
- How will accepting the gift impact my ability to make objective, unbiased clinical decisions?
- Could the patient’s family perceive that accepting the gift constitutes fraud or theft, or be a result of manipulation?
Assessing the risk of accepting a gift
||Valuable (monetary or meangful)
|For a group
||To an individual
|"Thank you" at discharge
||During the course of treatment
|Private pay patient
||Third party insured patient
It is always up to your discretion to accept or decline a gift. If it “feels wrong” take that as a sign that you would be best to graciously decline the gift.
Consider developing strategies that discourage gift giving. An example would be developing policies that make it clear what you will do with any gift, such as donating all monetary gifts to charity, or placing consumable gifts in a staff room. This will help to minimize the pressure to give or accept gifts.
Rural practitioners often treat members of their small community with whom they have business/casual relationships or friendships and are often the only physiotherapy provider available.
These clinicians need to give some consideration on how to manage professional boundaries to ensure the person’s needs come first when they are assuming the role of a patient and that confidentiality is upheld at all times to foster trust in the broader community.
- Develop strategies to redirect treatment-related questions to the clinic setting and social questions to the community.
- Don’t discuss patient care in non-clinical settings.
Treating family, friends + co-workers
While this may seem appealing, or in some cases be unavoidable, the overlap between a personal relationship and a professional relationship makes maintaining appropriate boundaries especially difficult.
What are the risks?
- The physiotherapist’s ability to be objective may be compromised.
- The physiotherapist may make assumptions instead of asking thorough questions.
- The patient may not want to answer questions honestly (due to embarrassment, or not wanting to hurt the physiotherapist’s feelings).
- Documentation may not adhere to regulatory standards.
- The personal relationship may suffer if the professional relationship is not successful.
- The physiotherapist may be placed in a real or perceived conflict of interest.
Be aware that the Conflict of Interest Standard of Practice requires that physiotherapists refrain from providing care to related persons and only do so if no other provider is available. In these situations, the relationship must be disclosed to third party payers or any other party that will use information about the patient’s health status to make legal, administrative (financial) or health-care decisions, the conflict of interest must be documented and formal processes must be followed.13
Touch in therapeutic relationships
Q: I often give my patients hugs, especially if they are distressed. It seems like the caring thing to do. There’s nothing wrong with that, is there?
A: Offering a hug can blur the boundary between personal and professional relationships. A hug isn’t always perceived by the patient in the way the physiotherapist intended. The patient may view a hug as inappropriate, but feel obliged to accept it.14
Physiotherapy treatment regularly includes the physiotherapist entering a patient’s physical space and touching their body. Although patients may be aware of this aspect of physiotherapy before seeking care, the physiotherapist cannot assume that the patient fully understands, or consents to physical contact. Informed consent is required.
Similarly, physiotherapists need to be aware that the consent to physical contact is context specific. Consent to physical contact in the context of providing treatment does not automatically extend to non-treatment related contact, such as hugging. Engaging in such behaviours can cause the patient to misunderstand the therapist’s intent.14
“Where physical contact is… intended for emotional support (e.g., a gentle pat on the hand or shoulder), the physiotherapist should weigh the likelihood of therapeutic benefit against potential harm or misunderstanding.”14
Professional boundaries in social media
Physiotherapists who use social media need to be aware that their online activities are subject to the same ethical and professional obligations as their usual (face-to-face) practice.
Some important considerations:
- Privacy settings are imperfect, frequently changed by online providers, and may be compromised. The physiotherapist should not assume that anything they post on social media is private or that only “friends” can see the content.
- Patients and potential patients may search social media sites for information about their health-care providers. Clearly distinguish between your personal and professional social media accounts, and ensure the content of your “professional” account remains that way.
- Even if you remove names and other identifiers from social media posts, colleagues, competitors, patients and their families may still be able to identify themselves in your comments. This may result in a breach of patient confidentiality, or damage therapeutic relationships.
- Do not initiate personal online contact with patients.
- Develop your own policy for how to deal with a patient request for online communication and how you will reply to posts that includes client information.
- Keep in mind that electronic communication lends itself to a more casual style than typically seen in professional communication. This may impact your professional reputation and your patient’s perception of your professionalism.
- Don’t post anything on social media that you wouldn’t want to appear on the news.15
For more information see Physiotherapy Alberta’s Social Media Practice Guideline.
Not sure if you’ve crossed the line?
Ask yourself these questions:
- Would I tell a colleague about this activity or behavior?
- Would another physiotherapist find my behavior acceptable?
- Would I disclose my actions to a third party payer?
- Will these actions change the patient’s expectations for care?
- Will these actions bias my clinical decision making?
- How would I feel explaining my actions to Physiotherapy Alberta’s Complaint’s Director?
A boundary has been crossed. Now what?
It is the physiotherapist’s duty to establish, maintain and monitor the boundaries of a therapeutic relationship, and to take action if a boundary has been crossed. If a boundary crossing occurs, roles need to be clarified by the physiotherapist and treatment goals re-established.
If the therapeutic relationship cannot be re-established, it is the duty of the physiotherapist to ensure that the patient is not adversely affected by any interruption in physiotherapy care.
Reflect on what led to the situation, making use of support networks, consulting with colleagues or a supervisor, or contact Physiotherapy Alberta. Document any boundary blurring or violation that occurs and the action taken to re-establish the professional boundaries of the therapeutic relationship.
- Set the stage with appropriate boundaries from the initial assessment. Patients take their cues for acceptable behaviour based on how we speak and act.
- Understand and be aware of potential personal vulnerabilities and professional risk factors.
- Correct “yellow light” infractions immediately. Seemingly harmless comments from the physiotherapist or the patient can slide quickly into uncomfortable territory.
- Take responsibility to re-establish professional boundaries, regardless of who crossed the line.
- Document both inappropriate behaviour and measures taken to re-establish professional boundaries.
- Maintain clear professional boundaries to protect you and your patient.