Therapeutic relationships are working relationships established between physiotherapists and patients or substitute decision makers. It is the role of the physiotherapist to establish and maintain ethical, safe and effective therapeutic relationships. Quality physiotherapy practice includes setting and maintaining appropriate professional boundaries in the context of patient centred care. Understanding the nature of the therapeutic relationship is fundamental to establishing appropriate boundaries.
View the Therapeutic Relationships resource guide as a PDF.
We develop relationships every day with patients, patient’s families, colleagues, and friends. Increasingly, research shows that effective therapeutic relationships play an important role in positive patient outcomes, making these relationships critically important.1
But what is the difference between a personal relationship and a professional relationship?
When the distinction gets blurry, what can physiotherapists do to ensure that they don’t cross boundaries and find themselves in a challenging situation?
Q: I live in a small community, and have known most of my patients since I was a child. Many have been coming to my clinic on and off for years. At this point they feel like old friends. That’s a good thing, right?
A: While it is a good thing to have a positive relationship with your patient, physiotherapists must recognize that there are risks to having personal and professional relationships with a patient at the same time, including privacy concerns, communication considerations, the challenge of maintaining professional objectivity, and the risk of blurring the boundary between personal and professional relationships.
Although it seems obvious that there are differences between these types of relationships, problems arise when health-care providers fail to maintain the distinctions.
The table below focuses on the different aspects of personal and professional relationships. By focusing on the differences, physiotherapists may have an easier time identifying when they are, or are not, maintaining healthy boundaries between themselves and their patients.
Aspect of the Relationship | Professional Relationship | Personal Relationship |
---|---|---|
Money | Physiotherapist receives financial compensation for patient care. | Shared |
Duration | Limited to the duration of treatment. | No limit, may be lifelong |
Location | Limited to the treatment location. | No restriction, anywhere |
Purpose | To provide physiotherapy services to the patient. | Pleasure |
Structure | Organized around the provision of physiotherapy services. | Unstructured |
Balance of Power | Unequal. The physiotherapist is in a position of power, having more knowledge, influence, and access to private information. | Shared |
Responsibility for the Relationship | The physiotherapist is primarily responsible to establish and maintain the professional relationship. | Shared |
Preparation for the Relationship | The physiotherapist offers their training and experience and the patient places their trust in this. | Equal |
The following principles underlie all therapeutic relationships:
Duty of Care (fiduciary duty): the foundation for all therapeutic relationships is the duty to act in the patient’s interests.
Power is always held by the physiotherapist due to their unique knowledge and skills, access to the patient’s private information, and the patient’s reliance on them for care. Physiotherapists must keep this imbalance in mind and strive to equalize the balance of power in their patient relationships.
Respect for the patient’s beliefs, values and morals is required to develop a therapeutic relationship. This does not require that the physiotherapist adopts or even agrees with the patient’s views, but the physiotherapist must accept the patient’s perspective and ensure that their own values and beliefs do not negatively impact on the quality of care they provide.3
Trust between a patient and their physiotherapist is essential. If a physiotherapist does not use their skills and abilities to address the patient’s needs and act in their best interests, a loss of trust will occur.
Sensitivity is needed to protect the trust and respect of the therapeutic relationship. A patient’s sense of vulnerability may be increased by the physical proximity, varying degrees of undress and personal disclosure inherent in physiotherapy practice.
“…it took so long to realize that it was I, myself ,who was probably the main variable in outcomes—not the techniques.” David Butler4
Effective therapeutic relationships lead to increased patient satisfaction, better patient adherence to treatment plans, and improved function and mood.4 In some cases, an effective therapeutic relationship has been shown to impact patient-reported pain and other outcomes independent of the treatment provided.1 Some may argue that this impact represents a placebo effect, while others suggest that this finding supports the critical importance of an effective therapeutic relationship.
Regardless, the impact of effective patient-provider relationships cannot be ignored.
Simple actions can help establish therapeutic relationships and appropriate boundaries:
“Maintain your enthusiasm by viewing the patient through the lens of the individual vs. the lens of the injury.”4
“As many as one third [33%] of women and 14% of men are survivors of childhood sexual abuse… This means that all health-care practitioners – whether they know it or not – encounter adult survivors of interpersonal violence in their practices.”8
All health-care providers need to adopt “universal precautions” to ensure that they do not re-victimize these patients in the course of providing care.
Sensitive practice universal precautions:8
The physiotherapist may not ever become aware of the patient’s vulnerability. By demonstrating sensitive practice to all patients, you can decrease the likelihood of inadvertently re-traumatizing survivors of abuse.8
Canada’s multicultural society is often celebrated, but this diversity can also create challenges in the health-care environment.
For example, conflict may arise from differences in cultural norms and expectations related to:
Culture is “learned, shared, (and) transmitted inter-generationally, and reflected in a group’s values, beliefs, norms, practices, patterns of communication, familial roles, and other social regularities.”9 The culture of any group “may be directly or indirectly associated with the health-related priorities, decisions, behaviours, and or acceptance and adoption of health education and health communication programs and messages.”9
Patient-centered care includes the patient’s values, preferences, and expressed needs and includes the involvement of friends and family in patient care.10 All these factors are influenced by the patient’s culture; therefore, culture is an important aspect of patient-centered care.
Understanding the culture of a group allows health care and communication to be customized to better address the needs of the group;9 however, it is impractical for any one clinician to become familiar with all of the cultures that they encounter in daily practice. “Additionally, viewing patients as members of ethnic or cultural groups, rather than as individuals… might lead providers to stereotype patients and make inappropriate assumptions about their beliefs and behaviors.”10
What’s a clinician to do?10
Exhibiting these behaviours will help to develop effective therapeutic relationships with patients who are members of different cultural groups.
“The clinician’s responsibility to monitor and respond to the client’s verbal and non-verbal communication cannot be overstated… the onus of ensuring the client’s consent is truly ongoing is on the clinician.”8
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:
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 | Never apporpriate |
---|---|---|
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. |
“The crossing of boundaries usually begins with seemingly innocent comments or disclosure and escalates from there.”11
Some examples of warning signs include:
Personal and professional factors can increase your risk of engaging in questionable or inappropriate behavior.
Personal factors can include:
Professional factors can include:12
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:
Prohibited behaviours include:
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.
Ask yourself:
Less risk | More risk |
---|---|
Token value | Valuable (monetary or meangful) |
For a group | To an individual |
"Thank you" at discharge | During the course of treatment |
Spontaneous | Solicited |
Edible/Shareable | Person specific |
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.
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.
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
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
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.
For more information see Physiotherapy Alberta’s Social Media Practice Guideline.
Ask yourself these questions:
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.
Key points
- 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.