Am I crossing the boundary?

 
Am I crossing the boundary?

Am I crossing the boundary?

 
Am I crossing the boundary?

In this second of a three part examination into professional boundaries, the APA National Professional Standards Panel discuss some ‘signs and symptoms’ that could indicate you or a colleague may be slipping from a benign boundary crossing to a more serious boundary violation scenario. More importantly, they provide some advice on how to ‘treat’ these signs and symptoms before they become injurious to your personal and professional life.



Finding yourself attracted to another person is a normal psychological and physiological occurrence.


There is little that can be done to avoid this.


However, when this happens within a professional relationship, these feelings cannot be acted upon.


Some readers may think they are immune as they work in the paediatric or aged care setting; however, children have parents and our elderly have children.


The Physiotherapy Board of Australia is unequivocal in its commentary regarding inappropriate relationships.


These guidelines refer not only to the patients themselves but also ‘those close to the patient’ (Physiotherapy Board of Australia 2014).


The potential to cross boundaries exists for all physiotherapists.


It is acknowledged that boundary crossings happen and at times they may even be appropriate within a professional relationship.


It would be fair to say that most experienced physiotherapists will have crossed more boundaries than a Qantas pilot during their career.


If self-reflection is to be the best method to monitor boundary crossings, it is important to identify the behaviours that have the potential to blur the boundary between ourselves and our patients.


The following behaviours have been taken from a resource produced by the College of Physical Therapists of Alberta (2007).


Self-disclosure


In the majority of situations, it is inappropriate for a physiotherapist to provide details of their personal life.


The sharing of personal information not relevant to the patient’s therapeutic needs has the potential to change the relationship from a professional to a friendship one.


This is difficult to avoid, especially when the patient is attending over a long period of time.


Sharing of personal information, however, may be appropriate if used to enhance the patient’s adherence to treatment or understanding of their presenting complaint.


Dual relationships


Treating family or friends is to be strongly discouraged.


It is extremely difficult to establish and maintain a professional relationship alongside a personal one.


For some physiotherapists working in a rural and remote setting, treating family or friends may have to occur if no other options are available.


It is important in these situations that any treatment and education occurs within a clinical setting as this may in some part provide some separation between you as a health professional and you as the family member or friend. It should be noted that some health insurance funds frown upon these dual relationships, especially when a fee is generated for this service.


If you anticipate charging for your professional services you would be wise to discuss your plans with the relevant insurer prior to commencing any intervention.


Receiving and giving of gifts


This is often a contentious issue that needs to be managed with care.


Many larger organisations have clear policies around the giving and receiving of gifts.


For those members working in smaller practices or organisations, consideration should be given to the creation of an agreed policy to help in the management of this common scenario.


When receiving gifts from patients, it is important to consider the context of the timing of the gift and in particular its monetary value.


It is important for both patients and practitioners to understand that should a gift be offered and received, it cannot influence how the physiotherapist treats the patient, or change the patient’s treatment expectations.


An expensive gift early into the professional relationship is never appropriate; however, a token box of chocolates or bottle of wine at the cessation of a successful intervention can be accepted at the physiotherapist’s discretion.


Sadly, a bottle of Grange Hermitage could never be considered just a token (as former New South Wales premier Barry O’Farrell discovered in 2014: tinyurl.com/2fjtcvkw).


As per the receiving of gifts, the context and value of a gift being presented to a patient needs to be closely considered.


While gifts presented via a business entity is commonplace, giving gifts as an individual therapist to an individual patient is not.


If you feel it appropriate to give a gift to a patient, to mark a special occasion for example, it is recommended that the gift be of modest value, will not alter the dynamics of the relationship, and is gifted without expectation of reciprocity.


Social relationships with family or partners of patients


If there is an acknowledged potential for dependence within a professional relationship between a physiotherapist and a patient, then there is the potential for a similar dynamic to develop between partners and family of the patient and the treating therapist.


Particular care needs to be taken where any emerging relationship can impact on the therapeutic relationship between the physiotherapist and the most important person within this relationship, the patient.


Social relationships with former patients


This topic was discussed fully in an earlier InMotion article (‘After the professional relationship ends’, July 2020).


As was discussed, there is no clear answer to the question of relationships with former patients.


The onus falls on the therapist to consider a number of factors. These include:



  • the nature of the treatment provided

  • the duration of the therapeutic relationship

  • time since cessation of treatment

  • degree of dependence.


The Physiotherapy Council of NSW has a number of educational videos that provide further commentary on the topic of professional boundaries (tinyurl.com/bk9bhwr8).


Other behaviours that need to be closely monitored include:



  • thinking of the patient away from the work setting

  • prioritising one patient’s care over that of others

  • having longer treatment sessions than normal or clinically appropriate

  • providing the patient with personal contact details

  • changing dress style and enhanced personal grooming on the days that the patient is attending the clinic

  • more physical contact than is warranted

  • flirting

  • being defensive when challenged by a colleague about your relationship with the patient

  • self-disclosure of personal information, thoughts, opinions, experiences etc not relevant or suited to the context of the professional interaction.


Self-monitoring—questions to ask


As part of a routine self-monitoring exercise to ensure we are not shifting from boundary crossing to violation, the following questions may be helpful:



  • would another physiotherapist treat the patient in the same way that I do?

  • is what I am doing essential for them to achieve their goals?

  • can I defend my actions if challenged by a colleague?

  • am I sexually attracted to the patient?

  • is there the potential that the patient is confused by my actions or are considered to be inappropriate?

  • who is benefitting the most in this relationship?

  • if the treatment is covered by a third party, would they be happy with what is being provided?

  • does the patient know too much about my personal life than is necessary?

  • if there is a complaint, what would my family and friends think when the story hits the media?


Perhaps of greater importance when self-monitoring is to consider your own physical and mental health wellbeing.


The majority of readers will glance over this article and think they would never find themselves in a boundary violation situation and that this article is not relevant to them.


Life changes and personal situations change. Many practitioners who find themselves in boundary violations were experiencing significant health issues at the time (Bird 2013).


What if I answered yes to any of these questions?


It’s time to take immediate action before it’s too late! It is strongly advised that you discuss your concerns with a colleague and where possible look to transfer their care to another physiotherapist.


It is vital that you are open and honest with your patient as to why you feel they would be better managed by a colleague.


They need to understand that there is no fault or blame attached to them and that your intentions to remove yourself as their primary therapist is to ensure they get the best possible care.


It is important to document this discussion in the patient’s notes.


Physiotherapists who work in rural and remote settings may not have the luxury of having a colleague to talk to or refer their patient on to.


If there are no suitable alternatives for the patient, an open and honest discussion still needs to occur.


If the patient agrees to continue with the therapeutic relationship, then changes need to be implemented to ensure the relationship is as professional as possible. Explicit changes that can be made include:



  • keeping all conversations focused on their presenting problems and goals

  • ensuring the environment is as clinical and professional as possible

  • adopting professional attire over casual streetwear

  • ensuring visits are during normal business hours when reception staff are present

  • obtaining consent and explaining any procedures prior to intervention.


The next article will focus on inappropriate patient sexual behaviour towards their physiotherapist and strategies to manage this.


The National Professional Standards Panel comprises Ian Cooper (Chair), Dianna Bartlett, Anita Bir, Susan Coulson, Samantha Hall and Alison Smith.


>> The first article in this series, published in the February issue of InMotion, explored the professional boundary and the importance of maintaining such a boundary within a professional setting. Head here to read ‘Nothing is ever black or white, it’s all just 50 shades of grey’, published in the July 2020 issue.



References


8.2b Physiotherapy Board of Australia, Code of Conduct https://www.physiotherapyboard.gov.au/codes-guidelines/code-of-conduct.aspx

Therapeutic Relationships. Establishing and Maintaining Professional Boundaries https://scpt.in1touch.org/document/3648/albertatherapeuticrelationshipsg...

After the professional relationship ends. (2020) InMotion. https://australian.physio/inmotion/after-professional-relationship-ends

Physiotherapy Council of NSW. https://www.physiotherapycouncil.nsw.gov.au/physiotherapy-council-educat...


 





 




 


 

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