Boundaries such as those that form the perimeter of a football oval or basketball court are clearly visible, their intentions understood by players from both teams, the spectators—and sometimes even the umpires.

The boundary that is integral in any professional relationship between a physiotherapist and their patient, however, is not so easily identified or understood.

Unlike most sporting codes, where there are rules that describe the consequences when the ball or player crosses the physical boundary, there are no such rules available to patients entering into a professional relationship with their physiotherapist.

As a result, it is incumbent on the physiotherapist to manage the relationship.

In the sports setting, these boundaries are applied equally to all teams and players.

The invisible boundary within the professional relationship, however, is there to protect just one of the parties— the patient.

There is an acknowledged power imbalance in any therapeutic relationship.

One study examining this power imbalance between physiotherapist and their patients noted that ‘a key finding was the mismatch of perceptions between therapists and patients'.

The therapists perceived that there was a power imbalance in their favour, but it was not great.

The patients on the other hand, considered the imbalance overwhelming, with their own position one of relative powerlessness.

Such a mismatch in perception and expectation offers confusion to the boundaries of roles, responsibilities and autonomy and needs to be addressed (Harrison & Williams 2000).

The boundaries that exist in the professional relationship, unlike those in our sporting analogy, are not linear.

They are complex and subject to different interpretation that can be influenced by a number of variables.

Having a boundary that is not easy to identify and can shift can be challenging for the inexperienced physiotherapist to manage, especially when we consider that having a non-rigid boundary is at times required (Cooper 2012).

‘An absolutist position concerning treatment boundary guidelines cannot be taken. Otherwise, it would be appropriate to refer to boundary guidelines as boundary standards.

'Effective treatment boundaries do not create walls that separate the therapist from the patient. Instead, they define a fluctuating, reasonably neutral, safe space that enables the dynamic, interaction between therapist and patient to unfold (Beauchamp 1999).'

So why do we need to maintain a professional boundary with our patients?

Before we address this, it is timely to reflect on what a profession is and the requirements of members of that profession. 

Cruess et al (2004) define a health profession as: ‘An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills.

'It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others.

'Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and the promotion of the public good within their domain.

'These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation.

'Professions and their members are accountable to those served and to society.’ 

The social contract often called the fiduciary agreement or arrangement is all about trust. Breaching this trust not only places an individual at risk of disciplinary action but could impact the image and standing of the entire profession.

Crossing the professional boundary is commonplace  and  as discussed is not always wrong;  however, these instances need to be carefully managed to avoid any confusion on the part of our patients.

Boundary crossings are defined as ‘a deviation from classical therapeutic activity that is harmless, non-exploitative, and possibly supportive of the therapy itself. In contrast, a boundary violation is harmful or potentially harmful, to the patient and the therapy. It constitutes exploitation of the patient’ (Galletly 2004).

Boundary violations are rarely planned and actioned by physiotherapists knowingly.

The majority of physiotherapists are well acquainted with the APA’s and Physiotherapy Board of Australia’s codes of conduct and their ethical requirements.

I would, however, suggest that all physiotherapists have crossed the professional boundary at some time in their career.

If we are consciously aware that this has occurred, then we are part way to avoiding a more serious and potentially career-ending boundary violation situation.

The slippery slope phenomenon described by Galletly (2004) suggests that practitioners who frequently cross boundaries without being aware they are doing so may be on the slippery slope to a boundary violation scenario.

As physiotherapists we are constantly encouraged to reflect on  our clinical practice.

Self-reflection on our professional behaviour needs to be likewise encouraged.

This is particularly so for those physiotherapists who find themselves working in isolation without regular peer modelling or mentorship.

Awareness of when and why we have crossed the professional boundary can be a valuable learning opportunity.

Simple steps now to amend our behaviours within the professional relationship can keep us safely at the top of the slide, and hopefully avoid an unpleasant crash landing at the bottom.

Ian Cooper, APAM, is an adjunct associate professor in the School of Physiotherapy and Exercise Science at Curtin University, and the chair of the APA National Professional Standards Panel.

References

1.            Harrison, K. and Williams, S. (2000) Exploring the power balance in physiotherapy. Journal of

Therapy and Rehabilitation, volume 7 (8): 355-361

2.            Cooper I (2012) Professional boundaries: Forming relationships and working unsupervised. In Freegard H and Lysted L. Ethical Practice for Health Professionals 2nd Ed Cengage Australia.

3.            Beauchamp T. (1999) The Philosophical Basis for Psychiatric Ethics. Psychiatric Ethics, 3d edn. Ed. S. Bloch, P. Chodoff, S.A. Green. Oxford: Oxford University Press,

4.            Cruess SR, Johnston S & Cruess RL (2004) "Profession": A Working Definition for Medical Educators, Teaching and Learning in Medicine, 16:1, 74-76, DOI: 10.1207/s15328015tlm1601_15

5.            Aravind, V. K., Krishnaram, V. D., & Thasneem, Z. (2012). Boundary crossings and violations in clinical settings. Indian journal of psychological medicine, 34(1), 21–24.

6.            Galletly C (2004) Crossing professional boundaries in medicine: the slippery slope to patient sexual exploitation. Medical Journal of Australia 181: 380–383