Respecting the boundaries
The professional standards of physiotherapy practitioners—which are based on the expectations of the community and peers—form the cornerstone of quality patient care. Taking steps to ensure not only the quality but also the safety of patient care has been brought in to focus in light of the global Me Too Movement (#metoo).
While a vast majority of physiotherapy clinicians are unlikely to ever be the subject of any claims of boundary violations on the part of patients, governing bodies such as the Australian Health Practitioner Regulation Agency receive around 100 complaints each year (see article page 38), of various natures, the majority of which result in either no action being taken or a caution or reprimand for the practitioner concerned.
Reflecting on the underlying causes of boundary violation complaints affords an opportunity to revisit some of the practical steps clinicians can take to limit the likelihood of receiving a complaint, such as ensuring clear and open communication between patient and clinician about the consultation and assessment process, having an appropriate clinical environment that offers privacy for patients to change clothes and features a lockable door, and providing adequate curtains and linen for draping.
Because of the more intimate nature of many of her patient assessments and treatments, Tarryn Lawrence, APAM, is continually reminded of the need for heightened awareness around patient boundaries. Tarryn, the APA Women’s, Men’s and Pelvic Health group Queensland chair, works in an advanced role in a primary contact pelvic health clinic in the public health setting in Queensland, and sees patients on the wait list for gynaecology, urogynaecology, colorectal and urology specialists.
Tarryn and her colleagues regularly call on their extensive training as well as on the procedures and policies in place in the workplace, such as the availability of a chaperone or accommodating the patient’s support person, and the use of a signed consent form prior to assessment, to ensure the delivery of quality and safe patient care.
‘Boundary violations are something that all physiotherapists need to be aware of, particularly because of the nature of our work and how we’re very often needing to observe different parts of the body and being hands-on in our assessment and treatment,’ Tarryn says.
‘It’s important to remember that for us, as clinicians, this is what we’re seeing every day but for the patient, removing their clothes or having parts of their body exposed, particularly during any internal or intimate assessment, can be really unfamiliar and uncomfortable. So, make sure to take the time to explain what the options and recommendations are, and allow patients the time to think about it and say “you don’t have to give me an answer about it today, we can talk about it at the next session if you’d prefer”.’
Tarryn says other ways to add another layer of protection for the patient and the clinician centre on ensuring practitioners are ‘really clear and detailed with our documentation’, where applicable, a colleague can be called on to be in the room during initial assessment, and that practitioners ensure they adhere to the professional codes of conduct and make themselves available for continued professional development. Being aware of any potential consent issues around language and cultural barriers, mental health problems, intellectual impairments or comprehension issues is also important.
‘If there are patients who are potentially are a bit more complex or you’re questioning something and have sought additional advice, perhaps from a more senior clinician or colleagues, actually document that you have done that. This shows your clinical reasoning and your thinking for why you have or haven’t done particular assessments or interventions, and it’s a good idea to make sure that if there is a problem, to then communicate it with their GP or their specialist, and make sure to document that as well,’ Tarryn says.
Having worked in both public hospital and aged care settings, Nicole Bellet, APAM, says she is aware of the need for supporting processes for staff such as additional training, supervision, maintaining safe treatment environments (eg, treatment consent, ensuring staff are not left alone with a patient in the practice), accommodating performance planning and ensuring staff debriefs are in place as part of normal procedures. Training should include yearly updates on the code of conduct, patient rights and social media training.
‘I always think clinicians need to put themselves or their loved ones in the position of the patient and consider if their actions would be what they would want for themselves or their loved ones,’ she says.
‘Similarly, if a patient crosses the patient–therapist boundary (eg, an inappropriate social contact, comment or touch), the therapist should clearly and immediately say that the action or deed is inappropriate as they are the patient’s treating therapist.
‘More recently patients or family have been noticed taking photos or recording treatments. We have recently had advice that it is an offence under section 44(1) of the Invasion of Privacy Act 1971 (Qld) to communicate or publish a private conversation using a listening device, which includes a mobile phone, without the permission of the other people involved in the conversation,’ Nicole says.
Boundary violations can also cross over into interpersonal interactions with patients, such as getting too close to them in a friendship capacity, and have ramifications for practitioners. There is a particular risk when the patient is of a similar age as the therapist and when there are extended periods of interaction (eg, in the treatment of patients with cystic fibrosis).
‘However, this can also occur in any area such as in aged care where the patient may become reliant on the physiotherapist for emotional support. It is very easy to become too close and discuss your private life with such patients. It is important to remember we are the patient’s therapist and health advocate, but we are not the patient’s family or friend. Social media violations, such as being “friends” with patients on social media platforms, should be avoided by practitioners,’ Nicole says. ‘It is vital that we engage in practices to ensure that patients and staff are not at risk of privacy violations.’
More information about patient boundaries can be found in both the APA and AHPRA codes of conduct.
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