New research and shifting cultural expectations are changing the way we understand and approach boundary violations. This article is based on an Annual Meeting 2020 presentation by Susan Paul and Leanne Loranger.
Boundary violations are not new within physical therapy regulation. However, as societal expectations regarding professional conduct have evolved, conduct that the public may have once perceived as acceptable is now viewed negatively.
How can regulators proactively help registrants understand the principles of professional boundaries, recognize and reset boundaries when they have been blurred, and avoid significant violations? Why should state boards consider an upstream approach on the issue of boundary violations? What can we learn from the experience of one physiotherapy regulator that faced major legislative changes related to this issue?
Before regulators venture into these discussions, we must consider the language we use when discussing this issue. PT regulators often use terms such as "boundary violations," "professional misconduct," and "transgressions." This is linguistic gymnastics to talk around the real issue: sexual abuse.
What is sexual abuse? In Canada, the Alberta Health Professions Act defines it as follows.
"The threatened, attempted or actual conduct of a regulated member towards a patient that is of a sexual nature and includes any of the following conduct:
Regulators need to stop talking around this issue and start calling it exactly what it is. While some people might find the term "abuse" uncomfortable, it reflects the significance of these situations and the very real abuse of power and trust that occurs when these behaviors occur within a patient-provider relationship.
The Alberta Health Professions Act also has a "sexual misconduct" definition. In some ways, these definitions clarify the difference between sexual assault and sexual harassment.
"Sexual misconduct is defined as any incident or repeated incidents of objectionable or unwelcome conduct, behaviour or remarks of a sexual nature by a regulated member towards a patient, that a regulated member knows, or should know, would cause offence, humiliation, or adversely affect the patient's health and wellbeing."
Why does this matter for physical therapists? In Canada, an estimated 33 percent of females and 16 percent of males will experience sexual assault within their lifetimes. Researchers also estimate that 50 percent of girls and 33 percent of boys will experience sexual abuse before they turn sixteen years old. (The reason those numbers do not match up is because sexual abuse of a minor is defined differently than sexual assault and includes exposing a child to sexual content or behavior—therefore, it encompasses a broader set of actions.) Physiotherapy regulators should find out the prevalence rates in their own jurisdiction to gain a stronger understanding of the public they are protecting.
This issue has broad implications for society as well as specific patient-provider interactions. A provider's inappropriate or insensitive actions can cause repeat trauma and patient harm, and, in turn, patient complaints. Survivors have an increased likelihood of experiencing a wide range of physical and psychological consequences. This includes post-traumatic stress disorder and the risk of re-traumatization during situations that may seem innocuous to someone who does not have a history of sexual assault. Given the prevalence of sexual assault and sexual abuse, sensitive practice must become a universal precaution for all practitioners. The term “sexual abuse" is appropriate because it gets at the abuse of the inherent power that comes with a provider-patient dynamic. Physical therapists may not think of themselves as "powerful," and many clinicians make a concerted effort to reduce that power imbalance. However, it is important to realize that physical therapists never fully eliminate that imbalance even with well-meaning efforts.
In complaints data, beyond clearly egregious behavior, often professional boundaries were blurred in conversations or where the patient experienced what was intended as therapeutic touch during treatment as sexual in nature. Unfortunately, complaints data also show instances of repeated boundary issues, by the same physical therapist, suggesting that some clinicians simply do not understand the problem and how to modify their actions. Therefore, regulators need to respond. To do so, regulators need to understand the issue fully.
One problem may be that physical therapists often go through education programs participating in labs where there is an expectation to disrobe with limited privacy—surrounded by teachers and fellow students, and looking at the body as a series of pulleys and levers. In these situations, what are educators teaching their students implicitly about boundaries? What are they teaching them about sensitive practice and consent for touch? How can regulators expect them to suddenly be sensitive to this when they graduate?
It is vital regulators get this right from the start because when it comes to sexual misconduct, "pretty good" is not good enough. For example, these may seem like pretty good results based on a survey question posed to British Columbian physical therapists:
"A physical therapist is currently treating a patient following an ankle fracture. The physical therapist is attracted to the patient and decides to pursue a sexual relationship with this patient. Is the physical therapist allowed to have a sexual relationship with this patient?" No – 99.5% (2,983) Yes – 0.5% (14)
However, when you pause and consider that fourteen practitioners (which could translate to about 140 patient interactions a day and possibly 35,000 patient interactions in a year) don’t know that having a sexual relationship with a patient is prohibited, well, that is not good enough.
Providers need to carefully consider physical contact and how that can lead to a misunderstanding. They must remember to ‘bring the patient along’ with them and ensure the patient understands why the practitioner is asking them to disrobe or where the practitioner will need to place their hands, or position themselves. Without explaining the clinical rationale, the patient might become uncomfortable, and be left to draw their own conclusions in terms of necessity and practitioner intent for disrobing or touch.
Note that both actions and conversations can have a slippery slope. For example, practitioners who share excessive details of their personal life or give inappropriate advice about a client’s partner or relationship. There may be a perception that if the patient does not object to the comments or laughs that it is okay. However, it is never okay for a health professional to act unprofessionally.
Once a patient suspects that something inappropriate might have happened, they look at the whole interaction with heightened sensitivity. They often do not seek clarification with the provider before they file a complaint. When regulators advise physical therapists of these allegations, they are frequently shocked and distraught that the patient interpreted the session that way. The frequency of that response indicates that regulators have work to do in terms of upstream education.
If regulators can promote sensitive practice as routine practice, that would ultimately advance public protection. Regulators should encourage practitioners to take the following actions:
Regulators also need to consider communications with the public. For example, here are some of the messages to the public in Alberta: "The physiotherapist acts with professional integrity and maintains appropriate professional boundaries with clients, colleagues, students and others."
"Clients can expect to be treated with integrity and respect, and that the physiotherapist will maintain professional boundaries appropriate to the therapeutic relationship in all interactions."
If regulators tell the public that, they need to deliver on that. They also need to be mindful that the world has changed. The #MeToo movement, along with high-profile cases of sexual abuse, has brought about reckoning on this issue. While this is not a new phenomenon, and it was never okay to sexually abuse patients, in recent years, we have seen movements that have led to a reduction of victim shame and an overall increase in attention devoted to this issue in the public discourse. Regulators are seeing increasing numbers of complaints of this nature. Regulators have also been able to identify trends in complaints received in parallel with high profile media stories, which may be partly due to increased public awareness.
In Alberta, legislators worked to pass legislative amendments that apply to all regulated health professionals. Mandatory penalties are applied if a regulated health professional commits sexual misconduct or sexual abuse. The penalty for sexual abuse of a patient is mandatory lifetime revocation of the regulated health professional’s license without the opportunity for reinstatement.
The legislation requires that regulators define, through the Standards of Practice, who is a patient and when the patient relationship begins. The trickier question is defining when the patient is no longer a patient. While there are some nuances and exceptions, Physiotherapy Alberta decided that the patient-practitioner relationship ends a year after the last treatment. However, this definition of when a patient-provider relationship ends does not cover all professions across Alberta. For example, for some professions the duration is much longer. For others, the relationship is over once the intervention is complete.
As a regulator, it is important to understand the basic information around the issues of sexual abuse. This is a vital first step. Next, it is important to understand how it applies to physiotherapists and whether practitioners have a basic understanding. Examine your data to see what risk factors might apply. Develop standards, messages, and resources to help both practitioners and the public better understand the issue and the rules.
One of the most important steps is simply communicating about the issue of sexual abuse. The vast majority of practitioners do not engage in sexual misconduct intentionally. However, there is a risk that physiotherapists may not be thoughtful about this issue, and they may unintentionally break these rules with significant implications for the patient and for the practitioner's licensure. While the regulator is there to protect the public, not the practitioner, when the rules change dramatically, it is the regulators' responsibility to inform practitioners. A failure to do so may make it harder to enforce the new standards in the future.
Education by regulators raises awareness for the uninformed. If regulators can provide this information, they can affect the decisions practitioners make, and, therefore, change the patient experience and protect the public. Here are a few things regulators in Canada have done:
If regulators are not communicating with practitioners about professional boundaries, then who is? If regulators rely on or outsource this to other entities, they lose control of the message. Educators provide students with this content, but it is often perceived as a lower priority compared to technical teaching. Additionally, peers and supervisors may be a positive influence, but they also may be role-modeling bad behavior and exhibiting conduct that practitioners come to think of as acceptable, even when it is not. Therefore, regulators need to be the leader of this conversation.
The regulatory community may have started talking about this a long time ago, but they need to keep talking about it and bring others into the conversation. New research and shifting cultural expectations are changing the way we understand and approach sexual abuse and misconduct. This problem is not going away. Being proactive as a regulator can have an impact on the patient experience. Prevention of boundary violations is the ultimate way to protect the public.
Permission to reproduce these in part or whole is granted; however, please include a printed acknowledgment of Physiotherapy Alberta - College + Association:
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Leanne Loranger, PT, MHM
Manager, Policy + Practice, Physiotherapy Alberta – College + Association
Leanne Loranger is the Manager, Policy + Practice at Physiotherapy Alberta and is involved in practice and quality improvement related activities, including policy and resource development and continuing education planning. She served as Physiotherapy Alberta’s Practice Advisor from 2014 to 2017. Leanne graduated from McMaster University’s Master of Health Management program in 2016. She currently serves as a volunteer accreditor for Physiotherapy Education Accreditation Canada and is a member of the Board of Examiners of the Canadian Alliance of Physiotherapy Regulators. Prior to her employment with Physiotherapy Alberta, Leanne worked as a physiotherapist for nineteen years in clinical practice.
Susan Paul
Manager, Professional Practice, College of Physical Therapists of British Columbia
Susan has worked at the College answering practice questions since 2002 in her role as Manager, Professional Practice. She assists with teaching the first year Masters of Physical Therapy students’ professional issues course at the University of British Columbia, where she is a Clinical Associate Professor with the Department of Physical Therapy. Susan practices clinically in an acute care cardiorespiratory setting.