Learning Objectives:
- Learn about your duty of care to your client.
- Learn how professional boundaries and fitness to practice can be affected by personal and practice-setting factors.
- Discover resources on mental health resiliency and evaluating your own fitness to practice.
Actionable Items:
- Take time to consider your current practice and the factors that can have negative effects on your ability to maintain both your fitness to practice and healthy professional boundaries.
- Use the resources available to help you become more resilient to the pressures of being a health care worker.
- Familiarize yourself with the College’s resources regarding duty of care, therapeutic relationships, and professional boundaries.
It is important to develop and maintain healthy therapeutic relationships with your clients. Feelings of being burned out, stressed, or overwhelmed can result from the demands of practice or from personal and family responsibilities. These feelings can create barriers for physiotherapists to maintain healthy therapeutic relationships. Occasionally we talk to physiotherapists who have struggled to maintain healthy boundaries with their clients. Physiotherapists develop trust by showing good listening skills and asking enough questions about their clients’ lives to identify goals and barriers and develop a treatment plan. However, while building that trust, you may struggle to avoid getting too emotionally invested in your client and their life. The College of Physiotherapists of Alberta has published several resources about this topic, which we have listed at the end of this article.
This article will use a scenario involving a newer registrant to provide an overview of the College’s perspective. We will use the Code of Ethical Conduct, the draft Standards of Practice including the newly formed Duty of Care Standard and other resources to focus on how you would establish a positive therapeutic relationship while maintaining appropriate boundaries, and how to manage your duty of care against your responsibility to attend to your own health and wellbeing to ensure your ongoing fitness to practice.
The Scenario
Daisy has been working for two years as a physiotherapist in an outpatient clinic. Daisy has been struggling with the demands of her caseload and it is spilling over into her home life where she is spending considerable time catching up on research and documentation. Overall, she is feeling mentally fatigued at work but is doing her best to keep a friendly disposition.
Daisy recently has taken on a more complex client named Estelle who is frequently attending physiotherapy to deal with severe burns to her arms. Due to the severity of the burns as well as previous health issues, Estelle is struggling to maintain independence and her ability to care for her 2 children. Over the course of treatment Estelle has developed a trusting relationship with Daisy and she tells Daisy everything that goes on in her life. Estelle admits to not having any other place to vent her struggles and initially, Daisy feels compelled to be a sympathetic ear to Estelle. Over time Daisy gets drawn further into Estelle’s life and Estelle asks Daisy if she can use her as a witness as she signs some legal documents and if she can use the clinic’s fax machine to send them. It seems like a small request and Daisy agrees to help Estelle out.
Estelle and Daisy continue to work together as she progresses in her rehabilitation and Estelle has successfully returned to work with some limitations on her duties. The downside is that the professional boundaries continue to fall. Estelle has been unable to find reliable childcare and has asked Daisy if she would consider babysitting for a couple of hours so Estelle can get to some appointments. Daisy is finding it awkward to say no to some of these requests as she wants to help Estelle and feels she is in a position to do so even though she knows she has forgone professional boundaries and these actions are coming at a mental and emotional cost to her.
**Keep Daisy’s situation in mind as we discuss Duty of Care and Fitness to Practice.
What is a Physiotherapist’s Duty of Care?
The expectations found within the draft Duty of Care Standard outline the responsibilities a physiotherapist has to their patients. It describes how a physiotherapist can respect a client’s decisions and how to end a therapeutic relationship when treatment is no longer required or if the therapeutic relationship deteriorates. Importantly,
The physiotherapist has a duty of care to their clients, and an obligation to provide for continuity of care whenever a therapeutic relationship with a client has been established.
Clients can expect that they will be provided with the information needed to manage their physiotherapy needs and access ongoing care if their physiotherapist is unavailable or unable to continue the therapeutic relationship.
One of the expectations in that Standard is that the physiotherapist
Takes responsibility for maintaining an effective therapeutic relationship.
The expectation is that Daisy would recognize the signs that the focus of the therapeutic relationship is starting to shift to be more personal in nature and take steps to re-establish the boundaries needed to maintain a positive therapeutic relationship. It does not mean that Daisy has to support Estelle in all aspects of her life or become deeply involved in Estelle’s personal life.
This can be a challenging line to walk where you need information about a client’s life to help identify what the client’s barriers to success may be and enough information to help you form a positive therapeutic alliance with the client, without getting too involved. The Therapeutic Relationship Guide provides some guidance on navigating these situations and signs that you may be blurring some of those boundaries.
Professional Boundaries are Important
Professional boundaries exist to provide structure to the therapeutic relationship so that the time spent together is focused on the client and their goals. Regardless of the practice setting you work in; you work with people. People will always come to you with feelings, emotions, personal histories, stressors, etc. which can create both positives and negatives when it comes to client care. Physiotherapists are people too. You will also come with your own emotions, histories and other things that can have both negative and positive effects on creating positive therapeutic relationships. Healthy boundaries help to keep the focus on the client’s care while recognizing that being human and building therapeutic relationships are part of providing good care.
Initially, Estelle’s requests to use the fax machine or sign some paperwork could be seen as a small matter outside of the typical boundaries established by Daisy, but Daisy made the choice to say yes to them. What was an opportunity to firm up the professional nature of their relationship has instead led towards boundary-blurring, with Estelle now looking to her for support with childcare, which is well outside the norms of a therapeutic relationship.
What might have led Daisy to make this error? Below are factors that can contribute to the loss of professional boundaries that negatively impact therapeutic relationships.
Personal Factors can include1:
- Physical and mental health concerns
- Stress
- Burnout or occupational exhaustion
- Social isolation
- Belief that the rules ‘don’t apply to me’ or to the situation at hand
Professional factors can include1:
- Workload or other system factors.
- Working in isolation
- Lack of knowledge or respect for the Standards of Practice and other professional obligations.
- Lack of clinical knowledge or experience
Evaluating Your Fitness to Practice
It is important to recognize signs of stress and burnout in yourself or in your colleagues as these factors can contribute to boundary blurring and patient safety incidents. Fitness to Practice is often discussed in professions characterized by frequent exposure to traumatic situations, overtime, and shift work. In nursing, fitness to practice is described as:
“All the qualities and capabilities of an individual relevant to their capacity to practice as an RN, including, but not limited to freedom from any cognitive, physical, psychological or emotional condition, and freedom from dependence on alcohol, drugs or other substances that impair their ability to practice [nursing].”2
As a physiotherapist, you must be aware of the mental and physical stressors that come with practice and have the ability to evaluate your own mental and physical fitness to perform your duties safely and effectively. The qualities and capabilities in the definition above also apply to physiotherapists.
Are you physically capable of doing your job?
Physical injuries and illnesses occur frequently. You wake up in the morning and have the flu so you call in sick to work to avoid passing your illness to others but also because you may not be capable of performing your work duties safely.
Injuries can also derail you from your work duties. You could be physically unable to perform a lift or transfer or appropriately assess someone due to the amount of pain and discomfort you are in which makes it challenging to physically assess a client or stay focused on the findings. So, you decide you need time away from work to focus on recovery and avoid making errors that could impact the safety or well-being of your clients.
Are you mentally capable of doing your job?
Being mentally capable of providing safe, quality, and effective care can be affected by sudden changes in your mental health, for example, due to the death of a loved one or a slow erosion of your mental health from burnout or accumulated stress. Addictions can have a huge influence on your fitness to practice whether it is a drug or alcohol addiction having direct consequences on decision-making and mental/emotional stability, or the toll financial pressures take from a gambling addiction.
When slow changes in mental health occur, it may make it more challenging to decide whether or not you are fit to practice. How do you tell exactly when you have hit the point that you are no longer able to stay focused, make good decisions, or keep from becoming emotional in front of a client?
The Code of Ethical Conduct states that you must “attend to your own health and well-being”. It is a reminder that at times you must put your health first and a failure to deal with your health and well-being can result in negative consequences to either or both the client or yourself.
Re-establishing Professional Boundaries and Next Steps for Daisy
It can be challenging to reset professional boundaries. Daisy has to spend the time and energy to reflect on what went wrong and how she got into this situation. She also needs to figure out the steps she needs to take to correct the situation and re-establish the boundaries needed between a client and a physiotherapist.
Daisy realizes things have gone past the point of a healthy therapeutic relationship. She has accessed both the Therapeutic Relationship Guide and the Managing Challenging Situations Guide to figure out her next steps. She reflects on her situation and how it evolved to where it is now. She realizes that she let her boundaries down from both fatigue and a desire to help Estelle and it clouded her judgement. She also realizes that her inexperience in dealing with complex patients led to some choices she now regrets. Therefore, she plans out a discussion with Estelle for their next session together to re-establish the proper boundaries needed to create a more professional relationship focused on completing Estelle’s care plan.
Resources for Physiotherapists
Below are mental health resiliency resources specifically for health care workers. This is just a sampling of online supports. You should also look to your employer for potential resources and support systems. If you are in distress, we encourage you to reach out for help whether through various hotlines, mental health workers, or by talking to loved ones.
Health Care Excellence Canada: This will take you to a variety of different resources with some focus on COVID-19-specific issues around burnout.
University of Toronto – Mental Health and Resilience for Health Care Workers: Offered through Coursera free of charge.
Mental Health Commission of Canada – Online Training in Psychological Health and Safety: Resources for both those in leadership positions and employees.
College Resources Available:
Guides
Therapeutic Relationship Guide
Managing Challenging Situations Guide
Videos
Setting Boundaries as a Physiotherapist
Warning Signs of Blurred Boundaries
Good Practice Articles
Preparing for Challenging Therapeutic Relationships
Effective Communication to Improve Therapeutic Relationships
Professional Boundaries: 6 Qualities Physiotherapists Should Focus On
References
- Pugh D. A fine line: The role of personal and professional vulnerability in allegations of unprofessional conduct. Journal of Nursing Law 2011; 14(1):21-31.
- College of Registered Nurses of Manitoba: Fitness to Practice (2022) http://www.crnm.mb.ca/wp-content/uploads/2022/01/Fitness-To-Practice.pdf Accessed on June 17th 2024.
