Good Practice: Challenging Situations

Over the course of their careers, physiotherapists will inevitably encounter several challenging situations. While it would be nice to believe that challenging situations will only occur to someone else, and not within one’s own practice, it is unlikely to be the case. Some challenging situations are particularly common in physiotherapy practice such as patients expressing suicidal ideation, the irate or unsatisfied patient, the patient who is hesitant to report an injury for fear of compromising their employment, or the patient who disagrees with the physiotherapist’s professional opinion.

Physiotherapy Alberta’s Challenging Situations Guide¹ was created to aid physiotherapists when they are faced with these types of situations, providing a step-by-step process for how to respond to challenging situations, information about what it means when there is a positive duty to report, a discussion of the components of an effective working relationship, as well as communication and conflict resolution models.

What is a Positive Duty to Report?
A positive duty to report means legislation requires the physiotherapist report a situation or issue to the appropriate authority. For example, under the Protection of Persons in Care Act 2, physiotherapists have a positive duty to report cases of suspected abuse or mistreatment of dependent adults to the Persons in Care office or to their local police. Under the Traffic Safety Act 3, if the physiotherapist knows that one of their patients is driving while intoxicated, they are required to report this to their local police service by calling 911.

Case Example – WCB Injury Reporting

One challenging situation bears special mention: What are you, the treating physiotherapist, supposed to do when a patient reveals that they were injured at work but wishes to avoid making a WCB claim? Worse yet, what should you do if the patient refuses to allow you to make a report to WCB, citing their right to privacy?

Section 34 of the Workers’ Compensation Act 4 requires that a health care professional who attends an injured worker must provide a report to the WCB within two days of the patient’s first visit. Although this section of the Act specifically refers to physicians who are providing care, the Act defines a physician as “a person licensed or authorized under the Health Professions Act to practice any of the healing arts in Alberta,”⁴ meaning that physiotherapists must comply with this requirement.

A challenging situation is born!

While it would be nice to simply pretend there wasn’t a problem, failing to actively address challenging situations in a professional manner represents a failure to meet the expectations for physiotherapists in Alberta. Physiotherapists are expected to proactively manage the challenging situations that they find themselves in and this is no exception.

In deciding how to proceed, it may be helpful to work through the step-by-step process for managing challenging situations outlined in the Challenging Situations Guide.

Define the problem

In this example, you are in the midst of a conflict between your legislated responsibilities established in the WCB Act and your ethical and professional obligations to act in a patient-centered manner, respecting the patient’s preferences. What values, beliefs and past experiences are influencing your perspective of the situation? Have you encountered a similar situation before? What did you do, and how did things turn out in that case?

Pause and consider what the other person’s values, beliefs and experiences may be. Are they fearful of losing their employment if they make a report? Have they been told by their employer not to report? Do they believe the injury is minor and not worthy of reporting? Have they had a negative experience with WCB in the past?

How severe is the problem?

Patient factors may mean that additional help or support from a colleague or manager is needed to help you address the situation and mitigate any negative effects. At a minimum you may want to make your employer aware of the situation so that they are aware of your legislated requirements and are prepared in the event that the patient makes a complaint to them about your course of action.

Does the situation create a safety issue? If so, who is at risk, the patient, physiotherapist or the public?

In the case of a suicidal patient, or a patient driving while impaired there are clear risks to the patient and in the latter case the public.

In this WCB example, the situation does not present the obvious safety risk to the public. However, handled poorly this could result in a safety risk to other people within the workplace, and you may feel that you are at risk of physical or verbal abuse when attempting to resolve the situation. Physiotherapists are expected to employ effective communication and de-escalation techniques to address the concerns of patients who are unsatisfied or aggressive, seeking assistance if necessary.

Although you are required to address and manage the situation, you are never expected to place yourself at risk of abuse from a anyone attending or employed at your workplace. Physiotherapist employers are expected to foster safety for employees and patrons of their business in accordance with Occupational Health and Safety legislation. In situations where you perceive you are at risk in the workplace, it is recommended that you involve your employer in the discussion. If an employee-employer relationship does not exist (i.e., you are a sole practitioner or independent contractor), you may wish to ensure that at a minimum another employee is present in the clinic at the time of the discussion, to ensure your safety.

What do you want from your discussion?

In this case, the best scenario is for the patient to understand why you must send a report to WCB and how reporting the injury to WCB will benefit them. Engaging in this conversation will hopefully foster a strong therapeutic relationship, enhancing patient care and outcomes.

Plan the conversation

Although it may not always be possible to do so, it will help if you spend a few moments preparing for the conversation. If you’ve never had to work through a challenging situation before you may even want to write yourself a script including some of the following points:

• Plan to ask the patient’s reason for not wanting to report to WCB.
• Prepare yourself to respond to some of the more common or anticipated reasons why they may not want to report.
• Outline the requirements that you must meet.
• Discuss how reporting benefits the patient in the long term.
• Outline what your proposed course of action is.

Discuss the situation

Avoid rushing through the conversation. When possible, allow yourself extra time to have a meaningful discussion with your patient about the situation.

Document the conversation and your management plan

As with any patient interaction, documentation of a challenging situation and attempts to resolve the situation should be included in the patient clinical record.

Monitor the outcome of the conversation

This step may be less relevant than in ongoing challenging situations (such as dealing with a patient who is chronically late or routinely cancels their appointments), but it is still important to reflect on how effective your efforts were. Did you resolve the situation and manage to retain the patient, or did they get angry and leave the clinic?

Reflect on the situation

What would you do differently? Will you institute a practice of screening for work-related injuries at the time that the patient books their initial appointment? Will you include a statement on your intake paperwork outlining the reporting requirement and have your patients sign an acknowledgment that they are aware of the requirement? Would you change anything about how you approached the conversation?

It is entirely possible that you take the necessary steps to resolve the situation and still have a dissatisfied customer. At the end of the day, you will need to accept that you did what you could to manage the situation and also meet the Standards of Practice and your legislated requirements.

Leanne Loranger, PT, Practice Advisor

Page updated: 03/01/2024