Positive therapeutic relationships are essential to positive patient health outcomes.
It is the physiotherapist’s job to establish and maintain positive therapeutic relationships.
Six traits of physiotherapists that patients value as indicators of a “good” physiotherapist are: responsive, ethical, communicative, caring, competent and collaborative.2
The recently revised Therapeutic Relationships Guide provides further information about how to establish and maintain positive therapeutic relationships. Read it today!
A positive therapeutic relationship takes time, energy, and skill to build and potentially even more effort to maintain through the ups and downs of clinical care. A positive therapeutic relationship entails “an interactive relationship with a client and family that is caring, clear, positive, and professional.”1 As the College of Physiotherapists of Alberta was re-doing the Therapeutic Relationships Guide, I came across an article by Kleiner et. al (2023)2 that reviewed 27 studies examining what clients and physiotherapists believed made a physiotherapist a “good” physiotherapist. In the introduction of the paper, they discuss previous research in nursing, medicine, and physiotherapy to explain what is meant by a “good” physiotherapist and quote the interpretation of good quality care as “the balance between technical competence and humanness.”3
As you can read in the Therapeutic Relationship Guide, there can be many positive qualities a physiotherapist brings to the therapeutic relationship. In this article, we are going to examine each of the 6 qualities identified in the Kleiner article and pair them with a scenario. The scenarios will demonstrate positive client interactions and the building of positive therapeutic relationships.
The 6 Qualities and Their Relation to Professional Boundaries:
- Responsive: Physiotherapists should actively listen to the client using verbal and non-verbal communication and be engaged in what the client is telling them.
Carrie is a physiotherapist working in the inpatient ward for post-op joint replacements. She and a PTA named Emmanuel visited Barb who is recovering from her total hip replacement yesterday. Carrie’s day is full, and she is already running behind after a longer-than-expected morning meeting. She is trying to get Barb to walk with her new walker and wants to see her do a toilet transfer onto the raised toilet seat she will be going home with. Barb is currently listed as a 2 person-assist and is hesitant to trust her new hip even with the surgeon’s clearance and Carrie’s encouragement. Carrie recognizes Barb’s hesitation is an issue that will add more pressure to her already full day, but she takes the time to listen to Barb’s concerns and alters her explanation in a way that Barb better understands. After some coaxing, Barb successfully gets out of bed and walks with her walker to the toilet under a 1 person-assist. Carrie gets Barb safely back into bed, gives instructions to Emmanuel regarding Barb’s exercise program, and hurries off to document an update for the staff that Barb is safe to get out of bed and transfer onto her toilet with a 1 person-assist. Then she is quickly off to her next client.
2. Ethical: Physiotherapists should be honest and transparent in their interactions with
clients and those involved in their care.
A few days have passed and Barb has worked hard with her rehab team to get ready for discharge home. Carrie is talking to Barb about her options for physiotherapy after she returns home, including treatment at a private practice clinic or a mobile physiotherapy service.
Carrie has been doing mobile physiotherapy for the past few years in the community where Barb lives. She could talk to Barb in a way that presents herself as the best and only option for mobile physiotherapy, but Carrie knows that to do so would be unethical and that Barb should be given the options and information needed to make an informed decision when choosing their physiotherapist. Supporting a patient’s autonomy is one of the 4 ethical principles found in the College of Physiotherapists of Alberta’s Code of Ethical Conduct. So, Carrie talks to Barb about her options for physiotherapy after she is discharged home and gives her several options for care, with one being Carrie’s mobile services. Carrie lets Barb know that it is up to Barb to choose and there is no pressure either way. In the end, Barb lets Carrie know that she really appreciated the time she took to help her get over her fears in these first few days and would like to continue with Carrie if it works out with her and Carrie’s schedules.
3. Communicative: Physiotherapists should focus on client education and show a
willingness to take time to explain the assessment results, treatment plan, and self-
management strategies to clients in a manner they can understand.
Rav is a physiotherapist working in a rural hospital with Gary, an elderly man who has recently had x-rays for ongoing knee pain and limited function. Gary’s doctor has referred him to Rav for physiotherapy. Gary is happy to see Rav but reports he doesn’t know what physiotherapy can do for him since his “cartilage is gone and what can physiotherapists do to help that?”
Rav discusses the role that physiotherapy can play in the treatment of osteoarthritis, reviews the research to support the role of physiotherapy, and how he would use that research to help Gary. Gary still struggles to understand so Rav pauses his explanation, grabs an anatomical model of the knee, and pulls up some videos on his clinic tablet. He shows Gary how osteoarthritis progresses and how physiotherapy can help his body cope with the changes and the benefits of exercise and movement. He also talks about how the x-ray findings do not always relate directly to the pain someone may have in their knee. Gary thanks Rav for the videos as he understands the videos much better than all of Rav’s talking. Rav then goes on to discuss the treatment plan for Gary and that there is good research to show that conservative management of his OA can be successful in delaying or removing the need for surgery. Overall, Gary is quite happy with the information received from Rav and is prepared to follow Rav’s recommendations on his course of treatment.
4. Caring: Physiotherapists should be invested in the client and work in the client’s
best interest. “A caring therapeutic relationship was noted as giving meaning to
clinical practice and as important for clinical and ethical decision making.”2
Let’s continue on with Rav and Gary but fast forward a couple years to where Gary’s knee is now much more painful. Gary has been limiting his time walking his dog and he can no longer play pickleball. Gary followed all of Rav’s instructions and hasn’t seen Rav in about a year when he was last in for an update on his exercises and a re-assessment. He is hoping Rav can help him with his recent struggles.
Rav reassesses Gary and there have been some significant negative changes in his ROM, his gait, and his self-report of pain and function. He discusses that he may be able to help with some pain control, but it is time for Gary to get a referral for a surgical consult. Gary wonders if he came in for multiple sessions, would it be worthwhile to change his current condition? Rav thinks a few visits would help but Gary shouldn’t expect physiotherapy to save him from surgery and it might be best to prepare for an eventual surgery. Rav is exhausted after his day and finally gets his charting done. As he gets ready to go home, he realizes he needs to send a letter to Gary’s doctor and some resources to Gary. Although he really wants to just head out Rav sits down and writes a letter to the family doctor regarding Gary’s current condition and sends some resources to Gary for pool exercises and pain management.
5. Competent: Physiotherapists should learn from each client, be well-versed in
evidence, and be confident in their skill sets.
Jaz has been working in private practice physiotherapy for quite some time and is qualified to perform spinal manipulations. One of his clients who he had successfully treated for acute neck pain has referred his wife, Clara, to see him for her chronic neck issues. She comes into his office looking for him to “crack” her neck like he did with her husband stating that it worked for him so she is hopeful it will work for her too.
On assessment, it becomes apparent that Clara has a more complex medical history. Clara has fibromyalgia and was in two significant ski crashes which started her neck pain 15 years ago. After the assessment Jaz talks to Clara about her goals of care and that he would suggest a different course of treatment that would work better for her as her issues are different from her husband’s. Jaz doesn’t rule out incorporating spinal manipulation into Clara’s treatments but knows that other avenues of care may work better. Clara is initially disappointed with Jaz’s treatment plan and is unsure if she should even continue with her appointment. However, as Jaz explains his reasoning, the evidence, and his own experience with clients that have similar issues as Clara’s, she begins to place trust in Jaz’s treatment plan for her and feels confident that he knows what he is doing.
6. Collaborative: Physiotherapists should seek to collaborate with their clients on their
treatment plans and be open to discussing aspects of the client’s care. The
physiotherapist should also collaborate with other health care providers
involved in their client’s care for the client’s benefit.
As we have seen in the previous example, there was some back-and-forth discussion between Jaz and Clara regarding the treatment that Clara wanted when she came in versus the treatment Jaz proposed. Jaz listened to Clara’s request for spinal manipulation but after the assessment was completed, Jaz’s training, experience, and clinical reasoning led to an assessment that performing cervical manipulation alone would likely not help Clara. Jaz took the time to explain to her why he felt other treatment options would be better. Clara wasn’t sold on this at first but as they talked more, and Jaz worked with Clara to help her understand his reasoning, she realized that Jaz had some very good points and that she would give him a chance to help her.
After several visits, Clara was seeing some positive changes in her feelings about how to manage her pain. Clara told Jaz of some past trauma she suffered when she was at university. Jaz understood how hard it was for Clara to disclose this information and the importance of listening to what Clara had to say. Jaz also knew that counselling was beyond his skills and the scope of physiotherapy practice. So, Jaz took the time to listen to what she was comfortable telling him. When Clara was done, he discussed with Clara how these past traumas could contribute to her chronic pain and how a psychologist could potentially help her not only with the trauma but also with some coping strategies for her pain. Jaz offered to make a referral for Clara to see a local psychologist and she accepted.
In all of these scenarios, there was constant overlapping of the six different identified qualities. All the physiotherapists interacting with clients were responsive, ethical, communicative, caring, competent, and collaborative. Each scenario might have focused on one theme, but it really is the combination of those traits that physiotherapists should incorporate into their practice.
Some ideas for actions you can take to improve your practice:
- Read the revised Therapeutic Relationships Guide.
- Consider the 6 qualities of a “good” physiotherapist that were discussed above. Evaluate where you currently excel and where you could improve.
- Seek feedback requests from trusted peers to get a second opinion about where you excel and where you could improve.
- Come up with a plan on how you might create positive change in those areas in which you could improve. Are there patients on your caseload right now that you could focus on?
References:
- Debra Ann Ridling, Mithya Lewis-Newby, Daphne Lindsey, Chapter 9 - Family-Centered Care in the Pediatric Intensive Care Unit, Editor(s): Bradley P. Fuhrman, Jerry J. Zimmerman, Pediatric Critical Care (Fourth Edition), Mosby, 2011, Pages 92-101, ISBN 9780323073073, https://doi.org/10.1016/B978-0-323-07307-3.10009-6.
- Michelle J. Kleiner, Elizabeth Anne Kinsella, Maxi Miciak, Gail Teachman, Erin McCabe & David M. Walton (2023) An integrative review of the qualities of a ‘good’ physiotherapist, Physiotherapy Theory and Practice, 39:1, 89 116, DOI: 10.1080/09593985.2021.1999354
- Nicola M. Kayes & Kathryn M. McPherson (2012) Human technologies in rehabilitation: ‘Who’ and ‘How’ we are with our clients, Disability and Rehabilitation, 34:22, 1907-1911, DOI: 10.3109/09638288.2012.670044
