Good Practice: Professionalism and the Physical Environment at the Practice Site

The physiotherapist establishes and maintains a professional physical environment that supports the maintenance of therapeutic boundaries during client assessment, treatment, and education in both formal and informal practice environments. This includes but is not limited to:

• Proactively providing options for draping and
• Providing privacy while the client is undressing or dressing

Boundary Violations is a new Standard of Practice that was introduced in 2025. As you can see from the performance expectation above, physiotherapists are required to provide a safe professional environment in which therapeutic boundaries and positive therapeutic relationships can be supported. How could the physical environment affect your level of professionalism or your ability to form positive therapeutic relationships? How can a physiotherapist proactively address potential issues?

This article will delve into various scenarios to identify some of the challenges that can occur based on where you work and how the physical space has been designed. Being aware of these issues can help you create change in your workspace and mitigate risks to improve client care and professionalism with both clients and colleagues.

We will look at physical environments such as acute care, out-patient treatment spaces, client’s homes, and the emergency room. We will explore how various factors that exist in these spaces can affect how you practice and how you interact with your co-workers.

Scenario #1

Garreth is a physiotherapist working in acute care at a large city hospital. The layout and design of the acute care ward has Garreth and the other physiotherapists on the same floor but away from the nursing station and the rest of the team. The nursing station seems to be the central hub of the unit and where most of the team members congregate. Garreth has noticed occasional miscommunications or challenges with communication around assessment and discharge planning within the unit. He also notices that he wastes a lot of time wandering the halls trying to find other staff members to discuss client care. It has been very frustrating overall and both the clients and Garreth’s colleagues are feeling that care is disjointed.

From this scenario we can see some of the issues that can arise with poor design layout or when health-care workers are separated due to facility limitations. Although the physiotherapist has little say in hospital design, it is important for physiotherapists to recognize these barriers to optimal client care and try to mitigate these in practice.

Design layout, workstation design and location can increase the workload on a physiotherapist and the rest of the health-care team.^1,2 Increased distance and/or poor layout of workspaces used by health-care teams can lead to “hunting and gathering behaviours” where the physiotherapist must walk farther distances to track down information, find team members, and organize client care.³

Physical barriers such as walls and partitions can decrease effective and efficient communication. Reduction in visibility and accessibility of workspaces can also have negative effects on all aspects of communication within a health-care facility.² Reliance on chart notes alone without face-to-face sharing of information and discussions of client care and client goals can lead to a breakdown in communication.¹

Workspace design and layout can create potential client care issues such as impairing interprofessional communication, negative effects on client outcomes, and poorer workplace satisfaction.³

Scenario #2

Jayce is a physiotherapist who has recently been hired to work in the ER (emergency room). Although he is confident in his abilities to assess and triage clients in this role he is finding some challenges with working in this environment. The ER has a centralized hub in which all team members can congregate to chart and discuss client care. Although it is great for connecting the team and enhancing communication there are some limitations and privacy concerns that Jayce has noticed. There are challenges to maintaining client confidentiality as anyone in the ER has access to the hub and therefore can see the computer screens and paper files, so he is constantly shutting off the screen or logging in and out of his workstation. It is also easy for those in the ER to overhear conversations the health-care team is having. He finds he is constantly distracted by the overall hectic pace and traffic as well as the number of interruptions he encounters when trying to chart. Last week he got so distracted that he nearly ordered the wrong diagnostic imaging for a client and this week he entered his assessment into the wrong chart before he noticed his error and corrected it.

Jayce has noticed several legitimate issues with having a centralized hub in a health-care facility. As was previously discussed, the physical environment can affect several factors relating to client care and the issues are quite different to Scenario #1.

Research has found that central hubs can provide many positives with communication, decreased workload, team building, increased efficiency in client care, etc.^1,3 However, there are some drawbacks that physiotherapists must be aware of so that they can make alterations to their practice.

Centralized hubs can increase the chaos surrounding a health-care worker and potentially more so in a busy environment like an ER. Increased levels of noise, people coming and going, and interruptions can all lead to an increased level of distraction. These distractions can result in errors which can have significant negative effects on clients. If Jayce did order the wrong imaging or had charting errors that went unaddressed, there could be real consequences for clients. It is important to recognize that reduced efficiency in documentation as well as increasing levels of fatigue can also contribute to issues like burnout.^2,3

Centralized hubs can also create privacy issues as the public or colleagues who do not have a right to access client information can potentially view paper charts and computer screens if left open or unattended. Physiotherapists must be consistent in putting files away, shutting off computer screens, logging out of computer stations, and other privacy safeguards in order to maintain their client’s privacy.³ Failure to do so could also result in confusion and charting errors as other health care workers may pop in to chart while you left your screen open. Regardless of the physical environment you work in, there are always safeguards that should be used to protect your client’s privacy. You can access more information on privacy safeguards here.

Scenario #3

Femi is a physiotherapist who works in home care. He has experienced quite a few concerns when he goes to see Mrs. Cameron. She lives in a townhome with many stairs and not much space for them to work together on her post-operative care. Mrs. Cameron also just took over care of her daughter’s chihuahua who gets quite aggressive when Femi shows up to treat Mrs. Cameron.

Home-based physiotherapy can pose many challenges that relate to the physical environment of practice. Smaller spaces, clutter, cleanliness, equipment, etc. can all lead to challenges to creating and implementing a successful treatment plan. These constraints can also impair the therapeutic relationship as you must discuss these barriers and may need the client to make changes to their home. As with the previous scenarios mentioned, there are limitations to what you have control over as a physiotherapist and the client may not be willing to make the suggested changes. However, you can often work with the clients and their family to find solutions and create a space that is safe and functional to use hopefully with minimal cost and workload.

Femi has managed to convince Mrs. Cameron’s daughter to clear some space in the dining room for her physiotherapy and home exercises and has purchased some exercise equipment that she can use that is easily stored in a cabinet when not in use. Mrs. Cameron has also agreed to keep the dog in a separate room while Femi is in the house so that Femi can focus on Mrs. Cameron’s care. As a way of apologizing for her dog’s behaviour she offers you a cup of tea and biscuits before each session.

Home-based care can also lead to the blurring of professional boundaries as you are in someone’s home, and they will sometimes treat you more like a guest than a professional coming to work. It is challenging to navigate as you also do not want to offend someone by refusing their offer. There are some communities and cultures in which spending the time together over a cup of tea is an essential part of building a positive therapeutic relationship. You need to be aware of these considerations, and intentional with your actions when it comes to interacting with clients in less formal environments so that you maintain appropriate therapeutic relationships.

Scenario #4

Mo works in a small clinic in rural Alberta. There are four treatment beds separated by curtains and two private rooms that are often used by the massage therapists. Mo is seeing Kathy in the clinic today to discuss her ongoing back pain. As Mo conducts his assessment, he is finding some yellow flags that are concerning. Upon questioning about saddle symptoms, Kathy denies any changes in sensation, bowel/bladder dysfunction, etc. Mo educates Kathy that if there are any changes to these potential symptoms, she should go to the ER as soon as possible. One week has passed and Mo has not had a return visit from Kathy. When he calls Kathy to follow-up, she discloses that after the physiotherapy appointment she went straight to the ER as they were having issues with incontinence and changes in sensation around their pelvis. She admits that she didn’t feel comfortable discussing it because they knew the person in the treatment room next to them and didn’t want to be overheard.

Although no adverse event occurred, and Mo gave the client the information they needed to access care, it is not an ideal situation to have a client deny symptoms required to properly diagnose and treat them. Curtained spaces are common and can be appropriate, but not when talking about sensitive subjects. Physiotherapists should be aware of the nature of the questions they are asking and how a client might perceive them. The curtained treatment space is not to blame as much as Mo not providing Kathy with an opportunity to use a more private setting to discuss health concerns that she may find sensitive or embarrassing to talk about.

This can work in the opposite direction as well with private treatment spaces creating a feeling of being enclosed or trapped once the door is closed. Clients with a past history of trauma may not want to be in a private treatment room with the door closed. It is important to consistently provide clients with options for their privacy and to be aware that certain topics may necessitate a change of location to continue with the assessment or treatment. This can be as easy as saying “I have some questions I need to ask that some folks may think are quite personal. Would you be more comfortable talking in an office or private treatment space?”

Apart from clients requiring confidentiality it is also important in smaller spaces to recognize that discussions amongst colleagues can also be heard through curtained spaces. There have been instances in which conversations about clients, weekend plans, gossip, etc. have been overheard by a client waiting in one of those treatment spaces or even from the waiting room. These conversations may breach client confidentiality and may not reflect well on the professionalism of the physiotherapist or the practice site. It is important to be intentional with where and when these conversations occur.

The physical space and layout of your practice site may not always be ideal for each client that comes to see you. It is important to be considerate of a client’s right to privacy and confidentiality and provide them with an opportunity to voice their concerns if they have any.

Million-dollar renovations to an acute care ward or limitations in space to build out more private treatment rooms are not likely to happen, and such decisions are often not up to the treating physiotherapist to make. Each environment will have its own challenges and opportunities to maintain your client’s privacy, build positive therapeutic relationships, and maintain appropriate boundaries and your professionalism. Hopefully, this article has provided some insight to help you become more aware of the current limitations in your practice site and take steps to address what you are able to.

Sean FitzGerald, PT, Practice Advisor

Page updated: 08/04/2025