Establishing and maintaining professional boundaries is a significant part of building positive therapeutic relationships. Boundaries refer to the accepted social, physical, or psychological space between people and create an appropriate therapeutic or professional distance between the physiotherapist and their client. This helps clarify respective roles and expectations.
Physiotherapists who treat clients in their home or those that have a mobile practice can encounter situations where professional boundaries can be eroded or blurred just from being out of the hospital/clinic and in someone’s home. As therapeutic relationships develop, it is important to keep the distinctions between personal and therapeutic relationships in mind and be attentive to maintaining professional boundaries.
This article will use two scenarios where physiotherapists experience blurred boundaries because of the environment in which they work to help you recognize and reflect on professional boundaries in your own practice.
Scenario #1
Francis is a physiotherapist who has been working in homecare for the past several months. He is seeing Mr. Adebayo who is recently discharged from the hospital after a stroke. During Francis’s scheduled appointments, Mr. Adebayo often has friends or family members visiting.
Initially Francis was adamant about privacy concerns and keeping the sessions focused on Mr. Adebayo, insisting that those who weren’t directly involved in his care step out. However, as time has gone on the family and friends continued to be around, Francis has grown tired of asking them to leave. Friends and family often hang around to chat and Francis enjoys their company as they work with Mr. Adebayo and his client is happy for them to stay and socialize. Unfortunately, as this has continued the focus of care has shifted and sessions are less productive. Mr. Adebayo’s daughter has noticed that her father is not getting the same attention and progress he used to and approaches Francis to discuss it.
Francis recognizes that what the daughter says is true. The hour session that was primarily focused on her father’s care has become less efficient and there are many distractions during the session. With Mr. Adebayo’s consent, Francis gets together with the family to discuss strategies to keep the sessions focused and make time before and after sessions for Mr. Adebayo to socialize with his friends and family as that is also an important part of his overall health and wellbeing.
Several weeks later Mr. Adebayo has started in the pool doing physiotherapy sessions but is having a hard time getting to and from the pool as many of his family and friends do not drive. Francis is asked if he would pick Mr. Adebayo up for the pool sessions as Francis lives near them and the pool is on his way.
Francis politely declines to drive Mr. Adebayo to and from the pool as this creates several potential issues. Giving clients rides to and from physiotherapy sessions is more in line with a personal relationship and not a therapeutic relationship and Francis should be working to maintain those boundaries. There are options such as taxis, public transit, accessible transportation services, etc. which would enable Francis and Mr. Adebayo to maintain their professional relationship. After discussing this, Francis provides Mr. Adebayo with details on accessing transportation services appropriate for his condition and needs.
Scenario #2
Adriana is a physiotherapist who works in pediatrics. She often sees infants in their homes and is seeing a new client today. Adriana is greeted at the door by the parents and they offer her a cup of coffee and some cookies if she would like them. Adriana declines and she starts her session with Nicola. As the sessions continue over the next several months Adrianna and the mother get to know each other better and Adriana starts accepting the coffee offered and they chat more and more while treating Nicola. Adriana also has found herself taking care of smaller tasks like changing Nicola’s diaper and feeding her during sessions.
Nicola’s mother has started getting into details of her recent split from her husband who Adriana met when first assessing Nicola. Adriana recognizes that he hasn’t been around for any of the other sessions conducted at their house but now the mother is discussing very private details of their relationship, what led to their split, and how it is affecting her personally.
A client having someone in their home can create a feeling of having to maintain social niceties of having a guest in your house. It might be intuitive for most people to offer something to eat or drink or settle into conversations that aren’t specific to the reason for their physiotherapist’s visit. In some cultures, having a cup of coffee and a brief visit is an important step to building a therapeutic relationship, and physiotherapists should be alert to situations where this is the case. However, in general, having something to eat and drink with a client is not part of developing the therapeutic relationship.
As the regulated health professional, Adriana has to establish professional boundaries and set the expectations around her visits to see Nicola. Although clients may recognize the importance of staying focused on their care it can be easy to blur boundaries when someone is in your personal space. Boundaries can erode over time, so what may start out as professional, focused appointments can start to change as time goes on and the relationship can become less professional and more personal.
The choice to assist with the care of Nicola can also be a slippery slope. At times a physiotherapist may have to stop their session to have the parent provide care such as changing a diaper or feeding a child. Sometimes it’s just the most efficient way to get as much treatment time as possible with an infant.
Everyday with every client, physiotherapists make choices that can help build up or erode professional boundaries. It is important for Adriana to make intentional decisions and be aware of how those decisions may impact the therapeutic relationship.
When Nicola’s mother starts divulging information that strays into personal matters that does not relate to her child’s care, Adriana must reset those boundaries as soon as possible. Adriana can do this many different ways, but it is important that she re-establish her role as a physiotherapist, her focus on Nicola’s care, and her inability to be part of personal conversations.
Conclusion
In both scenarios we saw physiotherapists initially establish good professional boundaries, focusing on client care. However, Francis and Adriana slowly allowed those boundaries to blur and relationships became more personal over time. Working in an environment that is more personal can contribute to this, but it is important for all physiotherapists to be able to maintain or re-establish boundaries to ensure that delivering safe, quality care is their primary focus.
Actionable Items
- Review your current therapeutic relationships with clients and family members. Are healthy boundaries in place?
- Review past issues that you have had with professional boundaries. Were there times that you let those boundaries blur? What you could have done differently to maintain or rebuild those boundaries?
