Over the course of a career, physiotherapists will inevitably encounter several challenging situations. This is part of working with people to provide care and interacting with individuals whose values and priorities may differ from your own. This guide is intended to provide assistance and serve as a road map through these challenging situations.
A challenging situation is defined as any situation that interferes with a physiotherapist’s ability to deliver quality patient care. Although the nature of the situation can vary widely, it is certain that some sort of challenging situation will arise during the course of a physiotherapist’s career. This guide focuses on challenging situations between physiotherapists and their patients. However, challenging situations may also arise between physiotherapists and patient family members or other health-care providers. The principles and approach discussed in this guide can be applied to any challenging situation, regardless of the individuals involved.
Challenging situations usually arise due to interpersonal conflicts related to differences in values or expectations, the availability of health-care resources or other contextual factors. The personalities and behavior of both patients and health-care providers also contribute to the situation. Regardless, physiotherapists are in a position of authority and are expected to manage challenging situations in a professional and respectful manner that promotes safe and effective patient-centered care.
While these situations can cause a great deal of concern for both patients and physiotherapists, it is important to remember that the vast majority of interactions with patients will be positive ones. When conflicts arise they can often be managed through clear and effective communication, expectation setting and a discussion of values and priorities with the patient. This approach demonstrates client-centered service, which is one of the Standards of Practice for Alberta physiotherapists.
This guide and its companion, the Therapeutic Relationships: Building and Maintaining Connections to Enhance Patient Care, discuss how to maintain healthy working relationships with those we serve. This document focuses on providing a framework and strategies to resolve challenging situations, discusses why these situations arise and reviews the responsibilities of physiotherapists in the management of these situations.
How to use this guide: This guide will provide you with information on why conflicts arise, components of effective relationships and outlines a few communication and conflict management techniques. A proactive approach to managing conflict is preferred. If you are currently in a challenging situation, got to "Steps to Follow if You Are in a Challenging Situation" for a step-by-step guide to managing the situation.
It might be helpful to think about challenging situations as being on a continuum. Some situations can be managed with effective communication and time spent reflecting on the different values and expectations at play. At the other extreme, are those situations that are more complex or severe and for any number of reasons more difficult to manage. Often these situations leave practitioners wondering “what is the right thing to do?”
Conflicts and challenging situations most often occur due to a difference in values, assumptions or expectations between two individuals.1 As such they are a normal, predictable part of human interaction. Given that any challenging situation will be impacted by the different personalities involved, no two situations will be exactly alike, neither will your strategy for dealing with them be the same. Although the vast majority of patient encounters will be positive ones, conflicts are an inherent part of clinical practice.
Taking the time to reflect on your own beliefs and values may help you to avoid future conflicts. Similarly, by taking proactive steps to define the values of your client and setting clear expectations, many conflicts can be avoided. Taking a positive view of conflict as a way to learn about yourself and develop new skills is one way to make a potentially negative situation better.
It is worth noting that there are times when challenging situations arise between health-care providers or between a physiotherapist and a patient’s family member. When considering conflicts with other health-care providers or with family members, it is important to note that in addition to differences of values, assumptions and expectations, these relationships can also be complicated by differences of influence (or hierarchy), differences of knowledge and different perceptions of the roles of those involved in the patient’s care. When conflict exists between the physiotherapist and a patient’s family members, issues such as the family’s desire to advocate for their loved one and their need to be valued for their contribution can also factor into the conflict.
The College of Physiotherapists of Alberta’s Standards of Practice require that physiotherapists appropriately establish and maintain therapeutic relationships with clients, work in collaboration with other health-care team members to meet the client’s goals and demonstrate respect towards clients and their families at all times.2 In other words, although conflict always requires two parties, it is expected that when a physiotherapist finds themselves in a conflict they will take action to resolve and manage that conflict in a positive and effective way.
Although it is beyond the scope of this document to discuss communication and conflict management theories, many books and journal articles have been published that discuss these topics. Appendices C & D provide two models that may help you in your practice.
Some examples of challenging situations that physiotherapists may encounter include:
- Patients uttering threats.
- Patients expressing suicidal thoughts
- Situations where public safety may be at risk (e.g., a patient who drives to their appointment intoxicated).
- Conflicts with patient family members advocating for the care of their loved one.
- Meeting specific contractual obligations such as mandatory reporting to WCB, when the injured worker does not want you to do so.
If you find yourself in a challenging situation here’s a step-by-step process for how to proceed:
- Define the problem. What exactly is the situation? Why is it a problem? Take a moment to reflect on how your own values, beliefs and experiences are influencing the problem. Consider what the other person’s values, beliefs and experiences may be.
- How severe is the problem? Do you need to get help from your manager or from an outside resource to safely and effectively manage the situation?
- Does the situation result in safety issues for the patient, the physiotherapist or the public? Do you have a positive duty to report the situation to the authorities? See Appendix A for specific examples of situations where you are legally required to report a situation to authorities.
- What do you want from your discussion? What sort of resolution are you hoping for? Knowing what you want before starting the conversation increases the likelihood of an outcome that you desire.
- Plan the conversation. The balance of power in a patient/provider relationship rests primarily with you and therefore so does the responsibility to resolve the issue. Even if the conflict doesn’t involve a patient, the onus is on you as a professional to address conflicts appropriately. Consider what you are going to say (make a script if you need to). Schedule a meeting with the other person to discuss the issue or set aside extra time at their next appointment. Even if your employer isn’t directly involved in managing the situation, it is a good idea to let them know your plan, especially if the person’s behavior is severe or you have concerns for your safety.
- Discuss the situation. Listen actively to the other person’s perspective.
- Document the conversation and your plan for managing the situation.
- Monitor the results of your conversation. Did the issue resolve? If yes, congratulations! If not, consider repeating the cycle, or getting help from your employer or from the College of Physiotherapists of Alberta.
- Reflect on the situation. What could you have done differently to manage things? Are there any changes you would make to your routine practices or communication with patients that would help to avoid a similar conflict in the future?
A positive duty to report means that you are legally required to report the behavior/situation to the appropriate authority as soon as you become aware of it. This includes breaching the confidentiality of the patient’s private information to make a report. In these situations, a failure to report can result in you being fined for not fulfilling your legal responsibilities. For examples of when a positive duty to report applies, see Appendix A.
When there is not a positive duty to report, the physiotherapist may still feel an ethical obligation to report their concerns to the appropriate authority. For direction of what to do when there is no positive duty to report, see Appendix B.
This decision cycle is intended to help you consider what steps to take when working through your situation. Obtaining input from trusted colleagues, your employer or mentors may also be helpful. In some cases, the most appropriate course of action is to have your employer involved in helping to resolve the situation. The College of Physiotherapists of Alberta also employs a practice support advisor who can help. Contact 780.702.5356 for assistance.
Since it is the responsibility of the physiotherapist to manage challenging situations, it is important to know how to effectively resolve them. More importantly, how can you avoid the conflict to begin with? The components of a good working relationship include:
- Non-coercive influence
When establishing any working relationship, consider your own values, beliefs and expectations. Knowing yourself and particularly the things that frustrate you will help you to identify potential conflicts when working with clients and others. Consider how your own emotions and reactions may be impacting your ability to establish an effective working relationship with your patient.
You also need to understand your client’s beliefs, values and expectations. Take a moment to think about how you would feel if you were in your client’s position and acknowledge their emotions. Begin with the assumption that you need to know more. It is not required that you share the same values or beliefs to work well together. It is required that you accept and acknowledge the other person’s values, treat them as an equal and demonstrate respect.
When you cannot meet the client’s expectations (for example due to funding or time limits) it is best to discuss the situation as soon as it becomes apparent. Similarly, if your employer has policies about billing for missed appointments or providing treatment when patients are late for appointments, conflict can be avoided or minimized by discussing the policies early in the relationship before issues arise.
By establishing expectations that you are sure you can meet, and applying a philosophy of “under promise, over perform” you will increase your chances of avoiding conflict.
If however, you choose to tolerate situations arising from a patient’s unrealistic expectations or inappropriate behavior by hoping the patient’s behavior will change or the patient will cease treatment, you are not actively managing the situation and are not meeting the expectations for physiotherapists in Alberta.
There are many resources available to support professionals who wish to improve their communication skills. The DESC method of assertive communication (Appendix C) and the BLAST technique for complaint resolution (Appendix D) are two such examples.
Basic principles of effective communication include:
- Practice active listening.
- Focus on the issue rather than the individual.
- Limit comments to the issue at hand, rather than past conflicts.
- Avoid the words always and never.
- Monitor both your verbal and non-verbal communication.
- Use humor cautiously, respectfully and never at the expense of the other individual.
Although these tips may seem like common sense, the College of Physiotherapists of Alberta’s experience fielding complaints from patients and others suggest that a failure to apply these basic principles is at the heart of many of the patient complaints we encounter.
In many situations, inconsistent behavior can be more of a challenge than predictably poor behavior. When building working relationships, strive to model behavior that is:
- Takes promises seriously
When seeking reliability from others, remember to give trust when it is deserved and approach problematic behavior as a joint problem, asking “how do we fix this?”
Remember that your focus is not on winning an argument, but on developing a better understanding of the patient and their perspective and settling on a new consensus about the best course of action. In clinical situations, it is rare that there is a single best course of action. The principles of evidence-based practice require that a combination of research evidence, clinical knowledge and patient preferences are used to inform treatment decisions. The best course of action for any given patient is not always the gold standard of care, but rather the best possible combination of all three sources of knowledge.
Remember that because of your knowledge, skills and role in the relationship you are in a position of power. It is important that you work to decrease any power imbalances that exist between you and your patient, their family or other health-care providers by paying particular attention to what the patient’s preferences are. In doing so, you support patient-centered care and self-management, leading to better long-term patient outcomes.
Acceptance does not require that you agree with others’ values or approve of their conduct. It does mean that you treat others with respect and as equals and acknowledge that their views or values are what they are.
There are times when it is appropriate for a physiotherapist to discontinue treatment even though a patient wants and needs continued care. Physical, verbal, sexual or emotional abuse have no place in a therapeutic relationship. If a physiotherapist perceives that they are at risk or are being abused by their patient, they have the right to decline to continue to provide treatment.
This is a circumstance where the physiotherapist’s employer (where applicable) should be involved in resolving the situation. The College of Physiotherapists of Alberta expects that employers will create and maintain healthy, safe work environments for their employees. This expectation extends to both physical and psychological hazards.
If the physiotherapist is discontinuing treatment, the Standards of Practice require that the physiotherapist (or his/her employer) discuss the situation with the patient, explain their decision, provide the patient with a list of other sources of similar treatment, and (when possible) assist the patient to find alternate treatment providers. Depending on the situation, it may be appropriate for the physiotherapist to provide a limited number of treatments until the patient can commence treatment elsewhere.
When family members are actively involved in the care of a client, there are a few important considerations to keep in mind. Firstly, is the patient competent to make their own decisions? If so, they should do so, and questions about patient preferences should be directed to them. It is also necessary to determine the extent that the patient wants their family member to be involved in their physiotherapy care and included in patient education and treatment planning.
In the event that an adult patient is unable to make their own decisions, the physiotherapist needs to establish who has the authority to make decisions on the patient’s behalf and direct treatment related decisions to that individual. When working with minors, it is equally important that you establish who is legally able to make decisions on behalf of the minor and who has the right to access information about the minor.
Establishing who can and should be involved in the patient’s care and the limits of that involvement, should be done at the onset of the therapeutic relationship.
Conflict can arise with colleagues as well, whether they are other physiotherapists, other health professionals or others within the work environment. Many of the same skills and techniques of establishing good working relationships can also be used to manage and develop these professional relationships.
Health-care environments are traditionally hierarchical in nature, however when hierarchy prevents effective communication and working relationships it can lead to patient safety incidents. In fact, it has been estimated that 70% of all patient harm incidents are caused by communication breakdown.4 All health-care workers have a responsibility to maintain positive working relationships with colleagues to facilitate safe care and healthy work environments. One way to achieve this is to seek ways to decrease the sense of hierarchy or power imbalance between you and those with whom you work. This can be achieved through simple behaviours like calling each other by first names, making eye contact, and seeking input from everyone, regardless of their role in the organization.
No one likes to be involved in a challenging situation. They are stressful and often leave professionals feeling uncomfortable or uncertain of their choices. Nearly every situation offers the opportunity to learn something, either about how to manage similar situations or about one’s self. An important aspect of professional life is to engage in reflective practice.
Once a challenging situation has been resolved, it is important to take the time to reflect on one’s own values and beliefs and how these may have impacted the therapeutic relationship and the situation itself (for better or for worse). Sometimes situations within a physiotherapist’s personal life may lead them to over-personalize a challenging situation. If the challenging situation has left you feeling emotions such as anger, guilt, shame or embarrassment, these feelings can cloud professional judgment and negatively impact other professional relationships.
It is important for physiotherapists to take some time to process these emotions, reflect upon how they managed the situation and what they would do differently when faced with such a situation again. This may include seeking outside help from a supervisor, mentor or health-care professional if they are having difficulty coming to terms with the situation and its outcome.
Although not every challenging situation will come with legal considerations, there are several laws that can become relevant to physiotherapists depending on the issue at hand. It is important that physiotherapists are aware of the broader ramifications of these situations and their actions in managing the situation.
The patient is intoxicated at his/her visit. The physiotherapist doesn’t treat the patient. The patient leaves and the physiotherapist is aware that the patient is driving while intoxicated.
Traffic Safety Act5
You have a positive duty to report.Contact: Your local police service by calling 911 (RID or Curb the Danger Programs).
The patient has a history of previously controlled seizures but has recently been having seizures again. The physiotherapist is aware of the patient’s seizures.
Traffic Safety Act5
You have a positive duty to report. Contact: Alberta Transportation, Driver Fitness and Monitoring at 780-427-8230.
The physiotherapist suspects that patient, a dependent adult, is being mistreated by a caregiver.
Protection of Persons in Care Act6
You have a positive duty to report. Contact: Protection for Persons in Care office at: 1-888-357-9339 or your local police service.
The physiotherapist suspects that patient, a minor, is being mistreated by their parents.
Child, Youth and Family Enhancement Act7
You have a positive duty to report all suspected incidents of child abuse. Contact: 1-800-387-5437 or your local police service.
The patient reports that he/she is planning to commit suicide. The patient asks the physiotherapist not to tell anyone.
Privacy Law: Personal Information Protection Act (PIPA)8 or Health Information Act (HIA)9 depending on the work environment.
There is no positive duty to report. See Appendix B for details on what to do.
The patient expresses his/her intent to harm another individual.
Privacy Law: PIPA8 or HIA9 depending on the work environment.
There is no positive duty to report. See Appendix B.
The patient reports that they were injured at work but requests that the physiotherapists not report the injury to WCB.
Workers’ Compensation Act
You have a positive duty to report. According to the Workers’ Compensation Act you must forward a report to the Workers’ Compensation Board within two days of the patient visit.
In cases where legislation does not require you to report concerns to authorities, there may still be an ethical or moral imperative that leads you to contact the authorities. When there is not a positive duty to report, the physiotherapist must use their judgment to determine whether to report their concerns. In this situation you need to balance the potential consequences of not reporting the situation against the serious nature of breaching a patient’s privacy. In these circumstances the test for determining the need to report is as follows:
- The physiotherapist perceives that there is a clear risk of harm to the patient or any other clearly identifiable individual.
- The danger poses a risk of serious bodily harm or death.
- The danger is imminent* (i.e., “a sense of urgency must be created by the threat of danger”).8,9
When all three requirements are met, legislation allows a breach of privacy without patient consent for the purpose of alerting the appropriate authorities.
For example, in cases where the patient is expressing suicidal thoughts, privacy legislation permits the therapist to breach patient confidentiality to report their concerns. The therapist needs to determine the most appropriate person to report the situation to. The most appropriate person may be a family doctor, another health-care provider who works with the patient, a family member or guardian, or the local police authority.
Similarly, when an individual is expressing the intent to harm a third party, the physiotherapist must use his/her judgment to determine whether to report this information and to whom. The same three requirements are applied to determine if disclosure without consent is acceptable.
Regardless of the actions they take, the physiotherapist must endeavor to maintain a therapeutic relationship with the patient by offering support and acting in the patient’s best interest, in keeping with the Client-Centered Care Standard of Practice.
* While the relevant legislation indicates that the danger must be imminent. This does not mean that the action be occurring immediately. “The risk could be a future risk but must be serious enough that a reasonable person would believe that the harm would be carried out.”9
These models provide a framework for handling any interaction where an individual needs to express their point of view. The DESC format is used when there is an established relationship with the other party and some confidence that the other party will respond in a mature, respectful manner.
In some situations there is greater risk and less certainty about the response from the other party. In this case, the E is replaced with an I for indicating the problem the behaviour is causing.10,11
- Describe the situation
- Express your feelings about the situation "I feel..." or indicate the problem the behaviour is causing
- Specify the change you want. "I'd like you to..."
- Identify the results that will occur. "In the way..."
The BLAST technique is a complaint resolution method. The mnemonic stands for Believe, Listen, Apologize, Satisfy and Thank.12
The BLAST technique of complaint resolution
Express your belief in the truth of the patient’s concerns and the validity of his/her emotions, even if you do not agree with the legitimacy of them.
Use active listening to determine what the patient’s concern is and what his/her unmet expectations are.
An apology is not always an expression of responsibility. However, if the complaint is legitimate, patients deserve an apology. Even if the complaint isn’t legitimate, they will expect one. By relating the apology to the patient’s unmet expectations you acknowledge their experience, even if you don’t perceive the complaint as legitimate.
Strive to satisfy the patient. Ask what the patient wants, to ensure you haven’t mistakenly assumed you know what he/she desires. Start by addressing any complaints or demands that you cannot meet. If the patient’s requests are reasonable, agree. If not, calmly explain why and propose some other options.
Thank the patient for sharing his/her concerns with you.
- Porter-O’Grady T. Embracing conflict: Building a healthy community. Health Care Management Review 2004; 29(3): 181-187.
- The College of Physiotherapists of Alberta. (2012). Standards of Practice. Available at:https://www.cpta.ab.ca/for-physiotherapists/regulatory-expectations/standards-of-practice/. Accessed on May 29, 2015.
- McFarlane, L-A. Trials and Triumphs: Working with challenging students. Lecture presented at The Collaborative for Scholarship in Clinical Education, Clinical Educator Workshop; 2015; University of Alberta.
- Rosenstein AH, O’Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. The Joint Commission Journal on Quality and Patient Safety 2008; 34(8): 464-471.
- Government of Alberta. (2014). Traffic Safety Act. Alberta Queen’s Printer. Available at: http://www.qp.alberta.ca/documents/Acts/t06.pdf. Accessed on June 9, 2015.
- Government of Alberta. (2010). Protection for Persons in Care Act. Alberta Queen’s Printer. Available at: http://www.qp.alberta.ca/1266.cfm?page=P29P1.cfm&leg_type=Acts&isbncln=9780779749904&display=html. Accessed on June 9, 2015.
- Government of Alberta. (2014). Child, Youth and Family Enhancement Act. Alberta Queen’s Printer. Available at: http://www.qp.alberta.ca/documents/Acts/c12.pdf. Accessed on June 9, 2015.
- Government of Alberta. (2014). Personal Information Protection Act. Alberta Queen’s Printer. Available at: http://www.qp.alberta.ca/documents/Acts/P06P5.pdf. Accessed on June 9, 2015.
- Government of Alberta. (2011). Health Information Act: Guidelines and practices manual. Alberta Queen’s Printer. Available at: http://www.health.alberta.ca/documents/HIA-Guidelines-Practices-Manual.pdf. Accessed on May 29, 2015.
- British Columbia Rehabilitation Society. Boundaries workshop materials. 1992.
- Davis, C. Patient Practitioner Interaction(4th ed). Thorofare: SLACK Incorporated, 2006.
- Steinman, H.K. A method for working with displeased patients—BLAST. The Journal of Clinical and Aesthetic Dermatology 2013; 6(3): 25-28.