Key Messages:
It is imperative that physiotherapists work in their client’s interests and maintain a positive therapeutic relationship by keeping to the following. Physiotherapists:
- Work in the client's best interests to provide safe, quality, and effective physiotherapy care.
- Take the time to listen to their clients, discover the reasons they are in front of you trying to get help, and help them feel heard.
- Inform and educate the client so that they can make informed decisions.
- Respect the decisions their clients make regarding their own health, even if they do not agree with them.
Intro
Listening and genuinely hearing what your client is telling you is a necessary skill of physiotherapy that should be a focus of continuous improvement for all physiotherapists.
During the initial visit or over the course of the care, there can sometimes be a disconnect in what you prioritize and what the client prioritizes. Open communication and using active listening skills can make the client feel that they are being heard, valued, and an active participant in their health-care journey.
Research has indicated that health professionals usually interrupt their client within the first 11-18 seconds of an initial visit and can average 11-12 interruptions per hour of care with over half of these interruptions being unnecessary.1-2 In light of this research, physiotherapists may not be fully listening to clients and may be missing key parts of a client’s physiotherapy goals and expectations for the care being delivered.
This article will focus on a scenario regarding the importance of centering the client’s interests and the challenges to doing so if physiotherapists don’t take the time to listen and understand what those interests are.
The Duty of Care Standard of Practice states that “clients can expect that their interests will be the primary consideration when receiving physiotherapy services…” It goes on to list that:
The physiotherapist:
- Takes responsibility for maintaining an effective therapeutic relationship.
- Facilitates shared decision-making by taking the time to provide education regarding the client’s condition, supporting health literacy and facilitating the transition to self-management.
- Recognizes that clients have the right to make informed decisions about their own care, even when the physiotherapist believes the decisions may put the client’s health at risk.
And the Code of Ethical Conduct states that:
- Beneficence guides the practitioner to do what is good with respect to the welfare of the client. In physiotherapy practice, the physiotherapist should provide benefit to the client’s health.
The Initial Assessment
Jarrod went to see a physiotherapist after a tibial plateau fracture. He had a previous knee injury a few months ago and was able to keep skiing on it until a second fall at the hill caused his fracture. At his initial assessment he felt like his physiotherapist was scolding him for choosing to ski on his injured knee. He thinks his physiotherapist doesn’t understand his desire to ski and missed the fact that he was skiing quite well despite his previous injury. Jarrod left his first visit feeling like his physiotherapist would not understand him and his goals for physiotherapy.
Where was the potential disconnect?
Jarrod did not think there was anything wrong with his decision to keep skiing on his injured knee and felt like the physiotherapist was judgmental about his choice. Jarrod spent a good part of his income on gear and his season pass so he felt financially compelled to make use of it. Jarrod also felt that his knee injury wasn’t hampering his skiing and did not cause his fracture. He felt like the physiotherapist was dismissive of why he made those choices.
How could the physiotherapist have approached this differently?
It may have been worthwhile for the physiotherapist to more fully engage Jarrod on the topic of his decision making and recognizing his priorities when it came to skiing and his initial injury. The physiotherapist could have taken more time to discuss the established risks of participating in sport when injured and the benefits of accessing physiotherapy when first injured. The physiotherapist has knowledge, experience, and skills that can provide value to Jarrod. Jarrod’s perspectives are also important as it is his life and ultimately his decision regarding his care. Communication between them should always be respectful.
The physiotherapist could have also taken the time to better understand Jarrod’s priorities instead of asking why Jarrod was skiing on an injured knee or what he was thinking. If they had asked about Jarrod’s priorities and the value he places in skiing it may have helped build a more positive therapeutic relationship starting from day one.
Discussions around what the client prioritizes in their rehabilitation
After the initial assessment Jarrod’s physiotherapist reflected on some of the communication with Jarrod and that they didn’t seem to be on the same page. The physiotherapist realized they may have came off a bit judgy around Jarrod’s decision making. The physiotherapist took the time at the start of the next appointment to reset the relationship and understand Jarrod’s perspective.
Now several weeks later, Jarrod is improving in his rehab and is progressing quickly through his program. He has an opportunity to go to a surf camp with friends and wants to jump ahead of his post-op protocol and go against his surgeon’s advice for return to sport. He brings this up at his appointment to see if this is a possibility. His physiotherapist has some valid concerns that Jarrod may not fully understand the implications of a re-injury or the risk that he would put himself in by surfing at this stage of his recovery. After what happened after the initial assessment, the physiotherapist understands they have to consider how best to respond to Jarrod to alert him to the risks while also respecting Jarrod’s thoughts and opinions.
What should the physiotherapist consider when Jarrod brings up his surf camp plan?
It is important to listen to Jarrod and hear him out regardless of the physiotherapist’s initial thoughts. The physiotherapist should take time to consider the question and respond with an evidence-informed response on how post-operative protocols are established, the reason they provide timelines for return to activities and sports, and discuss the potential risks of going to a surf camp at an earlier than planned timeline.
What is the hopeful outcome of these discussions?
Ideally, Jarrod is also listening and hearing what the physiotherapist has to say. The physiotherapist hopes Jarrod takes time to consider the advice provided and recognize the inherent risks of returning to sport too early, but also recognizes it is ultimately Jarrod’s decision to go to the surf camp or not.
Discussions like these should hopefully strengthen the therapeutic relationship and Jarrod may realize that the physiotherapist is working in his interests. Ideally a compromise occurs, and Jarrod schedules a beach vacation with his friends instead of a surf camp.
What are some important concepts to consider in these situations?
Professionalism: In situations like these it would be easy to roll your eyes and think that Jarrod must not care about himself or all the work he has put into his rehabilitation, or he’s just another kid without any concept of consequence.
Regardless of the inner thoughts you may have about Jarrod, you must be respectful and considerate even if you disagree with their decisions. The Duty of Care Standard expects physiotherapists to understand that a client can make choices regarding their care, even when you disagree with them or the evidence demonstrates a high level of risk.
Physiotherapists should always be working in their client’s best interests, for example by taking the time to talk to Jarrod, reason with him about his choices and provide as much evidence-informed advice as possible to inform Jarrod’s decision.
Managing Potential Conflicts of Interest
Jarrod and the physiotherapist have worked to get him ready to start back at some of his activities. He asks the physiotherapist about a knee brace and what type of brace she would recommend for him as he returns to skiing and other sports. The physiotherapist carries a few braces that are higher-end custom braces that are quite expensive and a few lower-end braces that are much more affordable. Jarrod has limited coverage for a knee brace and is struggling financially after his fracture. He is looking to the physiotherapist for assistance in getting him a brace suitable for his knee injury.
What factors could influence the advice provided by the physiotherapist?
Evidence: The physiotherapist should always base decisions on the best evidence and research available. It is important to take the time to evaluate quality research and provide a brace that would be indicated for a client like Jarrod.
Experience: Physiotherapists gain knowledge through their in-clinic experiences with clients. The physiotherapist can use this experience to assist them in discussing braces with Jarrod and what has worked and not worked well for previous clients similar to Jarrod.
Client Insights: Jarrod may have his own views on what would potentially work best for him, opinions on fit, pricing, goals for return to sport, etc. These all should be taken into consideration by the physiotherapist.
Finances: Jarrod’s finances matter. You may have a strong opinion as to what is best for your client but if Jarrod can’t afford it or you know it is a financial burden you will have to consider providing other options.
How can physiotherapists manage conflict of interest?
On the other side of the financial discussion there are the financial interests of the physiotherapist. In this case the more expensive brace does come with a larger profit margin. The physiotherapist must keep to the Code of Ethical Conduct’s requirement of Beneficence and work in the client’s best interests and not their own. Financial conflicts of interest can be managed several different ways. You can access several resources on conflict of interest:
- Therapeutic Relationships Guide
- College Conversations Podcast Episode 33: Conflicts of Interest in Physiotherapy Practice
- Good Practice: Conflict of Interest
- Good Practice: Back to the Basics
References
- Teigné D, Cazet L, Birgand G, Moret L, Maupetit JC, Mabileau G, Terrien N. Improving care safety by characterizing task interruptions during interactions between healthcare professionals: an observational study. Int J Qual Health Care. 2023 Sep 13;35(3):mzad069. doi: 10.1093/intqhc/mzad069. PMID: 37688401; PMCID: PMC10507660.
- Plug I, van Dulmen S, Stommel W, Olde Hartman TC, Das E. Physicians' and Patients' Interruptions in Clinical Practice: A Quantitative Analysis. Ann Fam Med. 2022 Sep-Oct;20(5):423-429. doi: 10.1370/afm.2846. PMID: 36228066; PMCID: PMC9512556.
