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Ethics in practice – communication and consent

This is a new series of articles from the Board’s Professional Advisors that will focus on case studies of competence, conduct and health dealt with by the Board, with the hope that practitioners can learn from the experiences of others.

All identifying details have been removed from the case studies.


This case study relates to a private physiotherapy clinic treatment by a male therapist in his early 50s. A female patient with an injured shoulder was unhappy with treatment received from this physiotherapist. The therapist felt she was not comfortable during the first treatment and the communication was a little forced. In the two follow-up treatments she was accompanied by a male support person, though the patient didn’t ask for him to be with her during the treatment, so he stayed in the waiting room. She received three treatments before switching to a different physiotherapist.

The Physiotherapy Board received a complaint from the patient, in regards to physiotherapist’s conduct during her physiotherapy treatment, three weeks after the last treatment session. The complainant questioned the professionalism of the physiotherapist during treatment. Specifically, the patient was concerned about:

  • having her bra undone, for the massaging of her neck and shoulder, while she was lying prone. She did note the therapist had said it was to prevent oil getting on her clothing
  • how potentially exposed she was with her bra undone. She mentioned this made her feel intimidated and vulnerable
  • the pain involved after the first treatment
  • a consultation with a subsequent physiotherapist resulted in a different diagnosis, treatment, and recommendation


The Board referred the complaint to the Health and Disability Commissioner (HDC) as the law requires the HDC to handle all complaints alleging the practice or conduct of a health practitioner has affected a health consumer. The HDC investigates any complaint from a consumer rights perspective as required by the Code of Health and Disability Services Consumers’ Rights (1994).

The physiotherapist was immediately informed and given a right to respond to the complaint – this is natural justice. The physiotherapist responded to the complaint in a timely manner.


The HDC decided to take no further action after seeking an expert physiotherapy opinion. The Board then received the complaint back (15 weeks after the last treatment).

The Board then has an obligation to review the complaint under the Health Practitioner Competence Assurance Act (2003) in regards to conduct, competence, and fitness to practise issues. The Board’s decision was for the physiotherapist to write a reflective statement on this experience to ensure it was a positive learning experience (19 weeks after the treatment). One month later the Board received his self-reflection, and the case was closed (23 weeks after the treatment).


In the physiotherapist’s reflective statement, he mentioned he was aware that the patient was uncomfortable during the initial treatment. He also stated that he wasn’t sure if he was clear in his communication about what the treatment involved, or regarding undoing the patient’s bra. He had the impression that she ‘was ok with it.’

The expert opinion did state the physiotherapy assessment, diagnosis and treatment were appropriate. The therapist also indicated that the patient was rung a week after her last treatment and she reported her injury was much better.

Key Lessons for physiotherapists

Communication was the important issue in this case. Patients are entitled to open, honest communication in a form, language, and manner that enables them to understand the examination or treatment proposed. The involvement of family, whānau or other support persons may often help with understanding.

This case appeared to make assumptions related to ‘informed consent’. This is an interactive process between a physiotherapist and patient where the patient gains an understanding of their condition and receives an explanation of the options available. This includes an assessment of the expected risks, side effects, benefits and costs of each option, and enables a patient to make an informed choice and give their informed consent.

A patient should always give informed consent when there is a need to remove any clothing during physiotherapy. This should always be followed by draping, as appropriate. Verbal consent was sufficient in this case, as it involved a routine assessment and treatments, and the perceived risk to the patient was minimal. It is prudent to note this in the patient’s record: ‘no notes is no defence’. 

Every consumer has the right to have support person(s) present during assessment and treatment. As the patient felt uncomfortable, this person should have been present for the treatment, rather than left in the waiting room.

The therapist had appreciated the patient felt uncomfortable but did not act on this feeling. It is always important to reflect on ‘gut feelings’, then decide on appropriate action(s) hypothetically, before implementation. A chaperone can be present at the physiotherapist’s or patient’s request which adds a layer of protection for both.

The process of investigating a complaint takes time. It follows a certain protocol. This can be harrowing for the people involved. If you find yourself in such a position, it is important to seek support from colleagues or your professional association.

Finally, if you have any patient or practice concerns that you are unsure how to resolve, consult with a respected peer, Jon Warren or Cheryl Hefford (the Physiotherapy Board’s Professional Advisors) or Physiotherapy New Zealand (the professional association). It is important the profession works together to maintain and improve the quality of physiotherapy.

Jon Warren is a Professional Advisor at the Physiotherapy Board. He has practiced physiotherapy for three decades, and previously lectured on Physical Therapy at the University of St. Augustine for Health Science, San Diego, where his teaching included ethics.