A PDF version of this Standard can be downloaded here.

Introduction

Appropriate professional boundaries are key to fostering and enhancing safe, effective therapeutic relationships between the physiotherapist and ngā kiritaki hauora as well as safe and effective relationships with colleagues, other health professionals and the wider community.

A clear understanding of and adherence to professional boundaries is necessary to protect the public and preserve the confidence and trust in the physiotherapy profession.

The physiotherapist-patient, ngā kiritaki hauora relationship is not equal due to the inherent power imbalance. Those who seek physiotherapy services are vulnerable as assistance, guidance or treatment is being sought and a physiotherapist has specific knowledge and training.

In the context of this Standard, physiotherapists are also required to maintain professional boundaries with those they interact with professionally , including research participants, physiotherapy students and colleagues.

If physiotherapists are currently in a relationship with an individual seeking physiotherapy services also refer to the ‘Treatment of whānau, family members and others close to you standard’.

This document is a Standard of ethical conduct and competence set by the Physiotherapy Board under section 118(i) of the Health Practitioners Competence Assurance Act 2003 (HPCAA). All physiotherapists are required to comply with this Standard.

Definitions

Emotional relationship: refers to any form of close emotional connection, including, but not limited to, emotional intimacy (where there is no physical or sexual relationship) and/or expression of romantic feelings.

Exploitation: involves any activity in which a physiotherapist takes advantage of a person situation through the use of manipulation, intimidation, threats or coercion.

Ngā kiritaki hauora: Person that uses health care services (patient, client or consumer).

Patient: In this Standard reference to patient includes clients, ngā kiritaki hauora, as well as others who physiotherapists engage with in their practice (regardless of the setting or location or whether the interaction is clinical or non-clinical). This also includes members of sports teams, cultural and social groups (such as kapa haka, dance or choir) and any other group of people seeking or receiving physiotherapy services, regardless of whether or not they personally receive the physiotherapy services.

Power imbalance: A power imbalance arises where one person has more influence, knowledge, experience, power or control (whether direct or indirect) than the other person.

Professional boundaries: are the limits which protect the zone between the physiotherapist’s power and the other person’s vulnerability and which allow for safe, objective and effective engagement with the individual. Professional boundaries preserve the clear separation between professional conduct that is associated with meeting the health needs of patients (or the needs of others in the context of a physiotherapist’s practice) and a physiotherapist’s own world views, feelings and relationships (including emotional and sexual boundaries).

Sexual relationship: A sexual relationship includes a relationship with any form of sexual contact and for the purpose of this Standard includes intimate contact with or without sexual intercourse and any sexualised behaviour by one or both parties.

1.   Professional boundaries

• Physiotherapists must always maintain appropriate professional boundaries with their patients and others they engage within the context of their practice, regardless of the setting, medium or location or whether the interaction is clinical or non-clinical. The responsibility for this lies with the physiotherapist.

Commentary: It is imperative physiotherapists keep professional boundaries and take responsibility for ensuring these are maintained no matter who the interactions are with, how those interactions occur (e.g.  in-person, messaging) or the setting or location such as clinic or clubrooms. As well as patients this may include research participants, physiotherapy students, colleagues and other health professionals.

Physiotherapy services are wide ranging and can be delivered to groups as well as individuals. Examples of this could be members of a sports team or club or cultural and social groups such as kapa haka, dance or choir. Regardless of whether physiotherapy services are received by an individual, professional boundaries need to be maintained with all members of such groups when providing physiotherapy services including for example, when going out for drinks after an event has finished or participating in team celebrations etc.

The standing of a physiotherapist in the community is not always restricted to business hours. As such, maintaining professional boundaries at all times is embedded within the position and responsibility of the physiotherapist.

Breaching professional boundaries may impair a physiotherapist’s professional judgment due to the nature of the relationship. Examples of this may include a lack of objectivity when providing physiotherapy services such as return to play decisions. It may also affect a patient’s ability to give informed consent or make it difficult for the physiotherapist or ngā kiritaki hauora to provide or refuse care. This can also have consequences for other team or group members.

• Physiotherapists must recognise when professional boundaries are being challenged and take appropriate action to ensure they are maintained.

Commentary: Due to the closeness, hands on, physical nature, and duration of the interaction, some elements of a physiotherapist-patient relationship have the potential to be perceived differently or misinterpreted by ngā kiritaki hauora or those close to them.

Recognising when boundaries are challenged

Recognising when professional boundaries are being challenged and taking appropriate steps is key to maintaining professional boundaries. Examples of behaviour that may indicate lines are being blurred may include:

(a) Seeing a patient at an unusual hour or location without clinical justification, especially when other staff are not present.

(b) Preferring a certain patient to have the last appointment of the day without any clinical justification.

(c) Making time to meet with a physiotherapy student alone where there is no clinical or educational justification for doing so.

(d) Accessing the patient’s records without any justification.

(e) Providing the patient with your personal contact information when there is no clinical basis for doing so.

(f)  Social invitations: Before accepting a social invitation from or extending a social invitation to a patient, consider the nature of the invitation and the perceived intent of acceptance.

(g) Altering your behaviour towards ngā kiritaki hauora because of gifts or koha received. An example of this may be giving extra time during a session to someone who has given you some free tickets to an event.

When a physiotherapist recognises that professional boundaries are being challenged they must take action to address this. This can include discussing the situation and seeking advice from a trusted colleague, discussing the concerns with the patient or arranging ongoing care with another health provider.

• Exploitation or influencing through the power imbalance of the physiotherapist-patient or other professional relationships for financial gain or benefits, which would not otherwise be present, or which may lead to a breach of trust or impair confidence in the professional relationship or the physiotherapy profession itself, is never acceptable.

Commentary: There is almost always a power imbalance in favour of the physiotherapist during a therapeutic relationship. There can also be a power imbalance when teaching or supervising another person or due to a physiotherapist’s standing or expertise. At times, for example, a power imbalance may exist between more and less experienced physiotherapists in a workplace.

• Physiotherapists must not encourage patients to give, lend or bequeath money or gifts that will benefit the physiotherapist.
• Physiotherapists must not accept gifts or enter into financial arrangements that may influence or give the appearance of influencing the physiotherapist’s professional judgement.

Commentary: At times, ngā kiritaki hauora, whānau or their families, may present you with small or consumable gifts or koha (in this context this means a gift, present, food, or donation) as a gesture of appreciation. Generally this is acceptable, provided they are token in nature, and do not influence or give the appearance of affecting or influencing the relationship or affecting decision making.

• For the purpose of this Standard, the behaviour of a physiotherapist and the physiotherapist’s relationship(s) with their patient(s) and others in the context of their practice are assessed objectively, and not on the basis of the physiotherapist’s intentions at the time.
• Physiotherapists must ensure professional boundaries are maintained when using electronic communication, including social media or online platforms (see Internet and electronic communication standard).

Sexual and emotional boundaries

• The exploitation by a physiotherapist of a power imbalance due to their position and/or professional practice which results in a relationship (whether sexual or emotional) is never acceptable.
• It is never acceptable for a physiotherapist to enter into a sexual relationship or emotional relationship with a patient currently receiving physiotherapy services.[1]
• Physiotherapists must never use sexually demeaning words or actions.
• It is never acceptable for a physiotherapist to enter into a sexual relationship or emotional relationship with a former patient where it could involve an abuse of the power imbalance.
• In some limited situations, it may be acceptable for a physiotherapist to enter into a relationship with a former patient, but physiotherapists in this situation must carefully consider the following:

• the inherent power imbalance
• the nature of the professional consultation(s) or professional interaction(s)
• the length of the professional relationship (not limited to date of discharge)
• the degree of dependency involved in the professional relationship
• the level of knowledge and personal disclosure that occurred during the professional relationship
• patient vulnerabilities such as, without limitation, age, mental health concerns or impaired cognitive function.
  • Subject to 1.8, 1.9, 1.10, 1.11 and 1.12 Physiotherapists must not terminate their physiotherapy services to a current patient for the principal purpose of starting a sexual relationship with the patient or any other person without first arranging appropriate ongoing care.

Commentary: The term ‘currently’ means that an individual is actively receiving physiotherapy services. This includes but is not limited to a series of treatment sessions, team involvement in a tournament or event (whether or not they receive physiotherapy services) or being managed in a return to work programme.

• A sexual relationship or emotional relationship with a person connected to a current patient (including carers, whānau, family, guardians, parents, spouse or parent of a child patient) is not acceptable if:

• there is an exploitation of the power imbalance between the physiotherapist and the other person because of the therapeutic relationship between the physiotherapist and the patient; or
• it may affect or give the perception of influencing the physiotherapist’s professional judgement or the professional relationship between the physiotherapist and the patient.
  • A sexual or emotional [or otherwise inappropriate] relationship is never acceptable with a student under a physiotherapist’s direct supervision.

Commentary: Physiotherapists must establish and maintain appropriate professional boundaries with students under their supervision. (Code of Ethics and Professional Conduct 2.10)

• Physiotherapists must, at the earliest opportunity, inform an appropriate authority (the Board and/or the Health and Disability Commissioner) if they become aware that another physiotherapist is, or may be, breaching professional boundaries (see Aotearoa New Zealand Code of Ethics and Professional Conduct 10.2).

Issued:  9 June, 2023. Effective 31^st July 2023.

This standard is scheduled for review in 2027. Legislative may make this standard obsolete before its review date review

[1] Where there is an existing relationship between the physiotherapist and the patient prior to the commencement of physiotherapy services refer to the Treatment of whānau, family members and others close to you standard.