2022 PISA Questions

Question 3

A new patient tells you that they stopped seeing their previous physiotherapist because the PT made comments about their body and appearance that made them uncomfortable. The patient confirms that the PT made sexual comments but did not touch them inappropriately.

Based on the information that the patient shared, you need to file a report with the College of Physiotherapist of Ontario.

• True
• False

Answer 3:

True. You need to file a report with the College.

As detailed in the Boundaries and Sexual Abuse Standard, sexual abuse of a patient includes the following:

• Sexual intercourse or other forms of physical sexual relations between the physiotherapist and the patient
• Touching, of a sexual nature, of the patient by the physiotherapist
• Behaviour or remarks of a sexual nature by the physiotherapist towards the patient.

In this scenario, the patient informed you that the physiotherapist made sexual comments toward them. Sexual comments or remarks are considered sexual abuse and you need to make a report with the College. 

By law, physiotherapists are required to report sexual abuse or suspected sexual abuse of a patient by any regulated health professional. 

If you learn that a physiotherapist or other regulated health care provider may have sexually abused a patient or been engaged in a relationship with a former patient (who was discharged from care within the last year), a report must be filed with the College of the health care provider. Failure to file the report may result in disciplinary action.

The report must include the name of the provider who may have abused the patient and can only include the name of the patient if the patient has provided their consent.

Physiotherapists can make a mandatory report with the College using our online form. 

Learn more about the Mandatory Reporting obligations for physiotherapists. 

You may also share some helpful resources with your patient. The College offers a program for funding for therapy/counselling for patients who have been sexually abused by a physiotherapist and we have a list of organizations that can support patients who have been sexually abused on the website. 

Question 5

Your patient’s treatment plan involves you using your hands to mobilize the patient’s hip joint. From the list below, what techniques might enhance a patient’s feeling of safety, and ensure professional boundaries are maintained?

Select all that apply.

a. Cover sensitive areas with a sheet (called draping) e.g. pelvic area and groin.
b. Ensure that you fully explain where the patient can expect the physical touch.
c. Ask the patient's permission before touching them.
d. Always lock the clinic room door.
e. Use strategic barriers like pillows between you and the patient.
f. Provide options for treatment that may include alternatives to touching.
g. Keep the time that body parts are exposed to a minimum.

Answer 5:

A physiotherapist must maintain professional boundaries within the therapeutic relationship and always create a culture of safe and supportive care with patients. 

The correct answer is a, b, c, e, f, g. 

• Cover sensitive areas with a sheet (called draping) e.g. pelvic area and groin
• Ensure that you fully explain where the patient can expect the physical touch
• Ask the patient’s permission before touching them
• Use strategic barriers like pillows between you and the patient
• Provide options for treatment that may include alternatives to touching
• Keep the time that body parts are exposed to a minimum

These are all things that you can do to help maintain the boundaries of the therapeutic relationship and create a culture of patient safety in all treatment and especially when treating sensitive areas. 

You should never automatically lock the clinic room door. Instead, ask the patient whether they would be more comfortable with the door locked or unlocked. Some patients may feel very uncomfortable in a locked room while others may feel more comfortable with the door locked if sensitive body parts are exposed.

Physical touch is an important aspect of physiotherapy, but PTs need to be sensitive to each patient’s unique boundaries. Different patients will have varying levels of comfort with physical touch.

Good draping techniques are very important when treating sensitive areas and can help to create a safe, comfortable space for patients. Be sure to read the College’s blog Patient Privacy, Dignity and the Importance of Good Draping to review the tips listed above in more detail. 

Please take a few minutes to watch the video Principles of Draping for Physical Exams on the importance of draping patients for physical exams.

It is the physiotherapist’s responsibility to establish and maintain the boundaries of the therapeutic relationship while acting in the patient’s best interest.

Often, the College hears of issues related to boundary violations where touching is unexpected or unexplained. Physiotherapists can help prevent these types of complaints by ensuring that they obtain informed consent and use appropriate communication with their patients.

The College’s consent resource details the responsibilities of physiotherapists when obtaining informed consent for treatment. You need to explain to your patient how you plan to touch them, why you plan to touch them, and which body parts need to be exposed. You need to get permission (consent) from the patient before you touch them, each and every time. 

Remember consent must be obtained on an ongoing basis and the patient is able to withdraw their consent to treatment at any time. 

When communicating with patients, be sure to speak clearly in a way they can understand, listen to any concerns they might have, and confirm their understanding to make sure your expectations are aligned. Review the 6 Keys to Communication. 

Question 7

A patient is attending physiotherapy for the first time. They tell you they are uncomfortable with physical touch and nervous about the appointment. What can you do to help make the patient feel more comfortable?

Select all that apply.

a. Acknowledge the patient's feelings.
b. Ask if there is anything you can do to make them more comfortable.
c. Ask the patient why they are so uncomfortable with physical touch.
d. Take your time — don't rush the appointment.
e. Remind the patient that they can stop treatment at any time.
f. Refuse to treat the patient.

Answer 7:

The correct answer is a, b, d and e. 
•    Acknowledge the patient’s feelings.
•    Ask if there is anything you can do to make them more comfortable.
•    Take your time — don’t rush the appointment. 
•    Remind the patient that they can stop treatment at any time.

These are all examples of things you can do to help the patient feel more comfortable. 

You should also consider additional things you can do to help the patient feel more comfortable like limiting the time that certain areas are exposed, offering alternatives to the patient, using appropriate draping techniques and barriers, and ensuring an appropriate temperature in the treatment room.

Remember to balance the need to expose certain areas with the patient’s need for privacy. Consider alternatives if they are uncomfortable with the suggested treatment. Ensure that you obtain informed consent in an ongoing way — the patient may feel comfortable with one aspect of treatment one day but may feel differently at their next appointment. 

If it is not relevant to your course of treatment, you do not need to ask the patient why they are uncomfortable with physical touch. You should be sensitive to their personal boundaries and adjust your practice accordingly. Additionally, you cannot refuse to treat the patient based on their discomfort with physical touch or nervousness. If the patient requests the discontinuation of care, for example if they would be more comfortable with another provider, you may transfer their care if alternate services have been arranged. 

Review the Providing and Refusing Care Standard for more information about when it might be ok to transfer or discontinue a patient’s care. 

As stated in the Boundaries and Sexual Abuse Standard, the physiotherapist’s responsibility is always to act in the patient’s best interest and to manage the boundaries within the therapeutic relationship.

Part of managing this responsibility is recognizing that each patient’s boundaries will be unique to their own experiences, including their culture, age, values or experiences of trauma.

Physiotherapists should also be sensitive to the practice setting, especially when providing care in an informal environment, such as a patient’s home. 

Physiotherapists should always strive to create a comfortable, safe space for their patients. The College has two blog posts related to establishing safe, inclusive spaces for patients. 

Now please read: 

• Patient Privacy, Dignity and the Importance of Good Draping
  
• Being More Inclusive in Your Practice

Question 9

You have been providing physiotherapy treatment to a patient for approximately two months, without any concerns. One day, the patient tells you that they are transferring to a different clinic for physiotherapy. When you ask why, the patient tells you that they think you are an amazing person, and they are interested in a romantic relationship with you. The patient reaches for your hand and asks if they can take you out for dinner.

What should you do?

a. Call the other clinic and tell them why the patient is leaving your clinic.
b. Go to dinner with them — they plan to stop attending physiotherapy, so they will no longer be your patient.
c. Move your hand away and politely explain to them that it would not be appropiate for you to go to dinner together.
d. Go to dinner with them but make sure you don't tell anyone.

Answer 9:

The correct answer is c — you should move your hand away from theirs and politely explain to them that it would not be appropriate for you to pursue a romantic relationship. Be sure to document the conversation in the patient’s record. If there is ever an investigation concerning the issue, it is helpful to have the information included in the record. 

It would not be appropriate to contact the other clinic to tell them what happened with the patient. This could be seen as a breach of privacy and could jeopardize the patient’s ability to access unbiased physiotherapy treatment. Under no circumstances are physiotherapists permitted to date their patients.

Even if a physiotherapist is interested in pursuing a romantic relationship with a former patient, the law dictates that they have to wait at least one year after the patient stops physiotherapy care. 

In addition to the one-year rule, it is imperative for the physiotherapist to ensure that the inherent power balance within the therapeutic relationship no longer exists. The patient should no longer be dependent on the physiotherapist in any way. It may be awkward to have these kinds of conversations with patients, but it is the responsibility of the physiotherapist to establish and maintain boundaries within the therapeutic relationship. 

You need to recognize signs of a potentially inappropriate interaction and take the appropriate steps to deal with it — even if the interaction was initiated by the patient. 

You cannot ignore the interactions. If you do not stop the interaction and re-establish professional boundaries, the patient may see this as a willingness to pursue a romantic relationship and things could escalate. 

Dr. Ziadee Cambier has given the College permission to share the following three videos that highlight verbal techniques that physiotherapists can use to stop inappropriate behaviour. 

Please watch these videos.

•    I Think, I Feel, I Want
•    Active Listening Broken Record
•    The Positive, Negative Warning

Test your knowledge of maintaining boundaries within the therapeutic relationship by completing the Boundaries and Sexual Abuse Standard E-Learning Module. The module is also available in French.