The Power of the Unwritten Standard: What Are They?

Where would we all be without following society’s unspoken rules?

There’s no law against standing two inches away from someone when talking, yet it’s socially uncomfortable, so we generally don’t do it. And you don’t need company policies and procedures to tell you that napping in meetings is frowned upon.

Flouting society’s accepted norms has consequences (lack of friends? lack of professional success perhaps?), but won’t land you in legal or regulatory trouble. Breaking your professions unwritten Standards just might.

All Colleges have written Standards. Yet many issues that come before the Inquiries, Complaints and Reports Committee (ICRC) and Discipline Committee at the College have to do with disregarding other rules — the unwritten Standards that establish expectations for the profession.

“In the context of a regulator, written and unwritten rules are of equal weight,” says Rod Hamilton, Associate Registrar, Policy, College of Physiotherapists of Ontario.

Consider the Standard on PTs working with assistants. When you are determining an appropriate level of supervision, you should factor in things like risks to the patient, caseload and treatment complexity. The Standard doesn’t provide a limit for how many people you can supervise, or at how many locations. It doesn’t describe every risk. You, the professional, must fill in the unwritten part using your professional judgment.

Why not write it all down?

If unwritten standards are critical, why doesn’t the College document them too? That gets at what it means to be a self-regulating profession. 

A standard is a signpost, laying out the basis for practice. It describes a level of professional performance considered to be acceptable. 

These written standards are the minimum, reminds Anita Ashton, Director, Professional Conduct for the College. Moreover, they don’t originate with the College. They’re the profession’s standards, reflecting how physiotherapists practice. 

If the College didn’t exist, physiotherapists would still have to meet the inherent rules established over time. The College gathers these standards and holds members accountable. 

Standards aren’t meant to be how-to manuals. If they were, anyone could read instructions, and physiotherapists would be technicians says Ashton. 

Regarding unwritten standards, one case often cited involves this profession, Mathews v. Board of Directors of Physiotherapy (1986). The case found that unwritten standards are just as real, and that some actions that are considered misconduct don’t need to be written down. 

Written standards aren’t where a professional’s obligations end — it’s where they begin. 

As a physiotherapist you are constantly using unwritten Standards — things such as asking a patient for permission before you touch them, giving the person privacy when they change, or not being late for appointments. 

The profession defines the rules

With complaints and investigations, the lack of explicit written Standards or the ignorance of unwritten standards, can be a poor defense. 

Following unwritten Standards, says Ashton, comes from experience, seeking advice from peers about practice situations, reviewing cases, being lifelong learners of the profession, and running decisions through an ethical filter.

The College could never codify everything in written Standards, even if it wanted. Standards can’t cover every situation (and are often purposely written not to), and the practices evolves. Yet Hamilton says physiotherapists won’t go wrong by condensing every written and unwritten Standard to this: put the interests of patients above all else.

“That should be your grounding principle,” says Hamilton. “Do that, and the vast majority of the time you won’t run into problems. As a professional, that’s the way to think at all times.”

Some of those unwritten Standards PTs follow every day

  • Being nice and polite to patients

  • Greet patients when they arrive

  • Introduce yourself to patients, families, caregivers, colleagues

  • Knocking before entering a patient’s room

  • Doing what you said you would do

  • Being on time for appointments

  • Making eye contact

  • Responding to patients questions and concerns

  • Being truthful

  • Listening

  • Being empathetic

  • Ask permission before you touch

  • Giving a patient privacy when they are changing

  • Apologizing when you are wrong or make a mistake