There are a variety of ways to identify and eliminate barriers to reporting, investigating, and defining sexual misconduct and boundary violation in physical therapy. This article is based on a 2022 FSBPT Webinar by Jennifer Wissinger and Kristina Lounsberry.
FSBPT formed the Boundary Violation Task Force in 2020 due to an increasing need among member boards to have adequate advice and resources. According to a 2021 poll by FSBPT, 63% of regulators reported an increase in sexual misconduct complaints. This number is alarming and further proof that this issue is an important area of concern.
One of the task force's goals was to identify potential barriers to reporting violations to regulatory boards. As one of its first projects, the task force assessed jurisdiction websites. The task force members only reviewed websites they were unfamiliar with, and they tried to view them via the lens of someone who had experienced sexual misconduct during physical therapy and was contemplating filing a complaint with the board.
One of the first things they looked at was how far deep into the website did they need to go to get to find where to file a complaint or find information about the complaint and actually input the information needed to formally file.
During the review, they counted how many mouse "clicks" it would take to get to a webpage to report a complaint (not just information about the complaint process, but the actual action: print a form, fill out an online form, or call a phone number). The average number of mouse clicks to report a complaint was 3.5. The task force applauds the jurisdictions that allowed individuals to report a complaint in just one or two clicks. However, many websites require multiple clicks. This was eye-opening as a barrier to how difficult it was to get to this important information on many jurisdiction websites.
How Many Clicks Are Required?
Takeaway tip: Consider having a quick link on your jurisdiction's main home page for reporting a complaint or inappropriate action of a licensee.
Once a potential complainant makes it to the correct information to file a complaint, they also will likely want to know if their complaint is confidential.
While reviewing the websites, task force members sought to find language to determine whether the complaint had to be part of the public record, or if it could be submitted anonymously or confidentially. While most of the websites did provide specific language, there were still a large number of jurisdictional websites where the anonymity or confidentiality of a complaint was not clearly identified.
Because of the sensitive nature of sexual boundary violations, the task force feels that clarity regarding the anonymity or confidentiality of a complaint is important information to share with complainants. The task force encourages jurisdictions to review the language of their websites and make changes as necessary to decrease any unnecessary barriers to reporting a complaint. This also includes how to collect contact information and explain the need for it and how that information will be handled.
Takeaway tip: Consider how your jurisdiction classifies reports made about boundary violations and if it is clear to the claimant that their report will be anonymous, confidential, or public record. Do you explain the need to follow up with contact to the claimant in order to fully investigate reports?
In reviewing the language of the website and the complaint form, the task force members identified any language they felt might be intimidating or a barrier to a complainant of a sexual boundary violation. Here are examples of language they found:
They found one instance discouraging the submission of sensitive or personal information—but you don't get more sensitive or personal than a boundary violation. Some websites required notarized signatures on the form to formally file the complaint. That is a huge barrier. Not only is it a challenge to access a notary, but potential complainants also may not want to share their sensitive stories with a notary. Additionally, some language warned about the length of time to process the complaint due to volume. Well, someone may think, why even submit a complaint if it will just be held up and bogged down by an arduous and slow process?
The task force feels that this kind of language might be a barrier to an individual who is already dealing with trauma and may be hesitant to report it.
Takeaway tip: Review language and discuss wording such as "complaint" "uncomfortable" "inappropriate".
So how are jurisdictions even defining what these violations are? When reviewing the websites, the task force members determined whether the provider-patient relationship was defined in rules or statutes (e.g., is 'patient' defined?).
The task force found that only nine jurisdictions had clear language defining the provider-patient/client relationship in rules or statutes. The power differential between the clinician and patient/client exists because the clinician has knowledge and skills needed by the patient, access to the patient's personal medical information, and the patient's reliance on them for establishing boundaries in care. This innate dependence makes dating current patients inappropriate, even when the relationship may appear to be mutually consensual.
"Patient" and/or "client" may be defined in different ways. Here are some examples:
You can read more specific examples from multiple jurisdictions here.
Takeaway tip: Consider reviewing your jurisdiction's practice act language and consider promoting future changes as necessary to clearly define who is a patient/client and when the patient relationship begins. The task force also encourages jurisdictions to consider changes to clearly define when the provider-patient relationship ends (if ever).
The task force found that only six jurisdictions had clear language suggesting the provider-patient relationship continues after discharge in jurisdictional practice acts. The power differential between the clinician and patient exists because the clinician has knowledge and skills needed by the patient, access to personal medical information, and the patient's reliance on them for establishing boundaries in care. That power differential may continue after the end of formal treatment sessions, and boards should develop appropriate standards to protect the public even when the relationship may appear to be mutually consensual.
Clinicians cannot have a relationship with someone who may still be vulnerable to the power imbalance that existed. Additionally, discharging a patient only to have a relationship with them would also not be acceptable and is noted in some administrative codes. You can read more specific examples of provider-patient relationship definitions here.
Takeaway tip: The task force encourages jurisdictions to review the language of their practice acts and consider promoting future changes as necessary to clearly define who is a patient, when does the provider-patient relationship begin, whether the patient relationship continues after discharge, and when does the provider-patient relationship end (if ever). Further, the task force encourages jurisdictions to develop messages and resources to help the public and licensees better understand the issue and the rules.
A research study in 2007 found that 38-52% of healthcare professionals report knowing of colleagues who have been sexually involved with patients. (Halter et al., 2007)
We know it is happening, and we know it is a problem. To learn more, the task force examined various cases from different states, and a common theme was that practitioners said they did not know their behavior was inappropriate. How could that be?
Physical therapist students often disrobe as part of learning. It may be uncomfortable for them at first, but then they can get desensitized to it. This may cause them to inadvertently be insensitive to patients' comfort levels with disrobing. Physical therapy is a hands-on profession in an increasingly contactless world. Most people communicate via digital means, so they may not be as used to having people in their space. People have avoided personal contact during the pandemic and may still have lingering preferences and hesitancies.
Previously, patients provided written consent upfront. However, with these social changes, ongoing consent is a better practice. Practitioners should be trained to regularly communicate with the patient about what step they will take and if that step is okay.
Similar to practitioners, patients also sometimes say they didn't initially report the behavior because they didn't realize it was not okay. So, what can regulators do? Boards have the responsibility to educate students, practitioners, and the public. Boards are in the position to be identified as valid, reliable sources of this good information. Boards can and do produce educational materials in a range of formats, including videos, newsletter articles, and FAQs.
Regulators can help patients by including information on handouts and websites to let them know "What to Expect." These can clarify what is appropriate touching versus what is inappropriate touching. FSBPT also has resources to help boards. Regulators can make sure that all physical therapists understand their Duty to Report. FSBPT created a brochure template called "Your Duty to Report" that boards can use. Boards enter their own information into the template and share it with practitioners and students to ensure they understand how to file complaints. The PT can also tell patients how to make a complaint. Even if it never happens, providing the patient with that information can empower them and help with the imbalance of the provider-patient power dynamic.
States handle investigations in various ways. Sometimes full-time staff are assigned to investigations; other times board members handle investigations. Investigators need education and training to understand definitions, rules, and how to work with complainants. This requires both initial education and continuing education. Some training resources include CLEAR, Justice 3D, and the International Association of Chiefs of Police .
The Task Force has transitioned into a standing committee: the Sexual Misconduct and Boundary Violations Committee, which supports an FSBPT webpage with resources. Going forward, the committee will focus on the following projects:
The Sexual Misconduct and Boundary Violations Committee looks forward to working with and helping jurisdictions decrease and handle boundary violations to advance public protection.
Kristina Lounsberry started her own physical therapy practice in Lake Charles, Louisiana, in 2003. She served on the Louisiana Physical Therapy Board from 2012 to 2018. She was also a ProCert Continuing Competence Reviewer from 2018 to 2019. She served on the FSBPT Sexual Boundaries Task Force for two years before transferring onto the committee. She has a long-standing interest in the compliance and education aspects of physical therapy. She is excited to share the progress and problems that other professions/organizations have encountered while exploring the topic of boundary violations. She hopes to add a local and international perspective on the issue of boundaries in physical therapy.
Jennifer Wissinger, PT, DPT, PCS, received her DPT degree from Slippery Rock University of Pennsylvania and has practiced as a pediatric physical therapist throughout east/central Ohio for twenty years. Jen taught in the DPT program at the Ohio State University for sixteen years and served fourteen years as a faculty mentor for the Nationwide Children’s Hospital pediatric physical therapy residency program in Columbus, Ohio. She served on the Ohio OTPTAT Board for seven years, where she helped develop the Ohio JAM and served as Secretary, Enforcement Review Panel, FSBPT Delegate and Alternate Delegate, and Delegate to the PT Compact. Jen chaired the Boundary Violations Task Force, which is now the Sexual Misconduct and Violations Committee.