Boards must consider punitive, remedial, and preventative measures to best protect the public from boundary violations. This article is based on a 2021 FSBPT Webinar by Nancy Kirsch and Dennise Krencicki.
In the wake of the “Me Too” era, many jurisdictions are seeing an increase in boundary violations complaints. While the number of incidents is still, fortunately, low, the impact is high. Even actions that many may not consider egregious can have a significant detrimental effect on a patient, causing isolation, anxiety, depression, confusion, and sexual problems.
The relationship between a physical therapist and a patient requires tremendous trust. Sexual misconduct of any kind is an abuse of power and a violation of that trust. This lack of trust can transfer to the entire profession. Cases like Larry Nassar, the physician convicted of sexually abusing multiple young female athletes, show how one unchecked complaint can spiral. This can cause the public to lose trust in medical care practitioners and health care systems. Some practitioners and regulators think that since boundary violations are not a significant problem in physical therapy, discussing it makes it seem like it is a problem, causing the public to be wary of the profession. However, not discussing it may lead to the appearance of a lack of transparency, and ignoring the problem that exists decreases awareness and potentially makes the problem worse.
First, what are boundary violations? APTA provides ethical guidance in The Code of Ethics for the PT and Standards of Ethical Conduct for the PTA. These documents state PTs and PTAs shall not engage in any kind of sexual relationship with their patients, clients, supervisees, or students. Additionally, PTs and PTAs shall not harass anyone verbally, physically, emotionally, or sexually.
The Federation of State Boards of Medicine has defined sexual misconduct as a range of behaviors:
We must all understand the inherent power dynamic in a clinician-patient relationship—regardless of gender or patient condition, this dynamic is real and powerful. Let’s look at this from the perspective of the consumer. What are their rights? According to the FSBPT Model Practice Act, the public expects to receive qualified services from duly scrutinized practitioners.
What should a patient expect?
What happens if this expectation isn’t met? How do they notify the board?
Before we tackle this issue, we must agree on some definitions. The FSBPT Model Practice Act provides clear legal guidance and definitions of sexual misconduct. However, not all jurisdictions have similar definitions and guidelines. Patients may have expectations, may be clear on the treatment they are supposed to receive, but still question whether their interaction with the provider was appropriate. Inversely, without clear guidance, the provider may unknowingly act inappropriately. Of course, there is the small percentage of providers that knowingly and willfully act inappropriately. We should encourage consistency to remove ambiguity: What is a patient? What is a sexual relationship? What actions, such as disrobing, are genuinely related to treatment? What is a patient-clinician relationship? When does it start? When does it end?
Regulators need to be clear on these definitions. We are challenged with investigating misconduct that may be sexually inappropriate and we must be able to differentiate between a communication problem and a much more troubling concern ranging from harmful patterns of behavior to overt inappropriate conduct. Protecting the public from inappropriate sexual behaviors requires punitive measures, but regulators are also challenged to consider ways to remediate offenders. Additionally, given our mission of public protection, we do not want to simply be reactionary. One of our goals needs to be to prevent incidences in the first place. Toward that goal, FSBPT established the Boundary Violations Task Force to provide guidance to boards to help them effectively prevent, remediate, and discipline licensees who commit boundary violations.
Regulators have many responsibilities in this process. Jurisdictions bear the responsibility for ensuring practitioners are duly scrutinized before receiving a license to ensure they are practicing safely and effectively. Regulators also need to do outreach to educate the public. Patients and family members need to know that anyone has the right to submit a complaint against any licensee. The board has the responsibility to provide this education and act on complaints.
While regulators are responsible, we do not share the burden alone. Licensees also have responsibilities. They must follow the law and professional ethics themselves, but they also have a duty to report when they have direct knowledge of unprofessional, incompetent, or illegal acts by other licensees (or themselves). The educational system and employers are also responsible for preventing and reporting boundary violations.
Collectively and individually, we need to develop a culture of sensitivity and respect. As social norms are changing, jokes that may have previously been borderline acceptable among colleagues are not anymore. As individuals, we can help by taking a colleague aside and encouraging them to refrain from those types of jokes and behaviors in the future. It’s also important to remember that there is a wide range of accepted behaviors in society that are not necessarily accepted in professional practice.
Regulators, licensees, and patients must acknowledge inappropriate behavior is not restricted to what happens in a clinic. There have been instances of inappropriate social media posts. We should remind practitioners those social media outlets are public forums. Our duty as regulators is to help practitioners understand inappropriate posts cross boundaries on many levels. In smaller communities, social media posts may even be violations of HIPAA. Depending on the circumstances, some social media comments could cause investigations and sanctions.
Investigating physical therapy boundary violations is a challenge as physical therapy is a hands-on profession. PTs and PTAs also have a long history of physical contact and often treat patients in private environments, including the home. Patients are often especially vulnerable: children, the elderly, people with psychosocial problems. All these factors could form the perfect storm for the misinterpretation of what is happening, or worse, the potential that a practitioner could take advantage of a patient in a vulnerable position.
When someone puts their hands on another person, they enter their space, physically and emotionally. The details and nuance become vital. How are your hands perceived, where are they? What kind of touch? How is that touch understood? What is the person feeling? Where are they feeling it? Most importantly, how has the practitioner communicated what they are going to do, where they will be touching, and what the patient might expect to feel? Has the practitioner made sure the patient has understood and given consent? There are also considerations beyond words and hand placement: voice inflection, tone, looks, and body language. Many uncomfortable or misinterpreted situations can be avoided with good, clear, proactive communication.
Physical therapy practitioners touch so frequently that they can get desensitized. This begins in the academic environment when students wear minimal clothing to practice techniques on each other. The education community, along with professional societies, employers, and regulators, all have the responsibility to remind practitioners that touch may be routine for them, but for a patient, it may be new and uncomfortable. A patient may have also experienced prior abuse and trauma that could make them especially sensitive. Licensees have the responsibility to be mindful of these concerns for all patients.
While our job as regulators is to protect the public, we cannot do that without fully understanding the environment. Unfortunately, it is not uncommon for patients to violate boundaries. This can range from asking a PT to be a medical directive, which crosses a line, to more nefarious actions, such as sexual harassment. Clinicians need system support, from their supervisors to their boards, to help them navigate these situations with effective strategies.
Ultimately, boards will not be able to address incidents if they are not reported. Sexual misconduct is significantly underreported. People are embarrassed; they’re scared and often they are not sure exactly what happened, if it was appropriate or not, or even wonder if what happened is their fault. Others may be afraid of professional or educational repercussions or perhaps they wonder if going through the process of reporting is even worth it. Will the board even do anything? We need the public to have faith in boards to protect them.
All members of the health care team have a duty to report; we exist in a complaint-based medical regulatory system. That duty extends beyond the clinician-patient relationship to interactions with other members of the health care team and with students, professors, and coworkers.
Silence is not acceptable. Ignoring incidents is a breach of the professional duty to report. Of course, it doesn't necessarily mean that the first time you hear somebody make an inappropriate comment, you report them to the licensing board. It means you talk with that individual or you go to a supervisor. A culture that encourages this type of response should start in educational programs.
However, what should the board do if it is not the first report? Any previous board sanction is a strong predictor of future board sanctions. Boards need to take initial action and continue to monitor that licensee. Multiple reports indicate a serious situation that requires close inspection. Actual predators, unfortunately, have multiple victims and we want to ensure they are nowhere near patients.
More, often however, complaints reflect practitioners who grew complacent and were not communicating well with the patient. These are the cases we can and should prevent in the first place. Here are some powerful tools: <
Prevention Tools for Clinicians:
Prevention Tools for Supervisors:
Prevention Tools for Boards:
Preventing boundary violations is an excellent area for partnership with APTA chapters and schools. Working together, we can all send clear messages about what is okay and what is not. We can prevent and reduce boundary violations and protect the public.
Nancy R. Kirsch, PT, DPT, PhD, FAPTA,received her PT degree from Temple University, her Master's in Health Education from Montclair University, Certificate in Health Administration from Seton Hall University, her PhD concentration in ethics from Rutgers University (formerly UMDNJ), and a Doctor of Physical Therapy from MGH Institute of Health Professions. She practiced in a variety of settings including in-patient rehabilitation, acute care, long term care, and home care. She owned a private practice for twenty years and currently practices in a school based setting. In addition, she is the Director of the Doctor of Physical Therapy Program at Rutgers, The State University of New Jersey. Nancy has been a member of the New Jersey Board of Physical Therapy Examiners since 1990 and was chairperson of the board for twelve years. She served as an evaluator for FCCPT. Nancy has been involved with the Federation of State Boards of Physical Therapy in the following capacities: she served two terms on the Finance committee and also served on several task forces, in addition to the Board of Directors. Nancy has been active in the American Physical Therapy Association since she was a student. She served the New Jersey Chapter as Secretary and President, and as a delegate and chief delegate to the House of Delegates. She served the national association as a member of the ethics document revision task force. She also served a five-year term on the APTA Ethics and Judicial Committee and the APTA Reference Committee. She received the Lucy Blair Service Award and was elected a Catherine Worthingham Fellow from National APTA and received an Outstanding Service Award and the President's Award from the FSBPT.
Dennise Krencicki, PT, DPT MA, is an Assistant Professor and Director of Clinical Education in the DPT program of Rutgers, The State University of New Jersey, on the Blackwood campus. She teaches in the areas of professional issues, ethics, and clinical education. She has her BS in PT from Boston University, MA, in applied physiology from Columbia University and her Post Professional DPT from the University of Medicine and Dentistry of New Jersey. She is a trainer for the APTA Clinical Instructor Credentialing Program Level 1 and Level 2 and conducts continuing education courses in Ethics. She has been active in APTA, including serving terms as NJ Chapter President, Chief Delegate, Chair of the Chapter Ethics Committee and Active Delegate for 29 years. She also served as a physical therapist member of the NJ State Board of Physical Therapy Examiners, having also served three terms as the Board Secretary and one term as the Vice Chairperson. She was appointed to the APTA Ethics and Judicial Committee in 2016 and currently serves as the Committee Chair.