Professional Boundaries in PT Practice PDF

PROFESSIONAL BOUNDARIES IN PT PRACTICE PT 8351 PROFESSIONAL ISSUES I BOUNDARY ISSUES Three common examples: Sexual harassment Gift giving Conflict of interest OBJECTIVES The student will be able to: Recognize harassment by other health care professionals or patients. Utilize appropr...

PROFESSIONAL BOUNDARIES IN PT PRACTICE PT 8351 PROFESSIONAL ISSUES I BOUNDARY ISSUES Three common examples: Sexual harassment Gift giving Conflict of interest OBJECTIVES The student will be able to: Recognize harassment by other health care professionals or patients. Utilize appropriate professional resources when you identify possible signs of harassment and/or domestic violence. Manage and prevent boundary issues in the workplace. Portions adapted from Dr. Rhea Cohn HARASSMENT IN HEALTH CARE True or False: Only health care providers, not patients, can be victims of sexual harassment. Men cannot be victims of sexual harassment. Patients are consenting to being touched by coming to a medical appointment. Harassment does not have to be sexual in nature.  SEXUAL HARASSMENT IS…. Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature when: Submission to such conduct is made either explicitly or implicitly as a term or condition of an individual's employment, or Submission to or rejection of such conduct by an individual is used as a basis for employment decisions affecting such individual, or Such conduct has the purpose or effect of unreasonably interfering with an individual's work performance or creating an intimidating, hostile, or offensive working environment. Civil Rights Act, 1964 (Title VII) [employers > 15 employees] APTA HOUSE OF DELEGATES TYPES OF HARASSMENT National Academies of Sciences, Engineering, and Medicine Report on Sexual Harassment Making the Case for Fundamental Institutional Change, 2018 https://jamanetwork.com/journals/jama/fullarticle/2697842?utm_source=silverchair&utm_medium=email&utm_campaign=article_alert- jama&utm_content=olf&utm_term=082018 Unwanted sexual physical and/or verbal attention (e.g. touching, inappropriate proximity, flirting) Quid pro quo: Sexual coercion in exchange for something: “This for that”- (e.g. money, grades, professional advancement) Gender harassment: … “verbal and nonverbal behaviors that convey hostility, objectification, exclusion, or second-class status about members of one gender.” Visual: (e.g. screen savers, inappropriate use of the internet, posters) IS IT UNLAWFUL? 1. Harassment must be unwelcome and based on the victim's protected status. 2. The conduct must be: subjectively abusive to the person affected; and objectively severe and pervasive enough to create a work environment that a reasonable person would find hostile or abusive. pixabay PERSONAL/SEXUAL RELATIONSHIPS Whenever a personal/sexual relationship exists between a medical trainee and a supervisor who has professional responsibility for the trainee, the supervisory role must be eliminated if they wish to pursue their relationship.  DeMayo, PTJ, July 1997 77:739-744 PTJ, Volume 97, Issue 11, 1 November 2017, Pages 1084–1093 86% respondents reported having had N=892 some experience with sexual behaviors during clinical practice. 84% had experienced inappropriate patient sexual behavior (IPSB)* at some point during 63% reported that at least one of these their career or training experiences was harassment. 47% had experienced IPSB within the last year *“Inappropriate Patient Sexual Behavior” (IPSB) can be from “leering and sexual remarks to deliberate touch, indecent exposure, and sexual assault.”  PTJ, Volume 98, Issue 9, 1 September 2018, Pages 804–814 Determine how many PTs, PTA, and SPTs address IPSB and examine strategy impact Results: 1. Common informal responses: distraction, ignoring it, altering treatment to avoid physical contact, avoid being alone 2. Formal responses: transfer care, reporting behavior, documenting behavior SUCCESSFUL STRATEGIES UNSUCCESSFUL STRATEGIES Distraction Ignoring the problem Avoidance Making jokes, giggling, Direct confrontation laughing Behavioral contracts Being indirect in your use of language Transfer of care Use of chaperones IPSB CAN ESCALATE Grabbing, touching, indecent Comments, Sexual gestures, exposure, romantic gifts propositions aggressive behaviors WHY ARE PTS AT RISK? We ask our patients to disrobe. We touch various body parts. We are in close proximity during transfers and lifting. We may work in private rooms. We discuss personal matters. We enter our patients’ lives when they are most vulnerable. We may be “young” and perceived as easy targets. We often work in hierarchical situations.  PTS ARE NOT ALONE Approximately 50% female physicians experienced gender-based harassment and 37% reported sexual harassment. (n= 4501) Frank et al, Arch Intern Med. 1998;158(4):352-358. 60% female nurses, 34% male nurses Cogin, J. & Fish, A. (2009). Sexual harassment--A touchy subject for nurses. Journal of Health Organization and Management, 23, 442-462.  NURSING 91% of nurses reported experiencing various kinds of sexual harassment in the workplace. 78.8% of nurses encountered teasing sexual remarks from patients and their relatives. 55.2% of nurses were asked by patients to initiate a romantic relationship. 48.5% of nurses experienced sexual jokes from patients. 45.8% of nurses experienced nonsexual touches. 20.8% of nurses experienced sexual touches during the performance of nursing tasks in healthcare settings. Bronner, G., Peretz, C., Ehrenfeld, M. (2003). Sexual harassment of nurses and nursing students. Journal of Advanced Nursing; 42(6), 637-644 HAS A “HOSTILE” ENVIRONMENT BEEN CREATED? Open discussions within earshot of other employees or patients. Promotion of an employee over another because of a sexual favor. A patient keeps asking his therapist for a date. Another employee downloads pornography onto an office computer or posts photos in the office. Supervisors or managers do nothing to change the behaviors. Dirty jokes are acceptable. Sexual slang is tolerated. YOU SHOULD NOT ACCEPT THIS AS THE NORM What is the workplace culture? What behaviors are accepted or tolerated? Not everyone perceives sexual comments or gestures (e.g. hugs) the same way. “License revocation accounted for 1.2 percent of the paid claims. These claims involved allegations of sexual misconduct and patient abandonment/neglect.” CONSIDER….. The victim as well as the harasser can be anyone. The harasser can be the victim’s supervisor, an agent of the employer, a supervisor in another area, a co-worker, or a non- employee (eg family member). The victim does not have to be the person harassed but could be anyone affected by the offensive conduct. Unlawful sexual harassment may occur without economic injury to or discharge of the victim. The harasser’s conduct must be unwelcome. FEDERATION OF STATE BOARDS OF PT (FSBPT) Sexual misconduct includes: Engaging in or soliciting sexual relationships, whether consensual or non-consensual, while a physical therapist or physical therapist assistant/patient relationship exists. Making sexual advances, requesting sexual favors or engaging in other verbal conduct or physical contact of a sexual nature with patients or clients. Intentionally viewing a completely or partially disrobed patient in the course of treatment if the viewing is not related to patient diagnosis or treatment under current practice standards.  MARYLAND CODE OF ETHICS FOR PT.02 Sexual Misconduct. A. A physical therapist or physical therapist assistant may not engage in sexual misconduct. B. Sexual misconduct includes, but is not limited to: (1) Sexual behavior with a client or patient in the context of a professional evaluation, treatment, procedure, or service to the client or patient, regardless of the setting in which the professional service is rendered; (2) Sexual behavior with a client or patient under the pretext of diagnostic or therapeutic intent or benefit; (3) Solicitation of a sexual relationship, whether consensual or nonconsensual, with a patient; (4) Sexual advances requesting sexual favors; (5) Therapeutically inappropriate or intentional touching of a sexual nature; (6) A verbal comment of a sexual nature; (7) Physical contact of a sexual nature with a patient; (8) Discussion of unnecessary sexual matters while treating a patient; (9) The taking of photographs of patients for a sexual purpose; (10) Sexual harassment of staff or students; (11) An unnecessary sensual act or comment; or (12) Sexual contact with an incompetent or unconscious patient.  VIRGINIA 18VAC112-20-190. Sexual contact. A. For purposes of § 54.1-3483 (10) of the Code of Virginia and this section, sexual contact includes, but is not limited to, sexual behavior or verbal or physical behavior that: 1. May reasonably be interpreted as intended for the sexual arousal or gratification of the practitioner, the patient, or both; or 2. May reasonably be interpreted as romantic involvement with a patient regardless of whether such involvement occurs in the professional setting or outside of it. B. Sexual contact with a patient. 1. The determination of when a person is a patient for purposes of § 54.1-3483 (10) of the Code of Virginia is made on a case-by-case basis with consideration given to the nature, extent, and context of the professional relationship between the practitioner and the person. The fact that a person is not actively receiving treatment or professional services from a practitioner is not determinative of this issue. A person is presumed to remain a patient until the patient-practitioner relationship is terminated. 2. The consent to, initiation of, or participation in sexual behavior or involvement with a practitioner by a patient does not change the nature of the conduct nor negate the statutory prohibition. C. Sexual contact between a practitioner and a former patient. Sexual contact between a practitioner and a former patient after termination of the practitioner-patient relationship may still constitute unprofessional conduct if the sexual contact is a result of the exploitation of trust, knowledge, or influence of emotions derived from the professional relationship. D. Sexual contact between a practitioner and a key third party shall constitute unprofessional conduct if the sexual contact is a result of the exploitation of trust, knowledge or influence derived from the professional relationship or if the contact has had or is likely to have an adverse effect on patient care. For purposes of this section, key third party of a patient shall mean spouse or partner, parent or child, guardian, or legal representative of the patient. E. Sexual contact between a supervisor and a trainee shall constitute unprofessional conduct if the sexual contact is a result of the exploitation of trust, knowledge or influence derived from the professional relationship or if the contact has had or is likely to have an adverse effect on patient care.  LEGAL RESOURCES US Equal Employment Opportunity Commission https://www.eeoc.gov/eeoc/newsroom/wysk/harassed_at_work.cfm Practice acts and regulations: Licensure boards HOW DO YOU MANAGE THIS? As students, contact GWU faculty for help. You do NOT have to tolerate harassment. As an employee, go to a supervisor if possible. Use the human resource director if available and be aware if the organization has a sexual harassment policy. Keep a journal with dates, who was involved, and what happened. Keep copies of written records or electronic records of harassment, if possible (e.g. emails, texts, photos) Consider if you have set appropriate boundaries (verbal, appearance, not accepting gifts etc). INSTITUTIONAL LEVEL POLICIES Employers should: conduct assessments for the risk factors have policies for protection of employees have regular training sessions for employees  https://titleix.gwu.edu/ INSTITUTIONAL LEVEL POLICIES  3 ASSERTIVE STRATEGIES TO COMBAT IPSB Positive/ Negative Active Warning Listening, Establish behavioral “I Think…”: What Broken Record expectations. you construe as the -Choose a directive Offer a positive patient’s intent statement as your outcome for “I Feel…”: Your broken record and compliance. emotion resulting from do not deviate from Offer a negative the patient’s behavior it. consequence for “I Want…”: Set out failure to comply. the expectations for -Use active listening to acknowledge the This MUST be the future enforceable. patient’s statements, but do not engage in argument. Slide from Ziádee Cambier, PT DPT  WHAT IS BOUNDARY CROSSING? anything that impinges on the therapeutic relationship between client and therapist large gifts sexual advances repeated missed appointments social contact outside of appointments 5 categories Sexual Physical Emotional Intellectual Spiritual http://www.hpso.com/risk-education/individuals/articles/Clients-who-Cross-the-Line  STRATEGIES Prevention—know practice guidelines and ethical standards, policies, etc. Act promptly—include documentation Have a plan—decision tools, witness Resolution—refer to another provider Be proactive http://www.hpso.com/risk-education/individuals/articles/Clients-who-Cross-the-Line HAVE YOU CLEARLY SET BOUNDARIES? Consider if you have set appropriate boundaries, both verbal and appearance. “I am here to take care of your arm. Let’s use the time for that purpose.” “I have a policy not to participate in social activities with patients. Let’s keep working on your strengthening exercises.” “As I mentioned before, I do not appreciate your advances. If it happens again, I will transfer you to another therapist.” GIFT GIVING Vs. CONSIDER THE FOLLOWING Does the gift suggest future preferential treatment? Will gifts change the dynamic between the provider and the patient? Will the provider feel obligated to treat the gift-giver differently? What is the timing of the gift? What is the value of the gift? EXAMPLES OF “CONFLICT OF INTEREST” Receiving gifts from equipment vendors or other suppliers if you make their product available to patients. Not revealing financial ties to device manufacturers when contributing to the research literature. Aiding referral sources and their family members hoping for more referrals (e.g. discounts, not collecting copays). PROFESSIONAL PRESENTATIONS Participation: All members of the team are expected to be integral members of the presentation from inception, planning, and delivery of the content. All deadlines are expected to be adhered to. PROFESSIONAL PRESENTATIONS Professionalism: All members are expected to treat team members with respect and professionalism. Students are representing GWPT during all presentations and should demonstrate professionalism whenever speaking with members of the community partners, guests, or other individuals. Professional communication includes prompt response and adequate time for requests to be met by peers, faculty, or community partners. PROFESSIONAL PRESENTATIONS Presentation: Students must dress in an appropriate manor when representing the program and the profession. Unless otherwise instructed it is expected that students will follow the dress code as outlined in the Guide to Success. Dress Code: Appropriate attire is expected at all times, in keeping with our representation as members of the professional community, as well as the GW community. Students should refrain from any attire that distracts from or interferes with the learning environment. Clinic Attire vs Professional Presentation 40 EMAIL COURTESY GW DPT Guide to Success (p. 19) “Faculty and staff consistently utilize email as a primary mode of communication with students; therefore, students are expected to check their GW email accounts frequently throughout the day for important announcements and to respond promptly.” “Students are required to utilize GW email accounts when communicating electronically with DPT Program faculty and administrative staff. “ DIGITAL PROFESSIONALISM In-Person Professional Digital Professional Behaviors Behaviors Professional dress Social media page layout, photos Verbal communication skills Video posts and stories Written communication skills Comments on posts, comment sections, “likes”, narrative posts, narratives on stories, product reviews Professional memberships Social media accounts, blogs What else can you think of? APPROPRIATE PROFESSIONAL USE OF DIGITAL MEDIA Connecting with other professionals Consider using dual platforms for personal social media vs. professional social media Building your brand or your organization’s brand Information gathering Public health messaging Community advocacy involvement INAPPROPRIATE USE OF DIGITAL MEDIA Never share patient information (e.g. name, diagnosis, birthdate, facility). HIPAA violation Consider how identities could be discovered Could be seen as doxing Educate yourself as to facility/clinic policies. Don’t speak on behalf of another entity. Inappropriate information sharing. Manage “friends” and “follows” carefully. Do not search for patient information. Monitor your online identity. GAGNON, K; SABUS, C. Professionalism in a Digital Age: Opportunities and Considerations for Using Social Media in Health Care. Physical Therapy. 95, 3, 406-414, Mar. 2015 DIGITAL MEDIA LANDMINES HIPAA violations Harassment Inappropriate crossing of professional boundaries Sets up the patient to have unrealistic expectations TIPS http://www.hpso.com/risk-education/individuals/articles/Perils-of-Social-Media-for-Healthcare-Professionals Be careful of all photographs. Don’t compromise the patient-therapist relationship or the employee- supervisor relationship. Do not comment about work online. Don’t publically embarrass another person. Privacy settings are not a guarantee of privacy. Use correct grammar! Be judicious with links that you share. Use the “mom” test. QUESTIONS?