Sexual professional boundaries: physiotherapy students' experiences and opinions.
Abstract: A high rate of inappropriate patient sexual behaviour (IPSB) has been reported to occur towards healthcare professionals and is associated with adverse consequences. This study aimed to: (i) determine the incidence and nature of IPSB experienced by physiotherapy students; (ii) compare students' responses to vignettes pertaining to sexual professional boundaries with responses from qualified physiotherapists; (iii) identify how prepared students felt to manage IPSB and strategies they used, and, (iv) determine if a need existed for more education on sexual professional boundaries within the undergraduate physiotherapy curriculum. A cross-sectional design with data collected via a self-complete questionnaire was used. Participants were from the BSc (Physiotherapy) final year student cohort at a West Australian university. Sixty-seven responses (48 female) were received from 109 questionnaires representing a response rate of 62%. Seventy-eight percent of respondents had experienced at least one form of IPSB and 50% had discussed the incident. Seventy-nine percent of respondents reported feeling unprepared to manage IPSB. Students were inconsistent in their attitudes regarding sexual professional boundaries in keeping with published data from physiotherapists. These findings highlight the need for education regarding IPSB and sexual professional boundaries in the undergraduate curriculum. Ang AY, Cooper I, Jenkins S. (2010): Sexual professional boundaries: physiotherapy students' experiences and opinions. New Zealand Journal of Physiotherapy 38(3) 106-112.

Key words: Patient sexual behaviour, physiotherapists, students
Article Type: Survey
Subject: Physical therapists (Behavior)
Physical therapists (Surveys)
Physical therapy (Health aspects)
Physical therapy (Surveys)
Therapeutics, Physiological (Health aspects)
Therapeutics, Physiological (Surveys)
Students (Sexual behavior)
Students (Surveys)
Authors: Ang, Alethea Yi-Chen
Cooper, Ian
Jenkins, Sue
Pub Date: 11/01/2010
Publication: Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 New Zealand Society of Physiotherapists ISSN: 0303-7193
Issue: Date: Nov, 2010 Source Volume: 38 Source Issue: 3
Product: Product Code: 8043600 Physical Therapists NAICS Code: 62134 Offices of Physical, Occupational and Speech Therapists, and Audiologists SIC Code: 8049 Offices of health practitioners, not elsewhere classified
Geographic: Geographic Scope: Australia Geographic Code: 8AUST Australia
Accession Number: 263880354
Full Text: INTRODUCTION

Sexual harassment in healthcare settings has been reported to occur at a high rate in the form of inappropriate patient sexual behaviour (IPSB) towards healthcare professionals (McComas et al 1993). Inappropriate patient sexual behaviour has been defined as "a verbal or physical act of an explicit or perceived sexual nature which is unacceptable within the social context in which it is carried out" (Johnson et al 2006). These acts can vary from forced physical advances to innuendos and sexist remarks (McComas et 1993). Specific to the physiotherapy profession, the close physical proximity, partial disrobing of patients and interpersonal relationships established over a course of treatment places physiotherapists at risk of experiencing IPSB.

Inappropriate patient sexual behaviour can lead to the development of significant physical and psychological symptoms (Fitzgerald et al 1988, Hotelling 1991, McComas et al 1993). These consequences can negatively impact on a physiotherapist's work in the form of absenteeism, reduced productivity, lack of confidence and poor concentration (Fitzgerald et al 1988, Weerakoon and O'Sullivan 1998). For students and educators, the effects of IPSB have the potential to reduce the quality of the learning experience (Hotelling 1991). However, despite reports of such consequences, there is a paucity of studies that describe the frequency and nature of IPSB towards physiotherapists. Further, there are no reported studies describing the frequency and nature of IPSB experienced by physiotherapy students outside of North America.

Surveys of graduate and undergraduate physiotherapists carried out in North America and graduate physiotherapists in New Zealand and Australia provide some evidence of a high incidence (40--80% of respondents) of IPSB (Cooper and Jenkins 2008, Cullen 1997a, deMayo 1997a, McComas et al 1993, Weerakoon and O'Sullivan 1998). Several reasons have been proposed to explain the occurrence of IPSB in healthcare settings. These include the side effects of the medications prescribed to some patients; behavioural changes resulting from neurological impairments; patients feeling isolated and needing reassurance due to prolonged hospitalisation, and the perception of physiotherapists as sexual beings (Cullen et al 1997a, McComas et al 1993, Weerakoon and O'Sullivan 1998, Johnson et al 2006). Irrespective of the cause, the magnitude of the problem reported in some studies identifies IPSB as important in the clinical setting and has the potential to affect the professional relationship (deMayo 1997a, McComas et al 1993, Weerakoon and O'Sullivan 1998).

The New Zealand Society of Physiotherapists, consistent with other similar organisations, publishes a code of practice detailing the expected behaviour of the physiotherapist engaged in professional practice (New Zealand Society of Physiotherapists 2003). There is no commentary within such documents on the expected behaviours of patients engaged in a professional relationship with their physiotherapist. Likewise, the Health and Disability Act (1994) legislates on the rights of the individual under its Act and Code; however, other than the expectations published by local health authorities, which vary considerably, there is no legislated behavioural requirements of the patient (Health and Disability Commissioner 2010).

The lack of training relating to IPSB, and the need for the issue to be addressed at both an undergraduate and postgraduate level, has been reported in the literature (deMayo 1997a, McComas et al 1993, Weerakoon and O'Sullivan 1998). Targeted education has been deemed an essential component when preparing physiotherapy students and physiotherapists to manage incidents of IPSB (deMayo 1997, Weerakoon and O'Sullivan 1998). However, survey findings reveal that physiotherapists and physiotherapy students often report receiving no formal training relating to IPSB (deMayo 1997a, McComas et al 1995). At Curtin University, physiotherapy students can attend a one hour, non compulsory lecture that examines patient sexuality, IPSB and inappropriate therapist behaviour. The IPSB component is approximately one third of this lecture. This lecture occurs in the 2nd year of training prior to the commencement of clinical placements (Moss P. pers. comm., Jul 10 2008)

The need to further develop policies and guidelines regarding sexual professional boundaries, and the education of physiotherapists regarding these policies and guidelines has been identified by authors who have reported on the issue of sexual professional boundaries between physiotherapists and their patients (Cooper and Jenkins 2008, Cullen et al 1997a, Delaney 2009). These needs arise from the findings of studies carried out in New Zealand and Australia that demonstrated a variation in the attitudes of physiotherapists regarding sexual professional boundaries (Cooper and Jenkins 2008, Cullen et al 1997a). Physiotherapists were shown to be inconsistent when faced with vignettes describing professional boundary violations. Further, a significant proportion of the physiotherapists reported they had dated a patient or were aware of colleagues who had done so (Cooper and Jenkins 2008, Cullen et al 1997a, Cullen et al 1997b).

The primary aim of this study was to determine the incidence and nature of IPSB experienced by final year physiotherapy students. This study also sought to: (i) identify how prepared students felt to manage IPSB and the strategies they used; (ii) compare students' attitudes to those of qualified physiotherapists regarding sexual professional boundaries (Cooper and Jenkins 2008); (iii) determine whether a need existed for more education on sexual professional boundaries within the undergraduate physiotherapy curriculum, and, (iv) provide data to guide a review of the undergraduate physiotherapy curriculum relating to professional practice.

METHODS

This study utilised a cross-sectional design with data collected via a self-complete questionnaire. Approval for the study was granted by the Human Research Ethics Committee of Curtin University. This study complied with the requirements of the Ethical Guidelines for Observational Studies (National Ethics Advisory Committee 2006). Consent to participate was implied by return of the completed questionnaire.

Questionnaire

The questionnaire consisted of 47 questions divided into six parts. Questions in Parts 1 and 2 were mostly derived from previous questionnaires, with permission from the authors (Cullen et al 1997a, McComas et al 1997, Cooper and Jenkins 2008). The study performed by Cooper and Jenkins (2008) in Australia utilised the questionnaire developed by Cullen at al (1997a) who first examined issues of sexual contact in the physiotherapy professional relationship in New Zealand. Modifications were made to some questions to ensure they were relevant to students.

Part 1 contained 16 questions pertaining to the specific forms of IPSB experienced (McComas et al 1997). The final question in Part 1 asked which clinical placements the respondent had completed and whether IPSB had been experienced during these placements.

Part 2 of the questionnaire comprised 13 questions that were divided into three sections. The first six questions related to professional sexual boundaries and the student's personal experience. This was followed by vignettes describing sexual contact between; (i) a physiotherapist and a patient (five vignettes), and, (ii) a supervising physiotherapist and a physiotherapy student (one vignette). These vignettes were identical to those used in our previous study (Cooper and Jenkins 2008). The respondent was asked to choose a single response to the vignette on a five-point scale that ranged from 'This is OK and I might do it if the circumstances were right', to, 'This is so wrong that the physiotherapist involved should be barred from practice'. The last question described a hypothetical scenario of alleged sexual misconduct by a physiotherapist. Respondents were told to assume they were a qualified physiotherapist and to choose, from 10 options, the action(s) they would take in the scenario described.

The third part of the questionnaire collected demographic information from the respondents. Parts 4 and 5 included closed and open-ended questions. Three questions (Part 4) pertained to education on IPSB in the BSc (Physiotherapy) course. The four questions in Part 5 only applied to respondents who had experienced IPSB and asked about the actions taken after the incident, their satisfaction and outcomes of those actions, and any barriers to discussing the incident of IPSB. Part 6 asked for any additional comments.

Participants

Participants were the final year students enrolled in the four year Bachelor of Science (BSc) in Physiotherapy at Curtin University (Perth, Western Australia) in 2008.

Distribution of questionnaire

Prior to distribution of the study documents (i.e. participant information sheet, questionnaire and return envelopes), an email was sent to potential participants that described the study and a message was posted via the School's web communication system. The aim of these messages was to raise awareness of the study and to encourage participation.

Distribution of the study documents occurred at the end of two scheduled teaching sessions during September and October 2008. The primary investigator (AA) attended these sessions to provide information about the study, the potential contribution students could make through their participation and to distribute the study documents. The deadline for return of the completed questionnaire was the 21st November 2008. Students who were not present at either of these sessions were requested to collect the study documents from the School of Physiotherapy Office.

Participants returned their completed questionnaire to the School Office. The completed questionnaire was placed within a blank envelope that was concealed inside a second (outer) envelope on which the student's name was printed. A School staff member, who was not involved in the study, recorded the student's name before discarding the outer envelope. Students whose names were not recorded (i.e. did not return a questionnaire) were sent an email by this staff member, three days prior to the deadline for return of the questionnaire, asking them to consider participating in the study. The blank envelopes containing the completed questionnaires were given to the investigators once the final date for the return of the questionnaires had passed. This distribution method ensured anonymity and aimed to optimize the response rate.

Preliminary studies

Two preliminary studies were carried out with a cohort of 11 recent BSc (Physiotherapy) graduates. The aim was to refine the questionnaire and the participant information sheet. The participants identified that minor amendments to one question were required to improve clarity. No changes to the information sheet were required. On average, participants took 12 minutes to complete the questionnaire.

Data analysis

Analyses were performed using SPSS (Version 17.0). A probability (p) value < 0.05 was regarded as significant. Analyses comprised descriptive statistics, tests of single proportions, Chi-squared test, cross tabulations and Fisher's exact test. Responses to open-ended questions were classified into common themes.

Responses obtained to the questions in Part 2 of the questionnaire were compared with the responses obtained from 939 qualified physiotherapists in a recent study published by the authors (Cooper and Jenkins 2008).

RESULTS

Sixty-seven responses (from 48 female and 19 male students) were received from the 109 questionnaires distributed. This equates to a response rate of 62%. The proportions of males (19/35) and females (48/74) that responded were not significantly different (p=0.29) and were representative of the demographics of the student cohort. The majority of the respondents (88%) were aged 19-24 years. Ninety-nine percent of all data cells were completed by respondents.

Inappropriate patient sexual behaviour

Table 1 displays data for the clinical placements undertaken by students and whether IPSB occurred. Musculoskeletal (99%), cardiopulmonary (91%) and neurology (84%) were the most common placements undertaken. The highest incidence of IPSB occurred on neurology placements followed by rural and then musculoskeletal placements (Table 1).

Fifty-two (78%) respondents (39 females, 13 males) indicated they had experienced at least one form of IPSB. The most common forms of IPSB experienced were patients telling suggestive stories or offensive jokes (47%) and patients making suggestive remarks about the student's appearance (43%). The least frequent forms of IPSB experienced were being propositioned by a patient to have sexual intercourse, receiving suggestions from a patient to engage in fondling with him/her, and having a patient deliberately expose his/her genitals or breasts (1 response for each).

Experiences and opinions relating to professional sexual boundaries

Students' reports of experiences relating to professional sexual boundaries are shown in Table 2 together with the responses from physiotherapists obtained in a previous study by the authors (Cooper and Jenkins 2008). In all cases, a lower proportion of students reported the experience when compared with qualified physiotherapists, however, none of these differences were significant (all p>0.05). Ten percent of students, in contrast to 50% of the physiotherapists, reported they had felt sexually attracted towards a patient. When compared to the students' responses, a higher proportion of physiotherapists had dated a patient or ex-patient or were aware of a colleague who had done so (Table 2),

Table 3 displays the responses of students and physiotherapists to the vignettes pertaining to professional sexual boundaries. Students and physiotherapists gave similar responses to four of the six vignettes (vignettes C to F). In vignette A, students were more likely (p=0.002) to find it acceptable for a physiotherapist to tell a patient that he/she felt much better after giving the patient a massage, and that it would be the patient's turn to give the massage to the physiotherapist the next time. Significantly more physiotherapists felt that it was acceptable for a single physiotherapist working in a rural physiotherapy practice to develop a sexual relationship with a patient to whom they were providing ongoing care (p=0.002).

Courses of action in alleged sexual misconduct

Table 4 illustrates the courses of action students and physiotherapists selected in response to the hypothetical scenario describing an incidence of alleged sexual misconduct. There was congruence between students and physiotherapists in the three most commonly selected responses. Physiotherapists were twice as likely to report their colleague to the relevant Physiotherapists' Registration Board compared to students, however this difference was not significant (p=0.44).

Education on inappropriate patient sexual behaviour and professional sexual boundaries

The majority of students (79%) reported that they did not feel adequately prepared by the education received in their BSc (Physiotherapy) course to deal with IPSB. One-third (67%) of the respondents who made comments considered the content on IPSB to be insufficient. Eighty-two percent of respondents regarded education on IPSB to be important and females were significantly more likely to report this than males (n=43, 90% vs n=12, 63% respectively, p=0.03).

Twenty-five respondents (56%) made suggestions for the course content relating to IPSB that could be classified under the themes of knowledge and coping skills, consistent with McComas et al (1995). The knowledge theme included descriptions of IPSB, reporting procedures for IPSB, roles and powers of relevant disciplinary bodies, patient and professional rights, and the legal ramifications associated with IPSB. The coping skills theme comprised strategies to manage incidents of IPSB and the available support services to deal with the effects of IPSB.

Ten respondents (22%) made suggestions relating to the format for delivering education pertaining to IPSB. These included lectures from speakers with specific knowledge of IPSB issues, and tutorials and seminars to discuss case studies. Three respondents stated that the educational content relating to IPSB should constitute only a very small part of the curriculum. Seven respondents (16%) stated that no additional content relating to IPSB should be incorporated into the existing BSc (Physiotherapy) course.

Dealing with inappropriate patient sexual behaviour (Part 5)

Where incidences of IPSB had been encountered, respondents were equally divided as to whether they had discussed the incident with another person. Persons with whom respondents had discussed the incident(s) included fellow students (n=13), clinical facility tutors (n=9) and university clinical tutors (n=6). Participants less commonly discussed an incident of IPSB with family members, friends, partners or ward staff (n = 4). The majority of the respondents (n=25, 93%) who discussed an incident of IPSB were satisfied with the outcome of the discussion.

Fifteen of the 20 (75%) respondents who did not discuss an incident of IPSB reported that they did not feel any barriers to doing so. The remaining five respondents identified the following barriers to discussing an incident of IPSB. Emotional barriers included feeling embarrassed, ashamed or uncomfortable discussing the incident. The cognitive barriers comprised perceiving that the incident of IPSB to be inappropriate for discussion; not perceiving the incident to be sufficiently severe, invasive or threatening that it would require any action, and, being concerned about how they would be perceived by others if they discussed an incident of IPSB.

Fourteen individuals (44%) responded to the question asking for details of other strategies for dealing with an incident of IPSB (i.e. other than discussing it with another person). Most respondents had chosen to ignore or let the incident pass (n=10, 71%). The next most common response was to let the patient know that their behaviour was inappropriate (n=4, 29%).

DISCUSSION

Whilst a few studies have explored the incidence and nature of IPSB toward qualified physiotherapists and other healthcare workers, this is the first study to report the frequency and nature of IPSB experienced by physiotherapy students in Australia. Despite the fact that the most frequent forms of IPSB reported were at the 'mild' end of the spectrum (McComas et al 1993), it was considered important enough for the respondents to suggest that education on how to manage this unwarranted behaviour should be included in the undergraduate curriculum.

The highest incidence of IPSB occurred in a neurological setting which may, in part, be explained by the relevant pathologies or injuries to the brain (Johnson et al 2006). The higher occurrence of IPSB in a musculoskeletal outpatient or rural setting, may in part be due to differences in the physical appearance and behaviour in these settings compared to a large metropolitan hospital. In outpatient and rural settings, the traditional role of health practitioner and patient may be considered to be less clearly delineated and the occurrence of IPSB in such settings should serve as a warning to both student physiotherapists and physiotherapists working in these areas. In order to reduce the risk of IPSB it is important to ensure that clear professional boundaries are established in these less formal settings.

Managing IPSB

Consistent with other reports (McComas et al 1995), the findings of this study support the need for education to raise awareness of IPSB, identify the early warning signs and provide strategies to handle IPSB. The participants in our study differed in the ways they chose to manage incidents of IPSB. The majority of respondents who did not discuss an incident of IPSB chose to ignore it, consistent with published findings (McComas et al 1993, Weerakoon and O'Sullivan 1998). In previous studies the respondents reported that by choosing to ignore this behaviour would result in it ceasing (McComas et al 1993, Weerakoon and O'Sullivan 1998). This is in contrast to the belief that ignoring IPSB demonstrates vulnerability or permission for the behaviour to continue (McComas et al 1995). It has been suggested that a direct approach, such as confronting the patient, is likely to be the most effective management strategy (Bravo and Cassedy 1992, McComas et al 1995).

The finding that only 50 percent of the respondents discussed an incident of IPSB with another person lends support to the claim by Hotelling (1991) that the reluctance of victims to report such incidents to the appropriate authorities causes the issue to remain "hidden". Students may be choosing this path to conceal from their supervisors their inability to handle the problem (McComas et al 1995).

Whilst this study did not report any gender differences in the incidence of IPSB, females rated the need for education more highly than males, possibly due to a perception that they are at greater risk of IPSB (Leslie and Williams 2005). The need for education regarding IPSB is a major recommendation to physiotherapy educators and managers.

Comparisons with qualified physiotherapists

Students differed from qualified physiotherapists in the incidence of sexual attraction towards patients and dating of patients. This may reflect their relative limited exposure to clinical practice. It is imperative that students are cognisant of studies that demonstrate that sexual attraction is more likely to be reported by physiotherapists who have worked a long time in the profession (Cooper and Jenkins 2008, Cullen et al 1997a, Cullen et al 1997b). Complacency during an early stage of a students' career may result later in what has been described as the 'slippery slope' where health practitioners gradually erode the professional boundary thus exposing them to greater risk of boundary violation (Gallety 2004). Both students and physiotherapists were inconsistent in what was deemed acceptable in hypothetical cases of sexual professional boundaries. One possible factor contributing to this finding may be a lack of sufficient education on this topic at both an undergraduate and postgraduate level. Students and physiotherapists should be cognisant of the fact that both groups were less conservative in their views towards a physiotherapist employed in a rural setting who had transgressed the sexual professional boundary. Whilst factors such as the small population and often close personal relationships within a small rural community may make the establishment of a professional relationship more difficult, nonetheless, the current Codes of Ethical Principles or the Professional Sexual Boundaries Policy of the New Zealand Society of Physiotherapists (NZSP 2003) and the Code of Conduct of the Australian Physiotherapy Association (APA 2008) does not differentiate between setting and the issue of relationships with patients. This in an important message when educating both students and physiotherapists regarding the sexual professional boundary.

While in general students and physiotherapists were similar in the actions they would take in a case of alleged sexual misconduct towards a colleague, students were less likely to report their colleague to the relevant Physiotherapists' Registration Board. This may simply reflect a lack of knowledge as to the appropriate actions in this scenario. Issues around complaint handling need to be included within the undergraduate curriculum.

Physiotherapy students were no different from their qualified peers in that they are exposed to a high incidence of IPSB. Whilst they reported a lower incidence of patient attraction and dating of patients they were likewise inconsistent in their views of the physiotherapists' behaviour described in a series of vignettes that portrayed violations of the sexual professional boundary.

The results of this study are consistent with those of other health professions that reported a high incidence of IPSB towards medical students (Schulte 1994) and psychology students (deMayo 1997b).

Recommendations

The data obtained in this survey provide support to the recommendations of previous studies that reported the need for education on the topic of IPSB. This education should be expanded to include all aspects of the professional relationship with particular attention towards those working in a rural community.

A limitation of this study is the small number of male respondents. Whilst the proportion of male respondents was representative of the study cohort their numbers prevented comparisons between students and physiotherapists according to gender. Social desirability bias, where an individual may respond in a way that is deemed more acceptable by others rather than present their true feelings, needs to be considered in this study, especially in response to questions pertaining to experiences and attitudes regarding sexual professional boundaries (Kreuter et al 2008). A further limitation is the restriction of the study to one School of Physiotherapy in one State of Australia. We recommend that this study is replicated both nationally and internationally. The response rate achieved in this study was acceptable given the sensitive nature of its content (Edwards et al 2002, Portney and Watkins 2009).

Further studies are required to investigate the impact of targeted education on the topic of IPSB in particular to measure both the rate of IPSB experienced and its impact. These studies should further compare the responses from physiotherapists working in rural and metropolitan settings to vignettes set in a rural and metropolitan setting. Finally, studies should seek to determine whether the ethnic background of students and physiotherapists influences responses to questions regarding IPSB,

KEY POINTS

There is a high incidence of IPSB towards student physiotherapists

* The highest incidence of IPSB was reported in a neurological, rural and musculoskeletal outpatient settings

* Student physiotherapists were similar to qualified physiotherapists in being inconsistent in their views of the physiotherapists' behaviour detailed in a series of vignettes describing violations of the sexual professional boundary

* Education on all aspects of the professional sexual boundary is recommended

ACKNOWLEDGEMENTS

The authors thank Peter McKinnon for statistical advice and Leslie Watts and Erin Cecins for their assistance with data collection. We also thank the student physiotherapists who completed the survey and the physiotherapists who participated in the pilot studies.

REFERENCES

Australian Physiotherapy Association (2008). APA corporate documents: APA code of conduct. http://physiotherapy.asn.au/images/Document_Library/Governance/ apa_code_of_conduct.pdf. [Accessed Sep 19, 2008].

Bravo E and Cassedy E (1992): The 9 to 5 guide to combating sexual harassment. New York: John Wiley. pp. 68-80.

Cooper I. and Jenkins S (2008): Sexual boundaries between physiotherapists and patients are not perceived clearly: an observational study. The Australian Journal of Physiotherapy 54: 275-279.

Cullen R, Davidson M and Guthrie B (1997a): Sexual contact in the professional relationship: the 1996 survey of NZSP members. New Zealand Journal of Physiotherapy 25(2): 7-9.

Cullen R, Davidson M and Guthrie B (1997b): Physiotherapists who have had sexual contact with patients: the 1996 NZSP survey. New Zealand Journal of Physiotherapy 25(3): 7-9.

Cooper I and Jenkins S (2008): Sexual boundaries between physiotherapists and patients are not perceived clearly: an observational study. The Australian Journal of Physiotherapy 54: 275-279.

Delaney C (2009): Ethics education will help clarify issues. The Australian Journal of Physiotherapy 55: 72.

deMayo RA (1997a): Patient sexual behaviours and sexual harassment: a national survey of physical therapists. Physical Therapy 77: 739-744.

deMayo RA (1997b): Patient sexual behavior and sexual harassment: a national survey of female psychologists. Professional Psychology: Research and Practice 28: 58-62

Edwards PI, Roberts, Clarke M, DiGuiseppi C, Pratap S, Wentz R, Kwan I (2002): Increasing response rates to postal questionnaires: Systematic review. British Medical Journal 324: 1183-1191.

Fitzgerald LS, Shullman S, Bailey N, Richards M, Swecker J, Gold Y, Ormerod M, Weitzman L (1988): The incidence and dimensions of sexual harassment in academia and the workplace. Journal of Vocational Behaviour 32: 152-175.

Galletly CA (2004): Crossing professional boundaries in medicine: the slippery slope to patient sexual exploitation. The Medical Journal of Australia 181: 380-388.

Health and Disability Commissioner (2010). Health and Disability Commissioner Act 1994. http://www.hdc.org.nz/the-act--code/the-code-of-rights/the-code-(full) [Accessed 14th October 2010]. Hotelling K (1991): Sexual harassment: a problem shielded by silence. Journal of Counseling and Development 69: 497-501.

Johnson C, Knight C, Alderman N (2006): Challenges associated with the definition and assessment of inappropriate sexual behaviour amongst individuals with an acquired neurological impairment. Brain Injury 20 : 687-693

Kreuter F, Presser S and Tourangeau R (2008): Social desirability bias in CATI, IVR, and web surveys. Public Opinion Quarterly 72: 847-865.

Leslie C and William EH (2005): Categories of sexual harassment: a preliminary analysis [Ph.D thesis]. Kent State University. In. Ohio 1-6.

McComas J, Herbert C, Giacomin C, Kaplan D, Dulberg C (1993): Experiences of student and practicing physical therapists with inappropriate patient sexual behavior. Physical Therapy 73: 762-770.

McComas J, Kaplan D, Giacomin C (1995): Inappropriate patient sexual behaviour in physiotherapy practice: a qualitative analysis of questionnaire comments. Physiotherapy Canada 47: 127-133.

Moss P pers. comm., Jul 10 2008 Curtin University, Perth, Western Australia.

National Ethics Advisory Committee (2006). Ethical guidelines for observational studies: observational research, audits and related activities. http://www.neac.health.govt.nz/moh.nsf/pagescm/520/$File/ethicalguidelines.pdf [Accessed 14th October 2010]

New Zealand Society of Physiotherapists (2003). NZSP Guidelines for the Code of Ethical Principles. http://www.nzsp.org.nz/Category?Action=View&Category_id=300 [Accessed Sep 19, 2008].

New Zealand Society of Physiotherapists (2003). NZSP Policy on Professional Sexual Boundaries http://www.nzsp.org.nz/ Category?Action=View&Category_id=300 [Accessed Sep 19, 2008].

Portney LG and Watkins MP (2009): Foundations of clinical research. (3rd ed.). New Jersey: Prentice-Hall Inc. pp. 285-312.

Schulte H, Kay J (1994): Medical students' perceptions of patient-initiated sexual behavior. Academic Medicine. Oct; 69(10) 842-846.

Weerakoon P and O'Sullivan V(1998): Inappropriate patient sexual behaviour in physiotherapy practice. Physiotherapy 84: 491-499.

Alethea Yi-Chen Ang, BSc (Physiotherapy) Hons (1)

Ian Cooper Grad DipPhys, Post Grad Dip, HealthAdmin (1,2)

Sue Jenkins Grad DipPhys, PhD (1,2,3)

(1) School of Physiotherapy and Curtin Health Innovation Research Institute, Curtin University, Perth Western Australia

(2) Physiotherapy Department, Sir Charles Gairdner Hospital, Perth, Western Australia

(3) Lung Institute of Western Australia and Centre for Asthma, Allergy and Respiratory Research, University of Western Australia, Perth, Western Australia

ADDRESS FOR CORRESPONDENCE

Associate Professor Sue Jenkins, School of Physiotherapy, Curtin University, GPO Box U1987, Bentley, Western Australia 6845. Tel: (+61) 8 9266 3639, Fax: (+61) 8 9266 3699. Email: S. Jenkins@curtin.edu.au
Table 1: Frequency of IPSB encountered by clinical placement
type

                                               Number (%)
                         Number (%) of        of students
                      students undertaking    experiencing
Clinical placement         placement              IPSB

Neurology                   56 (84)             20 (36)
Rural                       44 (66)             14 (32)
Musculoskeletal             66 (99)             19 (29)
Outpatients
Gerontology                 36 (54)              6 (17)
Elective *                  55 (82)              9 (16)
Cardiopulmonary             61 (91)              6 (10)
Paediatrics                 35 (52)              1 (3)
International               14 (21)              0 (0)

* Elective includes placements in amputees, burns, private
practice.

Table 2: Experiences relating to sexual professional
boundaries reported by students and physiotherapists

Experience                         Students     Physiotherapists
                                     n=67            n=939

Felt sexually attracted to a        7 (10)         470 (50) *
patient

Dated a current patient              0 (0)          37 (4) *

Dated an ex-patient                  0 (0)         160 (17) *

Aware of a fellow student/
colleague who has dated a            3 (4)         310 (33) *
current patient

Aware of a fellow student/           6 (9)         563 (60) *
colleague who has dated an
ex-patient

Data are numbers of respondents with percentages in
parentheses. * p < 0.001 students vs physiotherapists.

Table 3: Responses to sexual professional boundaries vignettes
from students (n=67) and physiotherapists (n=939)

Vignette                                             Acceptable

                                                    S           PT

A. After receiving therapeutic massage, a        17 (25)    90 (10) *
patient says he/she is feeling much better.
The physiotherapist replies that he/she is
too and it would be the patients turn to give
the massage to the physiotherapist next time.

B. A single physiotherapist in partnership in    9 (13) *    292 (31)
a rural area meets one of his/her patients
socially on a number of occasions and they
develop a sexual relationship. He/she
continues to provide him/ her with on-going
care for a chronic condition.

C. A physiotherapist has a sexual                 0 (0)       17 (2)
relationship with a patient while continuing
to act as his/her physiotherapist and as
physiotherapist to his/her children, and on
occasions to his/her spouse. The
physiotherapist has made the acquaintance of
the family through his/her position as a
physiotherapist.

D. A physiotherapist invites a patient to         3 (5)      111 (12)
meet him/her at a bar after work for a drink.
A sexual relationship develops and the
physiotherapist continues to provide
professional services.

E. A female physiotherapist is invited by her    40 (60)     614 (66)
brother to be the physiotherapist for his
rugby team. She agrees and a few weeks later
accepts an invitation to go on a date with
one of the team members.

F. A physiotherapist supervising a final year     2 (3)       61 (6)
physiotherapy student offers to assist them
out of normal working hours with their
studies. A sexual relationship develops
whilst the student remains under the direct
supervision of that physiotherapist.

Vignette                                                Unsure

                                                    S            PT

A. After receiving therapeutic massage, a         7 (10)       41 (4)
patient says he/she is feeling much better.
The physiotherapist replies that he/she is
too and it would be the patients turn to give
the massage to the physiotherapist next time.

B. A single physiotherapist in partnership in     9 (13)      127 (14)
a rural area meets one of his/her patients
socially on a number of occasions and they
develop a sexual relationship. He/she
continues to provide him/ her with on-going
care for a chronic condition.

C. A physiotherapist has a sexual                 3 (4)        10 (1)
relationship with a patient while continuing
to act as his/her physiotherapist and as
physiotherapist to his/her children, and on
occasions to his/her spouse. The
physiotherapist has made the acquaintance of
the family through his/her position as a
physiotherapist.

D. A physiotherapist invites a patient to         5 (7)        66 (7)
meet him/her at a bar after work for a drink.
A sexual relationship develops and the
physiotherapist continues to provide
professional services.

E. A female physiotherapist is invited by her    11 (16)      148 (16)
brother to be the physiotherapist for his
rugby team. She agrees and a few weeks later
accepts an invitation to go on a date with
one of the team members.

F. A physiotherapist supervising a final year     4 (6)        32 (3)
physiotherapy student offers to assist them
out of normal working hours with their
studies. A sexual relationship develops
whilst the student remains under the direct
supervision of that physiotherapist.

Vignette                                             Unacceptable

                                                    S            PT

A. After receiving therapeutic massage, a        43 (64)      807 (93)
patient says he/she is feeling much better.
The physiotherapist replies that he/she is
too and it would be the patients turn to give
the massage to the physiotherapist next time.

B. A single physiotherapist in partnership in    49 (73)      520 (56)
a rural area meets one of his/her patients
socially on a number of occasions and they
develop a sexual relationship. He/she
continues to provide him/ her with on-going
care for a chronic condition.

C. A physiotherapist has a sexual                64 (96)      910 (97)
relationship with a patient while continuing
to act as his/her physiotherapist and as
physiotherapist to his/her children, and on
occasions to his/her spouse. The
physiotherapist has made the acquaintance of
the family through his/her position as a
physiotherapist.

D. A physiotherapist invites a patient to        59 (88)      760 (81)
meet him/her at a bar after work for a drink.
A sexual relationship develops and the
physiotherapist continues to provide
professional services.

E. A female physiotherapist is invited by her    16 (24)      171 (19)
brother to be the physiotherapist for his
rugby team. She agrees and a few weeks later
accepts an invitation to go on a date with
one of the team members.

F. A physiotherapist supervising a final year    61 (91)      846 (91)
physiotherapy student offers to assist them
out of normal working hours with their
studies. A sexual relationship develops
whilst the student remains under the direct
supervision of that physiotherapist.

Data are numbers of respondents with percentages in parentheses. S
= student; PT = physiotherapists. Acceptable comprises the response
choices "This is OK and I might do it if the circumstances were
right" and "I wouldn't do this, but I wouldn't criticise anybody
who did'; Unsure, "I don't know if this is right or wrong";
Unacceptable comprises the response choices "This behaviour is
wrong" and "This behaviour is so wrong that the physiotherapist
involved should be barred from practice". * p<0.05 (Chi-squared
test) students vs physiotherapists.

Table 4: Responses to a hypothetical scenario regarding
inappropriate therapist sexual behaviour

                                       Students   Physiotherapists
Response                                 n=67          n=939

Advise the patient that he/she         50 (75)        782 (83)
may lay a complaint by writing
to the appropriate disciplinary
body

Offer to talk to your colleague        30 (45)        286 (30)
and then get back to the
patient

Comfort the patient                    18 (27)        244 (26)

Report him/her to the                   6 (9)         174 (19)
Physiotherapists' Registration
Board

Report him/her to the Australian       11 (16)        142 (15)
Physiotherapy Association's
Professional Standards Panel

Inform the Health Department's         51 (76)         56 (6)
Office of Health Review

Offer to arrange a meeting to          15 (22)        207 (22)
discuss the incident between
the patient, your colleague and
yourself

Inform the patient that this is        10 (15)        142 (15)
something she should take up
with your colleague

Assure the patient that she must        0 (0)          9 (1)
have misinterpreted whatever
your colleague did

Do nothing                              0 (0)          3 (<1)

Data are numbers of respondents with percentages in
parentheses.
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