A question from her mother about current physiotherapy practice prompted CSP professional adviser Gwyn Owen to reflect on the part touch plays in the profession.
Are physiotherapists still taught to touch patients?’ my mum asked a couple of weeks ago.
She’d been chatting to her friend Helen (not her real name), who’d just seen a physiotherapist.
After asking Helen questions, the physio printed off an exercise sheet and sent her off to make a follow-up appointment.
This was not what Helen had expected.
‘How can the physio know what’s wrong with me, or show me what I need to do without touching me?’ she asked.
It was Helen’s frustration and disappointment that led to my mum’s question. It made me uncomfortable. I could see the situation from both sides.
Helen is right: physiotherapy is a profession that works through touch. Touch runs through the approaches and modalities that sit within the scope of physiotherapy practice defined by the CSP’s Royal Charter.
Definitions of contemporary physiotherapy refer to using touch and movement to assess clients’ movement and function, and to decide on interventions.
And we only have to look at the CSP’s lozenge badge to see physiotherapy’s use of touch represented symbolically by a pair of hands.
Physiotherapy’s use of touch is potentially challenging. Touch requires us to enter the personal space of someone we may not have met before. Next time you’re travelling on a busy bus or train, or walking in a crowd, notice what happens when someone bumps into you accidentally.
Often an apologetic look acknowledges that a social boundary has been crossed.
In the context of physiotherapy, the process of crossing that boundary, from my space and into yours, takes time and requires attention – to ensure that the touch-based relationship is comfortable for both parties.
Failure to establish a professional touch-based relationship based on mutual trust and respect produces an imbalance of power, which will cause considerable discomfort and distress for the person we touch.
This could potentially lead to disciplinary action – from our employer and even from the Health and Care Professions Council.
The intimacy of touch-based practice moves beyond normal social relations, which is why the use of touch is subject to professional codes and regulatory frameworks (see resources box below).
The intimacy of touch also challenges organisations seeking to control costs by providing service sthat can be standardised, quantified and delivered in a short timeframe.
Perhaps a drive for increased productivity left Helen untouched by her physiotherapist.
Touch in practice
Touch is socially constructed: who touches what or whom, and how, for example, depends on cultural, historical, political and social contexts.
Think of examples when you modified your use of touch because your client was not willing to be touched – perhaps because of a history of being physically or sexually abused, or because of religious beliefs, for example.
Or when someone consented to be touched in the privacy of a consulting room, while declining to be touched in the open environment of the gym.
The literature shows that touch is an integral part of three different types of physiotherapy-related activity.
Touch can be physical. We touch someone as we help them transfer from their wheelchair on to a treatment couch, or as we fasten their gown before mobilising them on the ward.
We use touch with talk and observation to conduct our assessments. And then physical touch can become our mode of treatment – as a specific technique, for example.
Touch is also about communication. It enables us to establish and maintain a working relationship – complementing our use of speech with physical gestures.
Touch is also how we gather information about our client’s body – we palpate soft tissues, handle limbs, feel the temperature and texture of someone’s skin.
Touch is also present as we show someone how to perform an activity – as we move a limb in the direction it needs to go in order, for example. And then there’s the emotional work we achieve through touch – holding a client’s hand if he or she is frightened by the thought of a particular intervention, for example.
If we can articulate what we can achieve through touch, it becomes possible to develop arguments that are supported with concrete evidence to challenge the drive to cut the time we spend with clients.
And that is what the continuing professional development (CPD) activity is designed to help you do. fl
Touch and professionalism: resources
- Go on to the CSP’s website at: www.csp.org.uk and search for ‘consent’, ‘duty care’, ‘chaperone’, ‘PFC’ and ‘appearance’.
- Soundy A et al (2013) Sexual professional boundaries perceived by undergraduate and graduate physiotherapists: A cross sectional survey. Physiotherapy (online first).
- Visit: www.sciencedirect.com/science/article/pii/S003194061200140X
Beyond the CSP
NHS Employers/Council for Healthcare Regulatory Excellence (2009) Clear sexual boundaries between healthcare professionals and patients: information for patients and carers.
Visit: www.nhsemployers.org and search for ‘sexual’.
Using this article
This CPD activity aims to help you think critically about what your touch-based practice achieves, and how you might construct an evidence-based argument to challenge a proposal to limit your ability to use touch.
Thinking about your work with clients, describe how you use touch. Think about your use of touch along the timeline of a specific session with your clients.
Some key points to consider are:
- How do you establish a safe professional boundary for your touch-based practice?How and when do you introduce touch?
- Do you use different sorts of touch during a session? How do you and your clients respond?
- Does your use of touch change in different environments or clients?
- Use this description to analyse what your touching practices enable you and the client to do. Figure 1 might help.
- Make a list of the evidence from your personal experience and from relevant publications that supports your claims about what your touching practice does.
- You might want to visit the CSP’s Physiotherapy works series at: www.csp.org.uk/physiotherapyworks, and the CSP Library Information Services at: www.csp.org.uk/professional-union/library to look for published evidence.
- As part of a cost-saving exercise, your employer says you must cut the time spent with clients by 10 minutes.
How you use touch in your practice would change.
Use your notes from steps 1-3 to produce an argument, backed by evidence, about the consequences of having less time to touch your clients. You might want to think about your argument from the following perspectives: ethical practice; clinical effectiveness; cost effectiveness.
Now put yourself in the shoes of the person who wants to cut service costs and ask whether the argument you’ve produced in step 4 would convince him or her to reconsider the proposal.
To complete the reflective cycle, record what you have learnt from working through this activity. Remember to date the record, and file it with your notes in your portfolio.
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