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physiotherapy.ca | March/April 2018 3

1811 24

March/April 2018 | Vol. 8 / No. 2

5 President’s Message

7 Core Professional Values and Behaviours

11 Functioning as a Professional Team

15 Reflections on Fostering Professionalism Among Physiotherapy Students

18 What is Professionalism in Physiotherapy Practice in Canada today?

24 The Hazards of Social Media for Regulated Professionals

30 Employment Decision Tool

34 Cultural Safety: A Key Component of Professionalism in PT

37 Clinical Reflection – Does it Occur Only in an Ivory Tower or is it Clinically and Professionally Important?

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Our newly minted Strategic Plan (2018-2023)1 was created by over one thousand members of CPA, from the grassroots level to leadership, over a period of almost two years.

This consultation produced some big aspirations for our profession, aspirations that are our goals for the

next five years. The Strategic Plan is at the heart of what being a Canadian physiotherapy professional is all about.

While the CPA looks after the big “A” Advocacy piece, being a physio or a PTA/PRT means small “a” advocating in our communities, big and small, for more equitable access to health care. It means speaking up at school board meetings and at town halls, in grocery stores and at the local health clinic to represent with pride the finest health care profession that exists.

We must be sure that the population at large knows what physiotherapy is, and is able to get access to us, in an equitable fashion. We, as members of the CPA, know that physio-therapy is effective, but we all need to get used to making the case to the public, to insurers, to other health care practitioners, and to big and small government deciders, to influence the systems that limit and cap access to treatment and scope of practice. While the CPA does the big “P” in Policy, physiotherapy professionals are all able to move the profession forward, leveraging with the small “p” policy work that we can do in communities across the country.

Being a professional – our strategic plan speaks to this: advocating for equitable, optimal, professional and expert care for our patients/clients. By contributing to our collective sense of professional pride, this issue of Physiotherapy Practice presents you with many insightful points of view.

Professionalism in physiotherapy starts early: Kathleen Norman, from Queen’s Universi-ty, illustrates challenges and successes in addressing and facilitating professionalism among students in physiotherapy programs. Professionalism in physiotherapy is difficult to teach and harder to evaluate, in the eyes of Sue Murphy, Head of the PT department at UBC.

The inimitable Diana Hopkins-Rosseel, Clinical Specialist in Cardiorespiratory physio-therapy, turns her gaze to what exactly do we mean when we talk about professionalism in physiotherapy in this day of flip-flops, Facebook and phones.

In our Clinical Specialist feature article, Anne Rankin shared her Clinical Reflection: Does Professionalism Occur only in an Ivory Tower or is it Clinically and Professionally Important? Katie Gasparelli, physiotherapist at Six Nations Health Services, and Stephanie Nixon, co-founder and Director of the International Centre for Disability and Rehabilita-tion, unpack and discuss how professionalism in PT must include cultural safety.

You may have seen a survey in your e-mail’s inbox from Pat Miller and Vanina dal Bello-Haas about their PT Values Project. The CPA is proud to be a part of this exploration of what do we as PT professionals feel are critical values in our profession; read more in this issue.

And finally, we have two ‘math-themed’ contributions: “The Sum is More than the Parts: Functioning as a Professional Team,” by Tanja Yardley, and BMS Group Healthcare Profes-sionals Insurance Alliance legal team at Gowling WLG (Canada) LLP (Gowlings), “Think Twice before you Tweet: The Hazards of Social Media for Regulated Professionals.” Both important vitally topics in terms of behaviour in this complex world where various bound-aries seem to be changing on a continual basis.

And for some of you, this may come as an interesting fact: the Editor assures me that, totally randomly, all the contributors to this issue are women! No manels in this issue.

As I close, I wish you all good luck in planning a terrific National Physiotherapy Month (May), and don’t forget to save-the-date to travel to Montreal for this year’s combined AQP/ CPA/OPPQ Congress in November!

Happy reading!

Sarah Marshall, PT, MScPresidentCanadian Physiotherapy Association

@PhysioSarahPT

Managing EditorKim Tytler

Art DirectionShift 180

Cover DesignPatrick Rosche

Contributors

Advertising [email protected] Publication of advertisements does not represent an endorsement by CPA.

PublisherCanadian Physiotherapy [email protected]

ReprintsMaterial in Physiotherapy Practice is protected by copyright and may not be reprinted without the permission of the publisher.Canadian Physiotherapy Association

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Return undeliverable Canadian addressed mail to:Canadian Physiotherapy Association955 Green Valley Crescent Suite 270Ottawa, ON K2C 3V4

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©Canadian Physiotherapy Association, 2018. All rights reserved. No part of this material may be reproduced, stored in a retrieval system, or transcribed in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the Canadian Physiotherapy Association. Requests should be made to the Managing Editor, at 800-387-8679, ext. 231, [email protected].

The opinions expressed in Physiotherapy Practice are those of the authors and contributors, and do not necessarily reflect those of the CPA, the editors, the editorial board, or the organi-zation to which the authors are affiliated.

BMS Canada Risk Services LtdVanina Dal Bello-HaasKatie GasparelliGowling WLG (Canada) LLPChantal LauzonDiana Hopkins Rosseel

Pat MillerSue MurphyStephanie NixonKathleen NormanAnne RankinTanja Yardley

PRESIDENT’S MESSAGE

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Have you ever tried to articulate what makes our profession unique? You might start by describing the specific knowledge and skills physiotherapists possess, or the range of populations or conditions we treat, or the areas in which we practice. But what if you were asked to identify the core values that are important to us as a physiotherapy profession in Canada – how would you respond?

A value is an “operational belief” that can guide one’s behaviour.1 Core values are at the centre of professionalism, guide the decisions we make as physiotherapists, and determine the behaviours in which we engage as professionals. Articulated (as well as ‘hidden’) values of a profession are ideally upheld by all members and guide how we practice day in and day out. Not only do a common set of core values direct an indi-

vidual physiotherapist’s clinical practice, but core values can influence and direct the pro-fession as a whole. While it might be easier for you to describe your own personal values, e.g., the values that you developed through your parents, family, teachers, peers – such as respecting your elders or telling the truth regardless of the potential ‘punishment’, you might be more challenged to articulate the specific core values that are considered important to us as members of the Canadian Physiotherapy Association (CPA).

The physiotherapy profession in Canada currently does not have a specific set of core professional values, while our physiotherapy colleagues in the United States of America

and Australia do. As part of its transition to a doctoring profession, the American Physical Therapy Association (APTA) undertook an initiative to conceptualize professional values

explicitly. Following a review of the literature related to medical professionalism, 18 physical therapists participated in a consensus conference to identify a final list of seven core values of the APTA: accountability, altruism, compassion/caring, excellence, integrity, professional duty, social responsibility.2 Recognizing the physiotherapy profession is shaped by culture and context of each country and health care system in which it exists, Australian physiotherapists undertook a similar initiative to begin to identify their own list of values.3 A qualitative study involving 14 experienced Australian physiotherapists was employed to identify common values to begin the process of identifying an Australian specific set of values and behaviours. Three overarching themes of values were identified: those relevant to the “patient and patient-therapist partnership”, those


Core professional values and behaviours The time is now for members of the Canadian Physiotherapy AssociationPat Miller, PT, PhD; member of the CPA since 1981; Vanina Dal Bello-Haas, PT, PhD; member of the CPA since 1984; and Chantal Lauzon, PT, Senior Practice Manager, CPA, member since 1995

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pertaining to “physiotherapy knowledge, skills, and practice” and finally those which represented “altruistic values”.3

To address the gap that exists in Canada, a project entitled “Core Professional Values: What do Members of the Canadian Physiotherapy Association Think?” is currently underway, in collaboration with the CPA. The purpose of the project is to identify a set of core professional values and associated behaviours considered relevant and essential to the members, through an online consensus exercise involving physiotherapy stakeholders from across the country. This project directly aligns with one of CPA’s four strategic priorities of the 2018 Strategic Plan “Toward 2020 and Beyond: A New National Vision for the Physiotherapy Profession in Canada” - “Champion excellence, innovations and professionalism in physiotherapy.”

At the outset of this project, an initial list of core values was identified through two processes. First, a comprehensive scoping review was undertaken. Searches of the inter-net and Ovid MEDLINE, Ovid EMBASE, and CINAHL databases were conducted to identify primary and grey literature where physio-therapy values were identified. Secondly, a survey was conducted with members at the 2016 CPA Congress in Victoria. Eighty-eight individuals responded to our survey. These two components of the project were con-ducted by four McMaster Master of Science (Physiotherapy) Program students, Alana Boyczuk, James Deloyer, Kyle Ferrigan, and Kevin Muncaster, as part of their Research and Evidence-based Practice course. This ini-tial work was presented at the Ontario Phys-iotherapy Association’s annual conference, InterACTION (March 2017), and at the World Confederation for Physical Therapy Congress in Cape Town, South Africa (July 2017).

Through these processes, a list of 10 core values: accountability, advocacy, altruism, compassion/caring, equity, excellence, in-tegrity, patient/client centered, respect, and social responsibility, was identified. These 10 core values were circulated in an initial survey distributed in January 2018 to all

CPA members that included practicing and retired physiotherapists, physiotherapist as-sistants and physical rehabilitation therapists, students, educators, regulators and physio-therapy stakeholders.

What’s Next?The project will involve a series of surveys, known as a Delphi process4, through which a consensus on the core values and associ-ated behaviours will be determined. In the Delphi process, the results and feedback from the last survey inform the subsequent survey. Once the analysis of the January 2018 survey results is completed, a survey with a revised list of values and behaviours will be circulated in March. This version will include those values and associated behav-iours that the majority (80% or more) of the CPA members deemed to be important in the initial round, as well as any new values and behaviours that are suggested. In each subsequent survey round, you will be asked to confirm the values and behaviours you feel are relevant and essential to be included. You will also be asked to confirm the exclu-sion of the values that have been eliminated because they did not have the support of 80% or more of respondents. We anticipate that we will be circulating surveys in June and October as well, in order to come to a final consensus of the core professional values and related behaviours that are relevant to us all as members of the CPA.

If you participated in the January survey, thank you and please continue! If not, please consider participating in the subsequent sur-veys, and provide your voice to the direction of this important national initiative! Surveys will take about 15 minutes to complete. The greater the number of CPA members who participate and provide their input, the more representative, relevant, and valid the final core values document will be to our profes-sion, and to the Champion excellence, innova-tions and professionalism in physiotherapy strategic goal. We welcome your input as the process for identifying our core professional values unfolds.

The purpose of the project is to identify a set of core professional values and associated behaviours considered relevant and essential to the members, through an online consensus exercise involving physiotherapy stakeholders from across the country.


About PatPat Miller is a registered physiotherapist and an Associate Professor (Part-time) in the School of Rehabilitation Science at McMaster University. She contributed to the devel-

opment of the CPA Clinical Speciality Program as the Chair of the Assessment Tools Working Group, and has served as a member of the CPA Awards Committee, and on the executive of the Neurosciences Division. Her teaching and research interests include professional practice issues and neurosciences rehabilitation. You can email Dr. Miller at [email protected].

About Vanina Vanina Dal Bello-Haas, PT, PhD is Assistant Dean (Physiotherapy) and Associate Professor in the School of Rehabilita-tion Sciences, McMaster University. Vanina is a

physiotherapist, educator, and researcher, and has served on numerous professional commit-tees at provincial/state, national and interna-tional levels since graduation. She has extensive experience in the assessment and management of people with neurodegenerative diseases and older adults, and her education scholarship interests are diverse and include professional issues and using technology to enhance student engagement and learning. You can email Vanina at [email protected]

@VaninaHaas

About ChantalChantal Lauzon, PT is the Senior Practice Manager at the Canadian Physiother-apy Association. She leads the QualityPT campaign and co-lead the #30Reps campaign. She is also

providing leadership on the program planning committees of Leadership Forum and Congress Montreal18. She previously worked in public practice at an Academic Health Science Center as the Professional Practice Coordinator. You can email Chantal at [email protected]

@CPA_Chantal

References: 1. Davis C. Patient practitioner interaction. Thorofare, NJ: SLACK; 2011.2. American Physical Therapy Association. Professionalism in physical therapy: core values. BOD P05-04-02-03 [Amended BOD 08-03-04-10] American Physical Therapy Association, Alexandria, VA. [cited 2018 Jan 9] Available from:https://www.apta.org/uploadedFiles/APTAorg/About_Us/Poli-cies/BOD/Judicial/ProfessionalisminPT.pdf 3. Aguilar A, Stupans I, Scutter S, King S. Exploring the Profes-sional Values of Australian Physiotherapists. Physiother Res Int. 2012;18(1):27-36.4. Hsu C, Sandford B. The Delphi technique: making sense of consensus. Practical Assess Res Eval. 2007; 12(10): 1-8.

Core Professional Values and Behaviours

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Professionalism is a nebulous term that’s thrown around a considerable amount. If you ask what it means, you’ll get a myriad of answers that vary based on training, history, and cultural context. The Merriam-Webster dictionary defines it as “the conduct, aims, or qualities that characterize or mark a profession or a professional per-son”; and it defines a profession as “a calling requiring specialized knowledge and often long and intensive academic preparation.”

When referring to an individual, it gener-ally refers to attributes such as:• looking and acting professionally; • demonstrating integrity and being account-

able for what you say and do; • being honest and respectful; • developing specific knowledge, skillsets

and competencies; and • effectively managing your conduct and

emotions. It’s rare that any professional operates in

isolation. As health care delivery increasingly relies on integrated or collaborative care models, most of us have become accustomed to functioning in a team environment. While it’s true that exhibiting individual profes-sionalism will undoubtedly contribute to the successful function of a group, these attributes alone will not guarantee that a team will be perceived as professional. In addition to the individual contributions of each team member, functioning as a profes-sional team requires a respectful and col-laborative approach, a shared understanding of what is expected of each other, defining

principles for how team members interact and clear and open communication among team members. This can be challenging in interdisciplinary environments which challenge established hierarchies, norms, practice scopes and professional identities. Often, professionalism devolves in those situations where disparate individuals are competing for status and resources rather than collaborating to evolve new models of care that are effective, efficient, accessible and sustainable.

To understand the notion of professionalism in a small team or larger organizational envi-ronment, it’s important to frame organizational teams as dynamic, living, social systems that adapt and change. In the same way that we as-sess patterns and relationships between form and function when we work with patients, understanding the structure and relation-ship dynamics of a team yields useful clues about optional functioning. It’s not just about individual discipline accountability to profes-sionalism and performance, it’s the mutual awareness, understanding and accountability to those elements that creates collective results far beyond what any individual could achieve.

In my last 25 years in a leadership role, I’ve encountered hundreds of teams with vary-ing degrees of professional behaviour, and in my experience, the highest functioning teams were not only made up of members who dem-onstrated personal accountability and profes-sionalism, but those who collectively mod-elled those elements in a way that impacted extraordinary results.


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The attributes of those teams included the following:1. Meaningful common purpose that the team helped to shape (Katzenbach & Smith, 1993)2. Clarity on the specific roles, key accountabilities, interdependencies and deliverables of the

team members 3. Specific individual and group performance goals that are compelling and flow from the

common purpose (Katzenbach & Smith, 1993)4. Emotional Intelligence (Druskatt & Wolff, 2001):

• Emotional Awareness (interpersonal understanding, perspective-taking, mechanism for team self-evaluation, seeking feedback consistently, organizational understanding)

• Emotional Regulation (confronting, caring, creating resources for working with emo-tion, creating an affirmative environment, solving problems proactively, building external relationships)

5. Mix of complementary technical and functional skills (Katzenbach & Smith, 1993):• profession-specific skills• problem solving and decision-making skills• interpersonal skills

6. Sensitivity to the dimensions of relationships:• mindfulness, or engaged presence/open-ness (Weick, Sutcliffe, & Obstfeld, 1999), • heedfulness, or attentiveness to impact (Weick & Roberts, 1993), • strength or weakness of ties between individuals (Granovetter, 1973; Papa, 1990), • quantity of connections (Kauffman, 1995; McKelvey, 1999),• quality of connections (Daft, 1989; Thompson, 1967)• respectful interactions (Lanham et al., 2009)• rich and lean communication (Lanham et al., 2009)• trust, and willingness to be vulnerable (Lanham et al., 2009)• diversity (Lanham et al., 2009)• social/task relatedness (Lanham et al., 2009)• destructive interpersonal conflict vs constructive idealogical debate (Johnson, 2014)

7. Strong commitment to how the work gets done (Katzenbach & Smith, 1993):8. Mutual accountability (Katzenbach & Smith, 1993):9. Agreed-upon code of conduct, rules or behavioural norms that govern and support ethical

practice 10. Operates within the context of clear, effective communication (Johnson, 2014),

which embodies:• Simplicity (clear, concise, doesn’t contain superfluous information)• Relevance (thoughtful in terms of who needs to know, what, and how much) • Repetition (repeated as needed to ensure clear understanding)• The right medium for the message (face to face vs email, phone, video, etc.)• Timeliness (appropriate level of urgency, responsiveness)• Cascading messages (clarity around who will communicate what to whom and when - in

such a way that doesn’t allow speculation or misinformation as the message travels through levels of the organization)

• Reciprocal, not top-down (taking into consideration the need for messages to be processed, heard, understood, responded-to, leaving opportunities for buy in or debate)

• Removing distractions, eliminating incivility (distractedness, interrupting, being late, being impolite)

• Giving and receiving feedback (considering intent and impact)

can I reach out to if I want to learn more about this? How can I model this quality, educate my-self, or educate others? What can our team do to function better or more professionally? This process requires an open heart and an open mind. It’s not about assigning blame or even re-sponsibility if your conclusion is that your team needs work. EVERY team needs work. Start with clarity about what YOU can do. Start the conversation. Start the work. Be an exemplary team professional and inspire others to do the same. Whether it changes quickly or you have slow incremental gains, every evolutionary step will take you closer to maturity, wisdom and peak performance. Imagine what is possible if we all hold ourselves aligned and accountable to values and behaviours that manifest a shared vision of what physiotherapists can lead and achieve in an integrated health care system. It’s not just possible. It’s achievable. Take the first step in your own journey as a professional. The next step will be to positively influence others and co-create positive consequences. Effec-tive teams from coast to coast can collectively influence communities, provincial and national health care systems.

“ The journey of a thousand miles begins with one step.”

- Lao Tzu

About TanjaTanja Yardley is the Vice President of Outpatient Services for CBI Health Group in British Columbia and past co-owner

of Rehabilitation in Motion, Pro-Motion Consulting Ltd. (Multimedia Training Resources) and Ergonomics in Motion (Occupational Health and Safety Consulting). She previously chaired the Business Affairs Committee and served on the Board of the Physiotherapy Association of British Columbia and the Private Practice Division of the Canadian Physiotherapy Association. She teaches internationally on clinical best practices and effective communication strategies for complex clinical cases and consults with numerous insurers on best practice service delivery models. She oversees the operations of 47 interdisciplinary clinics, providing mentorship and coaching to clinicians and managers who want to start, grow and sustain a successful healthcare practice. She recently co-authored a book on business ethics and best practices and regularly submits articles to trade publications.

@TanjaYardley

One of my favourite mentors on this topic is Andy Johnson, who I encountered though Target Training International (TTI) and the Complete Leader Training Program. In his book, “Pushing Back Entropy – Moving Teams from Conflict to Health” (2014), Andy describes a healthy team as: “an identifiable, rightly sized, well-organized, strongly interconnected group of securely attached members in vital relationship with one another, who share common language, culture, core values and beliefs, who operate in accordance with them, and who clearly under-stand individual group roles and core purposes that together co-create positive consequences of all sorts.” These teams are defined by their cultural connection and their congruence to shared values in service to a common purpose. They are intrinsically motivated and bonded by

their integrity, their passion, and their purpose. Before concluding that such a team ex-

ists only in business fables, it’s important to acknowledge that effective teams embody those qualities to varying degrees. Like every dynamic, living, social system, teams evolve and change, progress and regress as new circum-stances arise and as conditions change. Coach-ing teams to peak professional performance brings endless opportunities to reflect, grow and gain insight. As with any endeavour in leadership, whether you are leading yourself or leading a team, the first step is self-awareness. Review the list of attributes of healthy profes-sional teams, grab a journal, and start with self-reflection… Am I behaving professionally? To what degree am I aware of, and contributing to, the particular elements of group success? Who

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To be a member of a profession is clas-sically associated with acting in good faith, with integrity, and in the interests of the people whom the members of the profession serve. To be a member specifi-cally of the profession of physiotherapists is to have those interests be focused on how people’s bodies move, and how their move-ment might be compromised by illness, injury or pain. Physiotherapy students professa to have these qualities before they have even entered physiotherapy education. Having been involved in the review of applicants’ files for many years, I have read or heard some version of the statements “I want to help people…” and “I’m fascinated by how the human body moves…” literally thousands of times. The task of teaching about professionalism in practice, therefore, is to guide students to develop these qualities into a robust professional identity, to equip students to conduct themselves legally and ethically, and to help students understand the big picture of health systems and other en-vironmental and societal features that impact physiotherapists’ practice.

In their recent book about the future of the professions, Susskind & Susskind highlight

four key features of modern professions: possessing specialized knowledge, having ad-mission be dependent on credentials, having activities that are regulated, and being bound by common values.1 Susskind & Susskind also discuss at length the concept of the Grand Bargain. In short, one side of the bargain is that society has granted several things to a profession: the right to self-determination about who is permitted to enter and prac-tise the profession; autonomy about what it deems to be its own expertise; and social re-spect for its exclusive title. In return, society expects members of the profession to make their expertise available for the common good. Susskind & Susskind point out that it was a good bargain on both sides in the pre-Internet era. Professionals got well-paying, stable jobs and social respect; the public got the benefit of expertise that would otherwise be locked up in books or other university learning experiences only available to people who spent years learning their profession. The Grand Bargain is under threat in the modern era when the public can look up expertise using the devices that are frequent-ly found at our fingertips. Any specialized

Reflections on fostering professionalism among physiotherapy students

Kathleen E. Norman, PT, BSCPT, PhD, CPA Member since 1986

16 Physiotherapy Practice

knowledge that can be presented on a screen is no longer ‘ivory tower’ knowledge. Susskind & Susskind indicate that the Grand Bargain is also under threat if a profession retreats from the public service inherent in the bargain and instead focuses on boutique services for the more affluent members of society.

Every year in teaching physiotherapy stu-dents, I restrain myself from embedding all the history, philosophy and policy reflections that I find fascinatingb. However, I believe that the concept of the Grand Bargain, even if only implicit, must be central to teaching about professionalism. As a profession, phys-iotherapists are a community of people that make community decisions about what we deem to be valid knowledge and how we ap-ply that knowledge. The public perception of us is critical to the success of the profession in achieving its contribution to the public good, which in turn is critical to the chances that our members can feel fulfilled and earn a good livelihood. And the public perception of us is influenced by a multitude of factors. First, we must not only have specialized content knowledge – i.e., we know facts – and procedural knowledge – i.e., we know how to do stuff. We must also have the ability to apply that knowledge in a compassionate, personalized way that achieves something better than a member of the public could do by trying to find a solution to their move-ment and pain problems from reading blogs and watching online videos. Second, we must hold ourselves accountable to rigorous standards, avoiding not only impropriety, but also the appearance of impropriety. This accountability is related to the concept of regulated activities and being bound by

common values. Consequently, much of a course on professionalism is about the laws, regulations, standards and codes to which physiotherapists must adhere. That brings me to a principle highly applicable to teach-ing, among many other domains.

They may forget what you said, but they will never forget how you made them feel.A version of this principle has been attrib-uted to Maya Angelou because she is perhaps the most famous of those who have stated some version of it, although the originator was likely Carl W. Buehner. Many years ago, when I was new to teaching, hearing the statement drove me crazy, wondering why I was working so hard to guide students to accurate, up-to-date knowledge if the only thing that mattered was how I made the students feel. But I have since come to think that one of the most important elements of what I convey as a teacher is a passion and commitment for seeking to be as accurate and up-to-date as I possibly can be, and an ethical obligation to learn about the small details for when they might turn out to be important.

I have also come to see that one of the most important things I do as a teacher about professionalism is to use first-person plural pronouns – we, our, and us. For example: we as physiotherapists must understand and apply the relevant clauses of health care consent legislation; our College [in Ontario] is governed by members of ourselves along-side publicly appointed members; it is up to us, as with many professionals, to report privacy breaches if we have knowledge that

they have occurred. There is no getting around the fact that most physiotherapy stu-dents – indeed, most health care professional students – would rather watch paint dry than study clauses from legal statutes. However, I think that the atmosphere of “we’re all in this together and we have common obligations” helps to make it slightly less like a stereotypi-cal sermon and more like a rallying cry to be part of a professional community whose members conduct themselves honourably. I think it’s part of building professional identity to understand stories of how we act both as individuals and as a community, and stories of how professionals can undermine public trust through not respecting the statutes, regulations and standards that act as buttresses to our practice. My former stu-dents may have forgotten what I said a few years ago about things like provincial College standard statements and reporting obliga-tions under provincial privacy legislation, but that’s okay because some of those statements are now inaccurate, superseded by updates in recent years. Nevertheless, I hope the way that I made them feel fostered a strong sense of the importance of how we all need to at-tend to any such changes in the buttresses of our practice.

Let’s return to the Grand Bargain concept, and consider a statement about self-regu-lation I have created that is a variation of something attributed to Winston Churchill in speaking about democracy. (Like the situa-tion for the quote above is often attributed to Maya Angelou, Winston Churchill was prob-ably not the originator of the statement about democracy, although he is the most famous of those who said it.)


Self-regulation is the worst form of professional regulation, except for all those other forms that have been tried from time to time.It is a high honour within the Grand Bargain for a profession to be granted self-regulation. That physiotherapists have been granted self-regulation indicates a high degree of public trust. It’s also a tremendous burden. On an individual level, the burden is univer-sally felt on a financial basis through annual fees, but also through the time devoted to keeping up-to-date, and occasionally hav-ing to prove that one is up-to-date. On a whole-profession level, the burden is felt in the pressure that we cannot afford to turn a blind eye to unscrupulous practices, or allow poor quality physiotherapy to develop or persist. However, what flows from the Grand Bargain when it is upheld is the potential for tremendous power for professionals to do good for the public, and have a well-re-spected, usually well-remunerated position in society.

Let’s also return to concepts of storytell-ing and of building professional identity and understanding how we are bound by com-mon values, and consider how to foster stu-dents’ development in these areas. Fairbairn has described the importance of storytelling as a means of “rehearsing decisions, reasons and justifications” especially in the area of moral understanding and ethical reasoning.2 Three of the assignments in our professional practice course are essentially storytelling exercises. They were the inspired creations of my predecessor in this teaching role, Professor Diana Hopkins-Rosseel. In one of them, students create realistic but fictional

cases of how physiotherapists might come close to, or over the border of, breaching a professional boundary, and then provide an analysis of their cases. In others, students write reflections – one about applying ethi-cal reasoning to a difficult clinical situation and another about how one or more dimen-sions of cultural diversity influenced a clini-cal encounter. In all of these assignments, the students are writing stories. Of necessity, these stories embed elements of the people and principles (rules, laws, policies, etc.) that need to be respected in each situa-tion. The storytelling format adds context that would be absent in a list of rules. For example, I believe it is less relevant to state a rule about professional appearance (e.g., related to clothing, piercings, tattoos, or reli-gious symbols) and more relevant to think of stories in which some aspect of appearance may have contributed to cultural safety or interprofessional collaboration.

Having read Fairbairn’s reflections about the value of storytelling in developing empathy and understanding, and through collaborating with Dr. Trisha Parsons for her Phoenix Projectc work about narrative practice, I have come to understand why I see so much value in these writing assign-ments and insight by students in the stories they tell. We build, and then continually rebuild and reshape, a sense of what a right-minded physiotherapist would do in diverse situations when we have a wealth of stories to guide us and the confidence to contribute our own stories.

In summary in my humble opinion, the key features of helping students reach high-er with respect to professionalism are as fol-

lows: we all need to understand the essence of the Grand Bargain; we need to focus on the we, because we need to foster the feeling of being all in this together as a professional community; and we need to recognize the value of storytelling to develop deep skills in professional reasoning. Together, these build the conscience within us that motivates us to keep up-to-date on the specific legal clauses and standards throughout our careers, even if reading those documents never makes our list of favourite things to do!

About KathleenKathleen Norman is As-sociate Professor, and As-sociate Director (Research and Post-Professional Programs), School of Rehabilitation Therapy at Queen’s University. She has

been a physiotherapist since 1987 and has been a member of Queen’s faculty since 1998. She is also currently a member of the Council of the College of Physiotherapists of Ontario. She can be reached at [email protected].

References1. Susskind R, Susskind D. The Future of the Professions: How tech-nology will transform the work of human experts. Oxford: Oxford University Press, 2015.2. Fairbairn GJ. Ethics, empathy and storytelling in professional development. Learning in Health and Social Care. 2002; 1(1): 22-32. doi: 10.1046/j.1473-6861.2002.00004.x. The quote is from page 23.a. I almost wrote “(pun intended)” and then reflected that it’s not actually a pun. It’s exactly the right word.b. Those of you who knew or know me as an instructor might think I hadn’t restrained myself much, but I encourage you to trust me that I was tempted to have embedded far more!c. See http://www.ams-inc.on.ca/ for more information about the Phoenix Project.

Reflections on fostering professionalism among physiotherapy students


Professionalism as a concept is so complex and multi-dimensional that it has been studied by philosophers, educators, ethicists, and professional groups, for literally centuries without an accepted consensus on its scope or key attitudes, skills or behaviours. To make the concept even more daunting is to realize that the theories and practices of professionalism are dynamic, changing as the world evolves. And yet, we as a profession are undaunted! Our university programs, regulatory bodies and professional associations have all provided us with their standards and guidance. Before we go there, however, let’s step back and try to understand the vital nature of professionalism, trying to appreciate the concept. Then we can dive into what our profession of physiotherapy in Canada has determined to be essential.

An ethicist or philosopher would go back to the roots of the word(s). To “profess” is to make a public declaration or commitment according to which one’s actions can be judged. Medical ethicists Alastair Vincent Campbell and Anita Ho, in their June 2015 op ed piece for the Centre for Medical Ethics and Professionalism stated, “Every aspect of professionalism flows from this commitment’.1

A Socratic definition might be derived from the definition of ‘a profession’:

“A profession is a number of individuals in the same occupation voluntarily organized to earn a living by openly serving a certain moral ideal in a morally permissible way beyond what law, market, and morality would otherwise require”.2

Therefore, if we assume those individuals are considered professionals, then professionalism encompasses the morally-based characteristics and acts of professionals. This circular pattern, or tautology, of defining a profession, professionals and professions is rife in the literature!

In 1988, Friedson defined a profession as ‘… an occupation that has been given the right to control its own work’.3 Thus, a profession would be considered autonomous and trustworthy in its self-directing and self-regulating. This is helpful, adding perhaps a modern twist to the previous definition. But then Friedson continues his argument to stipulate that, if this were true, then professionalism could be defined as easily as ‘… the set of attributes said to be characteristic of professionals’. Another tautological argument … defining singing by saying “it is what a singer does”.

Would you wear a fishnet, see-through vest, shorts and sandals to work?

What is professionalism in physiotherapy practice in Canada today?Diana Hopkins-Rosseel, RPT, DEC, BSc(PT), MSc, Clinical Specialist (CRPT), CPA Member since 1982


In 2015, Alejandra E. Aguilar published her PhD thesis entitled: ‘Professionalism in physiotherapy and occupational therapy in Australia: Towards a definition and understanding’.4 Aguilar does a laudable job of reviewing both the limited OT and PT literature, as well as the broader, more extensive literature generated across the health sciences and healthcare professions. Her conclusion, published in 2011, was that ‘… professionalism is variably defined as upholding professional values, exhibiting professional behaviours or demonstrating professional attitudes.’. If we accept this cyclical definition, then we need to define those values, behaviours and attitudes.

In fact, as early as 1999, Bossers et al., published their work on developing a curriculum in professionalism for Occupational Therapy (OT) students.5 In this paper they not only breakdown professionalism into (i) professional parameters, (ii) professional behaviours and (iii) professional responsibilities but they begin to flush out the characteristic features of each of the embedded streams. They have done such an excellent job that, when teaching professionalism at the university, I often referred to the summary chart proposed by the authors and copied below. You will see some familiar core values embedded in the professional parameters streams.

What do all authors seem to agree to when considering the concept of professionalism? The consensus is that professionalism is based in morality, ethical standards, and the values of the profession. Further, that those ethical standards tend to be reflected in legislation and regulation, and that, the ethical standards change as the context of any situation or era is applied. What else seems to cross all sectors? That learning professionalism has two components: the cognitive, or knowledge base, and the experiential, sequentially applying that knowledge to develop and hone relevant behaviours over time. Finally, once defined and broken down into attitudes,

skills and behaviours, it is the consensus that the core attributes of professionalism must be assessed formally and through self-reflection both as an entry-level student and regularly throughout one’s career.

Let’s dissect the two components of the cognitive foundations and the applied experiential learning further. Cruess and Cruess, leaders in the pedagogy of professionalism for healthcare students and providers, stated that “Teaching the cognitive base of professionalism and providing opportunities for the internalization of its values and behaviors are the cornerstones of the organization of the teaching of professionalism at all levels”.6

So what do we teach in physiotherapy in Canada? Our national curriculum guidelines published in 2009, considered ‘Professionalism and Ethics’ as one of four foundations of practice, along with ‘Biological and Basic Sciences’, ‘Scientific Inquiry’, and the ‘Psychosocial Sciences’.7 Similarly, the ‘Essential Competency Profile for Physiotherapists in Canada’ (2009), stipulates that one of the seven essential competencies roles is the ‘Professional’.8 They describe this role: ‘Physiotherapists are committed to the best interests of clients and society through ethical practice, support of profession-led regulation, and high personal standards of behaviour’. Similarly, our Physiotherapy Education Accreditation Canada’s (PEAC) published standards, by which all Canadian university programs are evaluated, has 6 standards and Role 6.7 is entitled: ‘Professionalism’ and under this banner stipulates that: ‘The program prepares students to demonstrate ethical practice, support of the profession, and high personal standards of behaviour’9 breaking this down to include: (i) conducting ones-self within legal/ethical requirements, (ii) respecting the individuality and autonomy of the client, and (iii) contributing to the development of the physiotherapy profession.

Bossers A, Kernaghan J, Hodgins L, Merla L, O’Connor C, Van Kessel M. Defining and developing professionalism. Canadian Journal of Occupational Therapy. 1999 Jun;66(3):116-21.

This is a chance for us to reflect, take stalk, and prevent the otherwise foreseeable wearing down of an exemplary group of professionals.

PROFESSIONALISM

ProfessionalParameters

LegalIssues

ProfessionalBehaviour

ProfessionalResponsibility

Client Team

• Legislation• Malpractice• Confidentiality• Sexual

Harassment• Documentation• Insurance &

Legal Work

• Constructs & Theories

• Integrity• Honesty• Making

Choices• Dignity

• Skills Application

• Roles & Limitations

• Client- Centred• Evidence-Based• Accountable• Resource

Management• Knowledge of

Discipline• Compliance w/

Rules

• Therapeutic Relationship

• Enabling• Holistic• Respectful• Understanding

Differences• Trusting• Objective • Advocacy

• Conflict Resolution

• Resource• Giving/Receiving

Feedback• Respectful• Diplomatic• Role Negotiation• Value

Contribution• Cooperation

• Image• Dress/

Grooming• Flexibility• Adaptability• Confidence in

Values• Inventive• Creative• Mature• Supportive• Assertive

• Association Membership

• Advocate• Student

Supervision• Interest

Groups• Marketing• Inquiry• Research• Mentorship

• Current Knowledge

• Self- Evaluation

• Continuing Education

• Job Seeking Skills

• Career Path Development

• Educate• Advocate• Enable• Network

• Salaried Mentality

• Accountability• Advocacy

Ethics &Morality

Skills/Practice ProfessionPresentation Self Employer/

ClientCommunityRelationships

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If ethics are the basic building block of professionalism, what are the ethics of physiotherapy in Canada? The Canadian Physiotherapy Association’s Code of Ethics10 (https://physiotherapy.ca/cpa-code-ethics) states:

‘The Canadian Physiotherapy Association Code of Ethics defines CPA expectations for the professional values and behaviour that underpin all CPA members’ physiotherapy roles and responsibilities.

The following are the principles upon which the CPA’s Code of Ethics is determined:

1. CPA members’ responsibilities to the patient/client.2. CPA members’ responsibilities to society.3. CPA members’ responsibilities to the profession.

Specifically, the Code is based on the following ethical values and professional principles:

• Respect and dignity: to acknowledge, value and appreciate the worth of all patients/clients

• Respect for patient/client autonomy: to respect a patient/client’s or substitute decision maker’s right to make decisions

• Beneficence: to provide benefit to patients/clients• Non-maleficence: to do no harm to patients/clients• Responsibility: to be reliable and dependable• Trustworthiness and integrity: to be honest and to be trusted• Professionalism: to be a good citizen/member in good standing of

the professional association.’

I would suggest that it would be difficult for any of us to disagree with these principles and foundational ethical values.

In 2009, the American Physical Therapy Association (APTA), published their ‘Professionalism in Physical Therapy: Core Values’ of accountability, altruism, compassion/caring, excellence, integrity, professional duty, and social responsibility.11 Again, strong ‘parenthood’ values and hard to argue against. So, are we worried? We should be. Why? Because we are a uniquely diverse profession with a distinctively broad scope of practice and practice contexts. An enviable place to be, yet this leaves us open to the struggle to maintain our past robust, cohesive belief in and understanding of our core ethics and values. Further, we must be steadfast in our applications of our consensus principles and values of professionalism in today’s context.

This brings us back to the question posed at the outset … ‘Would you wear a fishnet, see-through vest, shorts and sandals to work?’. Answer: I wouldn’t but a colleague did! By the end of the work day, several patients had expressed concerns about this attire and two chose not to return to that facility for physiotherapy. The simple act of dressing in consideration of the patient’s values and perceptions is a key professional behaviour.

Were the decisions fewer and easier when we were not autonomous, wore uniforms and had less responsibility for the public’s perceptions of our credibility? No. We have always had the imperative of respecting our patients, being trustworthy and responsive. So, then, what are the issues we may charge ourselves and the profession to watchdog? Most of us could cite countless

Wilkinson TJ, Wade WB, Knock LD. A blueprint to assess professionalism: results of a systematic review; Academic Medicine, 2009 May 1;84(5):551-8.

Professionalism in physiotherapy practice in Canada today

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developing challenges to professionalism in today’s practice. A few examples:1. Changes in the culture of health care – we are solely responsible yet we

are part of a team, consulting and collaborating with stakeholders, with the patient in the lead

• The patient is autonomous – not to be cared for, but to be consulted;

• The patient as the consumer – a financial perspective;• Time is money – efficiency is paramount and must be valued

alongside effectiveness.2. Multiple funding models – financial incentives and disincentives

compete with personal, moral and ethical responsibilities• Many can no longer afford physiotherapy services;• Public practice in hospitals, rehabilitation facilities, homes,

community facilities and LTC facilities with long waiting lists and difficult triage decisions;

• The growing private practice sector where the bottom line is more evident;

• An often hidden and tenuous mixed public-private practice everywhere!

3. External regulation may drive the practice rather than solely protect the patient

• An intrinsic motivation to improve and explore might be pushed aside by institutional and individual professional accreditations rather than by the respect of the practitioner for self-reflection, career development and the natural evolution of the profession.

4. The personal pressures of time, income and family• As a student, you depend on clinicians for over 30% of your curriculum delivery and yet, as graduate practitioners we are slow to become clinical instructors and take on the mentorship of those who follow us. • We have committed to ‘… responsibilities to the profession’ and altruism and professional duty and yet, when we perceive the day is too long, or client satisfaction or income is at risk, we falter.

5. The growing diversity that comes of opening our hearts and borders to all

• Reconciliation allows us to consider our academic and clinical patterns and gives us a chance to evolve

• Changing patterns of diversity in our classrooms, research labs and clinics suggests continual self-reflection and professional development in cultural sensitivity should see increasing prominence.

This is not to be in any way negative, it is a chance for us to reflect, take stalk, and prevent the otherwise foreseeable wearing down of an exemplary group of professionals.

This brings us to the last step in the chain – evaluation. How are we doing? Are we demonstrating the cognitive knowledge and applied behaviours of exemplary professionals? In their publication ‘A Blueprint to Assess Professionalism: Results of a Systematic Review’, Wilkinson et al. attempted a blueprint to assess professionalism.12 Their conclusion: “Professionalism can be assessed using a combination of observed clinicalencounters, multisource feedback, patients’ opinions, paper-based tests or simulations, measures of research and/or teaching activities, and scrutiny of self-assessments compared with assessments by others…”. Their blueprint, as seen in the table on page 21, is an (somewhat daunting) illustration of the interconnected pieces.

Professionalism in physiotherapy practice in Canada today

About DianaDiana Hopkins-Rosseel is a tenured full Professor in the School of Rehabilitation Therapy at Queen’s University and a physiotherapist at the Cardiac Rehabilitation Centre in Kingston, Ontario, Canada. Diana taught professionalism in the Queen’s University, School of Rehabilitation Therapy’s ‘Professional Practice’ course for over two decades. Diana’s research

portfolios include simulation in interprofessional education, professional practice in physiotherapy, and behavioural modification, best practices and development and validation of a risk triage tool in cardiovascular rehabilitation and cardiovascular rehabilitation as a chronic disease prevention and management paradigm. Diana has over a hundred peer-reviewed podia and numerous peer reviewed publications, as well as being a book author, contributor to the Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention and the Cardiac Care Network of Ontario Standards for Cardiovascular Prevention and Rehabilitation.

Diana was awarded the designation of Clinical Specialist in Cardiorespiratory Physiotherapy in Canada in 2012, University of Toronto Alumni Achievement Award in 2013, the 2014 Canadian Association of Cardiovascular Prevention and Rehabilitation Award in Knowledge Transfer, and the Canadian Physiotherapy Association’s Life Membership Award, June 2015.

References1. Vincent AC & Ho A The Philosophy of Professionalism and Professional Ethics Centre for

Medical Ethics and Professionalism, SMA (2015); https://www.sma.org.sg/UploadedImg/files/Publications%20.../4706/CMEP%204.pdf

2. Encyclopedia of Science, Technology, and Ethics Profession and Professionalism; © 2005, Thomson Gale.

3. Freidson E. Theory and the Professions. Ind. LJ. 1988;64:423.4. Aguilar AE Professionalism in physiotherapy and occupational therapy in Australia: Towards a

definition and understanding; Thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy, School of Pharmacy and Medical Sciences, Division of Health Sciences, University of South Australia; 2015.

5. Bossers A, Kernaghan J, Hodgins L, Merla L, O’Connor C, Van Kessel M. Defining and developing professionalism; Can J of Occupational Therapy, 1999 Jun; 66(3):116-21.

6. Cruess RL, Cruess SR. Teaching professionalism: general principles; Medical teacher, 2006 Jan 1; 28(3):205-8.

7. Entry‐to‐Practice Physiotherapy Curriculum: Content Guidelines for Canadian University Programs; A Council of Canadian Physiotherapy University Programs publication©, produced by HealthQuest Consulting in association with the Canadian Physiotherapy Association, the Canadian Alliance of Physiotherapy Regulators, and the Accreditation Council of Canadian Physiotherapy Academic Programs; 2009.

8. National Physiotherapy Advisory Group (NPAG) Essential Competency Profile for Physiotherapists in Canada; with project partners Accreditation Council for Canadian Physiotherapy Academic Programs, Canadian Alliance of Physiotherapy Regulators, Canadian Physiotherapy Association and the Canadian Council of Physiotherapy University Programs; Oct. 2009.

9. Physiotherapy Education Accreditation Canada 2012 Accreditation Standards For Physiotherapy Education Programs In Canada; London, Ontario, Canada; 2012. www.peac-aepc.ca

10. Canadian Physiotherapy Association Code of Ethics; https://physiotherapy.ca/cpa-code-ethics .11. APTA Professionalism In Physical Therapy: Core Values; BOD P05-04-02-03 [Amended BOD

08-03-04-10]; https://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/BOD/Judicial/ProfessionalisminPT.pdf

12. Wilkinson TJ, Wade WB, Knock LD. A blueprint to assess professionalism: results of a systematic review; Academic Medicine, 2009 May 1; 84(5):551-8.

I am tired just contemplating the complexity of such a multidimensional and longitudinal evaluation scheme! And yet, we physiotherapists in Canada have many of these evidence-based practices in place. We undertake education and academic and clinical evaluation in ethics and professionalism as entry-level MScPT students, we are provided with and evaluated on provincial regulatory standards utilizing multi-modal processes, we co-operatively and independently pursue the development of and acquisition of professional development leading to clinical certifications, advanced practice and specialization, and the list goes on. If we were to dissect these evaluations, it would be simple to discern the ethical underpinnings in all of them. So, we can pat ourselves collectively on the back but we cannot become complacent.

What’s the recipe for success? Never let up – keep the focus on ethics and professionalism in our schools, our everyday practices and in our professional organizations.

Think Twice before you Tweet:

The hazards of social media for regulated professionals

Introduction The number of regulated professionals taking to social media is skyrocketing, particularly in health care. More than 84% of physio-therapists use Facebook, with 21% having patients as friends and 27% having employers as friends. Physicians are also very active on social media, with 90% using social media for personal activities and 65% using social media for professional reasons. Additionally, nearly 85% of radiologists use social media; Facebook is most popular for personal use and LinkedIn and Twitter are most popular for professional use.

Social media is a double-edged sword. It offers an unprecedented marketing platform for regulated professionals and serves as a convenient and cost-effective way to share ideas and industry trends with other profes-sionals and clients/patients. However, social media is filled with landmines for unwary users. As a result, regulatory bodies are increasingly challenged by registrants using social media in ways that may reflect poorly on the profession. In recent years, profession-als using social media have been disciplined for a variety of issues, including: (i) disclosing confidential information; (ii) making dispar-aging remarks and allegations, often regard-ing members of the same profession; and (iii) posting content that contradicts a regulatory body’s policies or is unprofessional.

This article focuses on several recent deci-sions involving regulated professionals’ use of social media and the implications these could have on future social media behaviours.

Disclosure or Misuse of Confidential Information Regulated professionals are prohibited from using or disclosing confidential client or patient information without consent. Most regulators across Canada have imple-mented Codes of Ethics that contain provi-sions on the importance of maintaining confidentiality. Further, the Code of Ethical Conduct for Alberta Physiotherapists goes so far as to indicate an ethical responsibil-ity to use electronic communication and social media professionally, respectfully, and in conformity with confidentiality guidelines.

While codes of conduct and regulations governing regulated professionals gener-ally do not contain specific provisions regulating the use of social media, general confidentiality provisions continue to ap-ply. For instance, in its published Advice to the Profession on Social Media, the College of Physicians & Surgeons of Alberta (CPSA) provided that physicians will be held ac-countable to CPSA Standards of Practice, the CPSA Code of Conduct, and the Cana-dian Medical Association Code of Ethics in social media settings, notwithstanding that there are no provisions specifically dealing with social media in those codes. The following decisions serve as sober reminders that unauthorized disclosure of confidential information, regardless of the medium used and the regulated profession-als’ motives, will still attract professional discipline.



In the first decision, the Hearing Tribu-nal of the Alberta College of Pharmacists issued a fine and suspended a pharmacist’s practice permit for four months because she inappropriately accessed the confidential health information of four women and then disclosed this information in posts on her Facebook page.

An investigation into the allegations against Ms. Sonoggadan, a registered phar-macist in Alberta, revealed that she had been fighting with a group of women at her church. She then posted disparaging com-ments about one of the women on her Face-book page. After the woman complained to the church about her conduct, Ms. Sonogga-dan accessed the private health information of this woman and several others involved in the conflict and posted details about the prescription medications they were taking.

Ms. Sonoggadan argued that her Facebook posts were sufficiently cryptic such that most people would not be able to determine who she was referring to, and that she had restricted who could view the posts as she only had 10 friends on Facebook. However, the posts were detailed and public enough that the four women recognized that their health information had been used in the posts. Ms. Sonoggadan was suspended for disregarding the importance of her health custodian designation and the reputation of the pharmacy profession, and for breaching the Alberta Health Professions Act.

In the second decision, the Discipline Committee of the College of Nurses of Ontario held that Ms. Kaufman, a registered practical nurse, committed acts of profes-sional misconduct under the Nursing Act when she made publicly accessible posts on Facebook that disclosed a patient’s personal health information.

The patient in question was suffering from a terminal disease and a publicly accessible Facebook event page, entitled “Fundraiser to keep [the patient] housed and alive”, was established to raise funds for her. Ms. Kaufman posted on this page and in her posts disclosed that the patient required regular blood pressure checks, outlined her various medication requirements and noted a potential medical issue that the patient could suffer from. In addition to this medical information, Ms. Kaufman opined that the patient was “a difficult person,” and she cri-tiqued how the client spent her money and how her children behaved.

Ms. Kaufman claimed that she was under the impression that Facebook was “a forum for free speech” that people can use it to “say pretty much whatever they want”. Further, she claimed that she “felt a moral obligation to say something,” and that she “had the [patient’s] best interests at heart”.


However, the Discipline Committee found that she breached her duty of confidentiality and had acted dishonourably. The Discipline Committee was particularly troubled by Ms. Kaufman’s posting of negative comments and held that these actions constituted emotional abuse of a vulnerable patient. The Discipline Committee further held that her conduct was “disgraceful”.

Ms. Kaufman was suspended for four months and had to satisfy many terms and conditions before she would be permitted to practice again.

Disparagement on Social Media Codes of conduct and regulations govern-ing professionals generally do not contain specific provisions regulating the posting of critical comments harmful to the profession on social media. Rather, regulated profession-als are governed by the general obligation to maintain and protect the reputation of the profession and to not bring it into disrepute. This principle was demonstrated in the previ-ous examples and certain professions embed it into their code of ethics.

In a recent case, Ms. Strom, a registered nurse in the Prince Albert Parkland Health Region, faced a disciplinary hearing by the Saskatchewan Registered Nurses’ Association (SRNA) for comments that she made on her personal Facebook page following the death of her grandfather in a long-term care facility. Her post was critical of the end-of-life care provided by the facility’s staff and suggested that family members of facility residents should “keep an eye on things and report anything you do not like”. Her post further suggested that the staff would do well with some refresher training.

As part of the conversation generated by her post, Ms. Strom made a comment that directly linked her position as a registered nurse to her views on the care provided:

As an RN and avid health care advocate myself, I just HAVE to speak up! Whatever reasons/excuses people give for not giving quality care, I Do Not Care. It. Just. Needs. To. Be. Fixed. And NOW!

Ms. Strom further tweeted the post to the attention of the Minister of Health and the Leader of the Opposition, which made the content fully public.

Ms. Strom’s post was printed out by a receptionist and circulated in the long-term care facility in question. It was subsequently brought to the attention of the SRNA by a registered nurse at the facility, and the SRNA commenced a disciplinary proceeding against Ms. Strom for professional misconduct in relation to a violation of confidentiality (that was later withdrawn), failure to follow proper channels for her criticisms, the impact on the

reputation of the facility and staff, failure to first obtain all the facts, and using her status as a registered nurse for personal uses. Ms. Strom contested the charges, arguing that she wrote the post in her capacity as a grand-daughter and not as a registered nurse.

The Discipline Committee found Ms. Strom guilty of professional misconduct. While the Committee accepted that the Face-book post and subsequent online communi-cation was motivated by grief and anger, it reiterated that Ms. Strom was a professional and must act with integrity and in accordance with the Code of Ethics. The Committee emphasized that registered nurses must conduct themselves professionally and with care when communicating on social media. Ms. Strom was reprimanded and required to complete an ethics course. She was also required to pay a $1,000 fine and $25,000 in hearing costs. This decision highlights the consequences that can result from a regu-lated professional’s decision to broadcast critical remarks harmful to the profession or its members, regardless if the professional was acting in their capacity as a regulated member or not.

You Are a Health Care Professional 24/7Regulatory bodies are also faced with the issue of their members posting or reposting information on social media that are at odds with its policies or seen as unprofessional. It is important that health care profession-als remember that social media posts reflect on themselves, their employers and their profession.

In early 2017, the Manitoba Chiroprac-tors Association was provided several dozen examples of statements, claims and social media content posted by its members that contradicted public health policies or medical research on vaccination and im-munization. The Association had previously reminded its members that the administra-tion of vaccination and immunization fell outside the scope of chiropractic practice and cautioned the members about providing opinions on this issue. Following receipt of the online content, the Association advised that it would conduct an internal review.

In response to its members’ increased use of social media for both personal and profes-sional purposes, Colleges have issued poli-cies reminding members of responsible use of social media platforms. The BC College of Chiropractors has also cautioned its mem-bers with respect to the reuse or reposting of material online, specifically:

Before reusing or reposting information from another party, review it carefully to ensure it complies with the BC rules and regulations. As professionals, registrants are

ultimately responsible for the content posted in their marketing materials.

In addition to content shared on social media, Colleges monitor and regulate ad-vertising strategies used by members. While advertising is used to differentiate providers from the competition, Colleges are focused on the context and the message that adver-tising techniques relay to clients.

A recent example is the Alberta dentist, Dr. Zuk, who came under fire for breaches of the code of ethics that include his advertis-ing practices. The Alberta Dental Associa-tion & College has specific rules with respect to advertising. The College has banned many promotional techniques including testimo-nials, before and after pictures (outside of dental offices) and coupons. The College took issue with more than 20 of Dr. Zuk’s advertising and promotional practices, which included statements of being the best dentist in Red Deer and having the world’s most advanced dental restoration system. The case resulted in a one-year suspension and a $175,000 fine. The case is currently being appealed.

Actions in your Personal Life may be Grounds for DismissalIn January 2016, a fourth-year neurology resident threw a “temper tantrum” that was caught on camera, when she was refused a ride after attempting to take someone else’s Uber after a night out. The video itself has been viewed over eight million times on YouTube and there was significant social media outcry, including a web page aimed at disparaging her reputation. Ultimately, she was terminated from her residency by Jack-son Health System.

In another incident in June 2017, a Dean at Pierson College, a Yale residential college, was placed on leave after a series of her Yelp reviews were published in the Yale Daily News in which she called people “white trash”. A month after being placed on leave, she resigned. The head of Pierson College’s administrative office then spoke out about the posts and said they had “damaged [his] trust and confidence in Dean Chu’s account-ability and her ability to lead the students of Pierson College”.

Finally, the story of the Dalhousie Univer-sity dentistry students disciplined in 2015 for participating in a misogynistic Facebook group is a cautionary tale that personal social media activity can even have repercussions on licensure before you are a regulated professional. Following this incident, some Dental Colleges amended their licensing applications to capture whether an applicant was the subject of a complaint or inquiry at their post-secondary institution.

Social Media for Regulated Professionals


Tips to Use Social Media EffectivelyThe high standards of behaviour expected of a professional on social media also extend to their personal media use. The following are tips for using social media effectively:1. Keep your social media accounts private, cre-

ate a secure password, and avoid “friending” clients/patients;

2. Do not communicate with clients/patients on social media or via text messaging;

3. When communicating on social media, do not give out client/patient information, do not include specifics, and do not mix work and play;

4. Follow all rules your employer and profes-sion may have regarding social media use; and

5. Remember that your actions can be grounds for complaints to your regulatory body. It is important to take care to represent your profession with pride.

ConclusionSocial media can be an effective platform for regulated professionals to communicate mean-ingful information to a broad consumer base. However, considering the growing popularity of social media in recent years and the many troubling incidents involving its misuse by members of various regulated professions, the best practice for professionals using social media is to be professional, courteous and respectful in all online activities. The high standard of behaviour expected of a profes-sional on social media also extends to your personal media use.

Specifically, regulated professionals should limit social media accounts to a private net-work such that the public cannot gain access to specific contents and contact lists. Cau-tion must be exercised in sharing any client

or patient related information online, even if the specifics of the matter, such as the client/patient name, are not disclosed, keeping in mind that the applicable professional code of conduct or regulation continues to apply to online activities. Any inappropriate or critical remarks that may attract regulatory scrutiny if made in person will not be exempt from professional reprimand merely because it was made on social media. In fact, the unforgiv-ing speed of transmission of social media may exacerbate the effects of unprofessional com-ments.

General advice and practice tips regarding the use of social media have been published by some professional regulatory bodies. We encourage you to review these guidelines and steer clear of social media hazards.

Until there are specific policies and regula-tions governing the use of social media, the above decisions show the importance of being vigilant in using social media and understand-ing that social media is not an abstract world isolated from reality and beyond professional regulation.

Online posts take seconds to craft but the fallout from these posts can be permanent. As a regulated professional, our advice is to think twice before your next tweet.

This article was prepared and written by the BMS Group Healthcare Professionals Insurance Alliance legal team at Gowling WLG (Canada) LLP (Gowlings), one of the largest and most highly-recognized legal firms in medical defence and professional liability in Canada. In the event of an actual or potential professional liability claim, CPA members who participate in the Professional Liability Insurance program are eli-gible for 30-minute pro bono and inclusive legal claims defence services from Gowlings.

Gowlings Pro Bono Legal Advice line: 1-888-943-0953

Social Media for Regulated Professionals

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Aim: provide self-reflection tool for physiotherapists, physical rehabilitation therapists, and physiotherapist assistants to consider when seeking employment

Employment decision tool


While interviewing members and regulators during the Reputational Risk project, we heard many stories about PTs and PTAs being pres-sured into risky situations. These behaviours sometimes contravened standards of practice or the code of ethics

The following employment decision tool was originally designed to guide young professionals and internationally educated professionals transitioning into the Canadian workforce. This tool may be of benefit to anybody who is making a career change, regardless of circum-stance.

The tool with guide your self-reflection and fact searching process before, during and after an employment change. It may remind you of important questions to ask as you explore new opportunities.

We would like to thank the members of the Ontario Internationally Educated Physical Therapy Bridging Program and the staff of the provincial branches of CPA for providing feedback and guidance.

This tool is not all-encompassing. If you have thoughts to add to it, please reach out to us:

[email protected] or [email protected]

Before beginning any job search, it is important to ask yourself these questions:Location:• Where do I want to live? • Do I want to work and live in the same community?• Am I willing to relocate for a job?• If yes, have I explored options in rural and remote settings?

Clinical Practice:• Which clinical area(s) am I passionate about?• Which setting(s) am I comfortable practicing in?• Do I want to work in a sole practice or to be part of a team?

Practical Considerations:• Do I want to work as an independent contractor or an employee? • Am I clear on the difference? • What are the Canada Revenue Agency (CRA) rules I need to know to

ensure I am compliant?• What information from my regulatory body do I need to review? • Is there a tool to help guide me in my decision-making? (e.g. Ottawa

Personal Decision Guide)

Other Considerations:• Where do I see myself in 5 years?• What are the stepping stones to getting there?• Can I afford to wait for the perfect opportunity? • What am I willing to compromise on at this time?

Summary: What are my criteria for this employment? What is most important to me at this time?

Looking for work? Ask yourself these questions first…Melissa Anderson, PT, CPA Member since 2004 Chantal Lauzon, PT, CPA Member since 1995

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The interview with potential employers is a chance for them to ask questions of you, but also for you to ask questions about the employment opportunity. Asking questions shows that you are prepared and interested. When you are at the interview, think about what information you need to ensure you can make an informed decision.

If you are being interviewed as a potential employee:• Does this employer offer a formal orientation program?• Does this employer provide mentorship opportunities (formal or

informal)?• How does this employer facilitate/support professional behaviour? • What are the workplace expectations or policies with regards to:• Scheduling of patients• Patient quota (e.g. number of patients treated over specific time)• Billing practices and audit practices• Model of care/working with Physiotherapist Assistants• Working in team environment• Sale of merchandise/supplies• Workplace safety (e.g. working alone)• Employee health – sick days

Salary and benefits: • Salary• Vacation• Extended health benefits• Sick days• Professional development• Pension• Union

If you are being interviewed as a potential independent contractor:• What does this owner/manager offer in terms of orientation to the

facility?• How does this owner/manager facilitate/support professional

behaviour? • What are the workplace expectations or policies with regards to?• Administrative support for scheduling of patients • Patient quota (e.g. number of patients treated over specific time)• Billing practices and audit practices• Model of care/ working with Physiotherapist Assistants• Working in team environment• Sale of merchandise/supplies• Workplace safety (e.g. working alone)• Promotions and advertising of workplace and individual PTs

Remuneration: • How will my remuneration be calculated? • How and when will I be paid?• What is the cost for space and equipment usage (rent)? • How and when do I pay rent?• Does this meet CRA standards?

After completing your interview with potential employers, you should reflect on whether this employment relationship is right for you. Before making a decision, weigh out the pros and cons, and evaluate your options.

Regulation and legal considerations:• What are my responsibilities with regards to my standards of

practice? (advertising, delegation, record keeping, billing and fees)• Am I willing to enter into a different employment relationship

than I had planned? (Independent contractor versus employee)• Does the contract adequately reflect the definition of either

employee or contractor?• Does it meet CRA standards? • Is there a need to consult a lawyer or an accountant?• Do I understand and accept the expectations and policies of the

workplace?• Do I have any doubts/concerns that I will have difficulty meeting

my professional obligations with this employment opportunity?

Making a decision• Do I have all of the information to be able to make a decision? • Should I use a decision aid (e.g. Ottawa Personal Decision Guide)?• Are there any points that I need to clarify before making

a decision?• Is all of the information detailed in the contract? • Does the contract accurately reflect the discussions?• Who do I need to consult before signing a contract

(e.g. accountant, lawyer, regulatory body)? • To protect my interests• To ensure full understanding of my rights and responsibilities• Does this opportunity meet my criteria for employment?• Will this opportunity allow me to achieve the work-life balance

that I desire?• Does this employment setting provide an opportunity for

professional growth?• Do the terms of the contract meet my expectations? • Is this opportunity the best fit for me at this point in my career?

What are the next steps? Once you have accepted a new op-portunity. Set yourself up for success.• Notify your regulator of your new employment and contact

information (as per provincial standard of practice.)• Know your rights and responsibilities. Make sure that you

understand and keep your contract handy.• Start good work habits; as a health professional, you provide

advice to patients about health and wellness. Make sure that you build your own resilience and follow your own advice.

• Maintain your professional portfolio as required by your regulatory body.

• Create a professional network or support system.• Give back. Get involved with your professional association –

there are many opportunities for you to network, grow, learn, and practice your leadership skills.

Knowing what you are getting into is essential as you start your professional career or anytime you make a significant career change.


Cultural safety is gaining prominence as a strategy for improving health outcomes in environments where services are provided to Indigenous people and communities, in Canada and other coun-tries with colonial histories such as Australia and Aotearoa/New Zealand. The concept was developed by Maori nurse, Irihapeti Ramsden, in response to the mainstream health system’s inability to meet the needs of Maori People.1,2 Physiotherapy New Zealand Guidelines explain that cultural safety “relates to the experience of the recipient of physiotherapy service and extends beyond cultural awareness and cultural sensitivity.”3 This means that only the client can determine whether their experience has been culturally safe. The Health Council of Canada4 defines cultural safety as:

“.. an outcome, defined and experienced by those who receive the service—they feel safe; … based on respectful engagement that can help patients find paths to well-being; …based on understanding the power differentials inherent in health service delivery, the institutional discrimination, and the need to fix these inequities through education and system change; and requires acknowledgement that we are all bearers of culture—there is self-reflection about one’s own attitudes, beliefs, assumptions, and values.” (p.5)

Although not yet widely understood or practiced in physiother-apy in Canada, cultural safety is a crucial strategy for improving health outcomes for all our clients.

Cultural safety: A key component of professionalism in PTKatie Gasparelli, BSc PT, MSc, CPA Member since 2004; and Stephanie Nixon, BA, BHSc, MSc, PhD, CPA Member since 1993

Left to right: Katie Gasparelli, PT; Nadia Andruchow, Dietitian; Kelly Gordon, Dietitian; Lindsay Vanderspank, Dietetic Intern from Brescia. Teaching our dietetic intern and new employee, Nadia, how to braid and hang our Traditional white corn for drying. The corn is then lyed or ground to make flour for use in Haudenosaunee foods. Harvesting of corn is used as a land based physical activity and our cooking classes include many of the foods from our Traditional territory.


Why is cultural safety relevant to professionalism in Physiotherapy? The health disparities between Indigenous and non-Indigenous people in Canada are in part due to poor access to appropriate care. Indigenous people can face subtle forms of racism that create an unsafe environ-ment for them to communicate what they need. The Essential Competency Profile for Physiotherapists in Canada5 describes a key competency within our role to ”respect the individuality and autonomy of the client”. This includes respecting a client’s rights, dignity and uniqueness. Unfortunately, nega-tive attitudes, which may be unconscious and entrenched due to pervasive colonial perspectives, have resulted in poor treatment of Indigenous people within the Canadian health care system.2,6

Cultural safety takes us beyond the super-ficial differences between cultures that we might learn during cultural awareness or cultural sensitivity training. It requires us to look inward and examine our own values, beliefs and assumptions about ourselves and others. To begin the work of becoming a culturally safe provider, we must critically self-reflect and examine our own biases. Once we understand our biases, we can begin to challenge them and change the way we interact with our clients. This can improve our relationships not only with Indigenous clients, but every person that we interact with on a professional or personal level. Furthermore, cultural safety requires that we also understand how the inherent power embedded in our clinical interactions can (often unknowingly) reinforce historic ineq-uities. Becoming a culturally safe PT involves both learning (e.g., about the historic role of health care as a vehicle in the cultural geno-cide of Indigenous Peoples in Canada) and unlearning (e.g., harmful stereotypes about Indigenous People).

The College of Physical Therapists of Brit-ish Columbia7 has created a resource about communication in the therapeutic relation-ship and identifies that cultural differences can have an impact on our ability to commu-nicate effectively. This resource highlights the need for physiotherapists to understand their own perspectives in order to examine their reactions to differences (different from our own) in our clients’ behaviours. The process through which we do this reflection has been termed cultural humility.

“Cultural humility is a process of self-reflection to understand personal and systemic biases and to develop and maintain respectful processes and relationships based on mutual trust. Cultural humility involves humbly acknowledging oneself as a learner when it comes to understanding another’s experi-ence.”8

Working in a way that creates culturally safe spaces for Indigenous clients is essential if we are going to support the improvement of health outcomes in Indigenous commu-nities. However, working in this way will improve relationships with all clients that we interact with. Engaging in the process of cultural humility creates the opportunity for reciprocal, trusting relationships with clients that allow for improved communication and improved outcomes. Creating culturally safe environments requires ongoing engagement in self-reflection.

PTs care about providing optimal care to their clients. Cultural safety is an important strategy for growing as clinicians and as a profession.

About KatieKatie Gasparelli is a physiotherapist working for Health Services at Six Nations of the Grand River Territory, a First Nations community in

Southern Ontario. She worked as a clini-cian in the community for 6 years and is now part of the leadership team. Katie has been the Indigenous Health Representative in the Global Health Division of the CPA for two years.

@Gasparek

About StephanieStephanie Nixon is an Associate Professor in the University of Toronto Department of Physical Therapy, and Director of the Inter-

national Centre for Disability and Reha-bilitation. Stephanie is a member of the Indigenous Health Subcommittee in the Global Health Division of the CPA.

@sanixto

References1. Ramsden, I. M. (2002). Cultural safety and nursing education in

Aotearoa and Te Waipounamu (Doctoral dissertation). Victoria University of Wellington, Victoria, AU. http://www.nzno.org.nz/Portals/0/Files/Documents/Services/Library/2002%20RAMS-DEN%20I %20Cultural%20Safety_Full.pdf

2. Mackenzie Churchill, Michèle Parent-Bergeron, Janet Smylie, Cheryl Ward, Alycia Fridkin, Diane Smylie, and Michelle Firestone. (2017). Evidence Brief: Wise Practices for Indigenous-specific Cultural Safety Training Programs. Well Living House Action Research Centre for Indigenous Infant, Child and Family Health and Wellbeing, St. Michael’s Hospital. Toronto, Canada. file:///C:/Users/Stephanie/Downloads/2017%20Wise%20Practices%20in%20Indigenous%20Specific%20Cultural%20Safety%20Training%20Programs.pdf

3. Physiotherapy New Zealand Guidelines (2004). For Cultural Competence in Physiotherapy Education and Practice Aotearoa/New Zealand. http://physiotherapy.org.nz/assets/About-us/Tae-Ora-Tinana/5.-Cultural-Competence-in-Physiotherapy-Education-and-Practice.pdf

4. Health Council of Canada. (2012). Empathy, dignity and respect: Creating cultural safety for Aboriginal people in urban health care. Toronto, Health Council of Canada. https://healthcouncil-canada.ca/files/Aboriginal_Report_EN_web_final.pdf

5. National Physiotherapy Alliance Group. (2009). Essential Com-petency Profile for Physiotherapists in Canada. http://npag.ca/PDFs/Joint%20Initiatives/PT%20profile%202009%20English.pdf

6. Allan, B. & Smylie, J. (2015). First Peoples Second Class Treatment: The role of racism in the health and well-being of Indigenous peoples in Canada. Toronto, ON: The Wellesley Institute. http://www.wellesleyinstitute.com/wp-content/up-loads/2015/02/Summary-First-Peoples-Second-Class-Treatment-Final.pdf

7. Making a Connection: Communication in the Therapeutic Rela-tionship. 2012 College of Physical Therapists of British Columbia. http://cptbc.org/wp-content/uploads/2013/10/MakingACon-nection.pdf

8. First Nations Health Authority. (2017). Cultural Humility. http://www.fnha.ca/wellness/cultural-humility

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Introduction According to the Merriman-Webster Dictionary definitions of reflection include: “a thought, idea; or the opinion formed or a remark made as a result of meditation and consideration of some subject matter, idea, or purpose”.1 Clinical reflection is a skill valued academically at universities in health science programs and in accrediting agencies.2,3 While value has been attached to reflection, it could also be argued that research into the theory of reflection has not occurred in a fulsome way.2,4 In the busy day to day of clinical activity how do physical therapists use reflection? Are we able to become more effective and efficient in our reflection process and if so, how deeply should therapists be going beyond the initial act of “considering an idea or purpose”?

The act of clinical (or critical) reflection is more complex than what appears in the above definition. Theories suggest that students and newly practicing physical therapists are likely to practice “reflec-tion on action” versus the experienced practitioner who is thought to use “re-flection in action”.5 Reflection on action occurs after the event. The student or practitioner considers what occurred in an interaction later in the day or week to gain clarity and deeper insight. Reflection in action is more immediate. It occurs during an interaction with the student/practitioner analyzing the interaction and clinical findings, treatment approaches and results, as they move through a situ-ation. More advanced practitioners may not recognize that they are reflecting and simply attribute their thought process to “just knowing” or “thinking on their feet”. Gibbs’ reflective cycle acknowledges that “feeling” is part of reflection.6 Thompson and Pascal (2012) have also suggested that a third type of reflection: “reflection for action” in which the student or clinician may plan in advance for a more complex interaction based upon past knowledge and experience.4 It is very likely that stu-dents and experienced clinicians practice all three to varying degrees throughout their work day.

Levels of reflection The most basic example of a reflection is simply descriptive writing – this occurred and this is the result. The next higher level is descriptive reflection. In this type of reflection, the situation is described

with more detail but no attempt at analysis is provided. In a dialogic reflection students or professionals will attempt to piece together a situation using clinical reasoning but with little insight or discussion. “I learned this, did this in this situation and these are my findings.” This is useful when initially trying to puzzle through a potential assessment plan and findings, as well as treatment planning; execution and results.7 Dialogic style of reflection may initially be self-centered and not focused on the client. As the student (or clinician) continues through experiential learning they will begin a more holistic reflection process that reinforces their clinical reasoning and begins to focus on the client, and the client’s goals.8 As this process evolves it becomes a critical reflection. Continued thoughtful piecing together of findings with matching academic knowledge occurs, but will also consider other layers of an interaction including interpersonal interactions that may have had an effect on the learning experience.9 This process is a rather flat model of reflection. Further refinement of reflection by the student or clinician will result in an experience being examined more critically and at a deeper level. This should include review of personal interactions and self-beliefs, communication styles, the effects of systemic or societal forces on client health, validation or questioning of previous knowledge, and serve to enhance the application of newly acquired skills as well as advance learning.2,10

CLINICAL REFLECTION –

Does it occur only in an ivory tower or is it clinically and professionally important?ANNE RANKIN , BscPT, MScPT, Chair – CPA Oncology Division, CPA Member since 1979


Initial attempts at reflection may be considered hard work as students and novice clinicians try to analyze clinical findings within new environments. Quiet dedicated time is required in order to move through the reflective process to evaluate the client interaction and its impact2. Findings suggest that students found their ability to clinically reflect occurred at a more advanced level after completion of a module on clinical reflection and students recognized the professional benefits to reflection within a clinical setting. Wessel and Larin (2006) also noted an improved quality of reflection when they examined reflective journals at the beginning of their physical therapy clinical education and at completion of their program.6,11 Their work would indicate that clinicians can expand their skills of reflection.

Expert practice Is there purpose for critical reflection within a population of experienced clinicians? At a very basic level the purpose of reflection is to identify gaps in knowledge, facilitate clinical reasoning and stimulate learning. It offers the opportunity for self-identification of professional strengths and occasionally failures. With advanced reflective capacity, the expert clinician will be able to examine interactions with a questioning mind. Am I doing this because it has always been done this way? Why isn’t this working? What am I missing? Is there a better way to focus on this? This critical analysis is what potentially drives our own life-long learning, future research and our profession’s development. An editorial in Physiotherapy Canada by Gibson, Nixon and Nicholls (2010) challenged physical therapists to question or reflect on practices that have “always been done in one way” to develop new practice or research to replace outdated practice that is no longer supported by the evidence.12

Thompson and Pascal (2012) reported that while reviewing portfolio submissions for an educational award some practitioners submitted superficially written thoughts that did not indicate any form of critical analysis.4

As we move through the continuum of practice from novice to expert and then specialist, it is worthwhile to review what forms a thoughtful clinical reflection.

Experience in practice is not enough to advance knowledge or potentially develop advanced clinical reasoning. Reflection is critical to the development of self-evaluation of clinical practice. Donaghy and Morss (2009) presented a framework to stimulate reflection in practice. Their framework incorporates use of a circular evaluation to enable a therapist to reflect on a patient interaction to facilitate clinical reasoning.13 While it does encourage clinicians and students to identify potential pitfalls in a patient interaction, it does not examine the intangibles of patient cultural context and potential communication errors. Considering the multicultural face within Canadian practice, it is imperative that therapists be aware of such complexities. This model does not incorporate active questioning of present practice. As therapists become more experienced they move from consciously incompetent, to consciously competent to unconsciously competent (Maslow’s learning cycle). The challengave is to dig deeper into what therapists have learned in the past; what current practice is and how practice may be changed in the future. If active learning occurs during the consciously incompetent and consciously competent phase of the learning cycle, it may be helpful for experienced therapists (those who are unconsciously competent) to spend more time in these areas when reflecting. Exceptional patients that challenge clinical skills offer the ability to develop reflective practice further by stimulating a “gut feeling” or “intuition” that “something is different about this.” These patient interactions should inspire further learning opportunities and questioning of current practice. The “gut feeling” or “intuition” (referred to as “feeling” in Gibbs’ reflection cycle) needs to be listened to and acted upon.6 Active reflection on “what we have always done,” and considering what is unique about specific patient interactions should facilitate an internal conversation that could potentially focus on usual practice in exceptional circumstance. Critical reflection can spur lateral (or creative) thinking to problem solve.14

Summary Reflection is a task of integrating theory with all of the complexity of practice. Time is required

for reflection to occur. Critical reflective examination with a lens of curiosity of patient history, specific findings, differential diagnosis list or hypothesis, feelings elicited and/or response to treatment may highlight the need for future research and will likely steer advanced practice. It could be argued that when compared to continuing professional development expenses and the associated time investment of therapists, the stimulus of personal learning through reflection and identification of potential research should be considered good financial value. The challenge of self-reflection or critical reflection continues. Critical reflection on practice is a personally risky venture. Professionals are required to admit their potential personal and professional failings. Therapists, even expert therapists, should spend time in a reflective learning state to critically examine practice.

About AnneAnne Rankin is an Instructor at University of British Columbia and also practices part time at Sungod Sports & Orthopaedic Physiotherapy Clinic. She is presently co-leading a study regarding peer assessment of clinical reflection at UBC.

References1. Merriam-Webster dictionary. [cited Jan 5, 2018] Available from: https://www.merriam-webster.com/dictionary/reflection 2. Mann K Gordon J and MacLeod A. Reflection and reflective

practice in health professions education: a systematic review. Advances in Health Science Education. 2009;14:595-621.

3. Canadian Physiotherapy Association: Resources [cited: January 9, 2018]

Available from: http://www.physiotherapyeducation.ca/Resources/Clin_Ed_Guidelines_FINAL_%202011.pdf 4. Thompson N and Pascal J. Developing critically reflective practice

Reflective Practice. 2012;13:311–325.5. Schön, D. Educating the reflective practitioner. San Francisco:

Jossey-Bass; 19876. Gibbs, G. Learning by doing: a guide to teaching and learning

methods. Oxford: Further education unit. 19887. Williams R, Wessel J, Gemus M, Foster-Seargeant E. Journal writing

to promote reflection by physical therapy students during clinical placement. Physiotherapy Theory Practice. 2002;18:5-15.

8. Wessel J, Larin H. Change in reflections of physiotherapy students over time in clinical placements. Learning in Health Social Care 2006;5:119-132.

9. Thompson N and Pascal J. Reflective practice. An existentialist perspective. Reflective practice 2011;12:15-26.

10. Baker S, Painter E, Morgan B, Kaus A, Petersen E, Allen C, et al. Systematic clinical reasoning in Physical therapy (SCRIPT): Tool for the purposeful practice of clinical reasoning in orthopedic manual physical therapy. Physical Therapy 2017;97:61-70.

11. Roche A, Coote S. Focus group study of student physiotherapists’ perceptions of reflection. Med Ed. 2008;42:1064-1070.

12. Gibson B, Nixon S, Nicholls D Critical reflections on the physiotherapy profession in Canada. Physiother Can. 2010;62(2):98-100.

13. Donaghy M, Morss K. Guided reflection: a framework to facilitate and assess reflective practice within the discipline of physiotherapy. Physiotherapy Theory and Practice. 2000;16:3-14.

14. Jones M, Rivett D, editors. Clinical reasoning for manual therapists. Edinburgh: Elsevier Butterworth Heinemann; 2003

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