Professional Relationships

In accordance with the Standards of Practice, RTs must act with honesty, integrity, and respect appropriate professional boundaries with patients/clients, healthcare team members, students, and others. An important part of being a regulated healthcare professional is recognizing how a power imbalance can impact both therapeutic and professional relationships, and taking steps to ensure that you are acting with integrity in all interactions, including abstaining from entering into personal relationships where professional boundaries could be compromised.

Care in the community, particularly home-based care, is fundamentally different than the episodic, targeted interventions of the acute care system. Service provided near or in a client’s home requires a uniquely holistic, self-directed and patient-centered approach to care delivery. Home-based care presents opportunities to better integrate the plan of care into the client’s day-to-day environment, but also present some challenges as well, such as:

The primary goal of health care is to optimize the health of clients. This means that the interest of the client must always come first and not a financial interest. A conflict of interest arises when a secondary goal (e.g., personal gain for the health care provider) interferes or is perceived to interfere with the primary goal. The CRTO’s Conflict of Interest Professional Practice Guideline states that “a conflict of interest exists when an RRT is in a position where his/her duty to their client could be compromised, or could be perceived to be compromised, by a personal relationship or benefit”. The nature of community practice (i.e., long standing RT and patient/family interactions; financial compensation for services provided) has the potential to increase the risk of a conflict of interest situation developing. Any actual, potential or perceived conflict of interest must be properly identified, avoided and managed so as not to compromise the client’s best interests.

The first step is to recognize that a conflict of interest situation may exist. The Conflict of Interest Regulation (O. Reg. 596/94) outlines the situations in which an RRT might find themselves in an actual, potential or perceived conflict of interest [s. 3 (1)]. The likelihood of a conflict of interest increases when:

Example… An RRT working for a home care company has been providing care for a client in their home for a number of years. In gratitude for the services the RRT has provided, the client’s family offers the RT a gift card. Even if the RRT believes that the gift will not impact on the care they will continue to provide to the client – the RT must still politely decline the offer. This is because accepting the gift could potentially be perceived by the client’s family or others as altering the RRT to client relationship.

In situations where a conflict of interest situation exists, the RRT must declare the nature of the relationship/benefit to the client in advance of services being provided. This should occur regardless of whether the conflict of interest is actual, potential or perceived.

Example… An RRT who works for a hospital that is part of a hospital-home care company business relationship is making arrangements for an inpatient to be discharged with home oxygen. In addition to the home care company that is associated with the hospital, the RRT should – if possible – provide the client with other appropriate service providers. Where applicable, the RRT should advise the client that their selection of a supplier or a product or service will not adversely affect the assessment, care or treatment that they receive. This enables the client to exercise informed choice over the services provided to them. This includes allowing them to select a service provider, as well as the type of equipment/treatment received.

RRTs practicing in the community typically work with a diverse group of health care providers; some of whom are Regulated Health Care Professionals (RHCPs) (e.g., RNs, MDs, RSLPs), as well as some who are Non-Regulated Health Care Providers (NRHCPs) (e.g., PSWs, Customer Service Technicians).

NRHCPs can include an array of paid care providers and unpaid family members. One of the key considerations for RTs when working with NRHCPs in the community is to determine which services the NRHCP can provide to the client and which services are best provided by the RRT. As outlined in an earlier portion of this document entitled Exceptions in the RHPA, there is a legislative framework that enables care to be provided by NRHCP in the community under certain circumstances. As a regulated health care professional, the RT member of the health care team is expected to ensure that their clients receive optimal Respiratory Therapy services. If the RRT has any concerns regarding the care their client is receiving from any member of the health care team, the RT is expected to raise those concerns with the client’s primary care physician/nurse practitioner.

In addition to assisting other members of the health care, the RT practicing in the community is expected to know when it is appropriate to seek assistance from others.

More information on NRHCPs can be found on the CRTO website in the section entitled Working With Non-Regulated Health Care Providers.

Due to the fact that community-based RRTs interact with such a wide variety of care providers, it is essential to understand the difference between delegation and education, as well as which is required in certain circumstances. The CRTO Delegation of Controlled Acts PPG and the CRTO Respiratory Therapists Providing Education PPG provides detailed information on these two processes, which is briefly summarized in the table below:

Despite the fact they frequently work alone, highly developed communication and interpersonal skills are also essential for an RRT in a community practice setting. Community RRT’s are required to explain diagnosis/treatment plans and obtain informed consent from patient, as well as give instructions to anxious clients and/or their family members. In addition, community-based RTs need to maintain an open line of communication with other health care professionals, many of whom are not located at the site where care is being delivered.

Despite the convenience ofsuch communication mediums, the use of electronic communications to transmit sensitive information can increase the risk of such information being disclosed to third parties. The eCommunication Checklist produced by the Canadian Medical Protective Association provides some essential elements to considered when using electronic communication to convey sensitive PHI.

The discussion and client’s agreement should be documented in the medical record. Canadian Medical Protective Association (CMPA) has produced a consent template that could be modified and adapted to RT practice. To view the CMPA’s template Consent to use electronic communications (PDF). In addition, the Information and Privacy Commissioner of Ontario has published a Fact Sheet on Communicating Personal Health Information by Email that addresses the risk of email communication and how those risks might be mitigated.

In keeping with the Standards of Practice, “Respiratory Therapists must act with honesty, integrity, and respect appropriate professional boundaries with clients, health care team members, students, and others.” While most RTs will reflect on professional boundaries in relatively limited terms, such as romantic or financial relationships, “professional boundaries” covers every aspect of communication and interaction between RRTs and everyone with whom they come into contact in their roles. Perhaps it is because RTs don’t consider professional boundaries broadly enough that this issue results in the vast majority of investigations conducted by the CRTO; indeed, over 80% of concerns reported to the CRTO are related to professionalism.

“Professionalism” or professional conduct is a term that is often used to describe the behaviours that are expected of individuals who hold a certain role in society. A “professional” is typically someone who has obtained skills that are recognized as requiring specific, intensive training and who applies those skills in a position that impacts others (e.g., engineer, lawyer, RRT, PT, MD, etc.). Professionals are often held to moral, ethical and legal standards because of that potential impact.

In some circumstances, there is an inherent power imbalance between the Respiratory Therapist and the person with whom they are interacting. For example, treating a client, speaking with the SDM or family member of the client, or dealing with a non-regulated health care professional or a Student Respiratory Therapist. In all of these cases, the Respiratory Therapist has status and influence that makes overstepping their professional boundaries especially problematic.

More information can be found regarding Professional Boundaries in the CRTO Respiratory Therapists Providing Education PPG and the Abuse Awareness and Prevention PPG.

In 2016, the federal government passed legislation to amend Canada’s Criminal Code and established a framework for Medical Assistance in Dying (MAID) for individuals who meet pre-defined eligibility criteria. RTs in community practice may be required to provide information to clients seeking information about MAID or to assist a physician or NP in carrying out a request for a medically assisted death. Therefore, it is important that a community-based RT be knowledgeable about the following:

The above information, as well as addition resources can be found on the CRTO website in the section on the Medical Assistance in Dying.

In most circumstances, RRTs in community practice are obligated to maintain a professional relationship with a client as long as the client requires services from the RT. However, situations may arise that require the RT to end the professional relationship prior to reaching the normal or expected conclusion of the client’s treatment. These situations generally fall into one of two categories where the RRT will no longer able to provide the services:

All reasonable efforts must be made to resolve the situation in the best interest of the patient, and only consider ending the professionalrelationship where those efforts have been unsuccessful.

Example… Most home care companies have a policy in place to deal with situations where there is unsafe use of oxygen in the home (e.g., oxygen in use while patient/family member is smoking). These processes generally include all of the following steps:

1. Inform the client (preferably in writing) of what will happen if they use oxygen in an unsafe manner (i.e., how many warning they will receive and how those warning will be documented).

2. Notify the client (preferably in writing) of the decision to discontinue their treatment.

3. Document in the client’s medical record the reasons for the discontinuation of services, as well as all steps undertaken to resolve the issues prior to discontinuation.

4. Clearly convey to the client that they should seek ongoing care (e.g., speak to their primary care physician; go to their local emergency department).

5. Notify the health care provider(s) who ordered the oxygen that the therapy is no longer being provided to the patient. Also consider informing other members of the client’s health care team, as appropriate.