INTRODUCTION

Sport integrity and reputation is threatened globally with repeated media reports of doping, match fixing, sexual harassment, and physical and psychological abuse. Every stakeholder working in sport has a responsibility to speak up, but as physiotherapists our professional duty of care should prioritize protecting the health and well-being of athletes. Individual, professional, and organizational challenges to speaking up have been noted in the healthcare literature,1 including, fear of retribution, loss of employment with associated financial, social and emotional loss, and a culture of fear, bullying and intimidation. While candor is considered a professional duty, the challenges of speaking up in sport are critically linked to the environment, which is created through National Governing Bodies and clubs or squads, as well as personal resilience to possible acceptance of negative behaviors within everyone’s interpretation of a moral code.

BACKGROUND

A UK government report has criticized the high-performance sport culture, questioning the safety of these environments and their effects on athlete welfare.2 These criticisms have been further reported globally by individual athletes from various sports and countries. Figure 1 outlines examples of these global issues.

Figure 1
Figure 1.Examples of types of abuse at various levels in the public domain since 2015.

SPEAKING UP

Support staff, coaches and athletes involved with any organization should be able to report incidents or raise concerns. Speaking up is considered as voicing concern about an issue related to patient care and or safety, while whistleblowing often implies a more formal process to raise concerns about wrongdoing or malpractice.3 Regulatory and professional rules require physiotherapists to report safety concerns. International Federation of Sports Physiotherapy (IFSPT) competencies required of a sports physiotherapist includes a knowledge and understanding of the tensions between sporting interests and duty of care.4 However, global literature regarding physiotherapists speaking up and whistleblowing about observed negative behaviors is stark in its absence.5–7 The lack of published comment could reflect either fewer formal complaints that physiotherapists may have experienced, barriers to speaking up about these issues related to safeguarding athletes linked to sporting culture, power dynamics, hierarchies, and fear of negative consequences (e.g., job losses and a lack of psychological safety).3 As the published information tends to only cover formal complaints to regulating bodies, it is difficult to accurately identify incidences of physiotherapists speaking up in an elite system.

Sport integrity refers to issues such as bullying, harassment, discrimination, abuse (verbal & physical), sexual misconduct, sexual harassment, victimization, and doping. The oversight for sport integrity varies internationally.8 There are wide-ranging routes to speaking up in different cultures, making profession-wide education difficult internationally. In addition to existing formal structures, working environments in sport can vary considerably, which consequently affects willingness to engage with peers for advice or support in considering a specific incident or negative behavior. Thus, currently, interventions regarding sport integrity occur on a case-by-case basis rather than following an overarching international recommendation.

REGULATION AND MECHANISMS THROUGH WHICH SUPPORT STAFF SPEAK UP

Typically, elite athletes in most countries are supported by a team of staff across various disciplines, with different degrees of regulation (Figure 2). Some members of the team have a legal obligation to ethical principles including confidentiality, but others do not. While job titles vary internationally, the principle of a mixed professional make-up in a multidisciplinary support team will undoubtedly apply. Figure 2 outlines typical membership of the team in UK elite sport.

Employment structure also varies, as some staff might be employed directly by the sports organization and others indirectly, through national sport institutes or similar arrangements. The complexity of such a system is challenging when it comes to speaking up, particularly when it could compromise job security and safeguarding the whistle-blower. Sports physiotherapists in their unique role are allowed to practice in areas that are strictly restricted, including on or near the field of play. Therapists could therefore potentially witness behaviors unseen by others or be a target for others aiming to influence the outcome of a competition through athlete coercion. Speaking up in some of these complex situations is challenging and may include factors identified as barriers to speaking up in general healthcare, such as hierarchies, power dynamics, culture, perceived safety of speaking up (fear of response and repercussions), and lack of training.4 These factors could also occur in the elite sport environment and potentially lead to silence and acceptance of poor behaviors.

Figure 2
Figure 2.Typical membership of the multidisciplinary team supporting elite athletes (UK)

DEVELOPING THE SKILLS – RECOGNITION AND COMMUNICATION

Developing appropriate skills to recognize negative behavior and effective contextual communication requires a multifactorial, collaborative approach and an enabled ecosystem. Raising concerns appropriately within a team requires contextual intelligence to overcome some anticipated barriers of challenging observed negative behaviors. A model previously described by Paterson and Phillips9 outlined the importance of both formal and informal learning in developing expertise. While recognition of negative behaviors can be taught formally, learning effective and appropriate communication in different contexts is more likely learned informally through supervised experience and mentoring. Learning to balance ethical behaviors with and perceived job security requires both formal and experiential support. This is where a community of practice, that includes mentoring, perhaps generated in a national or international body, such as IFSPT, becomes so valuable to facilitate discussions.

TAKE HOME MESSAGE

Effectively speaking up regarding negative behaviors relies on the courage of the speaker, the listening skills of the receiver, as well as the action plan thereafter. It is critical to ensure that physiotherapists understand and act on their professional obligation and duty of care to report wrongdoing or address any negative behavior that may occur within the team setup. If barriers exist, it is incumbent upon the professional to address these through education, reflection, collaboration, mentoring, and continuous evaluation of processes. Ultimately, the aim is to ensure that physiotherapists can work in safe professional environments with opportunity to speak up through available channels, thus protecting the athlete and fostering an open culture.

Understanding the difference between speaking up informally to address environments within a team and a more formal “whistleblower” report made externally is an important integral foundation for educating physiotherapists. The communication skills needed to modify contextually appropriate conversation style need to be developed through mentored practice. The potential implications of the more formal option of reporting also need to be addressed so that physiotherapists can develop resilience to balance moral and ethical responsibilities within a performance driven environment in the interest of safeguarding athletes.