May 19th 2020
Recommendations for Registered Shiatsu Therapist’s Return to Practice in BC
The Shiatsu Therapy Association of B.C. has developed the following recommendations for a safe and effective return to practice for those in our profession in B.C. based on a number of sources, including WorkSafe BC and the recommendations of other colleges and associations.
Of course, your own judgment and personal choices will determine whether and how you implement additional measures specific to your practice setting, and specific to your patients’ needs.
Our aim is that the following protocol, if carefully followed, minimizes risk of transmission of the virus that causes COVID-19.
A return to practice of RST services requires clear and thoughtful communication that is based on trust between you, the RST, and your patient/client.
(We will use the terms patient or client interchangeably in this document).
Clear and honest communication, with listening, can build an environment of trust and safety where patients can again receive Shiatsu Therapy because the risk of transmission of the virus that causes COVID-19 is minimized.
This document reflects the state of our knowledge at the beginning of Phase 2 in BC’s return to work plan. It may change at any point as more information could be presented to us.
We will be notifying you, our members, of any changes via the usual email, and a post on the website, also available for public viewing.
1. Self-assessment and Pre-screening for Symptoms
Self-assessment and patient pre-screening be of paramount importance at this time.
We must self-assess for symptoms each day that we practice, and assess patients – each and every time we see them.
PRE-SCREENING PRIOR TO ARRIVAL
Inform you clients about the new procedures that we are implementing, before or at the time of booking.
Clear information should be included in all communications – website, online booking system, phone message, and auto-responses to email enquiries.
It is our responsibility to advise our client’s that additional screening and informed consent is required.
The reality of potential viral transmission exists, and as a result we must reaffirm with our clients that they understand the following.
We have taken measures to minimize risk of viral transmission, but the nature of Shiatsu Therapy means that physical distancing is not possible in the treatment room.
It is your responsibility to explain both the risks and the potential benefits of treatment, and to make decisions in the best interests of your patients and yourselves.
We recommend connecting personally with your patients to ask them to complete the BC COVID-19 Symptom Self-Assessment Tool ahead of meeting with you.
Tell your patient to stay home if experiencing any symptoms of COVID-19, including:
- shortness of breath,
- sore throat,
- loss of sense of smell.
If patients are experiencing these symptoms and have not been tested for COVID-19, you should recommend that they call 8-1-1 to seek out a test.
- Patients must confirm they have not travelled outside British Columbia in the previous 14 days.
- RST’s and clinic staff must also use the BC COVID-19 self-assessment tool daily, and stay home/cancel appointments if experiencing COVID-19 symptoms.
- For our patients at greater risk we MUST take additional precautions, such as discuss alternatives for care, and/or consider postponing treatment.
RST’s may provide Shiatsu Therapy when the patient and therapist both agree that the benefits of treatment outweigh the risk to the patient.
- Your cancellation policy should be relaxed to ensure honesty and compliance with pre-screening questions.
Our policies for personal protective equipment (PPE) are discussed below.
Advise your patients prior to arrival at your practice about provisions you’ve made for personal protective equipment (PPE, see below), and your rationale.
If they have a mask, ask them to bring it with them and wear it when they arrive.
We are providing a COVID-19 Screening and Informed Consent form available for download on the STA Website for Members.
We advise all RST’s to use this resource to confirm with their clients that they are using the proper assessment tool.
The RST and patient will run through the self-assessment tool again upon patient arrival.
The RST will cancel treatment if the patient doesn’t meet the pre-screening criteria on physical presentation at the practice environment.
Before and during each clinic visit, ensure your patient feels empowered to make their own decision on what they need to feel safe in order to receive treatment.
FURTHER SCREENING UPON ARRIVAL
If you share your practice environment – ensure that all practitioners who share the practice environment have a common understanding of these new operating procedures, and that all practitioners consistently apply these procedures.
PRE-SCREENING REGARDING CONTACTS – PRIOR TO ARRIVAL
It is at the RST’s discretion to include screening questions for patients’ contacts, e.g.
– Has the patient isolated within a restricted “bubble” and if so, for how long?
– Has he or she had extensive contact with individuals outside his/her immediate family, pod, or unit (other than service workers at grocery stores, banks, other)?
- Is the patient aware of anyone in their contacts who has COVID-19 symptoms?
- The RST should be prepared to share this information about themselves, as well.
2. Physical Distancing
It is an absolute requirement that we do what we can to maintain distancing protocols around our work environment. WorkSafe BC protocols are that “where physical distancing cannot be observed, it is recommended that both parties wear a mask.”
Many of us do work independently, even from home, but those who work in a clinical setting should establish clear distancing protocols with the other therapists.
There should be a standard protocol and consistent message of safety and consideration that is communicated clearly to the clients.
We look to WorkSafe BC and BC Centre for Disease Control for these recommendations.
RECEPTION & ENTRY
Clearly explain or mark distancing protocols.
Staff, RST and patient must maintain 2 meters / 6 feet of distance in clinic areas other than the treatment room, as much as possible within the practice setting.
- Remove all clutter, fabric furnishings, and decorations that cannot be sanitized after touch.
- Reduce traffic through staggered appointment start- and end- times.
- Direct patient to wait outside (in their car, or an area suggested by RMT or clinic staff) and not in reception – call or text when it’s time to enter.
- After treatment accompany patient to the exit and open the door for them (using a hand towel or other sanitized barrier).
- Make use of alternate entries/exits in practice environment to assist with distancing.
THERAPISTS’ SHARED AREAS
Shared areas, in a multi-practitioner setting (e.g., kitchen, lockers, charting stations), must:
- have separate, distanced workstations, or require therapists to use personal devices to access scheduling and accounting programs;
- minimize the use of shared equipment including computers and phones;
- stagger break times and use of shared facilities;
- frequently wash or sanitize hands. .
Clearly it is not possible to maintain physical distancing in the treatment room.
Pre-screening, physical distancing, hand hygiene, and enhanced cleaning help reduce the risk of transmission and enable return to practice while minimizing risk of harm.
WASHROOM FOR PATIENT USE
Physical distancing in washroom for patient use will be specific to practice setting.
Hygiene, sanitation, and distancing must all be considered.
Share clear instructions with patients in advance of arriving at the practice environment.
CLINIC ACCESS – Elevators/Stairs/Other
Clinic access will be specific to practice setting, similar to washroom for patient use.
Be aware of opportunities for incidental contact that violates physical distancing requirements, and place appropriate signage.
These areas shall be sanitized frequently.
RECEPTION & ENTRY
Consider a gradual re-entry to practice, to test that distancing measures put in place are sufficient, before increasing the number of patients/practitioners in the workplace at any one time.
Example: If five practitioners are usually in a clinic at any one time, consider starting with two to ensure physical distancing measures can be adhered to. Increase numbers once you have determined that you can do so while maintaining physical distancing.
Consider reducing chair usage.
Rearrange appointment process to prevent or at least minimize in-clinic waiting.
Patients who are infirm and require a companion present special challenges with regard to physical distancing from entry through treatment and departure.
Confirm that Shiatsu Therapy is essential at this time; postpone or refer to alternate care if possible.
If treatment goes ahead, RST will help patient and companion navigate every step of the way.
3. Hand Hygiene
RECEPTION & ENTRY
- Patient must wash hands upon entry with soap and water for at least 20 seconds, followed by thorough drying – must be done on arrival into and departure from the clinic, and before touching door/s.
- If soap and water are not available, provide sanitation station with alcohol-based hand rubs for patient’s use on arrival and prior to departure.
- If hands are visibly soiled, patient must use a wipe, then alcohol-based hand rub prior to moving to the treatment room.
- RST must wash hands often, using soap and water for a minimum of 20 seconds each time.
- Whether payment occurs in the Reception or Treatment area, a wireless point of sale system with tap feature may be used, or arrange e-transfer for payment. Receipt is emailed to patient.
- Cash is not preferred but may be handled provided that anyone doing so washes their hands immediately afterwards.
- RST opens the door to the treatment room and allows patient to enter; RST opens/closes door before, during, and after treatment as required, using hand towel/sanitized barrier as needed, and washing hands as appropriate.
- Hand washing/drying and sanitization options will be available for RST and patient.
- Hand washing will occur before and after each treatment (both RST and patient).
Patient should be able to see/hear RST washing and drying hands before and after treatment. If sink is outside the treatment room, RST must sanitize hands and confirm verbally that hands were washed before and after treatment, to maintain trust.
Remind and instruct your patients about proper hand washing.
You may wish to display hand-washing protocols, posted visibly in reception area and at sinks (including bathroom for patient’s use if applicable).
4. Face Touching Avoidance – e.g., avoid touching eyes, mouth, nose
- Share information about the reason for ‘no face touching’; COVID-19 can be spread by touch if a person has used their hands to cover a cough or a sneeze.
- Suggest patients use a tissue if an itch must be addressed.
- Tissues must be available for patient’s use in reception, treatment room, and washroom.
- Masks must be made available for patient and for RST.
- RST makes use of hand towel or tissue to touch or scratch face, or to sneeze into.
If RST is accustomed to sweating during her or his work, a head band should be used, or a hand towel should be available to wipe the forehead and face as required to avoid sweat from dripping into eyes necessitating touch.
5. Enhanced Cleaning & Related Practice Modifications
- Assure that all Therapists and Staff are aware of WorkSafe BC recommended cleaning/sanitation processes.
- Clean visibly soiled surfaces followed by disinfection.
- Clean and disinfect all high-touch surfaces in between patients, regardless of appearance.
- Linens (including blankets) must be single use only, then laundered in hot soapy water.
- Any pillows or cloth surfaces that cannot be sanitized must be removed from the treatment room
- OR you must cover with vinyl/plastic that can be sanitized. You can cover the vinyl/plastic with a pillowcase that can be used with one client only. This includes bolsters.
- Open windows in between sessions if possible.
Frequently clean and disinfect common areas and high touch surfaces, at least twice a day, e.g. light switches, window coverings, cell phones, tablets, chairs, stools, table surfaces.
Frequently clean and disinfect (at least three times per day, more if possible):
– handles: doors, cabinets, faucets, fridge, microwave, etc.
– electronic device keyboards and mice, phones,
– arm rests of chairs,
– desk and table surfaces,
– water cooler.
*Clean in view of patients so patients see the steps taken for safety.
*Schedule additional time between patients to thoroughly clean treatment room.
*Sanitize the treatment table and table adjustment levers after each treatment.
If you use a FUTON to provide treatment:
A futon is made of cotton/cloth and thus may harbour bacteria/virus. We recommend that a vinyl or plastic sheet that can be sanitized is place between the futon and the single-use sheet.
Possibly a shower curtain could accomplish this.
If you use a table:
Massage tables are vinyl/wood/metal and thus may be sanitized.
- Clean the face cradle (one more time) and arm rests (if used) in front of the patient, to maintain trust.
- Clean equipment and supplies (table levers, lotion bottles, etc.) immediately after each patient.
- Attach Cleaning and Disinfectants for Clinic Settings poster from the BC Centre for Disease Control in reception area, washroom for patient use, treatment room.
WASHROOM FOR PATIENT USE
All contact areas must be cleaned and disinfected several times a day.
Ensure that soap is available for hand washing, clean material for drying, and wipes (or paper towels, tissues) are available for doors and touch-surfaces.
CLINIC ACCESS – ELEVATORS/STAIRS/OTHER
All contact areas must be cleaned several times a day, e.g. doors, elevator buttons.
Provide wipes if available. If wipes are unavailable, provide paper towels or tissues for patients to use as a barrier when contacting high-touch surfaces
Post a schedule of cleaning and disinfecting routine (area, last completed, initials).
- Air purifier / filter in the treatment room may be helpful if room has no windows or external air exchange.
- Good air flow is always important.
- In a low-risk environment created by pre-screening of RST’s and patients’ health, supported by good hand hygiene and cleaning protocols.
- Therefore, use of an air purifier / filter is at the RST’s personal preference and discretion
- (To the best of STA knowledge and at the time we were editing this text, there is minimal evidence that aerosolization of the virus increases the rate of transmission.)
6. Personal Protective Equipment (PPE)
Please read the CDC link on MASKS – provided below – to familiarize yourself with the facts.
- WorkSafe protocols state the following:
- Fourth level protection (PPE): If the first three levels of protection aren’t enough to control the risks, supply workers with personal protective equipment (PPE), such as non-medical masks. PPE should not be used as the only control measure. It should only be used in combination with other measures.
- We interpret this as where physical distancing cannot be observed, it is recommended that both parties wear a mask.
- RST’s must have cloth or paper/disposable (surgical) masks available for patient’s use if requested, and for RST’s use if patient requests it.
- Cloth masks must be laundered after each use.
- If a cloth mask is offered to a patient, it must be evident that the mask is clean and has not been worn by others. Please present masks in a clearly sanitary fashion.
- It may even occur during treatment that the patient or RST feel that additional risk mitigation is necessary, and a decision to wear a mask can be made at that point.
- Putting on and removing mask: wash hands with soap and water prior to putting on a mask, prior to taking off a mask, and after disposing of a mask in the laundry or garbage (cloth or paper/disposable).
RST’s are not required to have gloves at this time, however having some present in the event that a patient or yourself decides this is appropriate is a worthy consideration.
Of note – Paper or disposable masks should be available for patient use rather than laundered cloth masks, to instill trust.
7. Additional Professional Obligations
RST’s returning to practice at multiple locations, including mobile, must be particularly conscientious about others’ safety protocols while also maintaining their own protocol.
Professional liability insurance
RST’s in practice are required by the STA’s Bylaws to carry professional liability insurance.
As Insurance coverage terms of policies can vary, RST’s are advised to contact their insurer to determine whether or not they are covered for claims related to COVID-19, e.g. alleged transmission of the virus.
Return to practice
There is NO duty or obligation to return to practice at this time:
This return to practice protocol does not require any RST to engage in practice if they individually assess the risk of practice as one they are not prepared to take.
The decision to return to practice is a matter of individual judgment and requires following the guidance of WorkSafe BC and other governmental authorities such as the BC CDC and Regional Health Authorities.
Please contact any of your regional representatives if you are at all unclear on regional parameters of returning to practice as we are considered “Personal Services”, or ‘unregulated’ Health Services.
RST’s who are employees of a clinic, spa, or who have employment contracts:
- RST’s in this work setting must clarify their relationship with their employer.
- An RST should consult legal counsel if needed, as STA BC does not provide legal advice. However, as a member of this professional association, the STA may be able to provide advice and/or support.
- RST’s are bound by their obligation and duty to STA BC, their regulatory body as a health professional, irrespective of employment agreements.
8. Frequently Asked Questions
1. What if a patient alleges they caught COVID-19 from a RST?
- The RST must immediately call public health at 8-1-1 and report the alleged transmission, providing both the RST’s name and the name and contact information of the patient.
- The RST must not provide any further Shiatsu Therapy treatment to anyone until public health has investigated and has provided direction.
- The RST must immediately self-isolate until the matter has been investigated and public health direction has been provided.
- If the RST is working in a team setting, it is the RST’s duty to immediately inform his or her colleagues of transmission risk.
2. What about asymptomatic spreaders?
This is an unavoidable risk of practice until there is either an effective treatment or an effective vaccine against COVID-19.
This return to practice protocol has elements that mitigate this risk:
- An RST can screen not only for symptoms, but for contacts, e.g., has the patient isolated within a restricted “bubble”, and if so for how long?
- Has he or she had extensive contact with individuals outside his/her immediate family, pod or unit (other than service workers at grocery stores, banks, other)?
- Is the patient aware of anyone in their contacts who has COVID-19 symptoms?
The RST should be prepared to share this information about themselves, as well.
Related is the question of trust –
- How well does the RST know the patient – and trust the patient to have been prudent and cautious?
- Ethical practice requires that RST’s honour patients’ trust in their RST – the trust relationship goes both ways.
- Wearing masks reduces the droplets that can spread to another person, which helps to reduce the risk of viral transmission. If both parties wear masks, this risk is additionally reduced.
- Very strict adherence to hand hygiene by RST and by patient
The risk remains, which is why the informed consent discussion at the outset of treatment is critical.
3. Can an RST limit their liability for potential COVID-19 transmission by having the patient sign a waiver?
This is a legal question and thus the STA of BC does not provide legal advice to its members.
However, RST’s have a professional obligation to obtain informed consent to treatment, consistent with our Standard of Practice and Ethics.
In the current environment of COVID-19 risk, informed consent requires that the patient is informed that:
- Any Shiatsu Therapy treatment involves some risk of COVID-19 transmission;
- the RST is following a protocol to reduce or mitigate risk, but that risk cannot be reduced to zero;
- the patient consents to treatment despite some risk; and
- the RST documents the patient’s consent.
The STA will be providing a sample COVID-19 Screening and Informed Consent form on the Website for your use. You may wish to add or omit areas you deem change worthy.
This is not a new requirement, but the appropriate negotiation of consent is significant in the context of COVID-19. Proper adherence to consent procedures may also have the incidental effect of reducing the chances for RST liability, although that is not their purpose.
RST’s practicing in “Phase 3” environments, (e.g. spas,hotels, etc)
Under current understanding from the B.C government RST’s fall under personal service establishments alongside Hair Salons and Barbers and thus RST’s may resume practice during Phase 2 by following the above protocol, provided that no other activities take place in violation of the government’s Restart guidelines (PDF).
This means that RST’s who practice in a spa or hotel may not have the opportunity to resume work until phase 3 OR they may be the only ones practicing in that setting for a period of time.
BC Centre for Disease Control – Covid-19
College of Massage Therapists of BC (CMTBC) – Guidelines for RMT’s returning to practice
Questions about your health, or reporting COVID-19 infection, call 8-1-1 at any time
Help and Advice in Other Languages, BC Government, call 1-888-268-4319
BC COVID-19 Symptom Self-Assessment Tool
BC’s Restart Plan (PDF)
BC Centre for Disease Control | BC Ministry of Health, COVID-19 Ethical Decision-Making Framework, March 28, 2020 (PDF)
BC Centre for Disease Control, Resources at a glance
Workers and employers with questions or concerns about workplace exposure to the virus that causes COVID-19 can call:
WorkSafeBC’s Prevention Information Line at 604.276.3100 in the Lower Mainland (toll-free within B.C. at 1.888.621.SAFE).
WorkSafe BC Returning Safe Plan/Guidelines.
Announcement regarding COVID-19 & R.S.T. practice recommendations from the STA
March 18th, 2020
A few R.S.T.’s have inquired about advice as to whether they should continue to practice in light of the situation around COVID-19. Of course, our Association does not have the legal authority to mandate practice closures or direct you to cease practice but we will provide the following recommendations.
We have been following the public health principles and guidance provided by BC’s Provincial Health Officer, Dr. Bonnie Henry to inform our advice to you and thus, how you interact with the public.
To date, we have trusted that you and clinic owners would do their own risk assessment and determine what is best for individuals, patients and staff.
Now, in light of numerous developments of March 16 and 17, the Board of Directors of the Shiatsu Therapy Association recommends that registered shiatsu therapists who are able to do so suspend practice for a two-week period, effective immediately, and re-evaluate the situation at the end of that period.
While there is no question that Shiatsu Therapy is a highly beneficial health care modality, it is not a primary or essential health care service. This is an important consideration at this time, when resources are being repurposed and prepared for delivery of extended emergency services.
Whether the benefits of Shiatsu Therapy treatment outweigh the current risks of providing that treatment is still a matter for the judgment for you, the individual R.S.T., informed by the overriding imperative to act in the best interests of your clients or patients at all times. At the current time, our view as the is that in most cases the risks of providing or receiving treatment (for both the patient and for the therapist) will likely outweigh the benefits.
We, as the Board of Directors, recognizes that decisions being made with respect to COVID-19 come with consequences: personal, financial and ethical.
Our recommendation to suspend practice is not made lightly, and we have looked to other organizations, such as the RMT’s, Physiotherapist’s, Chiropractor’s, and the provincial health authority to follow their recommended action steps in this area.
We do recognize that it may create serious financial hardship for some. Our understanding is that financial relief measures are being explored by the Federal and Provincial governments that may be of assistance.
We share the following link, released yesterday, to inform you of developments in this area:
Some have also inquired about whether we may apply for Employment Insurance as R.S.T.’s. Of course, if we have been making contributions to it we may easily apply. If we have not, then the government is reportedly drawing a plan together to facilitate this option.
When we confirm the link for this potential support we shall forward it in a subsequent email.
If you have any specific questions, please don’t hesitate to contact us at email@example.com. We will respond to communications from R.S.T.’s as best we can, though we appreciate your patience as the volume of those communications may increase. Finally, we will provide updates for you on the situation as it develops.
The STA Board of Directors.
For further information on COVID-19 resources we provide the following links.
From the BC Centre for Disease Control