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COURSE CODE
HOURS
PRICE
Ethics for Physical Therapists and Assistants (Mandatory)
3
$36.00
PTIL03ET-H
Evidence-Based Implicit Bias Implications for Physicians and Healthcare Professionals (Mandatory)
1
$12.00
PTIL01EB-H
Preventing Sexual Harassment in the Workplace for Illinois Professionals, 2nd edition (Mandatory)
1
$12.00
PTIL01SH-H
Aging Process: What is Happening to the Body and What Does it Mean?
3
$49.00
PTIL03AP-H
Differential Diagnosis for PT: Hematological, Cardiovascular, Immune and Digestive System Disorders 3
$49.00
PTIL03HC-H
Differential Diagnosis in Physical Therapy: Upper Extremity and Lower Quadrant
3
$49.00
PTIL03UE-H
Evaluation and Treatment of the Shoulder Complex
4
$65.00
PTIL04SC-H
Instrument-Assisted Soft Tissue Mobilization (IASTM) to the Lower Quarter
2
$33.00
PTIL02LQ-H
Instrument-Assisted Soft Tissue Mobilization (IASTM) to the Upper Quarter
2
$33.00
PTIL02UQ-H
Optimizing Outcomes in Rehabilitation: Motor Learning Principles and Beyond
6
$96.00
PTIL06ML-H
Return to Sport: Running Injuries in Student-Athletes
2
$33.00
PTIL02RU-H
INCLUDED IN THIS BOOK
1
Ethics for Physical Therapists and Assistants (Mandatory) Meets the ethical practice of physical therapy requirement [3 contact hours]
Periodic review of the Code of Ethics and the principles detailed within this document is important to fundamentally enhance the practice of the physical therapist. This course will provide an update of the revised American Physical Therapy Association’s (APTA’s) Code of Ethics for the Physical Therapist and Standards of Ethical Conduct for the Physical Therapist Assistant. 7 Evidence-Based Implicit Bias Implications for Physicians and Healthcare Professionals (Mandatory) Meets the implicit bias in healthcare requirement [1 contact hour] The purpose of this course is to provide a historical context of race and racism and its relationship to the development of racial implicit bias. The development of implicit bias will be discussed along with research demonstrating the impact of implicit bias on the clinical encounter. Recommendations for mitigating implicit bias are offered. 16 Preventing Sexual Harassment in the Workplace for Illinois Professionals, 2nd edition (Mandatory) Meets the sexual harassment prevention training requirement [1 contact hour] This basic-level course will help Illinois Healthcare professionals identify sexual harassment in the workplace, prevent it, and take appropriate action if it occurs. 31 Aging Process: What is Happening to the Body and What Does it Mean? [3 contact hours] This course is intended to instruct the professional of the physiological, structural and functional changes that occur in the body over time so that functional outcomes can be maximized. 40 Differential Diagnosis for PT: Hematological, Cardiovascular, Immune and Digestive System Disorders [3 contact hours] This course is intended to instruct the professional on screening multiple body organ systems for diseases and syndromes that are not of musculoskeletal origin. 54 Differential Diagnosis in Physical Therapy: Upper Extremity and Lower Quadrant [3 contact hours] This course is intended to instruct the professional on screening the multiple body organ systems for diseases and syndromes.
COURSE LIST CONTINUED ON NEXT PAGE ►
INCLUDED IN THIS BOOK (CONTINUED)
75
Evaluation and Treatment of the Shoulder Complex [4 contact hours]
The course provides a general overview of the shoulder complex anatomy before moving into the primary purpose of the course, evaluation and treatment of the shoulder complex through entry-level introduction of manual evaluation techniques of the connective tissue surrounding the shoulder complex. 87 Instrument-Assisted Soft Tissue Mobilization (IASTM) to the Lower Quarter [2 contact hours] This course provides the clinician with an understanding of the treatment concepts, as well as specific techniques, in order to effectively incorporate Instrument-Assisted Soft Tissue Mobilizations (IASTM) to common musculoskeletal disorders of the lower quarter. 95 Instrument-Assisted Soft Tissue Mobilization (IASTM) to the Upper Quarter [2 contact hours] This course provides the clinician with an understanding of the treatment concepts, as well as specific techniques, in order to effectively incorporate Instrument-Assisted Soft Tissue Mobilizations (IASTM) to common musculoskeletal disorders of the upper quarter. 104 Optimizing Outcomes in Rehabilitation: Motor Learning Principles and Beyond [6 contact hours] By the end of this course, participants will gain a knowledge and understanding of how to optimize rehabilitation outcomes in their patients by using current and evidence- based application of motor learning concepts and principles of neuroplasticity, including contemporary evidence for autonomy support and the effects of improving patient motivation and focus. 118 Return to Sport: Running Injuries in Student-Athletes [2 contact hours] This course focuses on commonly presented running injuries in student-athletes and how to effectively treat those injuries for return to sport. The course is designed for athletic trainers and allied health professionals who work in sport settings, particularly with youth and student-aged athletes.
The courses in this book meet the Illinois Department of Financial and Professional Regulation continuing education requirements.
FREQUENTLY ASKED QUESTIONS
License Expires
CE Hours Required
Mandatory Subjects
Physical Therapists - 40 Physical Therapy Assistants - 20
● 3 hours of ethical practice of physical therapy ● 1 hour implicit bias training per renewal period (beginning with 2023 renewals) ● 1 hour on of sexual harassment prevention training
An applicant may obtain 75% of his or her total CE credit by taking correspondence or web-based courses, including pre-recorded professional presentations and pre-recorded webinars, from an approved CE sponsor.
Licenses expire September 30 in the year of renewal
Are you a Illinois board-approved provider? Colibri Healthcare, LLC is an Illinois Department of Financial and Professional Regulation approved Physical Therapy CE Sponsor, #216.000315. Are my credit hours reported to the Illinois board? No. The board perform audits at which time proof of continuing education must be provided. Is my information secure? Yes! We use SSL encryption, and we never share your information with third-parties. We are also rated A+ by the National Better Business Bureau. Is there a new Implicit Bias requirement? Yes, for license or registration renewals occurring on or after January 1, 2023, physical therapists and physical therapy assistants who have continuing education requirements must complete at least a one-hour course in training on implicit bias awareness per renewal period. This course may count toward meeting the total credit hour requirements for continuing education. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at EliteLearning.com/Physical-Therapy you will see our robust FAQ section that answers many of your questions, simply click FAQs at the top of the page, e-mail us at office@elitelearning.com, or call us toll free at 1-888-857-6920, Monday - Friday 9:00 am - 6:00 pm EST, Saturday 10:00 am - 4:00 pm EST. Important information for licensees: Always check your state’s board website to determine the number of hours required for renewal, mandatory topics (as these are subject to change), and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file. Implicit bias in healthcare: Implicit bias significantly affects how healthcare professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact health outcomes. Addressing implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics. Disclosures: Resolution of conflict of interest Colibri Healthcare, LLC implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity. Sponsorship/commercial support and non-endorsement It is the policy of Colibri Healthcare, LLC not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners. Disclaimer: The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition. ©2024: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Colibri Healthcare, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers.
1
Ethics for Physical Therapists and Assistants: Summary
Ethics for Physical Therapists and Assistants 3 Contact Hours
ACCESS THE FULL ONLINE PRESENTATION
Scan the QR CODE to start online presentation or visit https://uqr.to/ptethics
Author Ron W. Scott, PT, EdD, JD, LLM, MA (Spanish), MSBA, MSPT, Esq.
Ron Scott is a Texas-licensed attorney-counsel to PTs and health and business professionals, and an attorney- mediator, based in San Antonio, Texas. His passions for teaching and learning focus on facilitating doctoral students’ development of higher-order critical analytical legal and ethicolegal skill sets, requisite for successful clinical practice, patient outcomes, liability risk management, and the advancement of healthcare professions, professionals and patients.
LEARNING OUTCOMES ● Discuss the purpose and the principles of the Code of Ethics for the physical therapist and explain how these principles affect the practice, ideology, and implementation of the duties performed by the physical therapist ● Summarize the core values, their definitions, as well as the sample indicators; explain how these values fundamentally shape professionalism within the physical therapy profession ● Recite the standards of ethical conduct for the physical therapist and the physical therapy assistant and summarize how these standards apply within daily practice
● Define and describe relevant ethical ideals and practices, such as nonmaleficence, justice, and autonomy, and how these—and other ideals— pertain to the practice of physical therapy ● Discuss examples of federal statutory laws and state regulatory directives and give examples of each ● Describe the HIPAA federal privacy statute and how this statute affects the decision-making process of physical therapists and physical therapy assistants
SELF-ASSESSMENT QUESTIONS
1. The commitment to meeting one’s obligations to provide effective physical therapy services to patients/clients, to serve the profession, and to positively influence the health of society is known as: a. Integrity b. Professional duty c. Accountability d. Altruism 2. Physical therapists should demonstrate integrity in their relationship with: a. Patients and clients b. Families c. Colleagues and employers d. All the above
3. The North Atlantic Free Trade Agreement is an example of which ethical obligations? a. Federal treaty obligations b. Federal constitutional standards c. Federal statutes d. Judicial case law decisions 4. Informed consent helps to promote which ethical concept? a. Justice b. Patient autonomy c. Beneficence d. Nonmaleficence
ANSWERS: 1: B
2 : D
3: A
4: B
2
Ethics for Physical Therapists and Assistants: Summary
• Social responsibility —the promotion of a mutual trust between the profession and the larger public that necessitates responding to societal needs for health and wellness Principles 1. Physical therapists shall respect the inherent dignity and rights of all individuals 2. Physical therapists shall be trustworthy and compassionate in addressing the rights and needs of patients/clients 3. Physical therapists shall be accountable for making sound professional judgments 4. Physical therapists shall demonstrate integrity in their relationships with patients/clients, families, colleagues, students, research participants, other healthcare providers, employers, payers, and the public 5. Physical therapists shall fulfill their legal and professional obligations 6. Physical therapists shall enhance their expertise through the lifelong acquisition and refinement of knowledge, skills, abilities, and professional behaviors 7. Physical therapists shall promote organizational behaviors and business practices that benefit patients/clients and society 8. Physical therapists shall participate in efforts to meet the health needs of people locally, nationally, or globally STANDARDS OF ETHICAL CONDUCT FOR THE PHYSICAL THERAPIST ASSISTANT These standards outline the ethical obligations and provide a foundation of conduct for PTAs with regards to the special obligation a PTA has related to enabling patients to achieve greater independence, health, wellness, and quality of life.
INTRODUCTION CODE OF ETHICS FOR THE PHYSICAL THERAPIST:
The Code of Ethics outlines the ethical obligations of all PTs and was established by the APTA in order to provide standards, guidance, and education for physical therapists. It is built upon the multiple roles of a physical therapist, core values of the profession, and realms of • Accountability —active acceptance of the responsibility for the diverse roles, obligations, and actions of the physical therapist, including self-regulation and other behaviors that positively influence patient/client outcomes, the profession, and the health needs of society • Altruism —the primary regard for or devotion to the interest of patients/clients, thus assuming the fiduciary responsibility of placing the needs of the patient/client ahead of the physical therapist’s self-interest • Compassion —the desire to identify with or sense something of another’s experience; a ethical action. Core Values precursor of caring. Caring is the concern, empathy, and consideration for the needs and values of others • Excellence —physical therapy practice that consistently uses current knowledge and theory while understanding personal limits, integrates judgment and the patient/ client perspective, embraces advancement, challenges mediocrity, and works toward development of new knowledge • Integrity —steadfast adherence to high ethical principles or professional standards; truthfulness, fairness, doing what you say you will do, and “speaking forth” about why you do what you do • Professional duty —commitment to meeting one’s obligations to provide effective physical therapy services to patients/clients, to serve the profession, and to positively influence the health of society
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Ethics for Physical Therapists and Assistants: Summary
Standards 1. Physical therapist assistants shall respect the inherent dignity and rights of all individuals 2. Physical therapist assistants shall be trustworthy and compassionate in addressing the rights and needs of patients/ clients 3. Physical therapist assistants shall make sound decisions in collaboration with the physical therapist and within the boundaries established by laws and regulations. Physical therapist assistants shall demonstrate integrity in their relationships with patients/ clients, families, colleagues, students, other healthcare providers, employers, payers, and the public 4. Physical therapist assistants shall fulfill their legal and ethical obligations 5. Physical therapist assistants shall enhance their competence through the lifelong acquisition and refinement of knowledge, skills, and abilities 6. Physical therapist assistants shall support organizational behaviors and business practices that benefit patients/clients and society 7. Physical therapist assistants shall participate in efforts to meet the health needs of people locally, nationally, or globally ETHICS ROADMAP LEARNING TIP! As a healthcare provider, a physical therapist is a fiduciary to their patients and is therefore required to place the patients’ best interests above all, including personal and organizational business interests. There are five sources of ethical obligations a PT must follow.
Five Hierarchal Sources of Ethical Obligations 1. Federal constitutional standards a. Example : First and Fourth Amendments (regarding patient privacy) 2. Federal treaty obligations a. Example : North Atlantic Free Trade Agreement—allows PTs to move between Canada, U.S., and Mexico to work 3. Statutes (federal and state) 4. Judicial case law decisions a. Cruzan v. Director, Missouri Dept. of Health (1990) 5. Administrative or regulatory laws a. Example: Federal regulation—the internal revenue code governing the payment of federal income taxes b. Example: State regulation—state a. Example: HIPAA is a federal privacy statute, whereas medical marijuana statutes are state-level statutes beneficentia, meaning “doing good.” PTs are charged to “do good” on behalf of their patients (i.e., act in the patients’ best interest) 2. Nonmaleficence —“do no harm.” Practically, this mean to do no malicious intentional harm to patients. This does not apply to discomfort that may be present with appropriate therapy interventions or evaluations 3. Patient autonomy —respecting patients’ fundamental right of self-determination over their bodies and what is done to them by others. This can be reflected in the concept of informed consent to interventions/ examinations 4. Justice —aspirations and endeavors in support of ensuring equal access to high- quality healthcare by all patients and clients, insurance commission rule requiring PTs to carry professional liability insurance Ethical Concepts 1. Beneficence —from the Latin word at an affordable cost. PTs and PTAs should advocate for and take necessary steps to ensure equality of access to services for patients
4
Ethics for Physical Therapists and Assistants: Summary
Personal Values Outside of the seven core values set by the APTA for Physical Therapists and Physical Therapy Assistants, many individuals have their own core values as well that contribute to and play a role in
• Staying focused under stress • Team play • Truthfulness Conclusion
Legal duties are defined by the Constitution, international treaties, federal and state statutory laws, judge-made case law, and administrative agency rules and regulations. Ethical duties are grounded in the four foundational biomedical ethical principles of beneficence, nonmaleficence, respect for patient autonomy, and the quest for justice in healthcare delivery. These are further augmented by the core values at individual, organization, system, or association levels. Legal and ethical duties are blended into a standard of conduct for health professionals. Slight variations exist across the country due to variations in state licensing laws.
their care toward patients. Common values include: • Accountability • Advocacy • Altruism • Autonomy • Compassion • Empathy • Fiduciary duty • Lifelong learning • Loyalty • Patience • Social responsibility
Case Study 1 A is a physical therapist in a solo private practice. B is A’s part-time staff physical therapist assistant. C is a patient referred by Dr. D for sharp debridement of a necrotic diabetic right foot ulcer. A is relatively unfamiliar with sharp debridement, but B has had substantial wound care experience. Is it appropriate for A to delegate C’s wound care to B? Commentary : A may be violating Principles 3B, 3C, and 3E by delegating advanced clinical care activities to B, for which A has insufficient practice experience and expertise to supervise. Case Study 2 E is a 20-year-old male physical therapy aide employed at ABC Hospital. F is a 19-year-old female inpatient who is receiving inpatient physical therapy services. In part to increase nonoperational revenue, ABC has a program in place to provide gourmet meals to inpatients and guests during dinner hours for a moderate fee. F invites E to join her in her hospital room this evening for a dinner-date. E shares this information with G, a supervising physical therapist assistant in the clinic. How should G respond? Commentary : G should inform E that his prospective conduct constitutes an impermissible conflict of interest. As a physical therapy aide, E is not subject to the requirements of the American Physical Therapy Association’s Code of Ethics for the Physical Therapist or Standards of Ethical Conduct for the Physical Therapist Assistant. G, however, is subject to professional ethical standards as a physical therapist assistant. If E does not heed G’s admonition, then pursuant to Standards 4C (misconduct) and 4D (vulnerable adult), G must report E’s prospective misconduct to the supervising physical therapist and/or other relevant authority. E’s conduct may also constitute an express violation of ABC’s organizational ethics standards for employees, making its prohibition more straightforward.
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Ethics for Physical Therapists and Assistants: Summary
Case Study 3 H is a private practice physical therapist who employs I as a staff physical therapist assistant. H’s practice is in a financial crisis. As part of his financial stimulus strategy, H begins to market transcutaneous electrical nerve stimulation devices to virtually all of his patients—in many cases inappropriately—at highly inflated prices. I is aware of H’s strategy to save his business but takes no action to confront H or otherwise stop what is going on. What principles and standards have H and I violated in pursuit of this marketing initiative? What must be I’s next step(s)? Commentary : H has arguably violated Principles 1A, 2A–D, 3A, 3B, 3D, 4A–C, 5A, 6A, 7B, 7D–F, and 8C. I has violated Standards 1A, 2A-C, 3A, B and E, 4A-D, 5A and E, 7A, C-E, and 8C and D. I’s next steps are (1) to consult with personal legal counsel for advice and (2) if cleared by legal counsel, to respectfully confront H, and, if H does not expeditiously and fully rectify the fraud committed on patients and third-party payers, report H to legal and regulatory authorities, pursuant to Standards 4D, 4E, 5E, 7A, 7D, and 7E. Case Study 4 J is a physical therapist member of the American Physical Therapy Association. J is passionate about fulfilling the biomedical ethical duty of justice for patients in her community, a large city in the southwestern United States. How can J accomplish her goals? Commentary : J can work individually or in concert with other physical therapists, physical therapist assistants, and other healthcare professionals to achieve her goals. In her own clinical practice, J can set aside a finite number of pro bono patient slots and rotate free-care patients in as existing ones are discharged. J can work with area physical therapists and assistants to form pro bono service networks and share the load among many participants. The American Physical Therapy Association should consider offering organizational assistance to pro bono networks, at the district, state, and national levels, similar to what is offered by attorney professional organizations such as the American Bar Association.
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Scan the QR CODE to start online presentation or visit https://uqr.to/ptethics
6
Ethics for Physical Therapists and Assistants: Summary
F INAL EXAM QUESTIONS
1. Physical therapists’ practice is guided by a set of seven core values that include: a. Altruism
7. Respect for patient _______ entails respecting patients’ fundamental right of self- determination over their bodies and over what is done to them by others. a. Discretion b. Beneficence c. Autonomy d. Justice 8. What is NOT one of the seven core values governing the conduct of American Physical Therapy Association member physical therapists? a. Accountability b. Professional duty c. Social responsibility d. Personal continuing education 9. Nonmaleficence literally means what? a. Do no harm b. Aspirations and endeavors c. Bullying d. Respect privacy 10. What core value is defined as “active acceptance of the responsibility for the diverse roles, obligations and actions of the physical therapist, including self-regulation and other behaviors that positively influence patient/client outcomes, the profession and thee health needs of society”? a. Altruism b. Compassion/caring c. Accountability d. None of the above
b. Compassion/caring c. Social responsibility d. All of the above
2. Beneficence is a derivative of a 15th-century Latin word beneficentia, which means what? a. Doing no harm b. Duty c. Doing good d. None of the above 3. ___________ is steadfast adherence to high ethical principles or professional standards; truthfulness, fairness, doing what you say you will do, and “speaking forth” about why you do what you do. a. Integrity b. Professional duty c. Altruism d. Compassion/caring 4. The Health Insurance Portability and Accountability Act (HIPAA) is an example of what sort of statute? a. State statute b. Federal privacy statute c. Beneficence d. None of these 5. Physical therapists are required to place ________ best interest above all others, including personal and organizational business interests. a. Their own b. Their families’ c. Their patients’ d. Their supervisors’ 6. The ethical concept of ________ reflects aspirations and endeavors in support of ensuring equal access to high-quality healthcare by all patients and clients at an affordable cost. a. Autonomy b. Personal health care for all c. Justice d. Nonmaleficence
Access the final exam to this course here!
COURSE CODE: PTIL03ET-H
7 Evidence-Based Implicit Bias Implications for Physicians and Healthcare Professionals: Summary
Evidence-Based Implicit Bias Implications for Physicians and Healthcare Professionals 1 Contact Hour
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Scan the QR CODE to start online presentation or visit https://uqr.to/bias
Author Dr. Benjamin D. Reese
Dr. Ben Reese is a clinical psychologist and president of Ben Reese, LLC., a North Carolina (USA) based global diversity, equity, and inclusion consulting firm. He earned a doctorate in clinical psychology from the Rutgers University, Graduate School of Applied and Professional Psychology. He is adjunct professor in the department of Psychiatry and Behavioral Sciences at the Duke University School of Medicine, Advisor, Trainer, and Executive Coach for Diversity Science, a diversity, equity, and inclusion public-benefit company, and Senior Advisor for Halpin, a London based consulting company. He is the former Vice President for Institutional Equity and Chief Diversity Officer for Duke University and the Duke University Health System.
LEARNING OUTCOMES ● Know how the history of race in America informs the development of racism ● Explain the definition of implicit bias and how it differs from explicit bias ● Describe factors that contribute to the development of implicit bias
● Describe research related to the impact of implicit bias on the clinical encounter and patient referrals ● Describe the relationship between racial implicit bias and healthcare disparities ● Describe strategies to mitigate the impact of implicit bias in decision making
SELF-ASSESSMENT QUESTIONS
1. Unconscious associations can contribute to the unequal treatment of people based on of the following expect: a. Gender b. Race c. Number of immediate family members d. Age 2. Factors that accelerate implicit bias and make it more likely to be a significant influence including: a. Ambiguity
3. An example of implicit bias includes: a. Treating every experience uniquely b. Asking someone their ethnicity/ background c. Preferring treating women patients as they tend to be nicer d. All of the above 4. Bias via nonverbal communication includes: a. Sitting down next to your patient to explain something b. A nurse allowing a young patient to hold their hand while getting a shot c. Helping an elderly patient out their car d. Standing further away from a patient who presents differently than you
b. Poor focus on task c. Physical constraints d. All of the above
ANSWERS: 1: C
2 : D
3: C 4: D
8 Evidence-Based Implicit Bias Implications for Physicians and Healthcare Professionals Summary
INTRODUCTION Although implicit or unconscious bias and its impact on healthcare can be understood in relationship to a range of identity characteristics (age, gender, sexual orientation, etc.), implicit bias related to race is particularly salient in the United States. This focus on racial implicit bias can be understood in the context of the history of race and racism in America. THE ENSLAVEMENT OF AFRICANS The first Africans were brought to this country forcibly on ships, arriving on the Southern shores of our nation. Packed body-next-to-body in the hull of ships, those that survived disease, malnutrition, and abuse entered this country as cargo…property. White farmers and various businessmen purchased Africans to plant and harvest crops and to cook, clean homes, and care for their children. They were the property of the individuals and families that purchased them. This forced enslavement of Africans was maintained by a system of inhumane physical and psychological abuse, norms, accepted practices, and laws. As property , Africans weren't considered human. They were property to be purchased, sold, and even named in the will of individuals before they died, like one might leave a house or wagon to a spouse or children. Like the evaluation or assessment of a used car or house, enslaved Africans were evaluated and rated according to their fitness and/or physical defects. They were not viewed as human beings on par with Whites. In the 18th and 19th century, the support of this belief of inhumanity took the form of scientific racism or pseudoscience. Many people, both professionals and laypersons, thought that Black people had an innate tendency to want to run away from the confinement of the plantation, had thicker skin and skulls, and had fewer nerve endings and therefore could endure more pain.
LEARNING TIP! This rationale was often used for the extreme brutalization and whipping experienced by Black men, women, and children. These beliefs contributed to the medical experimentation conducted on African American bodies, sometimes without any attempt to reduce the pain and suffering of Black patients or experimental subjects.
Although current laws, policies, and accepted medical practices have eliminated the horrendous abuses of Black bodies, it is important to recognize how deeply embedded many of the beliefs and perceptions of Black people are within American culture, consciously and implicitly. A 2016 study revealed that almost half of the medical students and residents surveyed endorsed notions of pseudoscience, believing that Black people had thicker skin, less sensitive nerve endings, and experienced less pain than Whites. In spite of conscious endorsements of equity, fairness, social justice, and providing the highest level of care, there is this parallel process of unconscious or implicit bias. It is not that providers are inherently bad. Rather, they are human and prone to internalize, to a greater or lesser extent, the beliefs and stereotypes resulting from centuries of systemic and structural racism. These beliefs and internalized stereotypes can cause physicians to behave in ways that violate their deeply held values of fairness and equity. The process is unconscious or implicit.
9 Evidence-Based Implicit Bias Implications for Physicians and Healthcare Professionals: Summary
SECTION 1. The Legislature finds and declares all of the following: (a) Implicit bias, meaning the attitudes or internalized stereotypes that affect our perceptions, actions, and decisions in an unconscious manner, exists, and often contributes to unequal treatment of people based on race, ethnicity, gender identity, sexual orientation, age, disability, and other characteristics. (b) Implicit bias contributes to health disparities by affecting the behavior of physicians and surgeons, nurses, physician assistants, and other healing arts licensees. (c) Evidence of racial and ethnic disparities in healthcare is remarkably consistent across a range of illnesses and healthcare services. Racial and ethnic disparities remain even after adjusting for socioeconomic differences, insurance status, and other factors influencing access to healthcare. (d) African American women are three to four times more likely than White women to die from pregnancy-related causes nationwide. African American patients often are prescribed less pain medication than White patients who present the same complaints, and African American patients with signs of heart problems are not referred for advanced cardiovascular procedures as often as White patients with the same symptoms. (e) Implicit gender bias also impacts treatment decisions and outcomes. Women are less likely to survive a heart attack when they are treated by a male physician and surgeon. LGBTQ and gender-nonconforming patients are less likely to seek timely medical care because they experience disrespect and discrimination from healthcare staff, with one out of five transgender patients nationwide reporting that they were outright denied medical care due to bias. (f) The Legislature intends to provide specified healing arts licensees with strategies for understanding and reducing the impact of their biases in order to reduce disparate outcomes and ensure that all patients receive fair treatment and quality healthcare.
LEARNING TIP! Implicit bias can be defined as those attitudes, beliefs, and
The majority of information is processed unconsciously, out of awareness. As people process this information, their unconscious association can reinforce stereotypes that most often differ from their conscious assessment of an individual or group. These unconscious associations can contribute to the unequal treatment of people based on their race, ethnicity, gender, gender identity, age, disability, sexual orientation, etc. Although implicit bias and unconscious associations can be a subtle influence on cognition and behavior, their impact on decisions can be significant . Recently, an increasing number of states have enacted legislation recognizing the criticality of implicit bias in healthcare. The following is an example from California: Examples include: Assuming a "strong accent" is related to intelligence; generalizing from one" bad experience" with a patient to every patient of the same racial background; and prefering patients and/or colleagues who are similar to you. ASSEMBLY BILL NO. 241 - CHAPTER 417 This bill would require the Board of Registered Nursing, by January 1, 2022, to adopt regulations requiring all continuing education courses for its licensees to contain curriculum that includes specific instruction in the understanding of implicit bias in treatment. Beginning January 1, 2023, the bill would require continuing education providers to comply with these provisions and would require the board to audit education providers for compliance with these provisions, as specified. stereotypes that affect our understanding, behavior, and actions in an unconscious (implicit) manner. A relatively small portion of the information the brain processes is conscious (explicit bias).
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Evidence-Based Implicit Bias Implications for Physicians and Healthcare Professionals Summary
Early Childhood Research One of the important areas of implicit bias research focuses on the question, how early in one's development does implicit bias begin to show up? Recent research suggests that the foundation for what later shows up as implicit bias occurs in infancy. For example, if we track the eyes of infants, at about four weeks of age they will stare longer and more frequently at female faces if a woman has been the primary caregiver. This is clearly not implicit bias, but it appears to reflect a differential association or a preference. As toddlers and older children begin to spend time online, watch television, and read books, they sense the race or gender of the people who tend to be in leadership roles, those who appear dangerous, those who are police and fire people, those who are doctors, etc. Inequities and biases in the broader society get incorporated into media, which get consumed by children, whether intentionally or not. These portrayals then influence and shape unconscious associations in children of all ages. Children are also influenced by the behavior of parents, caregivers, and other significant adults in their life, noticing the complexion and gender of their close friends, as well as comments and jokes. Adult Research Within the racial history of America, the complexion of Black people has always been a
complex dynamic. The One Drop Rule, in practice and then in law, has existed since Africans were forcibly brought to this country. Interracial relationships, both forced and voluntary, resulted in bi-racial children and adults. Essentially, any African ancestry (“one drop of African American blood”) classified an individual as African American. Although the deliberate disparate treatment of light-skinned and darker-skinned Black individuals has significantly diminished, unconscious bias related to the complexion of people still exists in many sectors of American society. Hiring and promotions of Blacks can sometimes be significantly influenced by implicit racial bias related to complexion. Excessive and biased focus on Black youth’s behavior in schools contributes to the disparate suspension rate for Black and White students in primary and secondary schools. This does not appear to be the result of conscious discrimination. It appears that similar behavior is judged differently when occurring by a Black versus a White student. Blake and colleagues went a step further and examined race, complexion, and suspension rates. They found that Black teenage girls with darker complexions are suspended at a higher rate than those with lighter complexions. Again, unconscious bias seems to be a major factor.
CASE STUDY - EXERCISE 1 You’ve just come from a meeting with a group of Black and Latinx community residents. They presented the committee, which you are a part of, with a list of demands related to what they perceive as a racist hospital environment. Your first patient is a 24-year-old Black male, dressed in a t-shirt and jeans. You greet him and before you can ask any questions, he asks you a few questions. ”Where did you grow up?” “Did you have any Black friends?” “Why are you looking at your watch?” “Is this going to be more than a 10-minute visit?” Question 1: Why might the community members perceive a hospital or healthcare system as being racist? Commentary on question 1 : In addition to the history and present state of a particular hospital or healthcare system, the history of racism in America in general, as well as continuing racial health disparities, may contribute to some Black and Latinx community residents perceiving a hospital as being racist.
11 Evidence-Based Implicit Bias Implications for Physicians and Healthcare Professionals: Summary
Question 2: Why might some Black patients question White providers about their background and experience in working with Black patients? Commentary on question 2 : The history of race relations in America has contributed to many divisions. White providers may not have many close friends who are Black or spend significant amounts of time in predominantly Black communities. Stereotypes about casually dressed young Black men may operate for some providers. Healthcare Research
In research by Mende-Siedlecki and colleagues, White providers demonstrated more stringent thresholds in perceiving pain on Black faces versus White faces, and those with more stringent thresholds for Black patients prescribed fewer non-narcotic pain relievers. Studies about implicit bias and pain indicate that Black women are often not believed when they express their pain level. Race of the woman appears to be A strong factor of implicit bias in maternal care. Research related to race and childbirth indicates that Black women are twice as likely to deliver a premature baby than White women. Studies of women dying during childbirth or during the postpartum period indicates Black women are 3-4 times more likely to die during childbirth than White women. Implicit bias has also been shown to impact the quality of the clinical encounter, particularly communication. Provider race bias on the IAT was associated with lower quality communication with Black patients, such as more provider verbal dominance, lower patient positive affect, poorer patient ratings of interpersonal care, lower perceptions of respect from clinicians, and lower likelihood of recommending the clinician. Additionally, an example of bias via non-verbal communication is medical professional standing further away from a black patient.
In addition to a provider’s conscious adherence to high ethical standards and a commitment to quality care, they are also subject to implicit bias, like the rest of the population. The national interest in implicit bias in healthcare intensified when the Institute of Medicine delivered their report, 'Unequal Treatment,' in 2003 . It concluded that implicit bias against social groups, including racial and ethnic groups, can impact the clinical encounter. Much of the research supporting this report utilized the online Implicit Association Test (IAT). The IAT measures the strength of associations between concepts such as Black or White, old or young, good or bad, desirable or undesirable, and dangerous or friendly. The reaction time (association) to various pairs of words or photographs is a measure of the strength of the association. Millions of people used this website (operated by Harvard University) to take the IAT or one of the other tests.
LEARNING TIP! Racial disparity in the judgment of pain has been studied as an example of implicit bias in healthcare.
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Evidence-Based Implicit Bias Implications for Physicians and Healthcare Professionals Summary
CASE STUDY - EXERCISE 2 John is a White nurse caring for a Black pregnant woman in an obstetrics unit in a hospital. The patient is a lesbian and had an in vitro fertilization. Her partner is White and asks to speak to you in private and not in the patient’s room. The partner mentions that she recently saw a news story about how Black women are treated unfairly in comparison to White women. You’re sure that her partner will be given the same level of care as other patients, and you give this reassurance consciously in a deliberate manner. However, you know that, in addition to this conscious process, there are potential areas of implicit bias that might occur, both in decision making and in communication. Question 1: How might the racial difference between the nurse, John, and the patient influence provider-patient communication? Commentary on question 1 : Given the history of racism in America, racial discordance between provider and patient may negatively impact trust in the clinical encounter. Black patients may have experienced racial insensitivities, bias, or discrimination in the past and may be vigilant for signs of caring and trust from the provider. In addition to racial implicit bias, there can be implicit bias based on other characteristics, such as sexual orientation. Question 2: How might implicit bias show up in this case? Commentary on question 2 : Given that there might be a difference between conscious attempts to be fair and equitable and implicit bias, care needs to be taken to ensure that word choice and nonverbal communication (eye contact, smiling, etc.) do not reflect unintentional bias. Self reflection and awareness can be useful tools. Reflecting on the question, Would I react differently if the patient was White or heterosexual? can be a useful strategy. Mitigating Implicit Bias
3. Organization Systems and Processes: Mitigating unconscious bias in rewards and recognition, as well as in selection decisions, is of critical importance in the work to increase the diversity of medical students, clinical providers, researchers, managers, and senior healthcare providers 4. Cues and Reminders: Information about implicit bias as well as motivation to reflect on personal biases can begin to fade months and even weeks after the initial intervention. Strategies to stimulate recall or remind providers about the work to mitigate implicit bias can be useful 5. Disparities in access to and delivery of health care services
There are several strategies that have shown promise in mitigating or reducing the occurrence of implicit bias: 1. Increasing Knowledge: useful for workshops and presentations to describe how implicit bias develops and its relationship to societal stereotypes (race, gender, sexual orientation, disability, etc.) 2. Self-Awareness: personal tendencies or becoming aware of an area of personal bias can help in modifying communication, where necessary
13 Evidence-Based Implicit Bias Implications for Physicians and Healthcare Professionals: Summary
Disparities in Access to and Delivery of Health Care Services The Department of Health and Human Services intends to directly address this inequality in the next four years. The first of the five stated goals are to “Protect and Strengthen Equitable Access to High Quality and Affordable Healthcare”. As part of this goal, one strategic objective specifies an intent to “expand equitable access to comprehensive, community-based, innovative, and culturally- competent healthcare services while addressing social determinants of health.” An increase in healthcare facilities, a more diverse healthcare workforce and collaboration with cultural and community services can all contribute to improvements in access disparities. Chin et al provided specific suggestions for community involvement through school-based care, household outreach, and religious based care delivery.
Accelerating Implicit Bias Several factors can accelerate implicit bias or make it more likely to be a significant influence: 1. Time constraints (e.g., limited time to be with a patient) 2. Complexity (e.g., multitasking or needing to consider multiple factors quickly) 3. Physical constraints (e.g., working long hours) 4. Poor focus on task 5. Ambiguity Conclusion The history of race and racism in America is central to the development of racial implicit bias across various sectors of our society and is a major contributor to racial healthcare inequities. However, we must not lose sight of the intersection of implicit bias and gender, sexual orientation, weight, race, and other individual and group characteristics. Our patients bring their unique physical condition, their intersectional identity, and, in many cases, significant time, living within the ingrained structures, attitudes, and beliefs of this nation. It’s our responsibility to not only engage what we are consciously aware of but also work to uncover personal and organizational biases that impede our movement towards a healthcare environment and society of true equity and the highest quality care.
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