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NEW JERSEY Physical Therapy Continuing Education
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WHAT’S INSIDE
Chapter 1: Ethical Issues and Decision Making 2nd Edition (Mandatory) [5 CE Hours] This course provides physical therapists and physical therapist assistants with an updated primer on the study of ethics and ethical behaviors as they apply to physical therapy practice. The course is designed to help clinicians effectively and efficiently integrate ethical decision making into their clinical practice. Chapter 2: ACL Injury, Surgery, and Rehabilitation: A Science-Based and Evidence-Informed Approach 24 [2 CE Hours] 1 Given the modifications and advancements in ACL surgical procedures and the proliferation of research on interventions and outcomes, many clinicians find it difficult to keep apprised of the latest evidence and integrate this new information into their clinical practice. Decisions regarding which patients are appropriate for non-operative management of an ACL-deficient knee, how to safely progress patients through a criterion-based guideline, and when to provide recommendations for a safe return back to sports after ACL injury or reconstruction are challenging. Physical therapists and physical therapist assistants will be able to use the knowledge and skills outlined in this course with their patients after ACL injury or surgery to maximize patients’ responses to exercise at their current functional level while minimizing risk of injury to the healing tissue(s). Chapter 3: Plantar Fasciitis: Diagnosis and Treatment 63 [1 CE Hour] The purpose of this course is to educate physical therapists about the most successful evaluation and treatment techniques available at this time. This course will cover the function of the plantar fascia, differential diagnosis of plantar fasciitis, special tests used, the most common risk factors to develop plantar fasciitis, a review of the most effective treatments and case studies to demonstrate practical application. Final Examination Answer Sheet 76
©2023: 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 in the areas covered. It is not meant to provide medical, legal or professional services 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 or circumstances and assumes no liability from reliance on these materials.
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PHYSICAL THERAPY CONTINUING EDUCATION
Book Code: PTNJ0824
FREQUENTLY ASKED QUESTIONS
What are the requirements for license renewal? License Expires
Competency Hours Required
Mandatory Subjects
Licensees must complete 4 hours of coursework in jurisprudence and professional ethics. Licensees must complete a 1.5-credit Jurisprudence Assessment Module offered by one of the sponsors listed on the New Jersey State Board of Physical Therapy Examiners’ website for the jurisprudence portion of the requirement.
30 (A maximum of 10 hours may be earned through home study)
License expires January 31 of even-numbered years.
How much will it cost?
COURSE TITLE
HOURS
PRICE COURSE CODE
Chapter 1: Ethical Issues and Decision Making 2nd Edition (Mandatory)
5
$60.00
PTNJ05ET
ACL Injury, Surgery, and Rehabilitation: A Science-Based and Evidence-Informed Approach
Chapter 2:
2
$24.00
PTNJ02AC
Chapter 3: Plantar Fasciitis: Diagnosis and Treatment
1
$12.00
PTNJ01PF
8
$96.00 PTNJ0824
How do I complete this course and receive my certificate of completion? See the following page for step by step instructions to complete and receive your certificate. Are you a New Jersey board-approved provider? Colibri Healthcare, LLC’s courses are approved by New Jersey State Board of Physical Therapy Examiners. Are my credit hours reported to the New Jersey board? No, the board performs random audits at which time proof of continuing education must be provided. Can the four (4) jurisprudence and professional ethics credits be taken through distance-learning courses such as home study or Internet courses? Licensees must complete a 1.5-credit Jurisprudence Assessment Module offered by one of the sponsors listed on the New Jersey State Board of Physical Therapy Examiners’ website for the jurisprudence portion of the requirement. Licensees can complete any ethics course (distance learning or live) of 2.5 credits or more to meet the four-credit jurisprudence and professional ethics requirement. 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. 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. 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.
Licensing board contact information: New Jersey Division of Consumer Affairs State Board of Physical Therapy Examiners
Phone: (973) 504-6455 Website: https://www.njconsumeraffairs.gov/pt
124 Halsey Street Newark, NJ 07102
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Book Code: PTNJ0824
PHYSICAL THERAPY CONTINUING EDUCATION
Please read these instructions before proceeding. Read and study the enclosed courses and answer the final examination questions. To receive credit for your courses, you must provide your customer information and complete the evaluation. We offer three ways for you to complete. Choose an option below to receive credit and your certificates of completion. How to complete continuing education
Fastest way to receive your certificate of completion
Online • Go to EliteLearning.com/Book . Use the book code PTNJ0824 and enter it in the example box that pops up then click GO . • If you already have an account created, sign in to your account with your username and password. If you do not have an account already created, you will need to create one now. • Follow the online instructions to complete your final exam. Complete the purchase process to receive course credit and your certificate of completion. Please remember to complete the online survey. By mail • Fill out the answer sheet and evaluation found in the back of this booklet. Please include a check or credit card information and e-mail address. Mail to Elite, PO Box 37, Ormond Beach, FL 32175 . • Completions will be processed within 2 business days from the date it is received and certificates will be e-mailed to the address provided. • Submissions without a valid e-mail will be mailed to the address provided.
By fax • Fill out the answer sheet and evaluation found in the back of this booklet. Please include credit card information and e-mail address. Fax to (386) 673-3563 . • All completions will be processed within 2 business days of receipt and certificates e-mailed to the address provided. • Submissions without a valid e-mail will be mailed to the address provided.
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PHYSICAL THERAPY CONTINUING EDUCATION
Book Code: PTNJ0824
Chapter 1: Ethical Issues and Decision Making 2nd Edition (Mandatory) 5 CE Hours
By: Bruce H. Greenfield, PT, PhD, FNAP Learning objectives After completing this course, the learner will be able to: Identify the differences and commonalities among morality, values, ethics, and the law. Describe the purpose and limitations of the American Physical Therapy Association (APTA) Code of Ethics for Physical Therapists. Identify types of ethical problems and issues in physical therapy. Course overview John works as a physical therapist in a small, privately owned physical therapy practice. Besides John, the professional staff includes the owner, Bill, a physical therapist, and June, a physical therapy assistant. John has worked in this practice 5 years and has developed a close relationship with Bill as a friend and mentor. June has been working there 3 months. Everybody seemed to have a good working relationship. Therefore, John was perplexed when June approached him in private and told him that since she began working at the practice, Bill has been making inappropriate sexual remarks to her; for example, commenting on her figure and suggesting that she should wear tight clothes to accent her backside and breasts. At this point, June did not know what to do. She really enjoyed and needed this job and was reluctant to confront Bill. She also did not want John to talk with Bill about this, because she did not want to make things worse. John was unsure about the right course of action. For physical therapists like John, there may be confusion about the most ethical course of action. What is his primary duty in this case? How should he respond to June? What are his obligations to his organization and to his profession? Is there a legal duty in this case? What other information would John need to make a justified decision? The responses to these and similar questions have to do with what it means to be an ethically engaged healthcare professional. Clinicians use ethics to examine issues and human behaviors based on values. Ethics involves making decisions about what is right or wrong, good or bad, and otherwise providing a justification for an ethical decision (Doherty & Purtilo, 2016). Because clinical judgments are invariably value laden, ethics figures strongly into the professional lives of physical therapy practitioners. Research, for example, demonstrates that expert clinicians use ethical reasoning as part of their critical thinking (Jensen, Resnik, & Haddad, 2008). The application of evidence to practice entails a clinician’s best judgment about what to do and when to do it, based on the needs and values 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,
Describe the ethical approaches, theories, and principles that can guide the physical therapy practitioner in making an ethical decision. Evaluate ethical issues based on an ethical decision-making model. Describe future considerations in ethical decision making.
of each client (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). Across all practice, educational, and research settings, physical therapy practitioners face issues that involve ethical questions. To navigate effectively and safely through ethical issues and problems, physical therapy practitioners should be well versed in the knowledge and skills of ethical decision making. This includes an understanding of their ethical and legal responsibilities under the APTA Code of Ethics for Physical Therapists (APTA, 2010b), APTA Guide for Professional Conduct (2010a), APTA Standards of Ethical Conduct for the Physical Therapist Assistant (2010d), the APTA Guide for Conduct of the Physical Therapist Assistant (2010c), and individual states’ practice acts. Although ethics education has become better integrated into physical therapy education over the past decade, many educators believe that, because of increasing professional autonomy and independence in clinical decision making and judgments, physical therapists face increasingly complex ethical issues in clinical practice. As a result, a gap remains between ethics knowledge and practice (Delany, Edwards, Jensen, & Skinner, 2010). Adding to the ethical theory-practice gaps in physical therapy is the increasing interdisciplinary nature of the clinical environment that requires decisions to be made in the best interest of the clients and within a web of health professionals (Banks, 2010) . Adding to this gap is the increasing focus on client-centered care, the extent and boundaries of client autonomy in clinical decision making (Young et al, 2017), the rapid development of technology and genomics integrated into rehabilitation (Greenfield & Musolino, 2012), and the ethical implications of value-based practice payments (Nathanson, 2015). This intermediate level course provides physical therapists and physical therapist assistants with an updated primer on the study of ethics and ethical behaviors as they apply to physical therapy practice. The course is designed to help clinicians effectively and efficiently integrate ethical decision making into their clinical practice. 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
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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.
MORALITY, VALUES, ETHICS, AND THE LAW
The ability of physical therapy practitioners to pursue their clinical practices in an ethical manner can be challenging when they fail to fully understand the subtle conceptual differences that underlie ethical decision making. To consistently and effectively address and resolve ethical and legal questions, physical therapy practitioners must be able to distinguish among Morality and values The root of the word morals, mos (pl. mores ), refers to the customs of the people (Engelhardt, 1996, p. 33). Morality is a relational concept concerned with how people choose to live together to protect a high quality of life for an individual or a community as a whole (Doherty & Purtilo, 2016). Morality includes the values, beliefs, and customs of a person or a group that influences behavior and judgment about what is right or wrong and good or bad. Values, in turn, are beliefs that a person, group, or society cherish (Rokeach, 1973) and are often culturally shaped and instilled through an individual’s family, community, school, or religion. Culture, which involves an integrated pattern of human behavior that includes the customs, beliefs, and values of racial, ethnic, religious, professional, and social groups (Crawley, 2005), has a great influence on morality. The concepts of cross-cultural health care and cultural sensitivity are based on the recognition and significance of cultural differences and the different perspectives on health, illness, and medicine that often arise among healthcare professionals, their clients, and their clients’ families (Prather, 2016). Moral values include compassion, courage, altruism, honesty, fairness, and integrity. Personal or professional moral values influence daily moral actions and behaviors. Most of us do not think about our moral values when we navigate daily life unless we encounter a situation that raises a moral question. In the case scenario depicted earlier, John had to consider what professional moral values are owed to June. Where did his professional duty lie? To whom was he most Ethics and the law Physical therapy practitioners need to be aware of how the legal rules and regulations affect their professional practices. Whereas ethics is defined by an individual, group, or community on the basis of what is considered a right or wrong action or good or bad behavior; in the case of a professional organization, based on the core values and principles underlying its code of ethics, laws are defined by the government, based on concepts of justice and equality. Specifically, the law is a compendium of rules governing power, property, and people that society wishes to enforce, particularly those rules that bear on liberty, harm, and its prevention (Doherty & Purtilo, 2016). For citizens of the United States, sources of legal duties include the U.S. Constitution, state constitutions, and federal and state statutes. State statutes consist of the administrative law that mandates how professionals are eligible and allowed to practice (Federation of State Boards of Physical Therapy [FSBPT], 2014a). In each state, the statutory law establishes the boundaries and requirements for professions to establish their state practice act. Physical therapists and physical therapy assistants are legally and ethically obligated to practice on the basis of their state practice acts. Specifically, state practice acts are enacted primarily for the purpose of safeguarding the public health, safety, and welfare by providing for state administrative control, supervision, and regulation of the practice of physical therapy (FSBPT, 2014a).
morality, values, ethics, and the law. Although some healthcare professionals use terms such as morality, values, and ethics interchangeably, healthcare ethicists such as Doherty and Purtilo (2016) contend that a more nuanced use of these concepts sharpens our approaches to ethical decision making.
accountable and why? What would a compassionate physical therapist do? Professionals like John, when faced with a moral issue, turn to ethics. Ethics provides the tools, language, and methods needed to make decisions when faced with moral dilemmas and moral issues. Specifically, ethics involves the “systematic study of and reflection on morality” (Doherty & Purtilo, 2016). It is a discipline that uses special methods and approaches to examine moral situations that involve reflection about one’s assumptions, beliefs, customs, and habits. Although the basic principles of ethics remain stable, particularly those associated with professional ethical codes, the understanding of morality changes as events and innovations create new situations that cause individuals to reorganize their thinking and alter behavior to address new issues. One example that will be addressed later is the emerging use of telemedicine and telehealth to provide client consultation and care (Greenfield & Musolino, 2012). The use of telehealth challenges healthcare providers to rethink traditional ethical obligations of confidentiality, privacy, and client-centered care in a new context. For example, can physical therapy practitioners implement a beneficial individualized physical therapy plan of care that is delivered to the client via live streaming on the internet, and simultaneously protect the client’s right to privacy and confidentiality? Or can a physical therapist in one state treat a client in a neighboring state using telecommunication when the therapist is not licensed in that client’s state? State practice acts provide the legal basis of the establishment of professional state boards. A state’s board of physical therapy is appointed by that state’s governor and confirmed by its state legislature. The state board of physical therapy establishes the rules and regulations guiding the practice of physical therapy within its geographic boundaries. Physical therapy practitioners must be aware of the practice act within the state or states in which they pursue their professional craft. In recent times, the substance of the formerly distinct obligations of law and ethics has become blended into increasingly unitary standards of professional conduct (Doherty & Purtilo, 2016). Courts now examine healthcare professional codes of ethics as secondary sources of legal obligations – for example, judicial case law labels client abandonment as a form of professional negligence (FSBPT, 2014b). Physical therapists violating their state practice act can be found liable for civil negligence, as well as criminal negligence. Although laws and ethical standards seem to reinforce one another, Doherty and Purtilo (2016) point out that professionals should not always expect to receive the same guidance from laws and policies as they receive from ethical principles and rules. That is to say, laws and ethical standards each have their own special function in governing the practice of physical therapy.
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CODES OF ETHICAL CARE
Codes of ethics are created by professional groups to organize the ideas about ethics that are viewed as most important within that profession. A code of ethics is “a set of standards and principles of professional conduct” (VanderBos, 2007, p. 185). Professional codes of ethics within health care usually have four purposes (Scott, 2009). The code: 1. Provides guidance regarding mandatory behavior expected of members while performing various roles and functions in the work setting. 2. States the rights of persons with whom members interact, such as clients, research participants, students, employees, colleagues, or the public at large. 3. Addresses ethical problems, issues, and dilemmas particular to the profession, such as when to initiate and terminate service. 4. Includes provisions for enforcing the code, either within the code itself or a companion document. Enforcement may be subdivided into several categories depending on the perceived severity of the infraction of the code. The APTA Codes of Ethics for the Physical Therapist The APTA Code of Ethics for the Physical Therapist and the Standards of Ethical Conduct for the Physical Therapist Assistant are the two major codes of ethics adopted by the APTA House of Delegates. The Code and Standards are primarily aspirational codes. The purpose of both codes is to define ethical principles that form the foundation of physical therapy practice and to provide standards of behavior guidance for ethical challenges and standards of ethical conduct. The principles in the APTA Code of Ethics for the Physical Therapist and the Standards of Ethical Conduct for the Physical Therapy Assistant are further interpreted in the APTA Guide for Professional Conduct and the APTA Guide for Professional Conduct for the Physical Therapy Assistant, respectively. These core ethics documents can be found at http://www.apta.org/Ethics/Core/ Because professions and society may change their ideas over time about morality and about which moral actions are considered right or wrong under different circumstances, a professional code of ethics must be reviewed and updated periodically to reflect these changing ideas. Updates are designed to modify, clarify, and expand the thinking of physical therapy practitioners and the actions they take with clients. In 2006, members of the APTA Ethics and Judicial Committee (EJC) recognized that the Code of Ethics for the Physical Therapist in effect at that time focused primarily on the client-practitioner interaction and did not give guidance for therapists’ roles as educators, consultants, and administrators. In addition, they acknowledged that the code did not: ● Provide guidance for the expanded responsibilities of therapists related to autonomous practice as described in Vision 2020. ● Recognize the complexities in contemporary healthcare delivery. ● Address concerns at the institutional and societal level. ● Capture a contemporary notion of relationships with other health professionals. ● Address the unique moral obligations of the physical therapy (PT) profession. Therefore, they requested that the APTA board of directors appoint a task force to study the Code and propose revisions. The APTA appointed a task force, cochaired by Hiller and Swisher, in 2007, and a revised document was presented to the House of Delegates and subsequently adopted in 2009. This revised Code, which incorporated the core values, became effective July 1, 2010 (Swisher & Hiller, 2010).
There are three types of codes of ethics: aspirational, educational, and regulatory. Aspirational codes encourage competent and moral behavior but do not provide guidelines for ethical conduct or sanctions for failure to follow the intent of the code. Educational codes state what constitutes ethical behavior and may provide case examples as illustrations but do not provide sanctions for failure to follow the code. Regulatory codes spell out the expected behavior, state guidelines for expected conduct, and give specific descriptions of sanctions for failures to follow the code (Reed & Slater, 2011). Historically, professional organizations have developed codes of ethics to strengthen their professional identities and to demonstrate their commitment to ethical practice toward the public good (Swisher & Hiller, 2010). The American Medical Association’s Code of Medical Ethics published in 1846 became the prototype for the first Code of Ethics of the American Physiotherapy Association (APA) published in 1935. The most recent revision of the American Physical Therapy Association (APTA) Code of Ethics for the Physical Therapist was adopted in 2009 and became effective on July 1, 2010 (Swisher & Hiller, 2010). The revised APTA Code of Ethics for the Physical Therapist is built on the five roles of the physical therapist (management of clients, consultation, education, research, and administration). Fundamental to the Standards of Ethical Conduct for the Physical Therapist Assistant is the special obligation to enable clients to achieve greater independence and quality of life. In Professionalism in Physical Therapy: Core Values (http:// www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/ Judicial_Legal/ProfessionalismCoreValues.pdf), the APTA has defined seven professional core values that guide PT practice and support the ethical principles set forth in the APTA Code of Ethics for the Physical Therapist: ● Accountability. ● Altruism. ● Compassion/caring. ● Excellence. ● Integrity. ● Professional duty. ● Social responsibility. Throughout the Code of Ethics for the Physical Therapist, the primary core values that support ethical principles are indicated in parentheses. The principles in both the Code of Ethics for the Physical Therapist and Standards of Ethical Conduct for the Physical Therapy Assistant address individual, organizational, and societal ethical actions. The Code is binding on all physical therapists, regardless of APTA membership. However, sanctions for violations of the Code can be imposed only on members of the APTA. Provisions for sanctions are mandated in the APTA bylaws through the EJC and also through an APTA document, Disciplinary Action Procedural Document (2012a), which clearly outlines provision for sanctions against members of the APTA who violate the Code of Ethics for the Physical Therapist. Sanctions are against membership rights and privileges. These sanctions include reprimands, probation, or suspension or expulsion from APTA membership. The APTA Code of Ethics for the Physical Therapist may be codified in part or whole into a state licensure law. When codified in state law, the sanctions are against the license of the therapist and affect the legal ability to practice. The regulatory component depends on the sanctions that are specific to a particular state licensure law. Sanctions that a legal entity (e.g., a state licensure board) may apply include requiring a person to attend continuing education courses, perform a
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specified number of community service hours, participate in a rehabilitation program for substance abuse, pay a monetary fine,
refrain from practice for a certain length of time, or permanently stop practicing as a physical therapist.
Limitation of the APTA Code of Ethics for the Physical Therapist Physical therapy personnel who use the Code of Ethics for the Physical Therapist to navigate ethical issues should be aware of the limitations of the Code in helping them solve an ethical problem (Greenfield & Jensen, 2010). One problem is that multiple principles that are contained in the Code and applied to an ethical situation may be equally compelling to a physical therapist. As a result, a physical therapist is faced with choosing between conflicting duties and justifying his or her choice. Second, the Code does not describe how physical therapists
The authors also suggest that invariably healthcare professionals will have to balance or weigh which ethical principle would best apply to achieve a justifiable outcome. These processes suggest the importance of understanding all the dimensions of an issue and ultimately making a practical judgment. Specifically, the Code alone is necessary but insufficient to make an ethical decision. The clinician needs to have knowledge of an ethical framework or decision-making model to make an ethical decision that he or she can reasonably justify. The APTA Ethics Page and APTA website for Ethical Decision-Making (see the Resources section) provide several tools to help physical therapy personnel make sound ethical decisions. These include Consensus Statement on Clinical Judgment in Health Care Settings, EJC Opinions in Practice articles, and Realm Individual Process- Situation (RIPS) Model of Ethical Decision Making.
apply ethical principles or specify rules to solve an ethical problem. As mentioned, principles sometimes may conflict with each other and will require further judgment to arrive at an ethical conclusion. To address the problem of conflicting principles, Beauchamp and Childress (2013) suggest that healthcare professionals must look toward the context of each case and specify how a particular principle may best apply.
DIMENSIONS OF ETHICAL PROBLEMS IN PHYSICAL THERAPY
How can physical therapy practitioners know if a situation involves an ethical versus a legal problem or perhaps a problem simply involving miscommunication? How does an individual recognize an ethical question that needs to be solved? Broadly speaking, ethical questions, according to Doherty and Purtilo Prototypical ethical problems To help clarify ethical questions, Doherty and Purtilo (2016) describe three prototypical ethical problems: moral distress, locus of authority, and an ethical dilemma. A prototype is a category that contains a set of necessary and sufficient conditions, dimension, or characteristics (Johnson, 1993). Prototypes are useful in ethics because they help clinicians sharpen the distinction of an ethical issue by clarifying the characteristics and dimensions of a problem or problems that must be navigated to make a successful decision. One of the initial steps in making an ethical decision is to define the type of ethical problem one is dealing with. Moral distress Moral distress occurs when a situation presents a barrier that blocks a clinician from doing what he or she perceives is right (Doherty & Purtilo, 2016). The barrier can result from an external source or from an internal source. In either case, the clinician experiences emotional, cognitive, and sometimes physical distress. For example, in the case above, John faces internal moral distress because he is uncertain about what the proper course of action is. He knows something is wrong, but the most appropriate course of action is a big question mark. Principle 4C of the APTA Code of Ethics for the Physical Therapist (2010b) states that “physical therapists shall seek to discourage misconduct by healthcare professionals and report illegal or unethical acts to the relevant authority, when appropriate.” Is it appropriate to report this case when it is not certain that the facts are clear? And who is the relevant authority in this case? According to the APTA Guide for Professional Conduct (2010a), the relevant authority can include a number of people or entities, including your supervisor, human resources, your attorney, the Equal Employment Opportunity Commission, the Licensing Board, the Better Business Bureau, the Insurance Commissioner, the Medicare Hotline, Office of the Inspector General (OIG) Hotline, the U.S. Department of Health & Human Services, an institution using their internal grievance procedures, the Office of Civil Rights, or another federal agency, state agency, a city or local agency, or a state or federal court. Who should John turn to first? Principle 4C also states that reporting should occur “when appropriate” (APTA, 2010b). The problem in this case is that reporting may not be appropriate because John does not know all the facts. He is also not certain about this legal obligation and
(2016) can be distinguished from strictly legal or clinical questions because ethical questions place the focus on the individual’s role as a moral agent and on those aspects of the situation that involve moral values, duties, and quality-of-life concerns in an effort to arrive at a caring response. may not want to assume legal responsibility when the matter can be resolved internally. Locus of authority A locus of authority problem arises from the ethical question of who should have the authority to make an important ethical decision. That is, who is in charge and is the rightful moral agent? Locus of authority is often based on professional expertise, traditional arrangements, institutional arrangements, or the authority of experience (Doherty & Purtilo, 2016). In professional health care, which has been traditionally viewed hierarchically, with the physician assumed to be the ultimate source of authority in clinical decisions about client care, physical therapists have often struggled in their professional roles to recognize their boundaries of decision making and care. John may not be certain that he has the professional authority to make an ethical choice in responding to June on the basis of his perception of his role on her healthcare team. It appears that the APTA Code of Ethics for the Physical Therapist provides clear guidance about John’s obligation in this scenario based on Principle 4C, which stipulates that “Physical therapists shall discourage misconduct by health professionals…” (APTA, 2010b). Ethical dilemmas Ethical dilemmas comprise the third prototypical category and are often the most challenging for clinicians to solve. An ethical dilemma occurs in the presence of an ethical conflict when one must decide a course of action by balancing two or more values, or ethical principles (obligations), that both equally apply (Doherty & Purtilo, 2016). For example, an ethical dilemma arises when a physical therapist has to balance his responsibility to continue caring for a client when therapeutic goals have not been met but reimbursement funds have run out. In the case vignette, it does not seem that John faces an ethical dilemma. Based on Principle 4C it is clear that John has to act. The challenge is what his appropriate course of action is. Physical therapy practitioners often encounter situations in which types of ethical problems overlap. The overlapping of moral problems makes ethical decision making a messy and often emotional experience for many, a situation that is often exacerbated when the physical therapy practitioner lacks the knowledge and skills of ethical decision making.
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Common ethical issues in physical therapy practice What are the common issues faced by physical therapy personnel in contemporary practice? In a recent article, Richardson (2015) describes how the current healthcare system often challenges physical therapists to compromise what is best for the client because of fiscally driven rules. In a seminal research article, Herman Triezenberg (1996) used a series of focus group interviews to identify three categories of ethical issues common in physical therapy practices: issues related to client rights and welfare, issues associated with professional responsibilities and role, and issues involving business relationships and economic considerations. The following case vignette illustrates an important issue related to clients’ rights and welfare – the limits of client confidentiality: Jay is about to be discharged home from the hospital as he recovers from a gunshot wound to the shoulder. He will need PT as well as wound care. Beth is a physical therapist who will be seeing him for PT after his discharge, and she learns that Jay’s sister, Marie, will do most of his wound care. Beth also learns that Jay is HIV positive and that he begs the staff to keep his HIV status confidential, especially from his family. He is afraid his father will evict him. Beth faces an ethical dilemma: Should she maintain confidentiality in keeping Jay’s HIV condition secret? Or should she break confidentiality because she has an obligation to protect the welfare of Marie? Of course, in grappling with this issue, it is likely that Beth is also experiencing moral distress because she is not certain what is the right or best course of action. The following case vignette illustrates moral distress based on an issue relating to professional roles and responsibilities and the concomitant duty of physical therapy personnel to report misconduct: Angela and Rod were classmates in school, and both now work as physical therapists at the local hospital. Rod is aware from socializing outside of class that Angela likes to go drinking. Nine months after accepting the job, Rod notices that Angela is consistently late to work, seems sluggish in the morning, and makes numerous documentation errors. Rod walks into the break room at 10 a.m. and sees Angela placing a flask into her locker. Rod is ethically and legally obligated to report Angela’s behaviors to the state board of physical therapy if indeed he suspects she is abusing alcohol while caring for clients (APTA, 2010b). Yet it is not clear to Rod whether Angela is indeed
drinking because he does not know with certainty what is in the flask. He is also distressed about potentially reporting a classmate and friend. This case raises the question of what Rod’s obligations are to Angela, the local hospital, and society. Is this an ethical or legal case, or both? What does the APTA Code of Ethics for the Physical Therapist say? What about state practice acts? In a situation like this, the therapist who suspects inappropriate behavior must have evidence. Protocols need to be followed – not only the institution protocols and Code of Ethics for the Physical Therapist, but most state practice acts have an “Impaired Practitioner” clause and define steps to report substance abuse. Finally, an important issue involves business relationships and economic factors. The involvement of physical therapists in business relationships that have the potential for exploitation is illustrated in the following case vignette: Mary is a physical therapist who recently took a position with a home health agency. The agency has negotiated a value-based payment (VBP) model with Medicare that incentivizes cost- effective care. The VBP provides incentives for a few specific elements of a single disease or condition that may neglect the complexity of care for the whole patient. Mary is treating an elderly woman recovering from a hip fracture to restore function. Although the patient’s Medicare reimbursement has an established cost-containment model that rewards outcomes based on cost, Mary’s patient presents with multiple morbidities that contribute to a slow recovery. Mary is faced with moral distress and a moral dilemma in that her company wants to discharge the patient within the standard parameters and time constraints established by the VBP for patients with hip fractures. Mary believes that the complexity of conditions presented by this patient does not fit the VBP for her primary condition and requires additional physical therapy. These three case vignettes raise some of the following questions. What are the issues? What are the obligations of the physical therapists and their justifications? What would be the most practical action to take and why? Physical therapy personnel should reflect on these questions as they continue to the next section, which explores theories and approaches as tools to help make ethical decisions. These tools will be applied to an ethical decision-making model to address the questions raised by these case vignettes.
ETHICAL APPROACHES, THEORIES, AND PRINCIPLES: TOOLS FOR ETHICAL DECISION MAKING
Making ethical decisions can be quite daunting in clinical practice when ethical issues unexpectedly arise and physical therapy practitioners are unable to clarify the issue or issues to make a fair and justifiable ethical decision. Doherty and Purtilo (2016) suggest that the focus of an ethical decision is a caring response that is directed toward the best interest, goals, and values of the client. Conceptual tools that help physical therapy practitioners make a caring response include the use of ethical Ethical approaches Several approaches have been identified to help physical therapy practitioners make ethical decisions. An ethical approach is a step (and a component) in an overall framework of ethical decision making. Depending on the ethical case and the type of information practitioners may need, they may choose to use one or more of these approaches in their ethical decision-making framework (Doherty & Purtilo, 2016). Narrative approach In the presence of an ethical issue, physical therapy practitioners often have limited information to make a caring response. An
approaches and theories. According to Doherty and Purtilo (2016), an ethical theory is well developed and expansive and provides physical therapy practitioners with assumptions about right or wrong or good and bad actions. In contrast, an approach is not a complete system or model but an aid to existing theories. The following section reviews basic but important approaches and theories that provide physical therapy personnel guidance in making ethical decisions. important step in making an ethical decision is to “get the story straight.” That means expanding the narrative of a case to fill in gaps in the story. The narrative approach to ethics is based on the observation that humans are storytelling creatures by nature and pass on information by sharing stories to make sense of experiences. As often is the case, many situations involving moral issues are presented or recalled in fragments in which only one perspective (the narrator) is favored and the perspectives of other stakeholders are not readily apparent. A stakeholder is “a person, group, or other entity that has a deep and compelling interest in a situation that it wants to protect” (Doherty & Purtilo,
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2016, p. 187). Stakeholders may have different priorities that can cause ethical conflicts. Kornblau and Burkhardt (2012) suggest that clients, family members, significant others, friends, neighbors, coworkers, students, colleagues, support staff, policy makers, and vendors all have roles in the healthcare delivery system; therefore, they are all potential stakeholders. Additional groups may be relatives, first responders such as police and firefighters, employees, visitors, and research participants. Caring approach and ethics of caring As indicated earlier, according to Doherty and Purtilo (2016), the goal of making an ethical decision is to make a caring response. The basis of a caring response is the fiduciary relationship that physical therapy personnel as healthcare professionals have toward their clients. A fiduciary relationship is a legal and ethical concept. In such a relationship, a “person [in] whom another person has placed a special trust or confidence is obligated to watch out for the best interests of the other party” (Doherty & Purtilo, 2016, p. 255). Physical therapy practitioners have a fiduciary obligation to clients and their families to care for them in a trustworthy manner with dignity, allowing the clients a “voice” in determining the nature and course of treatment, and Ethical theories Ethical theories, like ethical approaches, help physical therapy personnel make ethical decisions. As mentioned, ethical approaches are considered more limited in scope than an ethical theory. Beauchamp and Childress (2013) list several conditions that distinguish a theory from an approach. These include clarity, coherence, completeness, simplicity, explanatory power, justificatory power, output power, and practicability. For physical therapy practitioners, a theory helps clarify the ethical dimensions of a case and provides an option for making an ethical decision. As with ethical approaches, physical therapy practitioners often use elements of more than one theory to make an ethical decision. Deontology and teleology There are several traditional ethical theories, but the two most prevalent in the healthcare literature are deontology and teleology. Deontological theory is based on the concept of duties and rights (Doherty & Purtilo, 2016). Deontological theories hold that you are acting rightly when you act according to duties. Physical therapy personnel have a duty to protect and fulfill another person’s (client’s, student’s, or research subject’s) rights. To act rightly, however, a physical therapist or physical therapy assistant has to know what his or her duties are and how they apply in a particular situation. Deontological decision making based on principles and duties are made without regard for the consequences of actions. For example, a client has a right to autonomy, which the practitioner has a duty to respect. Under deontological theory, no other considerations are valid (e.g., whether the therapist likes the client, the client has good moral character, or the client is cognitively impaired). The duty to respect the client’s right to autonomy trumps these and all other considerations. Teleological theory, in contrast, is based on consequences or “ends” (Purtilo & Doherty, 2011). Actions are utilitarian and seek the best or least harmful consequences for the actions taken. For example, if two treatment techniques are equally effective according to research studies, the practitioner should consider the consequences: Which technique will bring the most benefit? That is, which will provide the best outcome to the client within his or her situation? Sometimes, these two theories may appear in conflict. For example, a client has a right to beneficial treatment, but suppose the best treatment is painful, such as stretching to prevent muscle shortening and joint contracture. Does the practitioner continue to stretch the limb (duty) despite the pain, or does the practitioner respect the client’s pain and quit stretching, thereby reducing the pain but also increasing the risk of contracture (consequence)? In this case, the physical therapist has conflicting
finally assuring the clients that competent care will be provided using sound professional judgment. Physical therapy practitioners that focus on providing a caring response to their clients use an ethics of caring approach. In this approach, ethical decision making is guided by the needs and goals of the client and family within a particular context (Doherty & Purtilo, 2016). Therapists who practice the ethics of care recognize that it is the relationships they develop with their clients that bring moral significance to clinical practice. Thus, ethical decisions focus on preserving that relationship or connection with the client for responsible decision making. To maintain a trustful relationship with their clients, practitioners who use an ethics of care approach tend to search for practical and creative solutions to moral problems that involve compromise. It is no surprise that experienced clinicians tend to use an ethics of care approach as part of their ethical decision making because they are very good at creative decision making and client-centered care (Greenfield, 2006). duties – not to cause pain and the duty to improve the client’s well-being by preventing contractures. As a result, the therapist is faced with a moral dilemma. One interesting solution to this dilemma is based on the “rule of double effect” (Beauchamp & Childress, 2013). The rule of double effect has been used to justify causing tolerable discomfort (or temporary harm). It is invoked to justify an intervention that has two foreseen effects, one good (preventing contractures) and one harmful (pain), which is not always morally prohibited. To involve the rule, four conditions must be satisfied: 1. The nature of the act must be good (prevent contractures). 2. The practitioner intends only the good effect (elongates tissue); the bad effect (pain from stretching a contracted limb) can be foreseen but is not intended. 3. A distinction is made between means and effects: The bad effect must not be a means to the good effect (increasing pain is not the primary means to elongating the contracted tissue). 4. There must be proportionality between the good effect and the bad effect. That is, in the example considered here, the practitioner violates Rule 4 if he or she accidentally fractures the client’s arm while stretching the contracture. The reason is that there is no proportionality between the harm and the good effect. A practitioner may be tempted to “split the difference” and stretch the limb until the client’s pain is no longer tolerable. The result may or may not be enough to reduce the risk of contracture. When the practitioner reflects on how to balance the correct ratio of benefit to harm, he or she is using ethical reasoning. Virtue ethics Virtue ethics has a long tradition in Judeo-Christian ethics and Western philosophy (Doherty & Purtilo, 2016). Virtue ethics teaches that one acts ethically when one acts according to certain virtues. The moral virtues include courage, temperance, liberality; the intellectual virtue of wisdom, according to Aristotle (trans. 1953), governs ethical behavior. As mentioned previously, the core values of the APTA represent the moral values (virtues) that the profession seeks to instill and guide ethical behavior. Doherty and Purtilo (2016) suggest that the easiest way to understand virtue ethics is through the basic idea of character traits and moral character. A character trait is a disposition to act in a certain way. Those who have character traits that are often praised by others are often referred to as having high moral character (Doherty & Purtilo, 2016). Certain character traits – honesty, compassion, courage – enable an individual to be the
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