Physical therapists as double agents. Ethical dilemmas of divided loyalties

Ethical dilemmas arise when physical therapists encounter conflicts between loyalty to their patients and loyalty to their employers. This type of ethical conflict is called "the dilemma of the double agent." If physical therapists perceive themselves as agents of their patients, their employment may be threatened. If physical therapists perceive themselves as agents of their employers, their patients may suffer physical or psychological harm. The double-agent dilemma is illustrated in this article by a hypothetical case study derived from sports physical therapy. Three ethical theories--egoism, utilitarianism, and formalism--are used to analyze the conflict and formulate solutions. A second conflict also is raised between patient autonomy and medical paternalism. As physical therapists become more autonomous, they will assume increased responsibility. Inherent in this increased responsibility is the obligation to recognize and confront ethical dilemmas in physical therapy practice. Resolving ethical dilemmas is difficult, but use of ethical theories can help in the systematic examination of basic assumptions and principles. This article introduces therapists to three ethical theories and presents a model for ethical decision making.     

Ethical dilemmas in family caregiving for the elderly: implications for occupational therapy

An analysis of 60 ethnographic interviews with family caregivers for frail community-based elderly persons has suggested that ethical dilemmas are an important organizing framework for family caregiving. The present paper explores this conjecture as it relates to the practice of occupational therapy with older clients and their families. Major themes of ethical dilemmas in family caregiving, as derived from the ethnographic data, are described. Verbatim interview data are presented to illustrate the close ties between caregiving activity and the caregiver's ethical convictions. Occupational therapists are encouraged to seek understanding of their clients' ethical beliefs in order to maximize the potential for a therapeutic relationship built on mutual understanding and partnership.     

The impact of nursing education on ethical/moral decision making

A study of 227 baccalaureate and 111 master's nursing students was conducted to determine the influence of the level of formal education on three selected factors: ethical/moral reasoning, attribution of responsibility, and ethical/moral dilemma resolution. Moral development theory and Heider's attribution of responsibility construct provided the theoretical framework. A comparison of the overall index of ethical/moral reasoning showed that graduate students reasoned at a higher level than undergraduate students. The amount of attribution of responsibility assigned and the dilemma resolution score did not differ for the two groups. The results of this study suggest that undergraduate and graduate nursing programs must place more emphasis on identifying dilemmas, increasing ethical/moral reasoning levels and attributing responsibility in a justifiable manner. Nurse researchers must continue to study how nurses respond in dilemma situations and how personal characteristics, factors in the environment, education, and the assignment of responsibility affect nurses' ability to resolve ethical/moral dilemmas.     

Ethics and sexual health: Exploration of the ethical code of conduct for physiotherapists concerning sexual health in clinical practice

ABSTRACT

Physiotherapists have an important role in sexual health, but there are specific ethical considerations regarding sexuality and the practice of physiotherapy which require serious consideration. This article aims to illustrate how the professional ethical code of physiotherapy can serve as a tool for ethical clinical reasoning regarding sexual health in clinical physiotherapy practice. We analyse the ethical codes for physical therapy, in relation to a definition of sexual health and the declaration of sexual rights. The analysis outlines several ethical considerations crucial in dealing with sexual health, while also acknowledging the critical role of cultural context in any ethical analysis. We conclude that physiotherapists need to practise ethical reasoning and that the ethical code of physiotherapy can act as a point of departure for reflection on thought-provoking ethical dilemmas to improve the practice of physiotherapy and support clients’ overall health.     

Professional Reasoning and Occupational Therapist's Use of a Multi-Sensory Environment for Clients with Dementia

ABSTRACT

Aims: To examine the professional reasoning process of occupational therapists using multi-sensory environments (MSEs) to treat clients with dementia. Methods: This was a qualitative study design which used interviews to uncover the multi-faceted professional reasoning process used by occupational therapists when implementing MSE interventions for individuals with dementia. Results: Qualitative data analysis yielded three themes regarding the professional reasoning process of occupational therapists that use MSEs to treat clients with dementia. Clinicians use MSEs because the intervention emphasizes client-centered care; facilitates neural changes; and promotes emotional connections. Conclusions: Current evidence does not support the professional reasoning process which occupational therapists use when integrating the MSE into the occupational therapy plan of care. Further qualitative research is indicated to explore why occupational therapists continue to use interventions that are not evidence-based and to examine the process in which clinicians abandon current practice methods when research evidence does not support their use.     

Ethical issues in physical therapy

Healthcare professionals can be confronted with a wide range of ethical and regulatory issues in today’s ever-changing practice environments. While achieving best practice standards, physical therapists may need to compromise what is best for patients due to fiscally driven rules, regulations, and limited benefits. Scenarios may surface where ethical issues and associated dilemmas become paramount between what is versus what should be. A challenge that should be in the forefront of professional endeavors is staying current with published rules, regulations, and conditions of participation, as applied to various practice models and environments while still adhering to ethical codes. Knowing and utilizing available resources especially American Physical Therapy Association (APTA), websites, documents, and references can strengthen practice patterns and treatment options.     

Ethical Dilemma Resolution In HIV/AIDS Counseling: Why an Integrative Model?

In this study the authors provide an in-depth analysis of each of the eight categories of ethical dilemmas faced by professionals counseling individuals living with HIV/AIDS. The eight ethical dilemma categories involve disclosure, vocational, legal, health, family/social, sexual, death, and counselor/client relationship issues. This study builds on previous research conducted by the authors by discussing the basic components of the Integrative Decision-Making Model of Ethical Behavior and analyzing reasons for making this approach the model of choice in resolving ethical dilemmas faced by counselors working with this particular population.     

Patient engagement in rehabilitation therapy: physical and occupational therapist impressions

Purpose. The study is performed to examine the impressions of physical and occupational therapists on therapeutic engagement among their patients. Engagement in this context was defined as a patient's deliberate effort to work toward recovery by participating fully in their rehabilitation therapies.

Method. Using a survey approach, physical and occupational therapists (N = 199) from across the United States were asked about issues they have encountered in their daily practise that have acted as either barriers or facilitators of patient engagement.

Results. Fear of pain, depressed mood and cognitive issues were rated as the most frequently encountered barriers impacting patient engagement. Making therapy tasks meaningful and explicitly related to personal goals of the patient was the most commonly reported practise for enhancing therapeutic engagement.

Conclusions. The knowledge of therapists gained from day-to-day experience with patients in rehabilitation can be of use to other rehabilitation professionals in treating patients who are difficult to engage in the rehabilitation process.     

Anthropology, occupational therapy, and action research.

This paper describes the research process and methodology used in the American Occupational Therapy Association/American Occupational Therapy Foundation Clinical Reasoning Study. This study examined the clinical reasoning of occupational therapists through a 2-year ethnography of therapists at one hospital site. The research was innovative in several important respects. One important innovation was a combined ethnographic and action research design that involved collaboration between the research team and those therapists being studied. Therapists who were research subjects became actively involved in examining and reflecting on their own practice through group analysis of videotaped sessions with clients. One outcome of this action research component was that the study served as both a research and a staff development project.     

Towards healthy professional-client relationships: The value of an interprofessional training course

Boundary violations that threaten professional-client relationships are rarely discussed at the coalface. There is an assumption that healthcare practitioners have the skills necessary to manage professional boundary dilemmas with clients. The issue, if addressed, is usually confined to discipline specific education and training. A one-day Professional Boundaries for Health Professionals (PBHP) training program was developed in response to real life practice dilemmas experienced by health practitioners across the continuum of care. The program was delivered to 109 participants throughout the state of Queensland, Australia, from government and non-government organizations. Participants were doctors, nurses, allied health (physiotherapists, occupational therapists, social workers, psychologists, dietitians, speech therapists), therapy assistants and personal care staff from a diverse range of hospital and community settings. Evaluations of PBHP suggest that the interprofessional learning context was valued with specific advantages identified in the use of adult learning approaches, the teaching of ethical decision making principles, the value of supervision and peer support and the opportunities provided for critical reflection. The effectiveness of training for healthcare practitioners in this area is discussed as a meaningful way of developing skills and engendering collaborative relationships between professional (e.g., occupational therapist, social worker) and paraprofessional (e.g., therapy assistant, personal care worker) groups. A combination of intensive training in professional boundaries and opportunities for ongoing professional development are important for all health practitioners.     

The nature of dilemmas in dialysis nurse practice

Dilemmas are a part of nurse practice. In situations where a problem potentially has two or more unsatisfactory resolutions, the nurse chooses which course of action to take. The decision to choose constitutes a dilemma. This study focuses on the dilemmas faced by nurses in dialysis units and the context in which they occur. A qualitative design was employed, using open interviews with eight nurses currently employed in dialysis nursing. This approach was taken in order to explore and gain in-depth understanding of the dilemmas in practice. Analysis reveals that dilemmas encountered in dialysis nursing emerge from conflicts in relationships with other people in the work environment. The dilemmas relate to the nurses' perception of the limited power they have in the determination of their practice. This powerlessness is reinforced by their perceived and real isolation from nurses working outside their area of practice. Traditionally, literature on dilemmas in nursing has focused on the development of ethical frameworks to guide practice and the resolution of dilemmas. However, the findings of this study suggest that if nurses are to deal with dilemmas effectively, both for the nurse and the patient, there must be an examination of the structural constraints affecting their practice. Models that are employed by nurses to guide practice must account for the structural elements in the work environment.     

Ethical Dilemma and Moral Distress: Proposed New NANDA Diagnoses

PURPOSE: To propose two NANDA diagnoses--ethical dilemma and moral distress--and to distinguish between the NANDA diagnosis decisional conflict and the proposed nursing diagnosis of ethical dilemma. SOURCES USED: Journal articles, books, and focus group research findings. DATA SYNTHESIS: Moral/ethical situations exist in health care. Nurses' experiences of ethical dilemmas and moral distress are extrapolated to the types and categories of ethical dilemmas and moral distress that patients experience and are used as the basis for development of two new nursing diagnoses. CONCLUSION: The two proposed NANDA diagnoses fill a void in current standardized terminology. PRACTICE IMPLICATIONS: It is important that nurses have the ability to diagnose ethical or moral situations in health care. Currently, NANDA does not offer a means to document this important phenomenon. The creation of two sets of nursing diagnoses, ethical dilemma and moral distress, will enable nurses to recognize and track nursing care related to ethical or moral situations.     

Liberal arts: the foundation for occupational therapy education

Occupational therapy lacks a consensus regarding its theory base, technical tools, contribution to society, ethical stance, and relationship to medicine. This study proposes steps to achieve a new consensus and to resolve the crisis focus on entry-level education. The proposed steps include the critical assessment of the educational foundation for practice, the recognition that a liberally educated occupational therapist can serve patients better and meet pressing societal needs, and the pursuit of closer relationships with liberal arts colleges by occupational therapy academic departments. A "new breed" of occupational therapists, that is, therapists who are liberally educated, will be capable of thinking in broad categories and will be open to new ideas and aware of ethical implications; they will be familiar with principles, able to practice from a knowledge base, and prepared to improve the profession's practice: they will possess the skills to be leaders.     

Ethical decision making in clinical research: application of CELIBATE.

The need for high-quality evidence to support practice is an ongoing issue in occupational therapy. As a consequence, growing numbers of occupational therapists are engaged in both clinical practice and research activities. Therapists who find themselves in these dual roles are sometimes faced with ethical conflicts when the responsibilities of being a researcher appear, on the surface, to diverge with the responsibilities of being an occupational therapist. This article applies one clinical tool, CELIBATE, to problem solve through an ethical dilemma experienced by a clinician involved in research. Based on the experience of using the tool, recommendations are presented to make CELIBATE more useful in research situations.     

Occupational Therapists’ Perceptions of Environmental Influences on Practice at an Inpatient Stroke Rehabilitation Program: A Pilot Study

ABSTRACT

Aims: To better understand occupational therapists’ clinical decision making processes as they selected which rehabilitation environment to work in, and how the therapists perceived the environment impacted their choice of intervention. Methods: Focus group and individual interviews were conducted following observation of three occupational therapists providing interventions for 16 months with 12 clients following a stroke at an inpatient rehabilitation hospital stroke unit. Therapists could chose from three different environments for interventions: a therapy gym, homelike space, or a combination space. Results: Three themes emerged that revealed therapists’ habits influenced their clinical reasoning; the environment influenced therapists’ intervention choices; and therapists felt safer treating in the gym environment. Conclusion: The environment influenced the therapists’ intervention choices as well as their clinical reasoning. Rehabilitation services on an inpatient stroke program may be improved if therapists increase their awareness of the influence of the environment on interventions.