The Ethical Triangle of the PT, PTA, and Patient Relationship

1. The Ethical Triangle of the PT, PTA, and Patient Relationship Melanie Heffington, PT, DPT, APTA Education Leadership Institute Fellow

2. Greetings and Salutations

3. But seriously… Let’s say the average PT or PTA works 40 hours/week from the age of 26 until 65 and gets two weeks of vacation every year. In that time, the average clinician will have worked a total of 78,000 hours 1/3 of a human life is spent working…

4. Top 3 Factors for Employee Satisfaction • Appreciation for your work • Good relationships with colleagues • Good work-life balance (Morgan 2014)

5. When we aren’t happy at work? • RESIGN • High turnover rates have been reported by OSHA as a workplace violence risk factor • 2015 NSG Solutions, Inc. found that turnover in first year allied health professionals and RNs outpaced other workplace categories and can make up over 50% of hospital turnover in a year (2016 looked better for Allied) • Costly to employers in terms of recruiting/hiring/training and coworkers who are tasked with more responsibilities • Difficult to accomplish patient satisfaction and budget goals with revolving door of employees

6. When we aren’t happy at work • Complain • Slow productivity, reach only for the minimum- clock watch • Lack of problem solving, feedback, or new ideas • Secrecy, conspiracy • Reluctant to engage

7. Who do we do we work for?

8. PT returns individuals to their life roles

9. PT, PTA, and Patient Relationship Matters

10. Pollev

11. Name some famous couples. • Pollev instructions

12. What are characteristics of healthy relationships?

13. What are characteristics of bad relationships? pollev

14. Describe in ONE word, the relationship with your PT(s)or PTA(s) pollev

15. Perceptions of Roles of PTA (Robinson 1994, 1995) • Despite documents from APTA, State Practice Acts, and education institutional standards- perceptions of the role of the PTA differ from PT to PT and PTA to PTA • This strains the relationship between the PT and PTA and ultimately the patient

16. Perceptions of the PTA continued

17. Perceptions of the PTA

18. Perceptions of the PTA

19. SUCCESS Develop a plan AHEAD of patient care time that takes into account differences in personality types as well as skill levels/experience levels and how the quality of the PT/PTA and Patient relationship MATTERS to patient outcomes

20. Jenny and Forest Jenny is a 15 year veteran PTA with experience treating adults in an acute care setting. She moves to a new town and finds the utilization of the PTA at her new hospital much below her perceived level of skill. Jenny feels very comfortable advancing gait/pregait skills and determining appropriate assistive devices for a patient in preparation to return home. Her PT, Forest, often times asks her to stick solely to training functional tasks that have been evaluated by the PT and insists on being contacted everytime Jenny wants to advance the patient from a RW to a cane etc.. . How does this effect the Patient????

21. Thor • Thor is a PT with 2 years of experience. He has difficulty maintaining his documentation and often has a PTA see a patient without initial evaluations or goals completed. When his PTAs complain he says “well I tell you everything you need to know verbally, so you are covered”. • How does this effect the patient???

22. Utilization Overutilization Underutilization Bored PTAs acting and getting paid highly to function essentially as techs Employee satisfaction Patient efficiency of care/budget Animosity • PTAs working outside scope of practice especially in areas of predicting/goal setting/equipment recommendations • Patient loses benefit of the PT skill level • PT and PTA taking risks with everyone’s licenses

23. Utilization • Today’s healthcare environment is much more dynamic and complex requiring a higher level of decision making from PTAs and PTs • Development of the DPT creating the pathway for the autonomous provider • Charge would be that we would all “up our game” to include acknowledgment of need to perfect our intraprofessional communication, delegation, and respect to maximize patient outcomes

24. What do we do to maximize relationship to best serve our patients?

25. Medical Ethical Principles

26. Non maleficence and Beneficence

27. Justice

28. Autonomy or Respect for Persons

29. Ethical principle defined as Acting in ways that are loyal Within a particular professional designation Perhaps the most common source of ethical conflict FIDELITY fidelitas fidem constantia castitudo

30. Fidelity… Building trusting relationships At any one time, clinician may find themselves in conflict between what the patient wants, what the clinician thinks is right and what another member of health care team thinks Getting out of that one is all about relationship, communication, delegation, and respect

31. Harley and Davidson • Harley is a PT with 30 years experience working with an outpatient orthopedic patient population. Davidson is a PTA with 5 years of experience working in a variety of settings to include HH, acute, and SNF. They are sharing a patient who has undergone a TKA 8 weeks ago and still hasn’t met ROM goals set at eval after 8 visits. Harley knows Davidson is not pushing the patient to end range. Davidson hates making his patient hurt. The patient is unhappy with his progress, but likes Davidson better than Harley because he sympathizes with his pain more. See relationships, fidelity, communication, delegation, and respect in this scenario?

32. Purtilo 2005 “Fidelity” What Patients Expect • Treat them with respect • Competent and capable in your role • Adhere to a professional code of ethics • Follow the policies and procedures of your organization and applicable laws • Honor agreements

33. APTA Professionalism Core Values • Accountability • Altruism • Compassion/caring • Excellence • Integrity • Professional Duty

34. Collaborative Practice Competencies APTA HOD 2014 1. Values/ethics: work with others to maintain a climate of mutual respect and shared values 2. Roles: Use knowledge of one’s own role and those of others to appropriately address needs of patients 3. Interprofessional communication: Responsive, responsible 4. Teams: Apply relationship-building values to effectively deliver patient centered care

35. Do we do that inTRAprofessionally? • Are we demonstrating the concept of FIDELITY to those in our profession? • Do we keep our “promises” to each other in our profession? How well? How often? • Does it depend on how busy we are or other factors? • How can the concept of duty to our PTA/PT team maximize work environment and patient outcomes?

36. Duty based ethics • Deontological ethics • Immanuel Kant 1778: “act only on maxims that treat each person involved as the end and not a means to an end” • Kant used “categorical imperatives” : a rule that is true in all situations (Gabard and Martin 2011)

37. Duty Based Ethics Theory • Duty based ethics focuses on the ACT and NOT the CONSEQUENCE • These approaches are heavy on obligations

38. Duty Based Ethics Theory • Kant 4 famous examples that assume all living beings : • Desire to continue living • Desire to develop their talents • Desire to NOT have insincere promises made to them • Desire necessary help when in severe hardship

39. Duty Ethics • These approaches in workplace tend to be heavy on “following the policy” regardless of the outcome • Equal respect to all human beings • Do we have a moral obligation to treat our coworkers with fidelity and respect regardless of the outcome?

40. Duty Ethics • An evolvement of Kant occurred in David Ross as most can agree that sometimes there might be an exception to a moral rule ie. Lie to keep someone alive • David Ross would say that there might be a prima facie duty in the above case which helps us rationalize an alteration in following a moral rule

41. Duty Ethics and Prima Facie Duties • Duty to maintain confidentiality, but also a duty to protect others from harm • Patient has hepatitis C loses balance in hall and drain falls out with blood leaking in hallway. Other health care providers arrive to help. Primary therapist has a duty to maintain confidentiality, however the prima facie duty would be to avoid harm to others and she discloses contact precautions are crucial to assisting this patient.

42. Pop culture associations

43. Doing “good for goodness sake”

44. Duty ethics vs. Outcome based ethics Duty based Outcome based Most benefit to the most individuals consequence • Moral perspective on the action • action

45. The Golden Rule Common to most major religions

46. The Golden Rule/Law of Reciprocity • Concept occurs in every major religion, examples: • ~664 BC in Egypt “That which you hate to be done to you, do not do to others” • ~500 BC China/Confucius “Never impose on others what you would not choose for yourself” • Judaism “You shall not take vengeance upon yourself…Love your neighbor as yourself…” • Christianity “Do onto others as you would have done unto you”

47. Think back to “ideal relationship” poll • APTA videos on PT/PTA • http://www.apta.org/SupervisionTeamwork/SuccessStories/

48. APTA Code of Ethics A ‘Code of Ethics’ is necessary for an occupation to be considered a profession A Profession “regulates itself” and has a “service rather than a profit orientation enshrined in its code of ethics” “Regulating of itself” is a social contract between a profession and the public (Starr 1982)

49. APTA Code of Ethics • “Vocabulary for intraprofessional argument, self-criticism, and reform” • “Stimulates a moral self-understanding” • “Collective conscience” (Fullinwider 1996)

50. APTA Code of Ethics/Standards • Principle 1: Ethical obligations to all people • Principle 2: Duties owed to patients and clients • Principle 3: Accountability for making sound professional judgments • Principle 4: Integrity in relationships with other people