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b y N a n c y R K i r s c b , P I D P I P h D

Improper Conduct: Case Three


A n i s s u e o f h a n d s - o n m e n t o r i n g .
T
he initial column in this series on
ethical considerations related to
improper conduct focused on a
physical therapist (PT) who became aware
of inappropriate behavior on the part of a
colleague and had to determine how best
to address the situation.' List month, we
looked at what might happen when a
patients behavior puts a student physical
therapist {SPT) on the spot.^ This final
scenario in the series involves a recent-
graduate PT s interactions with her PT
supervisor.
As you read, use the Realm-Individual
Process-Decision Making (RIPS) model
of ethical decision-making-^ to help guide
your thoughts on the issues presented and
potential ways of addressing them.
Avoidance Therapy
After reading the following scenar-
io, look at the accompanying boxes-
Components of the RIPS Model (at
right) and the APTA Code of Ethics on
the facing pageconsult the Ethics in
Action column "Ediical Decision Making:
Terminology and Context,"^ and use the
guiding questions within each of the steps
to ethical decision-making to help further
crystallize your thoughts.
Sally graduated from her DPT program
about a year ago and initially was thrilled
to be ojfered a fiill-time job at the hospital
at which shed completed her second clini-
cal affiliation. Shed felt very comfortable
at the startimpressed by staff's skills and
knowledge, gratified by their eagerness to
mentor her, and warmed by their kindness
and good humor.
Among her PT mentors is Paul, the hos-
pital's associate director of inpatient physi-
cal therapy. Early in her employment he
began encouraging Sally to practice therapy
techniques on him, partiailarly where he
has the most interest and expertisethe
loiver extremities, hips, and trunk. She
initially welcomed this attention and saw
nothing improper in it: He was, after all, a
well-respected administrator, married, with
three children. But he ff-adually has become
more demanding, sometimes insisting that
she practice techniques on him in a private
treatment roomso she doesn't get "dis-
tracted, " he says.
As these sessions have become more
frequent, Sally has felt more and more
uncomfortable. She has beenfrnding herself
actively trying to avoid Paul, and this has
meant sometimes making treatment deci-
sions based partially on staying away from
himrather than completely on what is in
the patient's optimal interest. Yesterday, for
example, Paul decided to treat his patient
on a mat near where Sally was working
with her own patient, so she instructed her
patient to move on to another activity even
though the move was a little premature. It
wasn't the first time she'd found herself cut-
ting an intervention shortor uprooting a
patient so as put physical distance betweetj
Paul and her.
But Sally doesn't quite feel comfortable
approaching anyone at the hospital about
her discomfort with Paul. She wonders if
she's misinterpreting his motives, and she
feels, at any rate, that he could convincingly
fttstify his actions were he to be confrvnted
about them. Sally worries that airing her
concems will only damage her credibility
and future at the hospital She tells herself,
too, that her efforts to avoid Paul haven't
Components of the
Realm
Individual (relationship
between individuals)
Organizational/
Institutional (good of the
organization)
Societal (common good)
RIPS Model
Individual Process
Moral Sensitivity
(recognize situation)
Moral Judgment
(right or wrong)
Moral Motivation
(moral values above
other values)
Moral Courage
(implement action)
Ethical Situation
Issue or Problem (values
are challenged)
Dilemma (right vs right
decision)
Distress (right course
of action blocked by
a barrier)
Temptation (right vs wrong
situation)
Silence (values are
challenged but no one
is addressing it)
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adversely affected patients in any significant
way "I'm a good therapist who Just needs
to be a little creative sometimes regarding
how and where I treat patients, "she assures
herself
StilL the question of whether she should
rake any sort of action nags at her.
Step 1: Recognize and Define the
Ethical Issue
Ask yourself:
Into which realm or realms does this
situation fall; individual, organiza-
tional/institutional, or societal?
: What does the situation require of
Sally? Which individual process is
most appropriate: moral sensitivity,
moral judgment, monil motivation,
or moral courage? Are there implica-
tions for action on the parts of any-
one besides her? What about Paul?
Is he aware of the awkward position
in which he has placed Sally? Are
any of Sally's colleagues aware of his
behavior toward her?
:* What type of ethical situation is
this: a problem, dilemma, distress,
or temptation?
-: What are the potential barriers to
Sally taking action?
Step 2: Reflect
Ask yourself:
: What is known about Paul, his past
behavior, and staff perceptions of his
behavior?
:' What does Sally know about her rights
in the workplace iind her options for
confidential discussion of die situation?
: Who are the major stakeholders? In
addition to Sally, her patients, and
Paul, who or what else may be affected
by this situation?
> What are the potential consequences of
Sally's action or inaction on her, Paul,
patients, and stall?
: Might her aaion or inaaion break any
laws?
What ethical principle or principles
may be involved? Do any of the fol-
lowing resources provide professional
guidance: the APTA Code of Ethics,
the APTA Guide for Professional
Conduct,'' and/or Professionalism in
Physical Therapy: Core Values?*' For
example, do you see a relationship
between this case and principles 2
and 4 of the APTA Code of Ethics?
Which principles, if any, strike you
as being applicable to Sally? To Paul?
To anyone on staff who is aware of
what's going on?
Finally, consider how this scenario
stacks up against the tests posed by
Rushworth Kidder in How Good People
Make Tough Choices^: legal, stench. Iront
page, parents, and professional ethical
violation. In other words: Is something
illegal going on? Does the situation feel
wrong? Would the hospital's reputation
suffer were all the details to become
public? What might parents do if faced
APTA Code of Ethics (HOD 06-00-12-23)
Preamble
This Code of Ethics of the American
Physical Therapy Association sets forth
principles for the ethical practice of physi-
cal therapy. All physical therapists are
responsible for maintaining and pro-
moting ethical practice. To this end, the
physical therapist shall act In the best
interest of the patient/client. This Code
of Ethics shall be binding on all physical
therapists.
Principle 1
A physical therapist shall respect the righfe
and dignity of all individuals and shall
provide compassionate care.
Principle 2
A physical therapist shall act in a trustwor-
thy manner towards patients/clients, and
in all other aspects of physical therapy
practice.
Principle 3
A physical therapist shall comply with
laws and regulations governing physical
therapy and shall strive to effect changes
that benefit patients/clients.
Principle 4
A physical therapist shall exercise sound
professional judgment.
Principle 5
A physical therapist shall achieve and
maintain professional competence.
Principle 6
A physical therapist shall maintain and
promote high standards for physical ther-
apy practice, education and research.
Principle 7
A physical therapist shall seek anIy such
remuneration as is deserved and reason-
able for physical therapy services.
Principle 8
A physical therapist shall provide and
make available accurate and relevant
information to patients/clients abaut their
care and to the public about physical
therapy services.
Principle 9
A physical therapist shall protect the
public and the profession from unethical,
incompetent, and illegal acts.
Principle 10
A physical therapist shall endeavor to
address the health needs of society.
Principle 11
A physical therapist shall respect
the rights, knowledge, and skills of
colleagues and other heolth care
professionals.
63
with a similar circumstance involving
their child? Can any ethical violations be
detected within the APTA resotirces listed
previously?
Step 3: Decide the Right Thing to Do
If the scenario fails any of the tests
described in the previous step, this step
is superfluous. In that case, action must
be taken; The quesdons become what
kind of action, and has Sally the moral
courage to implement it? Also, what is
the potential for collateral damage based
on her action or inaction? How might
Sallys inaction affect patients? What are
patients" rights regarding the effects on
their care of PTs' personal issues?
If you believe the scenario passes each
of Kidder' s tests, then its time to look at
the three possihie approaches he presents
for determining the right thing to do, and
also to look at whether any barriers loom
to implementing that response:
:* Rule-biised: Follow only the principle
you want everyone else to follow.
%* Ends-based: Do whatever produces
the greatest good for the greatest num-
ber of people.
> Care-based: Do unto others as you
wotild have them do tinto you. (The
"Golden Rule.")
Ask as well; Are there are potential bar-
riers to implementing any given decision?
Are there related ramifications for the
clinic, its PTs, and/or current and fiiture
patients?
Step 4: Implement, Evaluate, Reassess
Having determined in your own mind
the right thing to do and the best way to
implement that decision, reflect on the
course of action youVe chosen for Sally
and think about whether a change in tJie
department' s policies or culture might
prevent the scenario from recurring.
Let's Talk
This column arc will conclude in
September with an analysis of all three
scenarios related co improper conduct.
In the meantime, please let me hear from
you! (Note my e-mail address below.)
Tell me what your thoughts about these
casesyour resolutions and how you
arrived at them. And please share your
insights with other PTs and PTAs, as well.
Use Ethics in Action as a teaching tool, as
many of your colleagues across the coun-
try are doing. %
N a n c y f t K k s d i , P T , D P T , P h D ,
J u d i c i a l C o m m i t t e e , i s a n a s s o c i a t e p r o f e s s o r o f p h y s i c a l t h e r a p y i n
t h e U n i v e f s i t y o f M e d i c i n e a n d f k n t t s t r y ' s S T / K W / o f H e a l t h R e b t e d
P r o f e s s i o n s i n H e r n t k . H e w j e r s e y , a n d o w n e r a f N o i t h e m H i l l s
P h y s i c a l J h e w p y i s s o d a t e s i n F h n d e r s , f i e w j m e y . S h e c a n b e
c o n t a c l B d a t k i f s c h n o @ i m l n j . e ( i u .
References
1 . KirschNR. Improper condua: O L V one. PTM^azine of
Physical V xmpy. 201 )7:l^(5):34-.V),
2. Kirsch NR. Impnipcr condua: case two. PT^Magaziiu
ofliryiimlThrmpy. 2007i1 ' i(6):34-37-
3. Swisher l.t.. Aisianian I.t!, Llavis CM. ITic iralni-indi-
vldua] priKJSi-situacion (RIPS) niodfl of ethical ditision
making. HPA RtuiuTce. 20O' );' )(3):1 .3-a.
1 , Kirsch NR. Ethical ciecision making: lerminiitogj' andcon-
icxi. PTMagaanf of Phyacal Thmpf 2nO6;I4(2):38-
40.
5. American Phy^cal Therapy Associaiion. APTA Guide for
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Tcroplatc.ctm?Sec(ion=E[hics_and_LcgnLissues I &CON
rENTIL>=2478]&TEMPLArE-/ CM/ Cont cnt Di spky.
ctm. Atccsscd Fchruary 21 , 2(K)7.
6. Ameri an Phyiioil Therapy Associaiion. Professionalism in
Physical therapy: Core Values. Available ai www.apia.iirg/
AM /Tern pl ai cdm fSeciion=I' ro lixsio na Us m 1 & Templace^^ /
Ta^-dPi i gt / r^t^ed ["ageDisplay,d' m& ITI.I t)=y7fl(;Cx)nte
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6 4 l u l y 2 0 0 7