Why Is This Topic Important?
In my 40 years of practice, I have found that:
- Third party reimbursement policies are sometimes arbitrary
- Our health care system is enormously complex
- Our clients are enormously complex
- Competition for limited health care resources exist
- Facilities where OTs work are generally highly regulated
Third-party reimbursement policies are sometimes arbitrary and cause some distress. I have found that our health care system is enormously complex, sometimes working at odds with each other. Our clients are also enormously complex with multiple needs. There is competition for limited health care resources in any given program. Any facility where OT's work is generally highly regulated so there are a million rules, regulations, or laws. There are also specific policies and procedures for each facility.
- Being culturally competent requires understanding that power differentials exist between practitioner and client
- Inequities exist in America
And because our clients are so culturally diverse, aside from their conditions and everything else, this requires an understanding of the power differentials that can exist between a practitioner and a client. I think we are all aware that there are inequalities that exist in America, and this conversation is very appropriate in these times. Rather than thinking, we are all one big melting pot and a big middle class, inequities exist. I do not think anyone would disagree with that.
- Reasonable people can disagree
- Productivity standards for OTs are high
- OTs are confronted daily with the need for ethical decision-making
Reasonable people can disagree, and that is ok. Additionally, productivity standards are very high for OT's, and often, they are confronted daily with the need for ethical decision-making. This is not something that comes up only when you have a moment. We have to think quickly on our feet.
Skillfully, Speak Up!
According to your style and within the confines of your comfort level, the problems encountered during the day stay with you or they go away. I think some of the worries that stay with us are ethical issues. The basic definition of what is an ethical dilemma is anything that seems to violate one of these six AOTA Code of Ethics principles, or anything that puts these any part of these six principles in conflict with each other, which they frequently do. It could also be anything that causes you moral distress, where you feel like you should do something or say something, but there are going to be consequences. You also may feel that there is just no right answer, but there might be a choice of the least bad answer. Mostly, we feel ethical dilemmas in our heart. There is something wrong, and we (or somebody else) needs to do something. I am advocating that as OT practitioners, we need to step up.
OT Code of Ethics
The OT Code of Ethics guides OT practitioners toward ethical courses of action through adherence to six principles:
- Beneficence
- Nonmaleficence
- Autonomy
- Justice (procedural and social)
- Veracity
- Fidelity
(AOTA, 2015)
The AOTA Code of Ethics' principles are beneficence; nonmaleficence; autonomy, which usually goes with confidentiality; justice, which is procedural justice and social justice, two different types; veracity, or truth-telling; and fidelity, which I think they mentioned at the beginning. I am also an attorney. I like fidelity one as that is the one that says that we place value on building relationships with other people, which not a part of the attorney code of ethics, so I love that about OT. Each one of these codes of ethics has a basic definition. I am certain that each of you is familiar with the basic definitions of each of the code of ethics, but what I wanted to impress on you is that there might be some very surprising requirements in the nuances of each code of ethics, and some of this might surprise you.
Principle 1: Beneficence
Principle one, beneficence, says OT personnel shall demonstrate a concern for the well-being and safety of the recipients of their services. That is easy to understand. When they say OT personnel, they mean OTs and OTAs, or anyone under the OT's supervision, like students. It is also inherent in this principle that we need to demonstrate love, humanity, and altruism towards our clients (Scott & Reitz, 2013). It gives us permission to hold our clients in the highest esteem and to be informal with them. Love is the highest level of affection. Beneficence also requires us to defend the rights of others. It requires us to not use inappropriate or outdated tests, which is part of the big requirement of using evidence-based practice and intervention and updated therapeutic equipment. We are really scientifically driven.
Principle 2: Nonmaleficence
Nonmaleficence is OT personnel shall intentionally refrain from actions that cause harm. The word "shall" in this, and in all legal documents, actually means must. It is not if you are in the mood, maybe, perhaps, you kinda oughta, etc. Shall in these more formal documents mean must. We shall intentionally refrain from actions that cause harm. One of the nuances of this one is the requirement that OTs care for themselves. We take care of everyone else, and sometimes the person that we take care of the least is ourselves. In terms of interacting with our clients, we have to balance the benefits of treatment with the potential risks. We have to ensure continuity of care. We also have to address and report impaired practice, as in drugs and alcohol (Scott & Reitz, 2013).
This one switches the paradigm to pat yourself on the back and remember how much you are doing, and how vital it is to keep yourself healthy and sound.
Principle 3: Autonomy
Autonomy, which normally goes with confidentiality, and again, is that OT personnel shall treat the client according to the client's desires, within the bounds of accepted standards of care, and shall protect the client's confidential information. OTs talk about being client-centered all the time. With HIPAA. we have to keep our client's information confidential. Some nuances in there are that we have to fully disclose risks and benefits of treatment. This seems like such a black and white issue to students, but the truth in the matter is, that when we are working with clients in physical rehabilitation settings or with children with physical issues, we hurt them, we make them move, we make them stretch, and we cause them pain. You always want to be honest about that and fully disclose the risks and benefits of treatment. We also need to respect the client's right to refuse treatment. This is a real slippery slope because OTs are under enormous pressure to be productive and to get a certain amount of minutes of therapy in. We all know that OTs are really skilled at motivating clients and making what we are doing in treatment engaging. It can be a slippery slope when a client says no and really means no, but we continue to cajole.
One of these things in this area is that we have to address language barriers. If I had a nickel for every time I provided occupational therapy services for someone who spoke a different language than me, I would be quite rich. This is really unacceptable. We cannot do it with gestures and grunts and assume people understand what we are saying. We need to work with our local facilities to get adequate translation services there. A language barrier also pertains to patients with aphasia or a decreased understanding of what we are trying to do. We must address language barriers as it is so important to our treatment. And if we are addressing language barriers, we also must address cultural differences, cultural diversity, and cultural traditions. If we are truly client-centered, then we must help the clients be autonomous and make their own decisions, and we have to know a lot of cultural information about the client in order to do so.
Principle 4: Justice
The principle of justice, depending on which document you are looking at, can be listed as two separate principles. Procedural and social justice is that occupational therapy personnel shall promote fairness and objectivity in the provision of occupational therapy services, and respect the applicable law and standards related to their area of practice. This also includes all policies and procedures in our individual facilities, county regulations, and federal regulations related to safety and to third-party reimbursement.
The other piece that has been more recently developed in occupational therapy literature is the concept of social justice. I enjoy helping students see that occupational therapy is really a political practice, and it is certainly what motivated me to go to law school because I was an occupational therapist first. Inherent in both procedural and social justice is advocacy, which is going to be a strong message from me today. We need to advocate for changes to systems and policies that are discriminatory, unfairly limit, or prevent access to occupational therapy services. It is also important to teach self-advocacy skills to our clients. Now, this is a tall order. We must promote fairness and advocate for changes to systems and policies.
If we are talking about systems and policies, we are outside of working one on one with clients, and now we are getting into legislative and candidate advocacy and trying to change systems. I have done a lot of this in my work as an OT, and nothing has given me more satisfaction or success. I hope this inspires you a little bit. The highlights of justice are promoting advocacy, speaking up, being knowledgeable, and broadening our perspective of what occupational therapy is. Many students want to be "master clinicians" or the best clinicians they can. This is wonderful, but we are advocating a paradigm shift as driven by the code of ethics. One participant says that this takes personal backbone. Absolutely, but I am 100% certain that each and every one of you has a strong backbone. A strong backbone does not come from a place of power or from a place of being a know-it-all, it comes from caring. And if there is anything that really pulls OTs together, it is this.
Because I am an attorney, many people say, "You were born with this or you got this in school." That is not true at all. I got my fearlessness and my push for advocacy from being an occupational therapist and really caring about the clients.
Principle 5: Veracity
Veracity is that occupational therapy personnel shall provide comprehensive, accurate, and objective information. This is establishing trust to strengthen professional relationships. Identify and fully disclose to all appropriate persons when there is something that needs to be disclosed, and any errors or adverse events that compromise the safety of service recipients. Veracity is truth-telling. If you have this stance of being truthful, then you never have to worry that you are keeping something from somebody, especially your clients.
Principle 6: Fidelity
The last principle is fidelity. We should treat clients, colleagues, and other professionals with respect, fairness, discretion, and integrity. This means respecting the practices, competencies, roles, and responsibilities of other professionals, and using conflict resolution strategies. This refers to multi-disciplinary teams. If you have a conflict with someone else on your team, that is what is going to keep you up at night. It is generally not the workload, but rather things like this. It is important to address conflict head-on, mending those relationships, and making them better so you have the finest working team in the world. It can be exhausting and takes extra time, but it is worth the investment. A team needs to trust and communicate with each other to be effective. And many times, OTs are the ones that end up doing fun activities with staff like bowling or going to a baseball game. In the practice of law, no one is telling you to be nice to each other so I love this concept. Fidelity is making a commitment to iron out difficulties. We can disagree, and that is fine. We just need to make sure we resolve conflicts.
Spotting Ethical Issues
Now let's look at everyday work. For example, you are going about your business and all of a sudden you feel a little anxious, and you are not even sure why. You go home and the anxiety continues. You think, "It is only Tuesday. I wish it was Friday." If there is one thing that is consistent every day, it is going to be conflicts. Embrace it and try to find the best solutions out of it. In your daily work, you are making observations about systematic constraints, or as I like to call them, perverse incentives. These are things about your facility that help people be more helpless, like the bathrooms in skilled nursing facilities that are not big enough to fit a wheelchair. That is a perverse incentive. I work mostly in mental health in locked psychiatric hospital facilities, but I have worked in skilled nursing facilities. Other examples are narrow corridors and ADL equipment that has to be put away (like toothbrushes) so that people with cognitive impairment are never going to think about it.
There also may be some convicting values between you and your client and between you and the other staff. Again, reasonable people can disagree, however, there can be a lot of questionable behavior. We do not always trust every single coworker. Should you speak up? Often, scenarios, as I described, can accumulate and cause anxiety and burnout.
Ethical Tension/Moral Distress
Moral Distress-arises when one knows the morally right thing to do, but cannot act because of organizational constraints.
Symptoms
It can lead to:
- chronic stress
- “burn out”
- “hardening”
- disengagement
- lack of focus
(Kinsella, Park, Appiagyei, Chang & Chow, 2008)
We are the same person, only there are a few more million lines in our face, and we react a little more quickly or are disengaged. We might be smiling all day, but we are not really as engaged or have a lack a focus. Some examples of scenarios that might cause moral distress are short staffing, unfair policies, and huge caseloads.
Moral Courage
To combat moral tension, you need moral courage.
- Courage to take action for moral reasons despite the risk of adverse consequences.
- Courage is required to take action when one has doubts or fears about the consequences.
- Moral courage is the exemplary modernist form of courage.
- OT leaders who obtain knowledge outside of the clinical domain and broaden their experience to include knowledge of ancillary operations and financial processes can better influence their organizational colleagues for the betterment of patient care.
- OT leaders may ‘level their playing field’ by becoming members of, and fellows in healthcare-related organizations, such as the American College of Healthcare Executives (ACHE.org).
(Kinsella et al., 2008)
