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

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

The Ethical Triangle of the PT, PTA, and Patient Relationship Melanie Heffington, PT, DPT, APTA Education Leadership Institute Fellow Greetings and Salutations But seriously Lets 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 Top 3 Factors for Employee Satisfaction

1.Appreciation for your work 2.Good relationships with colleagues 3.Good work-life balance (Morgan 2014) When we arent 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 When we arent 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 Who do we do we work for? PT returns individuals to their life

roles PT, PTA, and Patient Relationship Matters Pollev Name some famous couples. Pollev instructions

What are characteristics of healthy relationships? What are characteristics of bad relationships? pollev Describe in ONE word, the

relationship with your PT(s)or PTA(s) pollev 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 Perceptions of the PTA continued Skill

% PTAs yes role % PTs MMT

84 67 Determine assistive device/orthotic device 52

10 Determine wc type/features 71 30 yes role

Perceptions of the PTA Skill % PTAs yes role % PTs

Design POC 16 5 Change PT goals/RX

31 8 Select US method/settings 52 32

yes role Perceptions of the PTA Skill % PTAs yes role

% PTs Execute therapeutic exercise 100 98

Respond to acute physiological changes 97 95 Administer gait training

100 99 Measure/adjust canes/crutches 100 97

Administer heat/cold 100 99 Perform therapeutic massage

99 99 yes role 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 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???? 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??? Utilization Overutilization Underutilization

PTAs working outside scope of practice especially in areas of predicting/goal setting/ equipment recommendations Bored PTAs acting and getting paid highly to function essentially as techs Employee satisfaction Patient efficiency of care/budget Animosity

Patient loses benefit of the PT skill level PT and PTA taking risks with everyones licenses Utilization Todays 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 What do we do to maximize relationship to best serve our patients? Medical Ethical Principles

Non maleficence and Beneficence Justice Autonomy or Respect for Persons Ethical principle defined as

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

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

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 hasnt 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? Purtilo 2005 Fidelity What Patients Expect 1.Treat them with respect 2.Competent and capable in your role 3.Adhere to a professional code of ethics 4.Follow the policies and procedures of your organization and

applicable laws 5.Honor agreements APTA Professionalism Core Values Accountability Altruism Compassion/caring Excellence

Integrity Professional Duty 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 ones 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 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? 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)

Duty Based Ethics Theory Duty based ethics focuses on the ACT and NOT the CONSEQUENCE These approaches are heavy on obligations Duty Based Ethics Theory Kant 4 famous examples that assume all living beings : 1. Desire to continue living

2. Desire to develop their talents 3. Desire to NOT have insincere promises made to them 4. Desire necessary help when in severe hardship 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? 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

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.

Pop culture associations Doing good for goodness sake Duty ethics vs. Outcome based ethics Duty based Moral perspective on the action

Outcome based Most benefit to the most individuals action consequence The Golden Rule

Common to most major religions 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 yourselfLove your neighbor as

yourself Christianity Do onto others as you would have done unto you Think back to ideal relationship poll APTA videos on PT/PTA http://www.apta.org/SupervisionTeamwork/SuccessStories/

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) APTA Code of Ethics Vocabulary for intraprofessional argument, self-criticism, and

reform Stimulates a moral self-understanding Collective conscience (Fullinwider 1996) APTA Code of Ethics/Standards Principle 1: Principle 2: Principle 3:

Principle 4: Ethical obligations to all people Duties owed to patients and clients Accountability for making sound professional judgments Integrity in relationships with other people Principles Code of Ethics/Standards continued

Principle 5: Fulfilling legal and professional obligations Principle 6: Lifelong acquisition of knowledge, skills, and abilities Principle 7: Promoting organizational and business practices to benefit patients/society Principle 8: Meeting the health needs of people locally, nationally, or globally Code/Standards

Duties owed to others Patient Integrity in relationships PT PTA

Values Based Behaviors APTA for the PTA Promoting positive working relationship with PT/PTA team Demonstrating respect for roles and contributions of both the PT and PTA in achieving optimal patient outcomes http://www.apta.org/PTPTATeamToolkit/ Benefits of the PT/PTA Team Extending the reach of the PT to improve access to physical therapy care

Consistency of care where patients can expect to see at least one of their PT team at each visit Opportunities for collaborative care that may result in increased efficiency and effectiveness Cost conscious care where both providers are able to work at the top of their license http://www.apta.org/SupervisionTeamwork/SuccessStories/ Dolly and Kenny Dolly is a PT in a SNF and works with a PTA named Kenny. In their facility, the PT evaluates and delegates select interventions to the PTA. Dolly the PT is only immediately on site available to

Kenny the PTA 3 days/week. The remaining 2 days a week Dolly and Kenny must rely on telecommunications to effectively manage their shared patients. Establishment of formal communication processes have been key in ensuring quality patient care. Dolly and Kenny meet for 15 minutes every day (either in person or by phone) to discuss progress and any needed revisions to POC or new patients. Once weekly, Dolly and Kenny meet for 30 minutes over lunch to formally and thoroughly manage shared documentation and participate in ongoing training and education. What does Dolly the PT consider?

Are the interventions within the scope of the PTA? Is the patients condition sufficiently stable? Are the intervention outcomes sufficiently predictable? Is the intervention within the PTAs personal knowledge, skills, and abilities? Are there risks and liabilities that should be considered prior to delegation? Would any payer requirements be affected by a PTA in the POC? APTA Algorithm for Direction and Supervision of the PTA What Does Kenny need to consider?

Does he have questions about the initial eval that need clarification? What data should he collect first and every visit that he can compare to initial eval? Does he have the personal skills, knowledge to perform the delegated interventions? Is patient safe/comfortable with interventions? If not can he modify? Does the patient data he collects (ROM, gait etc.) support progress towards goals? When must he stop RX and communicate with Dolly? APTA Problem Solving Algorithm Utilized by PTAs in Patient Interventions

State Practice Act This is law, not a suggestion. Skills, Re-evaluations, Supervision PTA Limits of Practice OK Practice Act (1) Specify, other than to the Physical Therapist of Record, perform or interpret

definitive (decisive, conclusive, final) evaluative and assessment procedures. Definitive evaluation procedures may not be recommended to anyone other than the patient's physical therapist, unless previously approved by the physical therapist. (2) Alter overall treatment, goals and/or plan. PTA Limits of Practice OK Practice Act (3) Recommend adaptive equipment, assistive devices, or alterations

to architectural barriers to persons other than a physical therapist. (4) File discharge documents for permanent record until approved by a physical therapist. (5) Perform duties or tasks for which he/she is not trained. http://www.okmedicalboard.org/physical_therapists/download/456/PTRULES.pdf PT and PTA Reevaluations OK Practice Act This will be performed no less frequently than:

(A) every 30 days in acute care, outpatient, inpatient rehabilitation and long term care settings with documented case consultation no less frequently than every 15 days; (B) every 60 days in home health settings with documented case consultation no less frequently than every 30 days; (C) every 90 days in consultative DDSD with documented case consultation no less frequently than every 45 days; Reevaluations NO less frequently

than: (D) very 10th visit for DDSD for patients under 21 years of age with documented case consultation no less frequently than every 5th visit; (E) every 60 days in educational settings with documented case consultation no less frequently than every 30 days; http://www.okmedicalboard.org/physical_therapists/download/456/PT RULES.pdf

Standards for Entry Level PTAs CAPTE PTA Educational Institutional Standards and Required Elements http://www.capteonline.org/AccreditationHandbook/ PT-PTA Team: A Tool Kit , Sept. 2014 page 40 http://www.apta.org/PTPTATeamToolkit/ Both places Information on how PTAs should be able to review POC Which interventions they should be competent in at entry level

What appropriate modifications to a RX plan within a RX plan a PTA can do i.e. use a wedge under a patient with reflux who needs supine ther. ex. Communication, Delegation, Respect Many ethical dilemmas in the PT/PTA/Patient can be categorized as issues with Communication Delegation

Respect Communication: Bruno and Adele Adele is tired of working with Bruno and it has only been 2 months. Bruno is a weak PTA in her view. His patients never seem to progress to meet the goals she sets when he is their PTA. Adele leaves notes for Bruno suggesting exercises that would progress her patients, but it seems Bruno ignores them or doesnt know how to do them. Adele doesnt feel like raising a new PTA anymore. Her

outpatient clinic has had quite a bit of turnover in PTAs and it seems to always be left to Adele to train them. Adele resolves to stop passing patients to Bruno and makes excuses to her manager everytime it is suggested Adele pass a patient. Bruno and Adele Passive aggressive Creating underlying hostility Does Adele have a responsibility to Bruno? Does Bruno have a responsibility to Adele?

What about the patient? Communication Ineffective communication Indirect, too much, too little, not specific, not timely No follow up Conflict avoidant No formal routes in processes/policies of facility Incomplete documentation

Communication: Kathy Lee and Hoda Kathy Lee has called Hoda 4 times since her last visit with Mr. Lauer and still no answer. Mr. Lauers BP dropped last visit to 100/60 when he stood and Kathy Lee is unsure whether to continue RX cautiously or insist on Mr. Lauer returning to his PCP since the new addition of a beta blocker for HTN. Kathy is due at Mr. Lauers house this morning. She resolves to do bed exercises and put in another call if his BP is low again and just document.

Communication No communication Delaying effective execution of POC Creates apathy Team splitting What are Kathy and Hodas responsibilities to each other? What are their responsibilities to Mr. Lauer?

Communication: Freddy and Jason Freddy sees Jason the PT of record on Ms. Sybill down the hall at their CIRE facility. Freddy has asked for new goals for the past 3 days and Jason still hasnt written them. Freddy has had it and charges towards Jason. Freddy: I REFUSE to see this patient until you write me new goals! You do this to me every time and I am sick of waiting for you to do your job! You are a lousy PT! Jason: Well I think you are a lousy PTA and what do you know anyway? I am balancing twice as many patients as you and there are only so many hours in the day! Get off my back!

Communication Disrespectful communication Creates hostility and resentment Personal not professional Often times is a product of ineffective or no communication Workplace? Patients? Manager? Cost of coaching/counseling/rehiring?

Communication Relate directly to APTA Code of Ethics/Standards Principle 2 Duties owed to patients Principle 4 Integrity in Relationships with other people Communication Practice Act lays out expectations of reevaluations and limitations of licenses Facility communication standards should be derived from Quality handoff communication is imperative

Patient has right to expect clinicians follow the Practice Act in a way that maximizes their RX Communication Study in Canada (Jelley, Larocque, and Borghese 2013) demonstrated PTs and PTAs as a group identify as high competency elements Demonstrates active listening, using verbal and nonverbal Expresses ideas and viewpoints in a respectful, confident, and concise manner

Shares and exchanges information effectively Delegation: Woodward and Bernstein Woodward, PT just completed an initial eval of a patient in an outpatient setting with schizophrenia (on meds), hepatitis C due to former IV drug use, referred for LBP. To say the patient was odd was putting it mildly. The patient was also unclean with strong smells of body odor and urine. While walking the patient out, Woodward tells

the receptionist please schedule this patient with Bernstein our PTA. Delegation: Russell and Andre Russell is a PT working in HH. He just finished an eval in a roach infested home of a patient who will need at least 2 weeks of PT s/p left tibia fx for gait training with device NWB. Russell calls his agency and says please schedule all the f/u with this patient with Andre our PTA.

Delegation: Vivian and Edward Vivian sighs as she transfers her new pt. back into her wc. Vivian is a PT working in a CIRE and she has just finished her last eval session of a patient who is max assist for transfers, wc propulsion and the biggest pusher/worst left hemi Vivian has seen for awhile. Vivian is t.i.r.e.d of lifting patients. She goes to Edwards (the PTA) schedule and begins to arrange for Edward to take over daily RXs. Delegation

How often do PTs delegate based off of emotions/work fatigue? How would you feel if your entire day was filled with schizophrenics, total assist pushers, and roach infested homes? What is our duty to demonstrate fidelity to the PTA? The APTA PTA Direction and Supervision Algorithm (Delegation to the PTA) Key components include: stable condition, interventions within scope of practice, outcomes predictable, payer requirements Delegation

No or limited intent to f/u with PTA or patient regarding progress other than in formality We cannot delegate away our responsibilities as PTs to progress patients/reevaluate Duty to patient and duty to PTA Delegation Every time we share a patient- we lose a bit of our own autonomy

Autonomy drives us and teamwork requires us to share/collaborate/yield Recognizing strengths/weaknesses can help ward off the dilemmas Respect: Respect your elders Respect must be earned Respect yourself

RESPECT Respect for Autonomy Personal autonomy Cultural differences Gender differences

Religious differences Introvert/Extrovert/Mixed Generational differences Generational differences Todays workplace is comprised of Baby Boomers, Gen X, and Gen Y (Millennials) Creates challenges as each of these generations were shaped by different forces Assist each other, appreciate each other, collaborate with each other

Generational differences Baby Boomers Gen X Gen Y Work Ethic Workaholics Work efficiently

Desire quality Self reliant Want structure Skeptical Multitasking Tolerant Whats next

Work Is Motivated by Exciting adventure A contract Means to an end

You are valued Do it your way Working with creative others Respect: Different roles

Different roles Same goal: Patients Communication dilemmas First- lets try to avoid them by increasing our communication skills What tools?

Tools for increasing communication Perfecting the Hand-Off Definition: transition of patient care from one health care provider to another Often reliant on interpersonal communication skills In physicians, it is a leading cause of preventable errors

Perfecting the Hand-Off Clinical environments are dynamic and complex with many challenges to effective communication NSG/physicians fouled up hand-off result in med errors, deaths, wrong site surgery, patient safety PT fouled up hand-offs result in precautions/contraindications blown, ineffective RX Perfecting the Hand-Off

How many patients are you handing off in a work week? In a shift? If you work prn, could the argument be all of them? How much effort is going into the hand-off? Do we assume the chart speaks for itself? Perfecting the Hand-Off Common issues with handoffs in NSG (consider some units transfer 40 -70% of their patients daily) Incomplete information

Inaccurate information Communication issues Perfecting the Hand-Off JCAHO has required formal standardized processes for hand-offs Meta analysis in 2016 found that across provider type, regardless of clinical focusstandardized hand-off protocols improved patient, provider, and organizational outcomes

(Keebler et al 2016) Perfecting the Hand-off Practicing teamwork has positive effects on workplace culture and clinicians, beneficial for all clinicians Recommend specifically: Training in specific teamwork education on how effective teams function These events have an opportunity for constructive debriefing Scenarios and simulation are effective in training team work/communication

(Eddy et al 2016 ) Communication: IPASS Illness severity: one word complicated, typical, healthy Patient summary: DX, RX plan Action list: things the receiver needs to do Situation awareness/contingency list: if this happens, then

Synthesis by receiver: opportunity to ask questions and synthesize info IPASS IPASS study demonstrated a 23% reduction in preventable errors in 9 pediatric residency programs Standardized hand-off training and full engagement of clinicians (Starmer et al 2012)

Communication: IPASS Uncomplicated 72 y/o female with Right THA 1 week post op, PMH of HTN, hypothyroidism Action needed: advance gait distance to community as tolerated ASAP

If she meets that goal, lets talk about transition to outpatient, If she doesnt by visit 3 call me So what approach is her THA? How is she with her TH precautions? What do we tell the patient? Another take on the Hand-Off What do we tell patients when we hand them off? Should reassure the patient they will be taken care of

Increase the level of trust with the whole team Make your patient feel understood Set the stage for compliance and comfortable RX Who What Where Why: The Patient Who: Jerry (patient), this is my assistant Tom. What: Tom is a part of our PT team and we work closely together on patient care.

Where: For the next few weeks, visits, minutes Tom will be working with you on the goals you and I set today. Specifically, your goal of picking up your grandson pain free (patient feels understood, some restatement of personal goal) Why: Be honest. Much of my job here at the clinic is to assess and reassess. I only work weekends, I will be on vacation. We share patients, so you get two brains for the price of one Tools for increasing communication

Situation Background Assessment Recommendation Communication: SBAR Situation: brief clear definition of the situation Background: relevant background info such as age, dx, referring doc

Assessment: your professional conclusion Recommendation: please tell me your recommendation, what to do SBAR Shown to increase self-confidence and attitudes with interprofessional collaboration (Kostoff 2016)

Shown to increase quality of communication and patient safety (Velgi 2008) Communication: SBAR Situation: Hermione fell out of bed last night and is complaining of right knee pain Background: She is our 68 y/o patient of Dr. Potter who is s/p left TKA Assessment: I think it is only bruised, but I cannot be sure

Recommendation: I need you to tell me Ron if it is okay for me to proceed with our regular RX plan Communication and Fidelity Communication is key to trusting relationships Think back to Poll Ethical duty to enter into Kants assumptions of humans Kants Assumptions

1. Desire to continue living 2. Desire to develop their talents 3. Desire to NOT have insincere promises made to them 4. Desire necessary help when in severe hardship Communication: Personality Who reads their email? Who prefers direct in person communication? What about phone calls?

What about written notes? Shouldnt the chart do this anyway?!?! Communication by Generations Baby boomers: tend to prefer face to face or phone calls, less likely to like communication after business hours Gen X: tend to be tied to their phones, feel as if they must be in touch at all times, dislike meetings, do not tend to mind after hours contact Gen Y: tend also to be tied to their phones, prefer working in groups,

even less concerned about after hours contact(Morris 2013) Communication dilemmas Reflective listening Self-Assessment Accept the role of teacher, mentor, collaborator Assertive communication Assertive Communication

Assertive Communication Assertive Communication WHEN you dont finish the evaluations in the EMR I FEEL uncomfortable BECAUSE Im not getting the full picture of the patient with an unwritten evaluation. I learn a lot from reading your evals. The State Practice Act and best practice standards would direct me towards not

initiating my RX without a full and complete evaluation. WHAT I NEED FROM YOU is to complete the written eval with goals and an outlined POC so I can best serve this patient. Is there another patient I can see for you so you can get caught up on your documentation? Delegation Dilemmas Avoid by using APTA Algorithm for Direction and Supervision Avoid by using APTA PTA Supervision Algorithm

Avoid by knowing State Practice Act Avoid by knowing Entry Level Expectations of PTA Delegation dilemma other strategies

Review charts together RX patient together CEUs together Sit in on part of initial eval Match personalities with patient personalities Develop complementary skill sets- PT develops vertigo assessment skills, PTA develops balance ther. ex. skills

Respect Dilemmas Avoid by accepting we all desire our own autonomy Avoid by developing appreciation for differences Avoid by understanding our different roles Avoid by Golden Rule, duty, fidelity Case Study: Julia, Richard, and Mr. Lovett

Julia is a 10 year veteran PTA working in an acute care setting with Richard a PT with the same experience. Julia has been working with their shared patient Mr. Lovett for 3 days and needs new goals as Mr. Lovett has achieved the last ones set at min assist. At lunch, Julia tells Richard this and Richard says just write down in the chart that I said new goals set for independent with extra time and he runs off to see his afternoon patients. Julia feels uneasy with this, but says nothing. She trusts Richard, but feels this is asking her to step outside of her scope of practice.

Julia, Richard, Mr. Lovett Which issue is causing Julia distress? Communication, delegation, respect? What supporting documents could assist Julia in decision making and justification for talking with Richard? Direction and Supervision Algorithm, Delegation Algorithm, State Practice Act etc. What strategies could she use to address with Richard? Reflective listening, IPASS, SBAR, Golden Rule, assertive communication, self-reflection Justin, Brittany, Taylor

Justin is a 21 y/o patient s/p MVA with multiple fractures and NWB right LE and left LE . He confides in Brittany, his PTA in CIRE that he was using meth while driving his car. He hasnt talked to anyone about his drug use including Taylor the evaluating PT. Brittany knows a tox screen was run at admit and revealed + for amphetamines. She doesnt know if his family knows. Must Brittany discuss this revelation with Taylor? What are Brittanys choices? Who should she talk to? Are there issues with communication, delegation, respect? What are the outcomes of Brittanys decisions on the patient? Does duty or outcome based ethics inform a better decision?

Peter and Gladys, Paul or Mary Peter has just evaluated two patients: Paul and Mary. Paul is a delightfully interesting WWII Vet s/p right BKA. Mary is a HOH, low pain tolerance individual s/ p right BKA. It is Peters turn to pass Gladys the PTA in their SNF a patient. Which patient should he pass and why? What ethical principle could assist him in making the decision? Kit, Sage, Josefina

Kit writes in a POC for a patient sharp debridement as indicated. Although Sage, PTA realizes the State Practice allows a PTA with training to perform this skill, Sage does not feel competent to address this on a patient. Josefina, PTA has spent several years studying with Kit and does feel competent in limited sharp debridement. Which elements of the PT/PTA relationship (communication, delegation, respect) weigh the most here on patient care? How can Sage best address the POC given the resources outlined in the scenario? What documents support her position?

Beyonc, Kelly, Michelle Beyonc, PTA wears a head wrap covering her hair daily to work in her outpatient clinic as a part of her religious tradition. Kelly, PT resents this as it seems to be out of line for typical PT dress code and as a result never passes patients to Beyonc. Michelle, PT doesnt have issue with Beyonc's dress, but several patients have complained to Michelle about Beyonc's dress being off putting. What strategies could be employed by Beyonc, Kelly, and Michelle to address these issues? Which element of the PT/PTA relationship (communication, delegation, respect) is in play here? What are the possible effects if this issue is not addressed?

Gracie, Lily, and Lola Lily PTA has called and left a message for Gracie PT. AGAIN. This is the third call this morning and it is only 10 am. At first Gracie recognized that Lily would need some extra supervision and guidance as a transfer to HH setting. However, it is now the 6th month and Lily still calls about every.little.thing. And a phone call from Lily is never a direct question- it is more a complaint session about patients. Gracie fires off a text to Lily giving general directions addressing Lilys message and goes to her next house to reeval Lola. Gracie finds little progress towards the goals she set 60 days ago. Gracie knows if she would have kept Lola, this patient would have been

discharged. Gracie, Lily, Lola What elements of the PT/PTA relationship are in play here? Communication, respect, delegation? What strategies or document could assist Gracie? Could assist Lily? How does Lola fair as a result? References

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Robinson, A. J., DePalma, M. T. & McCall, M. (1995). Physical therapist assistants perceptions of the documented roles of the physical therapist assistant. Physical Therapy, 75, 22-32. Robinson, A.J., McCall, M., DePalma, M.T., Clayton-Krasinski, D., Tingley, S., Simoncelli, S., & Harnish, L. (1994). Physical therapists perceptions of the roles of the physical therapist assistant. Physical Therapy, 74, 571-582. References Starmer, A., Spector, N. D., Srivastava, R., Allen, A. D., Landrigan, C.P., & Sectish, T. C. (2012). I-pass, a mnemonic to standardize verbal handoffs. Pediatrics, 129, 2.

Starr, P. (1982). The social transformation of american medicine. Basic Books. Swisher, L. L. & Hiller P. (2010). The revised apta code of ethics for the physical therapist and standards of ethical conduct for the physical therapist assistant: theory, purpose, process, and significance. Physical Therapy, 90, 803-824. Velji, K., Baker, G. R., Fancott, C., Andreoli, A., Boaro, N., Tardif, G., Aimone, E., & Sinclair, L. (2008). Effectiveness of an adapted sbar communication tool for a rehabilitation setting. Healthcare Quarterly, 11, 72-79. Online document links http://www.apta.org/PTinMotion/2010/9/PTADirectionAlgorithmChart/ http://www.apta.org/PTinMotion/2010/9/PTASupervisionAlgorithmChart/

http://www.okmedicalboard.org/physical_therapists#laws-rules http://www.apta.org/PTPTATeamToolkit/ http://www.capteonline.org/AccreditationHandbook/ http://www.apta.org/SupervisionTeamwork/SuccessStories/ Online document links http://www.nsinursingsolutions.com/Files/assets/library/retention-insti tute/NationalHealthcareRNRetentionReport2016.pdf

http://www.apta.org/uploadedfiles/aptaorg/about_us/policies/hod/et hics/codeofethics.pdf http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/ Ethics/Standards.pdf

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