by Nancy R Kirscb, PI DPI PhD

Improper Conduct: Case ThreeAn issue of hands-on mentoring.

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 PTs 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 TherapyAfter 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 page—consult 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 start—impressed 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 expertise—the

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 room—so 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

him—rather 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 short—or 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 (relationshipbetween individuals)

Organizational/Institutional (good of theorganization)

Societal (common good)

RIPS Model

Individual Process

Moral Sensitivity(recognize situation)

Moral Judgment(right or wrong)

Moral Motivation(moral values aboveother values)

Moral Courage(implement action)

Ethical Situation

Issue or Problem (valuesare challenged)

Dilemma (right vs rightdecision)

Distress (right courseof action blocked bya barrier)

Temptation (right vs wrongsituation)

Silence (values arechallenged but no oneis addressing it)

62

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 theEthical IssueAsk yourself:• Into which realm or realms does this

situation fall; individual, organiza-tional/institutional, or societal?

•:• What does the situation require ofSally? Which individual process ismost 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 positionin which he has placed Sally? Areany 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 toSally taking action?

Step 2: ReflectAsk yourself:•:• What is known about Paul, his past

behavior, and staff perceptions of hisbehavior?

•:' What does Sally know about her rightsin the workplace iind her options forconfidential discussion of die situation?

•:• Who are the major stakeholders? Inaddition to Sally, her patients, andPaul, who or what else may be affectedby this situation?

•> What are the potential consequences ofSally's action or inaction on her, Paul,patients, and stall?

•:• Might her aaion or inaaion break anylaws?

• What ethical principle or principlesmay be involved? Do any of the fol-lowing resources provide professionalguidance: the APTA Code of Ethics,the APTA Guide for ProfessionalConduct,'' and/or Professionalism inPhysical Therapy: Core Values?*' Forexample, do you see a relationshipbetween this case and principles 2and 4 of the APTA Code of Ethics?Which principles, if any, strike youas being applicable to Sally? To Paul?To anyone on staff who is aware ofwhat's going on?

Finally, consider how this scenariostacks up against the tests posed byRushworth Kidder in How Good PeopleMake Tough Choices^: legal, stench. Irontpage, parents, and professional ethicalviolation. In other words: Is somethingillegal going on? Does the situation feelwrong? Would the hospital's reputationsuffer were all the details to becomepublic? What might parents do if faced

APTA Code of Ethics (HOD 06-00-12-23)

PreambleThis 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 1A physical therapist shall respect the righfe

and dignity of all individuals and shall

provide compassionate care.

Principle 2A physical therapist shall act in a trustwor-

thy manner towards patients/clients, and

in all other aspects of physical therapy

practice.

Principle 3A physical therapist shall comply with

laws and regulations governing physical

therapy and shall strive to effect changes

that benefit patients/clients.

Principle 4A physical therapist shall exercise sound

professional judgment.

Principle 5A physical therapist shall achieve and

maintain professional competence.

Principle 6A physical therapist shall maintain and

promote high standards for physical ther-

apy practice, education and research.

Principle 7A physical therapist shall seek anIy such

remuneration as is deserved and reason-

able for physical therapy services.

Principle 8A 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 9A physical therapist shall protect the

public and the profession from unethical,

incompetent, and illegal acts.

Principle 10A physical therapist shall endeavor to

address the health needs of society.

Principle 11A physical therapist shall respect

the rights, knowledge, and skills of

colleagues and other heolth care

professionals.

63

with a similar circumstance involvingtheir child? Can any ethical violations bedetected within the APTA resotirces listedpreviously?

Step 3: Decide the Right Thing to DoIf the scenario fails any of the tests

described in the previous step, this stepis superfluous. In that case, action mustbe taken; The quesdons become whatkind of action, and has Sally the moralcourage to implement it? Also, what isthe potential for collateral damage basedon her action or inaction? How mightSallys inaction affect patients? What arepatients" rights regarding the effects ontheir care of PTs' personal issues?

If you believe the scenario passes eachof Kidder's tests, then its time to look atthe three possihie approaches he presents

for determining the right thing to do, andalso to look at whether any barriers loomto 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 youwotild 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 theclinic, its PTs, and/or current and fiiturepatients?

Step 4: Implement, Evaluate, ReassessHaving determined in your own mind

the right thing to do and the best way to

implement that decision, reflect on thecourse of action youVe chosen for Sallyand think about whether a change in tJiedepartment's policies or culture mightprevent the scenario from recurring.

Let's TalkThis column arc will conclude in

September with an analysis of all threescenarios related co improper conduct.In the meantime, please let me hear fromyou! (Note my e-mail address below.)Tell me what your thoughts about thesecases—your resolutions and how youarrived at them. And please share yourinsights with other PTs and PTAs, as well.Use Ethics in Action as a teaching tool, asmany of your colleagues across the coun-try are doing. %

Nancy ft Kksdi, PT, DPT, PhD,Judicial Committee, is an associate professor of physical therapy inthe Univefsity of Medicine and fknttstry's ST/KW/ of Health RebtedProfessions in Herntk. Hew jersey, and owner af Noithem HillsPhysical Jhewpy issodates in Fhnders, fiew jmey. She can becontaclBd at kifschno@imlnj.e(iu.

References1. KirschNR. Improper condua: OLV one. PT—M^azine of

Physical Vxmpy. 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 ditisionmaking. HPA RtuiuTce. 20O');')(3):1.3-a.

•1, Kirsch NR. Ethical ciecision making: lerminiitogj'andcon-icxi. PT—Magaanf of Phyacal Thmpf 2nO6;I4(2):38-40.

5. American Phy^cal Therapy Associaiion. APTA Guide forProtessional Cniidua. Available at www.apta.org/AM/Tcroplatc.ctm?Sec(ion=E[hics_and_LcgnLissues I & C O NrENTIL>=2478]&TEMPLArE-/CM/ContcntDispky.

ctm. Atccsscd Fchruary 21, 2(K)7.

6. Amerian Phyiioil Therapy Associaiion. Professionalism inPhysical therapy: Core Values. Available ai www.apia.iirg/AM /Tern plaicdm fSeciion=I'ro lixsio na Us m 1 & Templace^^ /Ta^-dPiigt/ r^t^ed ["ageDisplay,d'm& ITI.I t)=y7fl(;Cx)ntentlD=212t'..i. Attcsscd f-ebriury 21, 2007.

7. Kidder RM. Hnu; Good Pmplr Make Tnufi) Owka:Resolving liie Dihtmun of Eihicd Uvtng. New York, NY:Hnsitte. 1995,

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