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QI‘MW" ‘ . , .ch$ > . .f'f.m>.coul .231... 1|...i..|:?. .r...~.... lllllllllllllllllllllllllllllllllllIIIIHIIUllllllllllllll 300794 9807 This is to certify that the dissertation entitled The Identification of Ethical Issues in Physical Therapy and Procedures for Incorporating Instruction in Ethics into Physical Therapy Education presented by Herman Lee Triezenberg has been accepted towards fulfillment of the requirements for PhID. EOAOD. degree in /f/ Major professor Datfllialfit MS U is an Affirmative Action/ Equal Opportunity Institution 0. 12771 —'——— Michigan State l University » A *— *‘W PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINES return on or before date due. DATE DUE DATE DUE DATE DUE ‘ ‘ _ AN 0 4 1991 U j i ——l .L___ __IL__J V— MSU Is An Affirmative Action/Equal Opportunity Inetltutlon emails-9.1 I; {THE IDENTIFICATION OF ETHICAL ISSUES IN PHYSICAL THERAPY AND PROCEDURES FOR INCORPORATING INSTRUCTION IN ETHICS INTO PHYSICAL THERAPY EDUCATION by Herman Lee Triezenberg A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Educational Administration 1992 ABSTRACT THE IDENTIFICATION OF ETHICAL ISSUES IN PHYSICAL THERAPY AND PROCEDURES FOR INCORPORATING INSTRUCTION IN ETHICS INTO PHYSICAL THERAPY EDUCATION By Herman Lee Triezenberg A Delphi Study was conducted to identify ethical issues in physical therapy and to investigate methods for inclusion of instruction in ethics into educational curricula for physical therapists. The panel of experts was identified from the results of a questionnaire sent to past and present members of the Judicial Committee of the American Physical Therapy Association. The Delphi study consisted of a series of three questionnaires which were sent to the members of the panel. The first questionnaire contained broad questions designed to elicit a wide range of responses. The second and third questionnaires were developed from the information contained in the results of the preceding questionnaire. Each round of the Study built on the previous round and was designed to clarify the issues and identify consensus views. The Delphi method as applied in this study was used to obtain a consensus among the panel on a) current ethical issues facing physical therapists, b) ethical issues which will be faced by physical therapists in the future, 0) practice issues which have ethical implications, and d) methods for incorporating professional ethics into physical therapy education. The results of the study were discussed as they applied to each of the four The first research question concerned current ethical issues facing physical therapy. The results of the study identified 10 current ethical issues as consensus choices by the panel and three issues as near-consensus (one dissenting panel member). The results of the second question concerning future ethical issues facing physical therapists identified four consensus issues and no near-consensus issues. The results obtained in the research question concerning practice issues identified eight consensus practice issues and five near consensus issues. These practice issues were scored on a Likert scale as to their ethical importance and an average score was computed. The 13 practice issues were ranked in order of importance based on their average Likert score. The results obtained in the third research question concerning education methods identified: a) 10 topics to be included in ethical instruction for physical therapists, b) nine methods of instruction, c) four formal qualifications of an instructor, (1) 10 personal characteristics of an instructor, and c) three considerations for the time frame of instruction. Recommendations include: a) further study on the Specific ethical issues identified in the study, b) additional study of the practice issues to further define the ethical questions associated with practice issues, c) an examination of the effects of various methods of instruction on the moral development of physical therapy students and d) study of the process by which physical therapists should make ethical decisions in the clinical setting. Copyright by HERMAN LEE TRIEZPNBERG 1992 Dedicated to: My wife, Elizabeth, who stimulated my thoughts, nourished my spirit and gave mcaning to my work. My son, Seth, who challenged me to consider what is important to our lives. My son, Eric, who inspired me with his joy and imagination. My friend, Sue, who liberally gave advice, encouragement, and order whenever it was needed. ACKNOWLEDGEMENTS In sincere appreciation fOr their contribution to this project, I wish to acknowledge the following individuals: Dr. Eldon Nonnamaker, Chair of my doctoral committee, for his guidance and suggestions throughout this study. Dr. Tom Tomlinson, for sharing his thoughts and assisting me in all stages of this project. Dr. Louis Heckhuis and Dr. Marvin Grandstaff, for serving on my committee and providing advice on this study. ii LIST OF TABLES LIST OF APPENDICES Chapter I II III TABLE OF CONTENTS INTRODUCTION . . . . . . D100!!!» STATEMENT OF THE PROBLEM PURPOSE OF THE STUDY . . NEED FOR THE STUDY . . . METHODOLOGY . . . . . LIMITATIONS OF THE STUDY LITERATURE REVIEW . . . . . A. ETHICS IN PHYSICAL THERAPY B. ETHICS IN NURSING AND MEDICINE C. THE DELPHI TECHNIQUE . . METHODOLOGY . . . . A. THE DELPHI TECHNIQUE . B. THE DELPHI PANEL OF EXPERTS C. THE DELPHI INSTRUMENT . l. 2. GENERAL DESCRIPTION QUESTIONNAIRE A . . a. DESIGN . . . b. DATA COLLECTION QUESTIONNAIRE B . . a. DESIGN . . . b. DATA COLLECTION QUESTIONNAIRE C . a. DESIGN . . b. DATA COLLECTION D. METHOD OF ANALYSIS . . . iii Page vii xi Chapter IV RESULTS A. GENERAL RESULTS. . . . . . 1. 2. 3. 4. 5. PARTICIPATION OF PANEL OF EXPERTS COMPLETION RATE TIME FRAME OF STUDY THREE ROUND DELPHI DESIGN DIVISION OF STUDY INTO FOUR TOPIC AREAS a. CURRENT ETHICAL ISSUES b. FUTURE ETHICAL ISSUES c. PRACTICE ISSUES d. EDUCATIONAL ISSUES CURRENT ETHICAL ISSUES . . 1. 2. 3. 4. 5. 6. GENERAL DEFINITIONS QUESTIONNAIRE A, QUESTION 1 QUESTIONNAIRE B, QUESTION 1 QUESTIONNAIRE C, QUESTION 1 FINAL LIST OF CURRENT ETHICAL ISSUES ANALYSIS OF RESULTS FUTURE ETHICAL ISSUES . . GENERAL DEFINITION AND DESCRIPTION QUESTIONNAIRE A, QUESTION 2 QUESTIONNAIRE B, QUESTION 2 iv Page 63 63 66 88 Chapter 4. 5. 6. Page QUESTIONNAIRE C, QUESTION 2 FINAL LIST OF FUTURE ETHICAL ISSUES ANALYSIS OF RESULTS PRACTICE ISSUES . . . . . . 94 7. GENERAL DEFINITION AND DESCRIPTION QUESTIONNAIRE A, QUESTIONS 3 AND 4 QUESTIONNAIRE B, QUESTIONS 3 AND 4 QUESTIONNAIRE C, QUESTION 3 FINAL COMPILATION OF PRACTICE ISSUES RANK ORDERING OF PRACTICE ISSUES ANALYSIS OF RESULTS EDUCATIONAL ISSUES . . . . . 114 GENERAL DEFINITION AND DESCRIPTION QUESTIONNAIRE A, QUESTION 5 QUESTIONNAIRE B, QUESTION 5 RANK ORDER OF: a. TOPICS b. METHODS C. CHARACTERISTICS OF INSTRUCTOR ANALYSIS OF RESULTS Chapter Page V SUMMARY................129 A" GOALS OF THE STUDY . . . . . . . 130 B. REFLECTIONS ON IMPORTANCE OF STUDY . . . . . . . . . . 150 CL RECOMMENDATIONS AND CONCLUSIONS . . 152 BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . 241 vi LI 8T OF TABLES Table 4.1 Listing of original issues from Questionnaire A, Question 1. . . . . . . . . . 70 Table 4.2 Results of Questionnaire B, Question 1, Panel Analysis of the Twenty-Three Ethical Issues 0 O O O O O O O O O O O O O O O O O O O 7 4 Table 4.3 Results of Questionnaire C, Questions 1b, c, d, Panel Analysis of All Non-Consensus Ethical issues. . . . . . . . . . . . . . . . 78 Table 4.4 Ethical Issues Identified by panel Of experts on Questionnaire C, Question 1. . . . 79 Table 4.5 List of Ethical Issues Facing Physical Therapy. . . . . . . . . . . . . . . . . . . . 87 Table 4.6 Distribution of 15 Ethical Issues within Five Categories of Issues. . . . . . . . . . . 90 Table 4.7 Distribution of 15 Current Ethical Issues between Classifications of Issues with Legal Considerations and Issues which are Primarily Ethical Questions. . . . . . . . . . 91 Table 4.8 List of Future Ethical Issues Identified by Panel Members in Questionnaire A, Question 2. O O O O O O O O O O O O O O O C O O O O O O 92 Table 4.9 Results of Questionnaire B, Question 2 on Panel Acceptance Of Future Ethical Issues 0 O O O O O O O O O O O O O O O O O O O 9 3 Table 4.10 Results of Questionnaire C, Question 2 on Panel Acceptance of the Future Ethical Issues Identified. O O O O O O O O O O O O O O O O O O O O 94 Table 4 . 11 Consensus Future Ethical Issues as Identified by Panel in Questionnaire C, Question 2 O O O O O O O O O O O O O O O O O O 95 Table 4.12 Original list of Current Practice Issues which have Ethical Considerations from Questionnaire A, Question 3 . . . . . . . . . 99 Table 4.13 Agreement of Panel Members on Items in the Original List Of Current Practice Issues. Results of Questionnaire B, Question 3. . . . 101 Table 4.14‘Original List of Future Practice Issues Identified by Panel Members in Questionnaire A, Question 4. . . . . . . . . . . . . . . . . 102 Table 4.15 Agreement of Panel Members on Items in the Original List of Future Practice Issues. Results of Questionnaire B, Question 4. . . . 104 Table 4.16 List of Consensus Current and Future Practice Issues from Questionnaire B, Questions 3 and 4.1 . . . . . . . . . . . . . 105 Table 4.17 List of Practice Issues with Ethical Considerations for use in Questionnaire C. . . 107 Table 4.18 Average Score of Importance of Practice Issues on a Five Point Likert Scale by Panel Members...................109 Table 4.19 List of Ethical issues Associated with Specific Practice Issues. Results of Questionnaire C, Question 3b. . . . . . . . . 110 Table 4.20 Rank order Of the Importance Of Listed Ethical. Consideration based on a Likert Scale of 0-5 with 5 Urgent Practice Issues for and 0 being Unimportant. Questionnaire C, Question 3. Results of Table 4.21 Listing of Practice issues in Order of Importance. . Table 4.22 List of Topics in Ethical Instruction for Physical Therapists Identified by Panel. Results of Questionnaire A, Question 5a. Table 4 . 23 Table 4.24 List of Methods Of Instruction. Table 4.25 General Statement of Time Frames for Ethical Instruction from Statements of the Panel and the Specific Responses from Panel Members. 5b. 0 O O O O of Questionnaire A, Question 5c. Teaching Ethics in Physical Therapy. of Questionnaire A, Question 5d. Results of Questionnaire A, Question Results List of Characteristics of Instructor Results Table 4.26 Panel Member Agreement on Listed Topic Areas based on a Five Point Likert Scale. Results of Questionnaire B, Question 5a. Table 4 . 27 for Teaching Ethics and based on a Five Point Likert Scale. (of Questionnaire B, Questions 5b, 5c. 4.28 Point Likert Scale . B , Question 5d. Panel Panel Member Agreement on Time Frame Educational Methods Results Member Qualifications of Instructor based on a Five Results of Questionnaire Agreement on 114 114 119 120 122 123 124 125 126 .v‘ nu,“ Table 4.29 Rank Order Of Topic Areas for Inclusion Instruction of Physical Therapists in in the Ethics based on a Five Point Likert Scale. Results of Questionnaire B, Question 5a. 0 O O O O O O O O 127 Table 4.30 Rank Order of Methods for Instruction -of Physical Therapists in Ethics based on a Five Point Likert Scale. Results of Questionnaire B, Question 5c. . 129 Rank Order of Qualifications for Table 4.31 Teaching Ethics in Physical Therapy Curricula based on a Five Point Likert Scale. Results of Questionnaire B, Question 5d. . . . . . . . . 130 APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX .APPENDIX APPENDIX AIHEENDIX .APPUENDIX APPENDIX APPENDIX APPENDIX L APPENDIX LIST OF APPENDICES AMERICAN PHYSICAL THERAPY ASSOCIATION CODE OF ETHICS . . . . . . . . . LETTER TO JUDICIAL COMMITTEE . . . . . . FORM A SURVEY OF JUDICIAL COMMITTEE MEMBERS . . LETTER TO EXPERTS . . . . . . . . . FORM B-l OUTLINE OF STUDY GIVEN TO PANEL MEMBERS FORM B-2 CONSENT FORM . . . . . . . . . . . . . . FORM D-l INSTRUCTIONS FORM D-2 QUESTIONNAIRE A FORM E-l INSTRUCTIONS FORM E-2 QUESTIONNAIRE B . . . . LETTER TO PANEL TO CHANGE TIME TABLE . . FORM F-l INSTRUCTIONS FORM F-2 QUESTIONNAIRE C . . . . . . . . THANK YOU LETTER TO PARTICIPANTS FOLLOW-UP QUESTIONNAIRE . . . . AMERICAN PHYSICAL THERAPY ASSOCIATION ETHICAL VIOLATIONS AND RESOLUTIONS (1981-1991) . . . . . . . . . . xi 160 166 168 169 170 174 175 182 222 223 238 239 240 CHAPTER 1 INTRODUCTION Competence in ethical decision making is an important skill for all health professionals to develop. It is considered to be a critical component in the development of professionalism (Mathews, 1989) . Nearly allfl‘professions have established a code of ethics as _a guide for theibehayicrmfits members (Purtilo, 1981). The technical skills which are exhibited in varying degrees by each profession must also be controlled by a Specific standard of behavior if a profession is to be allowed to govern itself. This interest in controlling the behavior of the members of a profession goes back to ancient Greece and the Hippocratic Oath. For much of hiSliOli’y, codes or oaths were the primary guiding documents for ethical behavior. During the past twenty Y93£§-$§£§Sm§§m§wP£§§n a, greatly increased interestwin. .EtDiQaLissues (Veatch, 1989). With this increase in interest there has been a concurrent increase in publications regarding medical ethics. Almost all of this literature has been on ethical issues related to medicine and nursing. It is only very recently that other health professions have begun to address the ethical issues specific to their professions. This has become increasingly urgent as technological changes and expansion of responsibilities has placed practitioners in these professions into positions where ethical decisions must be made. The degree to which health professionals impact directly on the life of the patient also increases the importance of ethical considerations. Many of the allied health professions have substantial and extended contact with the patient. They are often critically involved in the life decisions Of their patients. They exert substantial formal and informal influence on their patients' lives. Statement of Ergblem One health profession which has undergone such change and has assumed an extensive and important role in patient care is the profession of physical therapy. Physical therapy has existed as a specific health profession since 1918 (American Physical Therapy Association, 1979). Its initial concerns were with the rehabilitation of injuries sustained in combat during World War I. Since that time, physical therapy has expanded its scope of practice to include the treatment of all patients with injuries or disorders which impair the ability of the patient to perform functional activity. Physical therapy is a health professionmwhicbhwflihsm sansemsdyith the rehabilitation- of patients. following, Aging. Physical therapists work with patients who suffer from a “great variety of different. types 3 of injuries. The patient may have received a minor sprain which needs short term care and where full recovery is anticipated or the patient may have received a severe life changing or life threatening injury such as a spinal cord injury or a cerebral vascular accident. Physical therapists are also involved in the long term management of patients who have congenital and life long conditions such as spinal bifida and cerebral palsy. Along with acute injuries and congenital problems, physical therapists also work with patients who have chronic and progressive diseases such as arthritis, muscular dystrophy and multiple sclerosis. Physical therapj 51,5 ~milemg}rect contact with a wide variety of Patients in differing stages of disability. The type of contact which the physical therapist has -C—vfi-W“ vlily—ml}”an-javatigent alsoyaries greatly. The patient with a 1“liner injury may require an initial evaluation and instruction in an exercise program while the patient with a s[Dinal cord injury may require up to two hours per day of direct contact for many months. Theti‘me involved and EB? -39352557ty of the contact varies. with each patient. £11 interventions #99 113?"? the common property that the Physical therapist deals directly with the patient for Effrne period of time. During that time the therapist will 133159 treatment_ decisions , interact personally with the Patient, ”receive information from the patient, and ERSEEBct the patient in appropriate activity. Knowledge, jgggemment skills. communication skills, psychomotor‘ tEEi-ning and management skills will be used by the therapist to assist the patient in recovery or '2‘ I .885. All": Ful - I “‘lr foal til maintenance of function. The physical therapist is therefore in a responsible position of: receiving M~ .A—‘as-N“ inf °mat£29199922r91n9 a Patient: ietemsting direct”. with a patient for extended periods of time, and applying ".1111‘;”.;.§1..m..... to effect changes in a patient's life. The process of physical therapy is performed with the absolute purpose of providing for the well-being of the patient being treated. This centralwpgrpgse of “p _..___ Kant-HM... BhYsical _Wtherapy _practice_ is _based on traditional PEEPciL-les of, medical etbi¢§._su<=h as bemficsncev non.- faleficence,_ g autonomy, and justice (Beauchamp & a—lb—r-‘afiu “*(mv‘w- ' Childress, 1989) . How these principles apply to specific issues within physical therapy needs further examination. The changing role of physical therapists, changing technology, and the changes in health care delivery have created many new issues which therapists need to identify and address. Over the last five years, the profession of physical therapy has increased its autonomy in decision making and has eXpanded its role in patient care. This can be seen by the changes made in the practice acts of nearly every =‘=te I.“ 1‘. ‘7 L “ CH HI. SESEYV F':R“ huh». I increa are c iii-“e: iacisi H rflhb . in "k" state to give physical therapists autonomy in practice (Burch, 1989). The change in practice can also be observed by a shift in practice setting from hospital Esed practice 13.91}!!! increasingly V predominant puri‘yat’e tpractigemsetting. This increase in_ autonomy has? ingreased the ethical considerations and served to focus more clearly the responsibility of physical therapists to answer their own ethical questions and make ethical deCisions. Many physical therapist educational programs are r eSponding to these challenges by incorporating courses or modules which deal with ethical decision making into their professional curriculum. Specific ethical issues are also being addressed by the professional organizations through the presentation of programs on ethics within physical therapy at national and state Ineetings. However, at present there is a very limited body of literature which identifies or evaluates ethical iSSues in the practice of physical therapy. Most of the athicles which have been published deal primarily with patient compliance and truth telling (Banja, 1987; Coy, a sys .5538! Pig'sic assist fer tt Sénera Within ‘4. c.~era Ethics 1989; Guccione, 1988; Purtilo, 1984). There has not been a systematic study to identify the specific ethical issues facing physical therapists in the context of the practice environment of today. As a health profession it is important for physical therapy to identify these issues. Without that information it is difficult to determine where to focus the study of ethics within PhYSical therapy. The issues also must be identified to aSeist educators and practitioners in developing guides 1501‘ their own behavior and direction for education. During the past 20 years medicine and nursing have generated an extensive literature on ethical issues within their respective professions. It is from that literature that most of the concepts and issues for ethics courses within physical therapist educational entricula have been taken. An examination of the roles of physician, nurse and physical therapist indicates there are substantial differences in their responsibilities and patient interactions. Although many °f the ethical principles apply to ethical decisions W1thin all health professions, many other issues and ethical dilemmas are specific to particular health professions. It is important for each profession to identify the ethical issues which are faced within their area of practice. The identification of specific ethical issues allows for a critical examination of those issues by the profession and assists educators to direct their instruction toward areas of relevance within their respective profession . u ose of the Stud This study has four primary purposes: 1) to identify the specific ethical issues facing physical therapists today, 2) to identify ethical issues which will be faced by physical therapists in the future, 3) to identify Practice issues which contain ethical considerations, 4) t0 provide information on how to incorporate professional ethics into physical therapist educational curricula. The general purpose, then, is to provide the initial foundation for the study of professional ethics within physical therapy. It is the belief of the investigator that identifying the specific issues will generate ‘finvr “to U PYAC f‘He “A.” “My analysis of these issues. The systematic consideration of ethical issues facing a profession will provide guidance to the individuals within the profession, improve patient care, and strengthen the profession. Need r t Stud The need for the identification and study of ethical issues in physical therapy comes initially from physical therapy' s position as a helping profession. As helping Profeisional_sL_ “physical therapists! are primarily Aconcerned with the needs of other individuals (Pellegrino, 1983) . This orientation puts the therapist ih__ 3__B9_,§Hi§j:99119£w§¥95t' The patient provides the J therapist with sensitive _and personalinformation .and the therapist is expected to use knowledge andflsfllginwtg e. -3933 thgpatiyent. The therapist will use technology which the patient does not necessarily understand and be trusted to apply this technology in the best interests of the patient. imfleatyeqe setting. thsupstcieniiis. °§Esp in a weeksaeieed .yulasralifle.-Posi§iea- (Kultgenr 10 1988; Pellegrino, 1983) . The physical therapist treating the patient will provide services which only therapists have access to through their training and position. They also make treatment decisions and give instructions which affect the patient's life. 'Kultgen (1988)" identifies two potentialutypeflst .9 eggse by 132,119. professional due to the positionflof, power: ‘ 1) t3 exploit the patient for yourhown benefit‘an‘d, 2) to, encroach onmtihfle- autonomy of the patient in hopesmof HEWim‘. The physical therapist in his or her r<'->le of the health care professional must consider these POtential abuses of patient rights. Evith constant Qhang‘esm‘in delivery of health care and changesmin technology, the patient becomes more vulnerable. The responsibility is then greater for the professional to P¥°tect thiPEf—EEEF'S interest. The physical therapist is involved daily in the protection of patient's Lights @3191 “ethical . decision making. To address the ethical issues facing the physical therapist it is important that we begin by identifying the most important ethical issues for physical therapists. This study was undertaken to the: the I 155: 530 9%" NJ.' 11 identify those ethical issues which face physical therapists. The need for such a study is great due to the limited literature available which identifies ethical issues in physical therapy and because of the clear exposure of physical therapists to ethical issues and ethical decisions in their professional role. Qvgrvieg 9f netnggology To identify the important ethical issues in physical therapy practice, a three-round Delphi technique was used. A panel of experts on ethics in physical therapy was questioned to identify current and future ethical issues within physical therapy. The Delphi method was utilized to attempt to obtain a consensus among experts on what ethical issues face physical therapy today and in the future. The Delphi method brings together the views of experts through a series of questionnaires. Each ‘I‘Iestionnaire was developed based on the information received from the preceding questionnaire. The method at“tempts to reach a consensus of opinion by the final questionnaire. A complete discussion of this method is ‘ n 4 1:1 (1 12 found in Chapter II (Review of Literature) and Chapter I II (Methodology) . t tions of Stud The Delphi Technique is a technique used to attempt to attain convergence of the opinions of experts. The technique is dependent on the participation of a small Population in the completion of a minimum of three questionnaires. The problems presented in this study were as follows: 1) There was a small population of experts chosen by the Judicial Committee of the American Physical Therapy Association (APTA) . How each member of the Judicial Committee defines what constitutes an expert may be different and it may be difficult to identify clearly an expert population. The researcher tried to L‘imit this problem by defining in a letter to the Judicial Committee members what constitutes an expert. 2 ) A second potential problem was with the small size of the expert pool any attrition would constitute a problem. Phis Problem was addressed by obtaining a commitment from the el'tpert panel at the beginning of the study. 3) There at: e few studies performed on the validity of the Delphi 'nflk obit! iti 13 Technique (Helmer, 1983) . This condition exists because it is difficult to perform controlled studies on groups of experts. The problem that this deficiency presents was limited because there exists a large body of literature on the results and value of Delphi studies as a method of making predictions and obtaining consensus among experts (Helmer, 1983) . t I,“ ' U. U‘ s a: e ‘h ::~SC ‘1 Q‘y "" “in n u“ L 14 CHAPTER II LITERATURE REVIEW A review of the literature on ethics in the profession of physical therapy reveals a limited number of entries. Prior to 1970 there were only a handful of artic1es which broadly considered the responsibility of PhYsical therapists to the physician and the patient (Hardenbergh, 1946; Haskell, 1949; Marton, 1950; I“cl-finlghlin, 1941) The concepts of ethics described in these articles were presented in terms of good behavior and etiquette rather than a consideration of ethical priDCiples of issues. Haskell (1949) states that: C:ouli‘tesy must be constant. 3 . eI‘Vice must obliterate self. p afiisonal appearance must be impeccable in uniform and off B . uslness ethics must be observed. (p. 232) M arton (1950) identified the ethical responsibilities of t he therapist as: 15 1 . Acceptance of the doctor’s diagnosis, prescription and judgement regarding treatment. 2 . Attainment of efficiency, thoroughness, and sincerity in the administration of treatments. 3 . Cooperation among therapeutic services. 4 - Respect for coworkers. 5- Respect for each patient as an individual. (p. 178) These principles define good professional behavior for that period in the history of physical therapy, but did not. attempt to identify methods of making decisions, Principles to consider, theoretical beliefs or specific ethical issues associated with physical therapy. The condition of a remarkable absence of any literature on et'-l'lics in physical therapy remained until the mid 1970's. The first Code of Ethics for the American Physical Therapy Association was developed in 1935 (Appendix A). This code as well as subsequent articles in the 1940’s and 50's (Avery, 1951; Hardenbergh, 1946; Haskell, 1949; Mar-ton, 1950; McLoughlin, 1941) , indicate that the Profession believed that ethical behavior should be 16 expected of its members. The responsibility of physical therapists to behave in an ethical manner was emphasized in subsequent literature (Banja, 1985; Guccione, 1988; Purtilo, 1974, 1975, 1977, 1978, 1983, 1986). This more recent literature identified physical therapists as Prefessionals who needed to make ethical decisions (Guccione, 1980; Purtilo, 1975, 1978, 1979) and understand ethical principles (Purtilo, 1974). Guccione (1980) states: The need to clarify ethical issues within a health Profession increases as the profession assumes {responsibility for those areas of direct patient care in 1‘18 domain. . . The physical therapist today, in defining the limits of his legal and professional autonomy, must ex{amine the practice of his profession from an ethical Point of view. (p. 1264) Purtilo (1979) stated: In short, nonphysician health professionals are involved 11 ethical decision-making processes and increasingly 7111 be asked to participate in determining moral policy. P- 729) AS a profession, physical therapy was moving toward greater responsibility in patient care and more 17 autonomous practice through the 1980's. There also was a corresponding increased interest in ethical decision making and ethical issues in physical therapy during that period. Guccione (1980) , through a survey of 450 APTA members in New England, identified seven primary and 11 Secondary ethical issues in physical therapy. He saw these issues as falling into four categories: 1) decisions regarding the choice to treat, 2) obligations deriving from the patient-therapist contract, 3) moral obligation and economic issues, 4) physical therapists’ relationship to other health professionals. This identification of specific issues facing physical therapists served to delineate physical therapy as a profession with issues particular toitself. It also placed additional responsibility on the profession to aiddress the ethical issues which are its own. The primary ethical issues identified by Guccione (1980) ihc lude : 1 ' Establishing priorities for patient treatment when time or resources are limited. 18 Discontinuing treatment for patients who habitually disregard instructions such as home programs, treatment regimens, and safety instructions. Continuing treatment with a terminally ill patient. Continuing treatment to provide psychological support after physical therapy treatment goals have been reached. Determining professional responsibilities when a patient's needs or goals conflict with a family's needs or goals. Deciding whether to represent certain necessary patient services in a way that would meet third- party payor limitations. Maintaining a patient's/family's confidence in other health professionals regardless of personal opinions. (p. 1267) The secondary issues included: 1. Defining the limits of the physical therapist’ s role in the initial diagnosis of a patient/family regarding diagnosis or prognosis. Informing a patient/family about the limitations of treatment. Assuring that the patient/family has input into treatment and discharge planning. 19 4. Assuming’ personal responsibility for continuing education to keep up with new treatment ideas in order to maintain quality of care. 5. Weighing the effects of treatment vs. the discomfort created by the procedure. 6. Maintaining a patient's sense of personal space and dignity when treatment requires arrangements such as close proximity and group settings. 7. Withholding or limiting physical therapy services in order to improve work conditions, salaries, staff/patient ratios, etc. 3- Determining criteria for delegating duties to supportive personnel. 9- Reporting questionable practices of another physical therapist to the appropriate person. 10. Reporting questionable practices of a physician to the appropriate person. 11. Reporting questionable practices of another health professionals who is not a physical therapist or physician to the appropriate person. (p. 1267) Guecione indicated in his conclusion that his objectives Were to establish priorities for action by the APTA to encourage discussion, to promote study, and to direct education. It is interesting to note that no subsequent articles were written on any of the seven primary issues 20 identified by Guccione and the only secondary issue considered in subsequent literature was informing patients on limits of treatment or informed consent. Articles on specific ethical issues facing physical therapy began to appear in the 1980's and 1990's. The two issues which received the most attention were informed consent (Banja, 1987; Coy, 1989; Purtilo, 1984) and issues of patient compliance (Clompton & McMahon, 1992; Coy, 1989; Davis, 1989; Guccione, 1988). The issue Of informed consent was addressed from both a legal and ethical point of view by Purtilo (1984) and Banja and Wolf (1987). Purtilo (1984) states that informed consent should be considered a contractual agreement between the Patient and therapist. She also warns that with the i“crease in autonomy in physical therapy practice and the shift in practice environment to a private practice setting that physical therapists will be more accountable 1fer informed consent. Banja and Wolf (1987) also warn of the legal implications and dangers of malpractice litigation if policies for informed consent are not strictly followed. Both Purtilo (1984) and Coy (1989) 21 discuss the ethical principles of patient autonomy, nonmaleficence, and beneficence as central to informed consent. The principle of fidelity is also presented by Purtilo (1984) as an important component of informed consent. The issue of patient compliance is closely aligned to informed consent. Guccione (1988) discussed compliance from a legal and ethical position. Legal questions involve whether the patient is consenting to treatment or being coerced by the health professional to comply. The ethical principles discussed in patient compliance again center around patient autonomy or the Patient's right to make his or her own decision and the Principle of nonmaleficience or the obligation to do no harm (Clompton & McMahon, 1992; Coy, 1989; Guccione, 1988) . The conflict presented between these principles Centers on whether the patient has the right to refuse treatment even if it is not in his/her best interest to do 80. Compliance is an important aspect of treatment pr ‘3th and methods to improve compliance were also treat! 1991) . iiscus :ract: Princi Princj Prefes of th 22 explored in these articles (Clompton & McMahon, 1992 ; Davis, 1989; Guccione, 1988). Some additional issues which have been examined include the right to health care (Purtilo, 1979) and the treatment of AIDS patients (Hansen, 1990; Sims & Purtilo, 1991) . The issue of the treatment of AIDS patients is discussed by Sims and Purtilo (1991) from both a practical and ethical point of view. The ethical principles predominant in this discussion were the Principles of beneficence, which requires that health Prefessionals work in the best interest or for the good Of their patients, and justice, which demands that Patients are treated according to their needs. The limited number of articles which have been Published on ethical issues in physical therapy suggest that much additional study needs to be conducted on the ethical issues in physical therapy. The seven primary and Eleven secondary issues which were identified by G11ccione (1980) did not receive additional analysis or disCussion in the literature during the decade following the Publication of his article. The implications of this H 23 problem will be further discussed in relation to the current study in Chapter V. The literature on ethics in physical therapy during the last ten years examined ethical issues primarily from the position of analysis of ethical principles (Coy, 1989a, 1989b; Guccione, 1988; Purtilo, 1984; Purtilo & Cassals, 1981). The principles of patient autonomy, beneficence, nonmaleficience, justice, veracity, and fidelity were clearly identified. Beauchamp and Chi 1dress (1989) discussed these principles in their classic text on medical ethics. Discussion of ethical theories were presented by a number of authors (Bruckner, 198'7; Coy, 1989a; Guccione, 1980; Purtilo & Cassals, 1981; Purtilo 1974, 1984). These authors primarily clarified the distinctions between the utilitarian and deontological philosophies of ethics. These traditional Ine‘thods of analyzing ethical questions were introduced into the physical therapy literature during the 1980's. A few articles written during the past ten years (ii-Seuss the distinctions and interconnections of legal and ethical issues (Banja & Wolf, 1987; Guccione, 1988; ‘44 {n ,| F4 U." l 24 Purtilo, 1984). As discussed earlier, the legal components of informed consent were the focus of these articles. Bruckner (1987) also discussed the legal implications of not reporting information that was obtained during treatment sessions which may implicate the patient in illegal activities. The only article discussing the teaching of ethics in physical therapy curricula was written by Purtilo (1979) . Purtilo conducted a survey of 59 baccalaureate PhySical therapy programs in the United States to determine the extent of instruction regarding ethics reeeived by physical therapy students. This study reVealed that of the 29 programs responding to the survey, six programs (21%) had a full course devoted to ethics, 18 programs (62%) had a portion of a course deVOtEd to ethics, and five programs (17%) did not formally present ethics in a course but integrated ethics throughout the curriculum. Purtilo compared these results to those reported in a survey of medical schools (Veatch & Sollitto, 1976) and nursing schools (Asoskar, 1977) . Purtilo concluded that physical therapy programs 25 were attempting to expose their students to ethics but medical schools and nursing programs were currently farther along in the process of both identifying issues and in providing students with instruction in ethics. At the conclusion of this paper, Purtilo identified the need to: 1) delineate the role of physical therapists and identify the areas of overlap and differences from nursing ethics and physician ethics, 2) develop guidelines for teaching ethics, 3) develop teaching materials which emphasize the unique and shared areas of PhYSical therapy ethics. The suggestions outlined by lPlurtilo in 1979 remain as important goals today. The American Physical Therapy Association (APTA) , then the American Physiotherapy Association, developed its first code of ethics in 1935 (See Appendix A). Purtilo (1977) states that the establishment of codes of ethics indicate the acceptance by health professions of collective responsibility and ethical obligations. The 1935 code was the first official statement by physical t1lerapists of what constituted correct behavior by thsical therapists. Purtilo (1977) traced the roots of 26 this code to the ancient codes of Hammarabi, the Hippocratic Oath, the Oath of Maimonides and the Pledge of Florence Nightingale. The form utilized by the American Physiotherapy Association in-1935 was based on the American medical Association (AMA) Code of Ethics which has served as a prototype for other health professions. Most of the early code was devoted to affirming the responsibility of the therapist to the physician and to identifying proper behavior in relation to other co-workers. The code did not reflect responsibility to the patient, professional responsibility in decision making or responsibility to the profession. These latter responsibilities were incorporated as the code was modified during the next 50 years to reflect the changes seen in the practice of physical therapy. The APTA Code of Ethics (1977) (See Appendix A) clearly identifies the physical therapist's responsibility to the patient, to exercise professional judgement, and to the profession. Purtilo (1977) stated that society now demands that codes of ethics of health professions reflect societal beliefs and ideas. The 27 concept of patient's rights has changed the structure of all ethical codes to reflect the responsibility of the medical practitioner to the patient. The growth in autonomy of the profession of physical therapy has also increased the responsibility of the therapist to exercise Professional judgement. These changes in societal demands and professional autonomy have transformed the 1935 Code of Ethics of the American Physiotherapy ASscaciation into the current code (Appendix A). The review of literature identified few available all‘tzlcles on ethics in physical therapy. Recent literature has begun to analyze some specific issues in PhYSical therapy practice. These articles have primarily been confined to the issues of informed consent and hOncompliance. One article addressed the teaching of ethics in physical therapy curricula (Purtilo, 1979). P\lrtilo (1979) called for further study to identify the unique components of physical therapy ethics and aciditional study to determine methods to incorporate e'lT-hics into physical therapy education. Guccione ( 1980) identified seven primary and 11 secondary issues facing 28 physical therapists in New England. Guccione indicated a need for further study of the ethical issues he had identified. He saw a need for physical therapy educators to be aware of the ethical issues to enable them to more effectively instruct students on addressing physical therapy's unique issues. During the 12 years since the publication of Purtilo's article on education (Purtilo, 1979) and c311c.=c:ione' s article on issues (Guccione, 1980) little has been presented in the physical therapy literature which addlresses these needs. The absence of study and Puhlications addressing these areas comprise much of the rationale for conducting the current study. Physical tZherapy as a profession needs to identify and then study the unique ethical issues affecting the profession. Universities must also determine methods for preparing S"lindents to address the ethical issues unique to the Profession. The goals of identifying ethical issues finning physical therapists and for determining methods of incorporating ethical instruction into physical therapy TH 29 education curricula are two of the primary goals of this study . Warts A review of the literature in nursing and medicine revealed an extensive body of literature on specific ethical issues and ethical decision making. Many articles and texts have been written which have identified ethical issues in nursing and medicine (Allmark, 1992; Beauchamps & Childress, 1989; Benjamin & Curtis, 1986; Monagle & Thomasma, 1988; Thompson, 1988) as well as the ethical decision making process (Beauchamps & Childress, 1989; Benjamin & Curtis, 1986; Davis, 1989; Fowler, 1989; Garritson, 1987, 1988; Retefian, 1989; Roche, 1987). There have also been l'“Ilmerous articles written on teaching ethics to medical and nursing students (Baldwin, Daugherty, & Self, 1991; Farrow, Arnold & Frader, 1991 ; Ketefian, 1981; Mustapha, 1989; Penticuff & Hinson 1991; Rest, 1982, 1988; sC-Illlaefli, 1985; Self, Wolinski, & Baldwin 1989). These 30 are only a handful of the possible citations in this rich literature. The literature in these areas is extensive but it is not the purpose of this paper to discuss these areas in any depth. It is interesting to note, however, that much Of .the earlier literature in both nursing and medicine Considered ethical issues to be an analysis or aEnlication of ethical principles (Beauchamp & Childress, 1983; Benjamin & Curtis, 1986; Ketefian, 1981) . However, in recent articles there have been attempts to identify the differences between the ways medicine and nursing approach ethical issues (Grundstein-Amado 1992; Jecker & self, 1991; Walker, 1991). The difference which was Presented most often was that the dimension of caring was Primary to nursing ethics (Carse, 1991; Griffin, 1983; Jecker & Self, 1991) . This differed from the emphasis in Inedicine which was on justice and ethical principles (Beauchamp & Childress, 1989; Jecker & Self, 1991; walker, 1991) . The difference in orientation toward ethical issues between nursing and medicine has been atZ‘tributed to both gender differences (Carse, 1991; 7H! 31 Gilligan, 1982; Grundstein-Amado, 1992) and to differences in the roles of nurses as caretakers and physicians as curers (Jecker & Self 1991; Walker, 1991). Some interaction between these two factors probably accounts for identified differences. When considering the profession of physical therapy in relation to both medicine and nursing it is clear that much can be learned from the extensive literature of these related professions in the areas of ethical decision making and education. The profession of physical therapy appears to relate closely to nursing in its primary orientation toward caring for the patient. Physical therapy is also a profession in which 70% of the practitioners are female. There are, however, substantial differences in educational preparation and practice environment between physical therapy and nursing as there are between nursing and medicine or physical therapy and medicine. These differences in education and in practice between these health professions strongly indicate the need for each profession to 1) identify the ethical issues which are unique to its practice and 2) 32 identify methods for teaching ethics appropriate to each profession. Nursing and medicine have come a long way towards addressing these issues while physical therapy is at the beginning of that process. The lack of discussion in physical therapy literature on the ethics of caring which is prominent in recent nursing literature identifies an area which may need investigation by physical therapists. It is not clear whether the orientation of caring or the justice orientation commonly seen in medicine is most descriptive of or appropriate to physical therapy. There is also an absence of articles on the effect of instruction on ethics on physical therapy students. This line of research is well documented in the literature of both nursing and medicine (Baldwin, Daugherty, & Self 1991; Farrow, Arnold, & Frader 1991; Ketefian, 1981; Mustapha, 1989: Penticuff 8 Hinson, 1991; Rest, 1982; Self, Wolinski, & Baldwin, 1989). This is also an area where physical therapy educators need to begin to investigate and develop their own literature. 33 The physical therapy literature shows a limited number of articles addressing ethical issues or ethical education. In contrast to this, nursing and medicine have an extensive literature in both of these areas. There are certain similarities between these professions in educational preparation and practice which allows one profession to learn from the issues and research of another. It is also clear that the differences in practice and education require that each profession identify its own ethical issues, its own orientation, and its own educational methods. Physical therapy currently needs to explore all of these areas. The current study was designed to help address these voids in the professional literature. Delphi Technique The Delphi technique was chosen as the research method for this study. The Delphi technique is a commonly used research method for determining consensus in social science research (Couper, 1984; Goodman, 1987; Weatherman & Swenson, 1974). The Delphi method was 34 developed in the early 1950's and was initially used in Future's research (Helmer, 1983; Rasp, 1973; Weaver, 1971). It has been used by the military, economists, corporations, and educators to guide decision making (Helmer, 1983; Rasp, 1973; Weaver, 1971) . The purpose of a Delphi study is to achieve consensus among a panel of experts. The Delphi study typically consists of four rounds (Erffmeyer, R.C., Erffmeyer, & Lane, 1986; Rasp, 1973) with each subsequent questionnaire being developed from the information received on the previous questionnaires. It was felt by Rasp (1973), however, that three rounds are usually sufficient as little change usually takes place between the third and fourth round. An important component included in. most Delphi studies is that the panel of experts chosen to participate in the study remain anonymous and do not communicate among themselves (Goodman, 1987; Helmer, 1983). This anonymity allows each member to be able to address the questions without fear of censure or reprisal 35 for their views, which in turn encourages a more open statement of the views held by each panel member. It is also important that each panel member is a knowledgeable expert in the area being investigated (Goodman, 1987; Helmer, 1983; Miles-Tapping, Dyck, Brunhan, Simpson, & Barber, 1990). The validity of the results in a Delphi study is largely determined by the knowledge of the panel members. Some additional factors which are needed for participation of panel members are identified by Delbecq, VandeVen, and Gustafson (1975) as: 1) panelists must feel personally involved in the problem addressed in the Delphi study, 2) panelists must have pertinent information to share, 3) panelists should be motivated to include the Delphi tasks in their schedule of competing tasks, and 4) panelists should agree that the judgements of the panel will include valuable information to which they would not otherwise have access. The selection of the panel needs to follow a procedure which identifies individuals with both expertise in the subject and interest in the study. 36 Another important component of the Delphi study is that the panel members receive complete and accurate feedback between rounds (Goodman, 1987; Helmer, 1983, Miles-Tapping, et al. 1990) . Appropriate feedback allows the panel members to analyze the responses of the other panel members and make the best possible answers to subsequent questions. The Delphi method has been used in nursing and allied health studies to identify professional needs and research priorities (Chaney, 1987; Couper, 1984; Lindeman, 1975; Miles-Tapping, et a1. 1990, Rines, 1990; White & Pearlman, 1986) . These studies have attempted to set priorities for research and development in areas Where resources are limited. They have used the Delphi method to set those priorities and direct the studies to areas of greatest need. The use of the Delphi method in the current study follows a similar procedure to identify ethical issues in physical therapy which require further study. In this Study, as in the previously cited studies, there were limited resources and the Delphi method was used to 37 identify priorities for future study. The researcher also used the Delphi method in its traditional application to attempt to identify future areas of ethical concern for the physical therapy profession. Both uses of the Delphi method have been well documented in the literature of both future studies and in studies of health research needs. 38 CHAPTER III METHODOLOGY he e ec e The Delphi Technique was chosen as a research method to bring together the views of experts from throughout the profession of physical therapy to form a consensus on Which ethical issues are important in physical therapy. In this study it is also used to determine what issues are facing the profession in the future. The Delphi Technique consists of a series of questionnaires which are given to a selected panel of e“Pei-ts. The purpose is to achieve consensus in the group but avoid the psychological distractions of groups (Helmer, 1983) . Typically the Delphi Technique consists °f four rounds of questionnaires (Rasp, 1973) with each cI‘leStionnaire providing the material for the development of the subsequent questionnaire. It has been found that thJi‘ee rounds is usually sufficient as little change takes p lace between the third and fourth round (Rasp, 1973) - [ TH? 39 The first questionnaire is composed of broad questions which will elicit open responses from the panel of experts. The composition of the questions in the second round is based on the responses from the initial broad questions. The second questionnaire provides the panel with a compilation of the results of the initial questionnaire and contains questions which will clarify the terms used by individual members. It also identifies specific areas of consensus and areas of disagreement. The third questionnaire provides the experts with additional data on the views of the other panel members. This questionnaire outlines areas of agreement between the experts but also gives minority opinions. The third questionnaire gives the panel an opportunity to make revision and respond to the information received in an attempt to obtain consensus among the panel of experts. If consensus is not obtained following the third questionnaire, a fourth round is used to obtain greater consensus among the experts. 40 The Delphi Panel of Experts' The choice of the panel of experts is an important Step in the Delphi Technique. In this study the panel of exPerts was composed of six members. These experts were chosen by a method of polling members of the Judicial cOmmittee of the APTA. . Each member who had served on the andicial Committee during the last 10 years was asked to identify five individuals whom they consider to be eXperts in ethical issues for physical therapy (Appendix A) . They were asked to write the names on a form Provided (Appendix C) and return this form to the investigator. Their responses were to remain anonymous. 0f the twelve current or former Judicial Committee members contacted, nine responses (75%) were received. These nine Judicial Committee members identified 15 individuals as experts. Nine of the individuals were identified by only one member. The remaining six were identified by between two and nine members. The nine individuals who were identified by only one committee member were eliminated from the panel. The panel of eXperts was then comprised of the six individuals who rH' 41 were mentioned by more than one member of the Judicial Committee. The six individuals identified as experts were then contacted by telephone to request their participation in the study. The study was described to each prospective panel member and they were informed that they would receive- a written description of the purpose and procedures of the study and a formal consent form (Appendices C, D & E). It was then important to obtain a commitment from each member of the panel to complete all three or four rounds of questionnaires. For panel members to participate consistently and effectively, it was stated by Delbecq, VandeVen, and Gustafson (1975) that the members must 1) feel personally involved in the problem addressed in the Delphi study, 2) have pertinent information to share, 3) be motivated to include the Delphi tasks in their schedule.of competing tasks, and 4) agree that the judgements of the panel will include valuable information to which they would not otherwise have access. Each prospective panel member was asked to consider these criteria before making a commitment to participate in the study. 42 All six of the potential panel members consented to participate in. the study and. returned. their signed consent forms. The Delphi method requires that a small pool of experts be identified in the initial stages of the.study; It is important that the subsequent responses of the participants be kept confidential. The following procedures were followed to protect the confidentiality of the participants. 1. The panel of experts was selected using the method outlined above. The Judicial Committee members were asked not to identify themselves when they submitted their lists of experts. The identified experts were contacted individually to request their participation in the study. They were informed of the method utilized in identifying them as experts. The experts were given a complete description of the methods and purpose of the study. The individuals who consented to participate in the study were then assigned a random number between one and ten. H! J 43 6. All data were collected in a system that identified the response of each expert by assigned number. 7. The investigator did not have access to the code which identifies the number with a specific panel member. Writes; The initial questionnaire of the Delphi Instrument was composed of five questions, each of which contained a series of sub-questions. The questionnaires for the second and third round of the Delphi Instrument contained a compilation of the. data received in the initial questionnaire and requested that the panel consider their responses in light of the additional information. The first questionnaire was designated as Questionnaire A, the second questionnaire as Questionnaire B, and the third questionnaire as Questionnaire C. The questionnaires for all three rounds were accompanied by a cover letter which described the procedures and purpose of the questionnaire and gave a description of the information obtained on the previous 44 questionnaire. Specific instructions were also given with each questionnaire. Questionnaire—A Design The initial questionnaire consisted of a series of broad questions (Appendix G). The panel members were requested. to answer ‘the. questions. as completely' as possible. The questionnaire consisted of the following five questions. 1. List the ethical issues which you feel are currently most important for physical therapists to address. 2. List any other ethical issues which you feel will become important for physical therapists in the next 10 years. 3. What current practice issues affect the physical therapist’s need for competence in ethical decision making? 4. Are there future practice issues which you feel will present ethical issues for physical therapists 45 in the next five years and what are those practice issues? 5- a. What topic areas should be included in ethical instruction for physical therapists? At what point in physical therapy education do you feel ethical instruction should be presented? Please discuss your reasons for the choices that you made. What methods of teaching do you feel are most appropriate for instruction in ethical decision making for physical therapists? What should be the qualifications of the instructor? Each question was designed to elicit an open ended l'-'esponse in which the panel member could write as much or as little as they felt necessary. ata Collect'on Questionnaire A The data for Questionnaire A were collected in a Chart form. Responses given to each question were listed F'H 46 following the question. The responses to each question were grouped according to similarities. As an example of this, in Question 1, the investigator asked the panel to list the ethical issues they felt to be currently most important for physical therapists to address. A topic area which was identified by the investigator was "utilization of support personnel". Under this topic area the investigator then grouped the £01 lowing statements made by the individual panel members. 1 - Delegation of direction and supervision of treatment of patients to personnel other than physical therapists. 2 - Supervisory relationships and the use of P.T.A.s for active treatment programs. 3 - Supervision of supportive personnel. 4 - Utilization of supportive personnel. 5 - Proper supervision of assistants and aides. 6 - Proper assignment of assistants and aides. .7 Appropriate use of non-physical therapy personnel in physical therapy clinics. 47 After a review of the responses of the panel members, a specific statement was written by the investigator which stated the ethical issue which incorporated the statements by the panel members on that topic area. For the topic area utilization of supportive personnel, the statement of the specific ethical issue which was written by the investigator was: "The determination of the appropriate utilization and supervision of personnel other than physical therapists ( i -e. , P.T.A. , aide, A.T.C.) in the treatment of physical therapy patients." This procedure was followed for both Questions 1 and 2 in Questionnaire A. If a particular topic area was identified by only one panel member then the statement of the ethical issue as presented by the panel member was included in the final list of ethical issues. This process yielded a total of twenty-three ethical isSues for Question 1 and eight ethical issues for Question 2. A complete compilation of these results is contained in Chapter IV of this paper. 48 The procedure for data collection of Questions 3 and 4 of Questionnaire A was similar to that used in Questions 1 and 2. For Questions 3 and 4 the panel members were asked to identify practice issues which affect the therapist’s need for competence in ethical decision making. For Questions 3 and 4, topic areas of Practice issues were identified by the investigator. The statements of the panel members were then listed under these topic areas. The investigator then combined the statements of the panel members into a single statement 0f the practice issue. In Question 3 a topic area identified by the investigator was "direct access 1eQislation". The members of the panel made the fhillowing statements which the investigator considered related to this issue. 1- Direct access. 2~ Entry point to health care direct access-referral relationships. 3° Independent practice. 4. Independence - increased autonomy as a profession. TH 49 5. Direct access; i.e., practice without.mandated need for a physician referral presents the opportunity for’ the jphysical. therapist to function. as ‘the initial decision-maker in the health care system. From those responses, the investigator developed the following statement of the practice issue: Most states have passed legislation which allows for direct access to physical therapy services. This procedure was followed for Questions 3 and 4. For Question 5 on educational concerns the data were collected by listing all responses to the parts of the question and then identifying how often the same response was made. An example of this is for Question 5a which asks the panel members to identify what topics should be included in ethical instruction for physical therapists. The panel members identified thirteen topics as listed below with number of times the response was given in parentheses. 1. Philosophical theories of ethics (3) 2. Ethical principles (3) 50 3. Ethical problem solving (4) 4. Codes of ethics (5) 5. Specific ethical issues (3) 6. Decision making process (2) 7. History of ethics (1) 8. Legal relationships - laws (1) 9. Bioethical issues (1) 10. Patient's Bill of Rights (1) 11. Resolution of personal and professional differences (1) 12. Awareness of personal ethical convictions in relation to the role of health professional (1) 13. Individual and collective obligations and responsibilities (1) The information received in Questionnaire A was compiled in data collection forms as described above. Based on the information received in Questionnaire A, Questionnaire B was designed. 51 Questignngire B esi Questionnaire B was developed based on the information received in Questionnaire A. The responses to the five questions in Questionnaire A were compiled, as discussed. The responses from Questionnaire A yielded: a. 23 statements of ethical issues. b. 8 statements of future ethical issues. c. 15 statements of practice issues. d. 14 statements of future practice issues. e. 13 topic areas for ethical instruction. f. 3 statements of when ethics should be taught. g. 16 methods for teaching ethics. h. 18 qualifications for teaching ethics. The statements identified were supported by differing numbers of panel members. Some statements were supported by all the panel members and some statements were supported by only one 'member (see Chapter IV Results). 52 The next step in the process was to determine the degree of consensus within the panel on the statements made. Questionnaire B (Appendix H) was developed to present the panel members with the statements of the other panel members and ask them to respond to these statements. It was designed to allow for clarification of the specific issues and to develop statements which accurately represent the various issues. It was intended to given panel members information on the views of the other members of the panel to assist them in responding to further questions. Consensus was sought on the issues listed. The purpose of Questionnaire B was then to: 1. Obtain clarification on the issues. 2. Obtain agreement on the content of the statements. 3. Obtain consensus on the issues derived from the first questionnaire. 4. Identify any issues which were omitted from the results of the first questionnaire. Questionnaire B was composed of five questions which reflected the results obtained from the five questions found in Questionnaire A. For Question 1 each of the 23 53 statements of ethical issues were listed as well as the statements made by the panel members in each of these 23 topic areas. The panel members were then asked to: a. Agree or disagree with the statement b. Suggest changes to clarify the statement c. Identify any panel statements which did not fit under this topic area d. Rephrase the panel statements which did not fit to clarify their distinctiveness from the ethical issues as written The same procedure was followed for Question 2 which dealt with the eight future ethical issues. Questions 3 and 4 followed the same basic procedure except that Questions 3 and 4 dealt with identified practice issues rather than statements of ethical issues. The practice issues included present issues in Question 3 and future practice issues in Question 4. For Question 5a the panel members were given a complete list of all topics areas for instruction in ethics which were identified in Questionnaire A. The number of times each topic area.was included by the panel 54 was listed following the statement. The panel members were asked to»grade each.topic area on a Likert scale of: 5 strongly agree; 4 agree; 3 neutral; 2 disagree; 1 strongly disagree. They were also given space with each topic area to comment on their scoring and to add any additional topic areas which they felt necessary. The same procedure was followed for Questions 5c and 5d. Question 5c consisted of a list of the methods of instruction and Question 5d consisted of a list of qualification for an instructor of ethics in physical therapy. Question 5b dealt with the question of when ethics should be taught in a physical therapy curriculum. The answers which were given by the panel members on this topic in the first questionnaire were divided into three basic responses. The panel members were asked to respond on a 5 point Likert scale of: 5 strongly agree; 4 agree; 3 neutral; 2 disagree; and 1 strongly disagree. The panel members were given the statements of all the panel members and were asked to make any changes in the statements which they felt were necessary. 55 Da C c 'on Questionnaire B Data for Questionnaire B were collected in table form for Question 1 to Question 5. For Question 1 the categories of possible responses to the question of "Do you agree with the statement of the ethical issue as written" are yes, no, with modification, or no response. These responses were recorded in chart form with additional comments listed separately.- The same procedure was followed for data collection in questions 2, 3, and 4. The results of Questionnaire B, questions 1, 2, 3, and 4 are recorded in Chapter IV, Tables 4.2, 4.9, 4.13, and 4.15. For Questions 5a, b, c, and d, a five point Likert scale was used. The data were collected in table format with the responses to each question recorded under the appropriate number score. If there was no response to the question it was recorded as a 0, but was not considered in calculation of Likert score. All additional comments were recorded separately. The 56 results of Questions 5a, b, c, and d are recorded in Chapter IV, Tables 4.26, 4.27, 4.28, and 4.29. The information compiled from‘Questionnaire B indicated that there was consensus on some issues in each question and disagreement on other issues. The areas of consensus and nonconsensus are discussed in detail in Chapter IV. Questionnaire C Design Questionnaire C was developed based on an analysis of the information received in Questionnaire B. It was designed to allow the panel to reach consensus on which statements to include in a listing of ethical issues facing physical therapy and of practice issues which have ethical ramifications. The purpose of Questionnaire C was then to: 1) clarify ethical issues and come to a consensus on present and future ethical issues, 2) rank order practice issues as to their importance for ethical consideration. In Questionnaire B of the twenty-three statements of ethical issues, nine statements were consensus choices by the panel for inclusion.in a list of 57 ethical issues. Nine statements were also chosen by the majority of the panel and five statements were rejected by the majority of the panel. Question 1a of Questionnaire C (See Appendix J) lists the nine consensus choices and asks the panel to confirm their choice or make changes as necessary. Question 1b lists the nine statements that were chosen by the majority of the panel and provides the panel members with the statements made by the panel members in Questionnaire B. The panel members are asked to accept or reject these statements and to provide any comments they feel necessary. The same procedure was followed in Question 1c with the five issues which were rejected by the majority of the panel in Questionnaire B. This process was also followed in Question 1d with two new questions which were introduced by panel members in Questionnaire B. Question 2 of Questionnaire C dealt with future ethical issues. Questionnaire B identified four future ethical issues in which the panel reached consensus. There were also two issues which were accepted by the 58 majority of the panel and two issues which were rejected by the majority of the panel. Question 2a asks the panel to confirm or change the four statements in which there was consensus. Question 2b asks the panel to confirm or reject the statements which were accepted by the majority of the panel. Question 2c asks the panel to follow the same procedure with those statements which.were rejected by the majority of the panel. Question 3 takes a compilation of the present and future practice issues which were considered by greater than 80% of the panel members to contain ethical ramifications for physical therapists. The present practice issues were derived from Question 3 of Questionnaire C and the future practice issues were taken from Question 4. These were considered together in Questionnaire C as it was indicated by many panel members that these two categories overlap. Many panel members stated that the current issues will remain in the future and the future issues are really present in some form today. The panel members were asked to judge on a six POint Likert scale the importance of the issue with five 59 being critical and 0 being unimportant. They were also asked to identify any ethical considerations associated with the practice issues being considered. Dunn Cgliection Questionnaire C Data for Questionnaire C were collected in a table format for all questions. For Question la the panel was asked to make any changes or comments on the nine issues which were identified as consensus ethical issues on Questionnaire B. Data were collected on a table that recorded any comments or changes. For Question 1b the panel was asked to consider statements that were accepted by over 50% of the panel in Questionnaire B and to either accept or reject the statement. They were also given space to make comments or suggest changes. The responses were collected in a table format. The results of Questions 1b, 1c, and 1d are discussed in Chapter IV and recorded in Table 4.3. With Question 2 of Questionnaire C, the same procedure for data collection was followed as With Question 1. The data for Question 2a were collected 60 in a table in which the comments of the panel were recorded. For questions 2b and 2c the data were recorded in a table which identifies whether the panel member rejected or accepted the statements. Results of Questionnaire C, Question 2 are recorded in Table 4.10 in Chapter IV. The additional comments were recorded on a separate form. Data for Question 3 of Questionnaire C were collected in a table which recorded the scores which the panel members assigned to the specific practice issues. Each questionnaire was assigned a number based on the order in which they were received. The scores were then recorded for each questionnaire. The results of Questionnaire C, Question 3a are recorded in Table 4.18. The question also asked the panel members to identify ethical issues that were associated with each practice issue. The responses to this portion of the question were recorded. on. a separate form.‘which listed. the practice issues and the ethical issues identified as being associated with them. A listing of these identified ethical issues is included in Table 4.19 of Chapter IV. {H 61 nethod of Analysis The data from the study were collected in Data Collection Forms 1-16 as previously described. The results are compiled in Tables 3.1 to 3.16. These results were analyzed by determining the degree of consensus among the panel members for each individual statement. The statements were then divided into: A) consensus choices; B) near consensus choices in which there is only one dissenting vote; or C) a non-consensus issue. The percentage of agreement among the panel members was also calculated for each issue. The comments were listed for each ethical issue and these comments were given to the panel members to use in their analysis of whether to accept or reject the final statements of the ethical issues. For Questionnaire B, Questions 5a, b, c, d and Questionnaire C, Question 3, a Likert scale was used to indicate the importance of the issues. For Questionnaire B, Question 5a, b, c, d, the average score was utilized to determine the amount of agreement or disagreement with the statements of a) 62 educational methods, b) topics, and c) modes of instruction. Those items receiving 4 or 5 scores from all participants were considered consensus choices. For Questionnaire C, Question 3a, an average Likert score was calculated for each practice issue. The practice issues included in Questionnaire C, Question 3 were consensus or near consensus items from Questionnaire B, Questions 3 and 4. The average score on the Likert scale was utilized to rank order the practice issues in degree of importance for determining future ethical issues. The ethical issues associated with the practice issues, as stated by panel members in Question 3b were then analyzed in relation to the rank importance of the practice issue. The comments which were included by the panel members throughout the series of Questionnaires were considered in analysis and.revisions.of the statements of the ethical issues and the practice issues. 63 CHAPTER IV RESULTS 9232211 The study consisted of a three round Delphi study in which six panel members were chosen through the procedure described in Chapter III as experts in ethical issues in the profession of physical therapy. All six individuals contacted consented to serve on the panel of experts for this study. The participation of the panel members in all three rounds of the study was excellent. In the first round all six members completed the questionnaire and responded to all questions. This provided the investigator with a large variety of responses from which to develop the second round. It was important for the study that the initial questionnaire was completed by all members of the panel and that the responses were adequate to develop subsequent questionnaires. The second questionnaire was the longest of the three questionnaires given and required the panel members to consider the responses of the other panel members in determining their {H ‘L 64 answers to the questions. In the second questionnaire, five of the six panel members completed the questionnaire for an 83% return rate. The loss of one panel member in the second questionnaire may have been due to the length and complexity of Questionnaire B. The 83% return rate was still a good return and provided more than adequate information on which to construct a third questionnaire. 'The third questionnaire was less complex than the second and required the panel members to come to consensus on issues presented in rounds one and two. This process is described in Chapter III. The response to this questionnaire was again five of six panel members or 83%. This was a good response rate for the final round of the study and provided the investigator with sufficient results for the study to be analyzed. The drop out of one individual from.the third.round of the study could.be the result of the loss of the individual in round two or due to the extended time required for the study. The study was originally scheduled to be completed in approximately three to four months but due to extended response time and time for analysis the study was not 65 completed for nine months. The questionnaires which were returned through the three rounds of the study were all complete with only a few isolated omissions of responses to specific questions. For the 18 questionnaires sent out in ‘the study, 16 completed. questionnaires *were returned for an overall response rate of 90%. To clearly present the results of the study, the researcher followed a format which described the progression of responses on each topic area through the series of questionnaires. This presented the initial list of responses identified in Questionnaire A and described the changes in responses through the three rounds of the study to arrive at the final listing of issues. The four topic areas to be discussed were: 1) present ethical issues in physical therapy, 2) future ethical issues in physical therapy, 3) practice issues which present ethical questions, and 4) educational issues in the instruction of ethics in physical therapy. The results of the study are discussed in each of these areas individually and the possible association between the four topic areas explored. 66 guzzent Etnicai Issues The first topic area to be discussed is that of current ethical issues facing physical therapy. In this section the investigator tried to identify a series of issues that were considered important to physical therapists in practice at the current time. In Questionnaire A the panel members were given the broad directive in Question 1 of: "List the ethical issues which you feel are currently most important for physical therapists to address." This question resulted in a total of 41 responses by the‘panel'membersu The number of issues indicated by the individual panel members varied from four to nine issues. Some issues were included by all panel members and some issues were only listed by one member. From the list of 41 statements of ethical issues, 23 specific issues were identified. As described in Chapter III the investigator then stated the issues in a form that represented the statements given by the panel members. The 23 statements of current ethical issues are listed in Table 4.1. 67 Issue 1: The inequity of the provision of health services within the current health care system. Issue 2: The determination of appropriate utilization and supervision of personnel other than physical therapists (i.e. I P.T.A., aide, A.T.C.) in the treatment of physical therapy patients. Issue 3: The involvement of physical therapists in business relationships which limit professional autonomy or have the potential for financial abuse. Issue 4: The overutilization of physical therapy services. Issue 5: The qualification of physical therapists as the entry point into the health care system. Issue 6: The delineation of professional expertise and practice in relationship to other health providers. Issue 7: The accountability of physical therapy educational programs to develop physical therapy students in the skills needed as professionals. Issue 8: The identification of what constitutes informed consent for physical therapy evaluation and treatment. Issue 9: The protection of the patient's right to confidentiality in interactions with therapists, personnel under the supervision of therapists, and physical therapy students. 68 Issue 10: Justifiability of fees charged for services and reasonable rate of return. Issue 11: Defining the proper ethical limits of intervention: when doing everything possible may not be in the best interests of the patient. Issue 12: Truth in advertising. Issue 13: Fraud in billing. Issue 14: Sexual abuse by physical therapists. Issue 15: The treatment or non-treatment of AIDS patients by physical therapists. Issue 16: Maintaining of clinical competency by physical therapists. Issue 17: Compliance of physical therapists with the need for supportive documentation for services and/or charges rendered. Issue 18: Resolving the conflicts that sometimes occur between what is permitted by law and not permitted by the Code of Ethics. Issue 19: The lack of research evidence to support clinical practice techniques. Issue 20: The lack of cultural diversity within the physical therapy profession. Issue 21: Adhering to the ethical guidelines for the use of human subjects in clinical research. Issue 22: The endorsement of equipment, products, in which the physical therapist has a financial interest. Issue 23: The use of ethics and the disciplinary process to achieve personal gain. 69 The 23 issues identified in the initial round of the study were the starting point for determining a list of consensus ethical issues facing physical therapy. The 23 statements of ethical issues were listed in Question 1 of Questionnaire B (See Appendix H). Each panel member was asked to consider the individual statements of ethical issues and agree or disagree with the statement. They were also requested to make comments on or changes in the statements when they felt it was required (See Appendix H). From the list of 23 issues, nine were identified by all panel members as important ethical issues facing jphysical therapy’ todayu The results listed in Table 4.2 indicate that the following issues were consensus choices of the panel in the second round. lssue_1: The overutilization of physical therapy services. 1%: The identification of what constitutes informed consent for physical therapy evaluation and treatment. SSH 70 The protection of the patient's right to confidentiality in interactions with therapists, personnel under the supervision of therapists, and.physical therapy students. Justifiability of fees charged for services and reasonable rate of return. Truth in advertising. Sexual abuse by physical therapists. Maintaining of clinical competency by physical therapists. Adhering to the ethical guidelines for the use of human subjects in clinical research. The endorsement of equipment, products, in which the physical therapist has a financial interest. 71 iiabiefl4§z3inesuitsfef3ouestionnairefs.fQuestlehCiififl éPanelfi ll ;AnalySi85efithevTwentysThreedEthical}Issuesgggg YES NO MODIFICATION NO RESPONBB Issue 0 Issue Issue 3 Issue 4 Issue 5 Issue 6 Issue 7 Issue 8 Issue 9 Issue Issue Issue Issue Issue Issue Issue Issue Issue Issue Issue Issue Issue Issue ommwwwumweememmmuphmuuw bOOPUUNONOO—‘OHOOOHPHOHHO HOOOOOOOOCOOOOOOHOOOHHU OOOOOOOOOHOOOOOOOOOOOO I" 72 There were also six statements in which there was only one panel member who did not agree with the statement. these included: Issug_z: The determination of the appropriate utilization and supervision of personnel other than physical therapists (i.e. P.T.A., aide, A.T.C.) in the treatment of physical therapy patients. 1§§u§_;: The involvement of physical therapists in business relationships which limit professional autonomy or have the potential for financial abuse. 1%: The qualification of physical therapists as the entry point into the health care system. 1ssug_1: The accountability of physical therapy educational programs to develop physical therapy students in the skills needed as professionals. I_s_sue_11: Defining the proper ethical limits of intervention: when doing everything possible may not. be in 'the best interests of the patient. 73 issue 1;: Fraud in billing. The consensus choices and the near consensus choices accounted for 15 of the 23 issues identified in Questionnaire A. One issue was unanimously rejected by the panel and two issues were near consensus rejections with only one member of the panel agreeing with the statement of the issue. These issues were: Issue 23: The use of ethics and the disciplinary process to achieve personal gain. Issue_§: The delineation of professional expertise and practice in relationship to other health providers. Issue 20: The lack of cultural diversity within the physical therapy profession. The remaining issues, 1, 15, 17, 18, and 19 showed a nearly even distribution of panel members that agreed with the statement and those that disagreed. At the completion of Questionnaire B, Question 1 showed the 23 statements of ethical issues divided into: 74 Consensus Positive 9 statements Near Consensus Positive 6 statements Consensus Negative 1 statement Near Consensus Negative 2 statements Near Equal Positive/Negative 5 statements It can be seen from these results that consensus or near consensus was attained on 18 of the 23 statements following the second round of the Delphi study. In Questionnaire C the results of Questionnaire B were compiled and the statements were presented to the panel members in an attempt to attain greater consensus on the remaining non-consensus items in Question 1. The procedure followed is described in Chapter III of this paper. Questionnaire C (See Appendix J) divided Question 1 into four parts: a) consensus items, b) items with greater than 50% approval, c) items with less than 50% approval, and) new items. The panel members were again asked to evaluate the statements based on the comments and choices of the other panel members and their own views of the issues. 75 The nine consensus statements from Questionnaire B, Question 1 remained consensus items in Questionnaire C. The results on the remainder of the statements are compiled in Table 4.3 Lie, 6, Panel Analysis of All Non-consensus Ethical ............. gissues.;gay,,_p,7_,._.m..,. . .29.-.. ..H19..ea€ NO Accept Reject Response Issue 1: 3 2 0 Majority accept Issue 2: 5 0 0 Positive ‘ consensus [Issue 3: 4 1 0 Near consensus Issue 5: 3 2 0 Majority accept I Issue 6: 0 5 0 Reject Issue 7: 1 4 0 Reject Issue 11: 2 3 0 Majority reject Issue 13: 4 1 0 Near consensus Issue 15: 3 1 1 Near consensus Issue 17: 2 Majority reject I Issue 18: 0 5 0 Reject Issue 19: 1 4 0 Reject Issue 20: 0 5 0 Reject Issue 23: 1 4 0 Reject u [H 76 Table 4 4 Ethical Issues Identified by panel of f 35 experts on Questionnaire C, QuestiOn 1. ~ :- LConsonsus Choices Issue 4: The overutilization of physical therapy services. IIssue 8: The identification of the factors which - constitute informed consent. Issue 9: The protection of the patient's right to J confidentiality in interactions with therapists, personnel under the supervision of therapists, and physical therapy students. IIssue 10: The justification of appropriate fees charged for the services rendered by physical therapists. Issue 12: The maintenance of truth in advertising. Issue 14: The identification and prevention of sexual (abuse) misconduct with patients by physical therapists. Issue 16: The maintenance of clinical competence by physical therapists. IIssue 21: The adherence to ethical guidelines for the use of human subjects in clinical research. Issue 22: The endorsement of equipment, products in which the physical therapist has a financial interest. Issue 2: The determination of the appropriate level of training, utilization and supervision of supportive personnel other than physical therapists who assist in the delivery of physical therapy treatments. 77 NOR! COBSODSUB Issue 3: The involvement of physical therapists in business relationships which have the potential for patient exploitation. Issue 13: The identification and elimination of fraud in billing for physical therapy services. Issue 15: The responsibility of physical therapists to provide adequate physical therapy services to all patients according to their need for care without regard to the patient's personal or social characteristics. MajorityAccepted Issue 1: The responsibility of physical therapists to provide for fair distribution of physical therapy services within the health care delivery system to meet the health needs of the population being served. Issue 5: The professional qualifications and competence of physical therapists to serve as an entry point into the health caresystem. Table 4.3 shows that with Questionnaire C, positive consensus was achieved on a total of 10 of the original 23 statements . three additional statements and there was negative consensus or near negative consensus on six of the 23 There was near positive consensus on 78 statements. Of the remaining four statements, there were two with a majority voting to accept and two with a majority voting to reject. The final listing of ethical issues chosen by the panel of experts in Questionnaire C yielded 10 consensus choices, three near consensus choices and two majority choices. The 15 statements listed in Table 4.4 are the final statements of the ethical issues facing physical therapy today as determined by the panel of experts. A fourth round for this question was not considered necessary since 19 of the 23 statements were at or near consensus. In analyzing the results of Question 1 on current ethical issues in physical therapy, five classifications of issues were considered. These are: 1) issues of patient rights, 2) practice issues, 3) issues in education and research, 4) issues of distribution and fairness and 5) issues involving business relations. Within each of these five classifications of issues some issues described behaviors with legal implications that .need to be addressed immediately. Other statements described areas where there is a need for an issue to be 79 more clearly defined and where policies need to be established to provide guidelines to members of the profession. In the first class of issues, which deal with patient welfare, three issues have been identified. These are Issue 8 which is concerned with informed consent, Issue 9 which deals with confidentiality and Issue 14 which deals with sexual abuse. The patient's right to confidentiality and informed consent are discussed throughout the literature in medical ethics (Banja 1987; Coy 1989; Purtilo, 1984) . These are patient rights which are grounded in the principles of patient autonomy and veracity. It is not the intent of this study to do a complete analysis of each issue presented, but rather to identify the issue and provide a classification for future study of the individual issues. The issues of confidentiality and informed consent fall under the classification of issues which need to be studied and where policies need to be determined to provide guidance to the therapist. The third issue which was identified as a patient rights issues is Issue 14 (See Table 4.4). This issued deals with sexual abuse of 80 patients. Sexual abuse is clearly an illegal activity. It is a legal as well as an ethical betrayal of trust. It does harm to the patient and needs to be identified and prosecuted. This is an issue where right and wrong are clearly defined. The second group of issues are classified as professional issues. These issues deal directly with policies affecting the delivery of physical therapy services. The issues identified as professional issues are Issue 4 which deals with overutilization of physical therapy services, Issue 16 which addresses the maintenance of clinical competence, Issue 2 which deals with the utilization of supportive personnel, and Issue 5 which deals with the qualification of physical therapists to serve as an entry point into the health care system. These issues all fall into the classification of issues which need to be studied and in which policies need to be determined to guide behavior. They all address problems associated with safeguarding the delivery of physical therapy services to assure the safety of the patient. 81 The third classification of issues is education and research. The only issue identified in this group was Issue 21 which dealt with ethical guidelines in clinical research. Ethical guidelines for clinical research are well established in medical literature and as physical therapists continue to become more involved in clinical research they must be diligent in applying those policies and standards. The fourth. category’ of ethical issues involves distribution of therapy services. The two issues which were classified under this category were Issue 1 which dealt with providing a fair distribution to meet the needs of the population and Issue 15 which addressed the issue of providing service to all patients regardless of social or personal characteristics. Issue 1 speaks directly to the need to establish a just distribution of physical therapy services. This would address issues of justice and patient welfare. This is an issue that needs study of the modes of delivery and policies established. The second issue deals with discrimination against patients based on social or personal characteristics. This issue is one that again has legal as well as ethical 82 considerations. Discrimination against an individual based on social or personal characteristics is both unethical and illegal. The final classification. of issues is business relations. These are Issue 10 which deals with charging appropriate fees, Issue 12 which deals with maintenance of truth in advertising, Issue 22 which deals with conflict of interest in endorsement of products, Issue 3 which addresses business relationships which have potential for patient exploitation, and Issue 13 which deals with fraud in billing. Of these five issues, two are listed which are clearly problems which contain some legal as well as ethical considerations. Both patient exploitation and fraud in billing are wrong and potentially illegal activities. The ethical issues in these cases is that the therapist is responsible to identify the exploitation and fraud in their practice for the protection of the patient. Fraud is illegal and needs to be addressed immediately. The remaining three issues deal with fair rates, truthful claims and conflict of interest. These are all issues which need to be studied to determine appropriate policies. It is not 83 always clear what the fair rate to charge for physical therapy services is, while it is clear that fraud and exploitation are wrong. There are also some questions as to what claims can be made in advertising. While known dishonesty is wrong and could be subject to legal action there is still a large area in physical therapy practice where results are not proven. Some important ethical questions of truthfulness arise when considering how much benefit we can claim from unproven methods. There are also questions of honesty which need to be considered with endorsement of products in which the endorser has financial interests This may not be wrong in itself, but there is potential for an ethical dilemma. In summary, three original issues were identified in the first topic area of ethical issues. At the completion of the three rounds, there were 13 issues which. were consensus or near consensus choices for acceptance by' the panel and six issues which. were consensus or near consensus choices for rejection by the panel. This represents a very high degree of agreement (79%) between members of the panel on which issues to include in a final list of current ethical issues facing 84 physical therapy. The final list of issues is compiled in Table 4.5. Issue 4: The overutilization of physical therapy 3 services. Q Issue 8: The identification of the factors which ‘ ‘ constitute informed consent. ‘ Issue 9: The protection of the patient’s right to ; confidentiality in interactions with i therapists, personnel under the supervision of therapists, and physical I therapy students. g L Issue 10: The justification of appropriate fees . ..... charged for the services rendered by physical therapists. I . Issue 12: The maintenance of truth in advertising. ! 8 Issue 14: The identification and prevention of sexual (abuse) misconduct with patients by physical therapists. ; Issue 16: The maintenance of clinical competence by physical therapists. Issue 21: The adherence to ethical guidelines for I the use of human subjects in clinical ! research. i , Issue 22: The endorsement of equipment, products f in which the physical therapist has a financial interest. level of training, utilization and supervision of supportive personnel other than physical therapists who assist in the delivery of physical therapy treatments. Issue 2: The determination of the appropriate 1 i I __m_____m_u__iiir_i 85 Issue 3: The involvement of physical therapists in business relationships which have the potential for patient exploitation. Issue‘13: The identification and elimination of fraud in billing for physical therapy services. Issue 15: The responsibility of physical therapists to provide adequate physical therapy services to all patients according to their need for care without regard to the patient’s personal or social characteristics. In the final list the investigator has also added.the two issues which were chosen by a majority of the panel but not as consensus or near consensus issues. These were included because they had strong support within the panel and were considered issues which therefore deserved further attention. Issug 1: The responsibility of physical therapists to provide for fair distribution of physical therapy services within the health care delivery system to meet the health needs of the population being served. The professional qualifications and competence of physical therapists to serve as an entry point into the health care system. 86 The resulting 15 issues can then be further analyzed in two areas. The first consideration was to identify to which general area of physical therapy the issue pertained. The five areas identified were: a) issues involving patient. welfare, b) professional practice issues, c) issues of education and.research, d) issues of health care distribution, and e) issues involving business relations. As can be seen in Table 4.6 the majority (60%) of the issues were distributed in the business relations and.professional practice areas. The smallest category was issues in education and research with only one of the 15 items identified as part of this area. This distribution of issues indicates the direction in which the profession of physical therapy is currently encountering ethical questions. This provides some direction to educators in determining how to direct courses in ethics for physical therapists. The 15 issues were also divided into: a) actions that have legal as well as ethical implications and b) issues which present ethical questions in which the issues need further study. Within the first classification, four issues have been identified which 87 have clear legal implications and four issues which contain primarily ethical questions. It was important to distinguish the issues which have legal implications from primarily ethical issues when considering the actions which are needed to address each issues. The implications of Question area 1 to research, education and practice will be further discussed in Chapter V. Table 4 6 Distribution Of 15 Ethical Issues Within 7 Five categories of Issues._",‘, , tjkfg9_ w we .,....1 18808 'ro-m. % 'ro'rzu. i CATEGORIES 0! 188088 NUMBER 188088 01' ALL E 188038 l Patient welfare 8, 9, 3 20 14 Professional practice 4, 16 4 27 s, .2 Education and research 21 I 1 ' 7 F Distribution of health 15, 1 2 23 care L Business relations 10, 12, 5 33 22, 3, 13 _ 88 0318608188 08 188088 L8GAL PRIMARILY 3 C0881D8RATION 8THICAL 1 18808 8088888 QU88TION8 18808 NUHB8RB | Patient welfare 4 8, 9 i 1 Professional practice None 4, 16, 5, 2 i Educational research None 21 1 * Distribution of health 15 1 care . 1 Business relations 3, 13 10, 12, 22 I Quesgion Area 2; Future Etnical issues The second area which was investigated was future ethical issues facing physical therapy. The investigative procedure ‘which. was followed. has been. described in Chapter III. In Questionnaire A, the panel was asked to respond to the broad question: List any other ethical issues which you feel will become important issues for physical therapists in the next ten years (See Appendix G). The panel members made 12 additional statements of issues from which eight specific statements of future ethical 89 issues were made. It was mentioned by three of the six panel members that all the current issues identified in Question 1 will remain in the future. As one panel member stated it: ”I don't expect the issues to change substantially in the next ten years and I doubt that many of the current issues will be totally resolved in the next ten years either." In the final analysis of the ethical issues facing physical therapy, the current and future issues will be considered together. The eight future issues were determined through an analysis of the twelve statements given by the panel and eliminating overlap or duplicate statements. fTable 4 8 List of Future Ethical Issues Identified . Why Panel Members in Questionnaire A, Quest1on 2. .--r Issue 1: The response of physical therapists to environmental issues of pollutants and health hazards associated with specific treatment modalities. Issue 2: Discriminating in employment opportunities within physical therapy private practices. Issue 3: The duty of physical therapists to report misconduct in colleagues. Defining the limits of personal relationships within the professional setting. _ I Issue ‘4?) 90 Issue 5: How to address the issue of encroachment of other disciplines into the practice of physical therapy. Issue 6: The utilization of treatment techniques without research to verify the degree of effectiveness. Issue 7: The use of advertising in physical therapy practice. Issue 8: The sexual and physical abuse of patients by physical therapists or those supervised by physical therapists. In Questionnaire B, Question 2, the panel was then given the eight statements of the future ethical issues and asked to agree or disagree with the statement as presented. The procedure was described in Chapter III. The results are compiled in Table 4.9. Table 4 9 .Results of Questionnaire B Question 2 _ on Panel Acceptance of Future Ethical Issues. Yes 9:ch No %No Modify No Response 5 100 o o o ' o 2 4o :3 60 o o n 5 100 o o o u 5 100 o o 0 fl 1 20 4 80 o o 3 60 2 40 o o 4 80 1 20 o o 5 100 o o o 0 fl ======.=== 91 From the responses obtained in Question 3 of Questionnaire B four statements were identified as consensus issues. These were Issues 1, 3, 4, and 8. Issue 7 was a near consensus choice by the panel. Questionnaire C, Question 2 was developed as described in Chapter III. The panel members were given the future ethical issues with the choices and comments made by the panel members on Questionnaire B. The panel members were then asked to accept or reject the statement of the issues as presented. The results of Questionnaire C, Question 2 are listed in Table 4.10. 'ion Panel Acceptance of the Future Ethical Issues : Ident1f1ed. g,-,iu;;;g;;grg;;gg,_n,,,,_,__u,flmgg Accept Reject We Response Issue 3 5 O 0 Issue : 2 2 1 Issue 3: 5 0 0 hIssue 4: S 0 0 Issue 5: 1 4 0 Issue 6: 2 3 0 Issue 7: 3 2 0 5 0 0 fl iIssue 8: 92 The results listed in Table 4.10 identified four future issues which were accepted by all members of the panel. One issue was rejected by all but one member and three issues showed a near even distribution between acceptance and rejection. There was only slight variation in the choices of the panel between QueStionnaire A and Questionnaire B. It was determined that a fourth questionnaire would not be useful for obtaining consensus in this question. The four consensus statements are listed in Table 4.11 and are included in the total compilation of ethical issues facing physical therapy in Chapter V. Table 4 11 Consensus Future Ethical Issues as Issue 1: The respon81bility of physical therapists to respond to the environmental issues of pollutants and health hazards associated with physical therapy treatment. Issue 3: The duty of physical therapists to report misconduct in colleagues. Issue 4: The need for therapists to define the limits of personal relationships within the professional setting. Issue 8: The sexual and/or physical abuse of patients by physical therapists or those supervised by physical therapists. j 93 Analysis of these issues indicates that Issue 8 of future ethical issues is the same issue as Issue 14 in the listing of current ethical issues. Both of these statements deal with abuse of the patient by the therapist. These two will be combined in the final compilation of ethical issues in Chapter V. Of the remaining three issues, 1 and 4 can be classified as patient.welfare issues. These issues deal with exposure of patients to environmental pollutants and health hazards and the limits of personal relationships within thprrofessional setting. Both of these issues need further definition and study on their specific ethical implications. The exposure of patients to known health hazards could have legal as well as ethical implications but the degree of exposure and risk to patient welfare will usually not be clearly defined. Further study needs to be made in this area and guidelines for specific hazards need to be developed. The last future issue identified is Issue 3 which involves the duty of physical therapists to report misconduct in a colleague. The researcher has classified this as a practice issue as it involves the process of a 94 profession monitoring the actions of its own members. The process of a profession attempting to control the behavior of its members is a primary characteristic of a profession (Kultgen, 1988). The responsibility of physical therapists to monitor the behavior of their co). leagues needs further definition and study. The investigator received four additional statements of ethical issues in response to the second question (Table 4.11) . Three of these were statements of new issues. The new issues included Issue 1 regarding EXposure of patients to health hazards, Issue 3 involving the duty of physical therapists to report the misconduct Of colleagues and Issue 4 which refers to the need to define the limits of relationships in the professional Setitling. These three issues will be added to the list of 155 <311rrent ethical issues identified in Question 1. 9W 'ce ss es 'c C nta' Et ic ons'de t' The third area investigated in this study was the 1<3e1"“t:ification of practice issues which contain ethical c . Ons lderations. The procedure for developing the 95 questions and conducting the study was described in Chapter II. Practice issues refer to the context in which the profession of physical therapy is practiced. Practice issues are issues which affect the environment in which physical therapy is practiced and the methods of dell. :ivering services. Practice issues would then include a large variety of issues in society, in the delivery of health care, in modes of practice and in technical slci Ills. Identifying current and future practice issues Which contain ethical content would assist the therapist in understanding when and where ethical considerations are most likely to occur. In Questionnaire A, Question 3 the panel was asked, "What current practice issues affect the physical therapist's need for competence in ethical decision maJ‘Eing?" (See Appendix G). There were 28 responses to this question by the panel. From these 28 responses, the inVestigator identified 15 statements of specific Practice issues. These statements are listed in Table 4-12- 96 Table 4.12 Original list of Current Practice Issues _gwhich haVe Ethical Considerations from Questionnaire 7’A Question 3.1;,ou.»w. . M,_, ,__ Issue 1: Most states have currently passed legislation which allows for direct access to physical therapy services. Issqsue 2: The current reimbursement system for physical therapy services. Irsaqsue 3: The change in the method for provision of services from hospital based and physical therapist owned practice to business relationships which involve physician ownership of physical therapy practice and joint business ventures. IIssusue 4: The change in the role of the physical therapist from a direct treatment mode to one requiring increased delegation and supervision of other personnel such as P.T.A.s and A.T.C.s. Ilissusue 5: The consumer is becoming more aware and sophisticated regarding their own health. IIZEBssue 6: The aging of the patient population. Issue 7: Increase in demands on physical therapists to be involved in: quality assurance, documentation of care, fiscal planning, management and the community. Issue 8: n Current challenge to licensure as a means to protect health professional privilege. Issne9° \ The current and projected manpower shortage in physical therapy. ISSUelm Increase in the conduction and use of research to support clinical practice in physical therapy. 97 .Isssue 11: The increase in high technology in what has been a traditionally low-tech profession. Is sue 12: The increase in the responsibility of physical therapists in overall patient care. i Issue 13: The increase in the sophistication of information gathering and information flow in health professions. Issue 14: Increased scrutiny of the qualifications and credentials of the individuals providing health services. Issue 15: Increased opportunities for physical therapists to become involved in highly successful business ventures with the accompanying risk that the profit motive will become primary and supplant the focus on quality patient care. The 15 statements of practice issues found in Table 4 - 12 were then used to construct Question 3 of Questionnaire B (See Appendix H). The procedure used in CODStructing Questionnaire B is described in Chapter III. In Questionnaire B, Question 3, the members of the panel Were asked to either agree or disagree with the statement of the practice issue as written. They were also asked to Ire-state or comment on the issue as they felt t"ecessary. The responses to this question are recorded in Table 4.13. These results indicate that three 98 practice issues were identified as consensus issues (Issues 2, 7, 12) and three practice issues were chosen by all but one panel member (Issues 9, 10, 15). These six practice issues were then identified as consensus or near consensus practice issues. \ Table 4 13 Agreement of Panel Members on Items inwifi the Original List of Current Practice Issues. """""" 3, Results of Questionnaire 8, Question 3- :‘ j1.:S3§iff1§§3zi~ixiii: Yes No Modification No Response 0 HMNONHHNON-fi-HHOQ OOOOOOOOOOONHOH H I: (D auumusswmwpwwmp ooooooowowoooo 99 In Question 4 of Questionnaire A, the panel was asked "Are there any future practice issues which you feel will present ethical issues for physical therapists in the next five years and what are those practice issues?" The panel made 17 responses to this question. From those 17 responses, the investigator identified 14 specific statements of future practice issues. These Statements are listed in Table 4.14. _-""1Table 4 14 Original List of Future Practice Issues e Identified by Panel Members in Questionnaire A, .: Question 4. a v . Issue 1: Practice without referral will become a common mode of practice. Issue 2: Changes in business relationships which physical therapists will become involved .\ in. Issue 3: Increased scrutiny of reimbursement and documentation of physical therapy services by outside agencies. Issue 4: Investment by physical therapists in health care products and services such as equipment companies and nursing homes. Issue 5: Increase in the manpower shortage. ISsue 6: Increase in the age of the patient population. 100 Issue 7: Increase in the questioning of the efficacy of some accepted and marginal treatment techniques. Issue 8: Increase in professional accountability and liability. Issue 9: Increase in insurance contracts that may limit access to care. .Issue 10: Additional unspecified changes in the health care system. Issue 11: Increased awareness and sophistication of consumer. lIsssue 12: Increase in the number of AIDS patients " seen by physical therapists. Issue 13: Increasing need to determine what our own identity is and develop autonomy as a profession. Issue 14: Increase in the use of advertising by physical therapists. These statements were then used to develop Question 4 of Questionnaire B (See Appendix H). aslied to again agree or disagree with the statement of tIIGE :future practice issues as written. this question are recorded in Table 4.15. The panel was The results for 101 lgTable 4.15 Agreement of Panel Members on Items in I the Original List 0£ Future Practice Issues. ~71 ;.. Results of Questionnaire 8, Question 4. ~> Yes No Modification No Response Issue 1: 4 1 0 0 Issue : 5 O 0 0 Issue 3: ”4‘ 1 0 0 Issue : 5 O O 0 Issue : 3 2 0 0 Issue : 3 2 0 0 Issue 7: 5 0 0 0 Issue 8: 5 0 0 0 Issue 9: 5 0 O 0 Issue 10: 1 3 o 1 Issue 11: 3 2 o o lasue 12: 2 3 o o _Eisue i3: 3 1 o 1 Issue 14: 2 2 o 1 From the list of 14 future practice issues found in Table 4: 14 , seven issues were either consensus choices by the panel or near consensus choices. The consensus choices were Issues 2, 4, 7, 8 and 9 and the near consensus choices were Issues 1 and 3. 102 Many of the panel members also stated that the present practice issues will remain in the future and the future issues are present in some form today. Since the (distinction between present and future issues was unclear, the investigator determined that it would be Inore accurate to combine the results of Questions 3 and 4 into one category of practice issues which contain ethical ramifications rather than dividing the issues into future and present issues. Combining the results of Questions 3 and 4 of Questionnaire B identified 13 Practice issues which were consensus or near consensus chC>:i.ces by the panel. These 13 issues are listed in Table 4.16. Table 4 16 List of Consensus Current and Future Practice Issues from Questionnaire B, Questions 3 c3liurrent Practice Issues, Question 3 ISsue 2: The current reimbursement system for .\ physical therapy services. ISsue 7: Increase in the demands on physical therapists to be involved in: quality assurance, documentation of care, fiscal planning, management and the community. Issue 9: The current and projected manpower shortage in physical therapy. 103 Issue 10: Increase in the conduction and use of research to support clinical practice in physical therapy. Issue 12: The increase in the responsibility of physical therapists in overall patient care. Issue 15: Increased opportunities for physical therapists to become involved in highly successful business ventures with the accompanying risk that the profit motive will become primary and supplant the focus on quality patient care. Future Practice Issues, Question 4 JIsssue 1: , Independent practice without referral will become a common mode of practice. Itemsue Changes in business relationships which physical therapists will become involved in. Jisssnna ‘ Increased scrutiny of reimbursement and documentation of physical therapy services by outside agencies. JESSEnua Investment by physical therapists in health care products and services such as equipment companies and nursing homes. ltfissnna Increase in the questioning of the efficacy of some accepted and marginal treatment techniques. ltfissnna Increase in professional accountability and liability. JEEBsnua Increase in insurance contracts that may limit access to care. 104 From the list of current and future practice issues in Table 4.16 and the additional comments and suggestions of 'the panel members, a final list of practice issues was developed for use in Questionnaire C. Question 3 of Questionnaire C was then developed :from the final list of practice issues which are listed 1J1 Table 4.17. In Question 3a, the panel members were asked to rank the importance of these issues on a Likert Scale as described in Chapter III. In Question 3b they Were asked to identify the ethical considerations associated with each practice issue. The payment systems being utilized for the reimbursement of physical therapy services. The delivery of physical therapy services in a setting which involves physician ownership (full or part) of the physical therapy practice. The increase which has been seen in the responsibility of the therapist in total patient care. The current and projected manpower _shortage in phy51cal therapy. 105 Issue 5: The increased opportunity for investment by physical therapists in health care products and services such as equipment companies and nursing homes. Issue 6: The current practice trend wherein more physical therapists are leaving institutions and establishing practice in the private practice arena. Issue 7: Independent practice without referral will become the common mode of practice. :Issue 8: Increase in the demands of physical therapists to be more involved in quality assurance, fiscal planning, documentation of care, and the community. Issue 9: The increase in the use of research results to support clinical practice in physical therapy. Issue 10: Changes in the types of business relationships with which physical ______ therapists become involved. Issue 11: Increased scrutinizing of reimbursement and documentation of physical therapy services by outside agencies. Issue 12: Increase in the questioning of the efficacy of some accepted and marginal treatment techniques. JESE-sue 13: Increase in insurance contracts that may limit access to care. The results of Question 3a are recorded in Table 4.18 and results of Question 3b are recorded in table 4.19. 106 Table 4 18 Average Score of Importance of Practicehfii 1 Issues on a Five P01nt Likert Scale by PanelPF» , pi Hembers- 'fflggggygga5g,;3¢mg,ggm¢¢fl,gganymgxg: yfifl ; Panel member Average 3.0 4.2 4.0 3.2 4.0 0.4 3.0 2.4 2.85 3.4 1.75 1 3.2 1 _.3 .2 1 Issue 1: 1 Issue 2: 1 Issue 3: Issue 4 : 1 Issue 5: 1 Issue 7: wquuumuu Issue 8: U UI 1 ISsue 9: 1 Issue 10: , ISsue 11: ISsue 12: 4 13: 3 1 NR 5 3 5 5 I Issue 6: O 5 3 NR 5 NR muumubmouummmu H c» rd u: H rd P‘ H .5 P‘ h.:» F3 a h 1» c: P‘ b ta +4 c: a» p (n L» o: u UUUU 1 1 1 1 1 1 1 107 ’ Table 4.19 List of Ethical issues Assoc1ated with 1 Spec1f1c Practice Issues .- :7 Results of Questionnaire 1 Issue 1 Practice Issue: The payment systems being utilized for the reimbursement of physical therapy , services. Ethical Issues 1 1 - Overutilization 2 - There may be ethical consideration for the payors but not for the physical therapist. 3 - If a system discriminates against poor or underprivileged. 4 - The payment systems are not physical 1 therapists but third party payors. Issue 2 Practice Issue: The delivery of physical 1 therapy services in a setting which involves 1 Physician ownership (full or part) of the physical 1 herapy practice. 1 a‘hliical Issues 1 1t: 1 1 1 I 1 1 - Choice - overutilization 1 2 - Contributing to conflict of interest 1 3 - Physician ownership in and of itself may not 1 constitute patient exploitation or illegality , - I would prefer to see this issue restated. - 4 - Overutilization Issue 3 Practice Issue: The increase which has been 1 seen in the responsibility of the therapist in total Patient care. E3":hical Issues \1 - Limits to optimal care and responsibility to public accountability l ___J -2 __ Approprate referral 108 " Issue 4 Practice Issue: The current and projected 9 manpower shortage in physical therapy. Ethical Issues . .1 - Overutilization of sugportive _personnel 2 - Participate in efforts to meet health needs, promote good consequences 3 - Not part of ethics Issue 5 Practice Issue: The increased opportunity for investment by physical therapists in health care IPlrcaducts and services such as equipment companies and nursing homes. Ethical Issues 1 - Advertising and endorsement 2 - Conflict of interest 3 - Overutilization 4 - Recommendations for monetaryL gain Issue 6 Practice Issue: The current practice trend Wherein more physical therapists are leaving lIl'lstitutions and establishing practice in the pr ivate practice arena. a‘7-111cal Issues 1 - This seems to be a market or supply-demand business issue not an ethical issue 2 - Not ethics I§sue 7 Practice Issue: Independent practice without referral will become the common mode of practice. B"zliical Issues 109 .2. Independent practice indicates isolation from other practitioners which is a dangerous concept and not what I think direct access means. 3 . The whole realm of responsibility and judgement in patient care Issue 8 Practice Issue: Increase in the demands of physical therapists to be more involved in quality assurance, fiscal planning, documentation of care, and the community. Ethical Issues - NONE GIVEN Issue 9 Practice Issue: The increase in the conduction and use of research to support clinical practice in physical therapy. Ethical Issues 1 . Research issues 2 . Needed if we are to promote good consequences 3 . Not ethics Issue 10 Practice Issue: Changes in the types of business relationships which physical therapists become involved with. Ethical Issues Utilization Issue 11 Practice Issue: Increased scrutinizing of reimbursement and documentation of physical therapy Services by outside agencies. Ethical Issues 1. Outside agencies do not fall under our ethics 110 : Issue 12 Practice Issue: Increase in the ; questioning of the efficacy of some accepted and : marginal treatment techniques. Ethical Issues .1 1 1. lPromise to public to be scientific 1 Issue 13 Practice Issue: Increase in insurance contracts that may limit access to care. 1 Ethical Issues _W__ , From the results of Questionnaire C, Question 3a the practice issues were ranked in order of their importance for ethical considerations. The ranking and the individual score for each issues is listed in'Table 4.20. The results of the three rounds of this study identified. 13 practice issues as consensus or' near consensus issues. A ranking of these issues on a Likert Scale placed these issues in their order of importance for considerations ‘A listing of the issues in.rank order is found in Table 4.21. 111 Table 4 20 Rank order of the Importance of Listedfiai |Pract1ce Issues for Ethical Cons1deration based on a Likert Scale of 0-5 with 5 urgent and 0 being “ ' Un1mportant.; 3' y _7 3f. g , SCORE 5 Issue 2 4.2 +Most Important Issue 3 4.0 Issue 5 4.0 Issue 10 3.4 Issue 4 3.2 Issue 12 3.2 Issue 13 3.2 Issue 1 3.0 Issue 7 3.0 Issue 9 2.85 mmUIU'IUI-bNNH H O Issue 8 Issue 11 Least Important Issue 6 :Table 4 21 L1st1ng of Practice issues 1n Order of '1 11mportance. ”a--._-w1_e ,_,,, ,U,H,,_,M ,2, ,4..-a The delivery of physical therapy services in a setting which involves physician ownership (full or part) of the physical therapy practice. responsibility of the therapist in total patient care. 3Issue 5: The increased opportunity for investment by physical therapists in health care products and services such as equipment companies and nursing homes. Issue 10: Changes in the types of business relationships with which physical therapists become involved. I Issue The current and projected manpower shortage in physical therapy. Issue Increase in the questioning of the efficacy of some accepted and marginal treatment techniques. Issue Increase in insurance contracts that may limit access to care. Issue The payment systems being utilized for the reimbursement of physical therapy services. LIssue Independent practice without referral will become the common mode of practice. Issue The increase in the conduction and use of research to support clinical practice in physical therapy. Issue Increase in the demands of physical therapists to be more involved in quality assurance, fiscal planning, documentation of care, and the community. Increased scrutinizing of reimbursement and documentation of physical therapy services by outside agencies. The current practice trend wherein more . physical therapists are leaving institutions and establishing practice Analysis of these practice issues indicates that of 113 Analysis of these practice issues indicates that of the seven most important issues identified by the panel, four relate to business relationships. The most urgent was identified as the practice of physicians owning physical therapy practices. Another important practice issue which is related to business involves the investment by physical therapists in equipment companies and service companies such as nursing homes. In both of these practice issues the potential ethical issues identified by the panel involved: 1) overutilization of services or patient exploitation, 2) loss of choice or autonomy of the patient. The increase in physical therapy responsibility in patient care was also considered an important practice issues. Some of the ethical considerations identified included: 1) optimal patient care or beneficence, and 2) responsibility and accountability to the public to provide needed service or fidelity. The current and projected manpower shortage in physical therapy was also identified as an important practice issue with ethical considerations. The ethical issues identified in this area are: 1) overutilization of 114 supportive personnel with potential for exploitation, and 2) meeting health needs of the patient and obtaining good consequences or beneficence. Another issue in practice which was considered important was the increase in the questioning of the efficiency of some treatment methods used in physical therapy.‘ Some ethical issues identified with this practice issue are: 1) keeping our promise to use effective. methods, and 2) telling the truth regarding effectiveness of treatments. Eadh of the 13 practice issues identified by the panel would need individual examination to identify the specific ethical problems encountered by clinicians in dealing with them. This is an area where further study is indicated. The implications for further study in these areas will be discussed further in Chapter VI. Question Area 5 Education Issues The fourth area of investigation in this study is the examination of educational principles to be utilized in instruction in ethics for physical therapy students. 115 This topic area was designed to identify: 1) topic areas to be included, 2) timing of ethical instruction, 3) methods of instruction, and 4) qualifications of instructor. The purpose of this section is to identify some criterion for organizing the delivery of ethical instruction within physical therapy curricula. The method followed to develop Questionnaire A is described in Chapter III. In Questionnaire A the panel members were asked four questions (See Appendix G). They were asked: a. What topics should be included in ethical instruction for physical therapists? b. At what point in physical therapy education do you feel ethical instruction should be presented? c. What methods of teaching do you feel are most appropriate for instruction in ethical decision making for physical therapists? d. What should be the qualifications of the instructor? The panel members made 26 responses to question 5a. From the 26 responses, 13 specific topics were identified. These topics are listed in Table 4.22. 116 :Physical Therapists Identified by Panel.» Results of EQuestionnaire Question 5a.¢,.-,._H,,_j_mqwhquur , List of Responses number of Responses Philosophical theories of ethics 3 Ethical principles Ethical problem solving Code of ethics Specific ethical issues Decision making process History of ethics Legal relationships - laws Bioethical issues Patient's Bill of Rights H r4 P‘ H Ia «J u: U! h ‘A Resolution of personal and professional differences Awareness of personal ethical 1 convictions in relation to the role of health professional Individual and collective obligations - 1 and responsibilities For Question 5b, the panel made 13 responses from which three general time frames were identified. In Table 4.23 the investigator has included the 13 responses under the three general statements. 117 ETable 4. 23 General Statement of Time Frames for x H jEthical Instruction from Statements of the Panel and ' Ipthe Specific Responses from Panel Members. Results 5 nof Questionnaire A, Question 5b ~ 1m¥5gauxgdflfi i Statement 1: Training in ethics and ethical decision making for physical therapy students should begin very early in the professional education of the students. 1. Day one and should be a thread throughout the curriculum. ~ 2. The first day. ‘ 3. Ethical attitude through the entire curriculum. 4. Early in the training-basic approaches and principles with some case material to highlight. 5. Must know principles prior to first clinical experience. Statement 2: Training in ethics should be » integrated throughout the entire curriculum. 1. Integrated with clinical component. 2. During clinical education small group discussions focused on actual and paradigmatic cases. Discussion of clinical issues after clinical experiences with advanced bioethical problem solving focus. Must know principles prior to first clinical __exper1ence.m 118 ——"“ ' _ ‘1 1 Statement 3: Ethical instruction should be related 3 to the clinical portion of the curriculum. , 1. Day one and should be a thread throughout the curriculum. - 2. Ethical attitudes through entire curriculum. 3. I don't feel there is a specific time and although I feel it needs individual attention, it should be reinforced throughout the ; educational process. 1 4. Early in training-basic approaches and principles with some case material to highlight. during clinical education-small . group discussions focused on ethical and 1 paradigmatic cases. Graduate school-seminar in ethical issues related to business aspects of ethics, leadership, administration, research. 7 i 7 7 ___ __ _ ____ ____ ___ __ __',J In response to Question So on the methods to be used in instruction the panel made 31 responses. From these 31 responses, 16 specific methods were identified. Table 4.24 lists the specific methods and the number of times that method was included in the responses of the panel. - Table 4 24 List Of Methods of Instruction. iResultsfif of Questionnaire A, Question 5c..g.> ~ 2+»91»9-1.9 xnrnons NUMBER or ' RESPONSES Case studies Discussion Lecture Clinical observation Problem solving Simulations Research _Presentations__ In response to question 5d which asks for the qualifications, the panel identified seven qualifications which were based on experience and training and 11 additional personal characteristics. These are listed in Table 4.25. é Table 4. 25 List of Characteristics of Instructor Teaching 5 Ethi es in Physical Therapy." 1 Question 5d.:.~ Results of Questionnaire A,5; ;f Qualifications 363903... Formal preparation in ethics 3 I 2. Continuing education course in ethics and 1 I teaching techniques for ethics 3. One term as a state board of physical l . therapy member 4. Ethics trained person and physical l therapist should team teach 5. One term on APTA Judicial Committee 1 6. Expertise in decision making process 1 7. Competent physical therapist 1 Personal ggalifications 8. Knowledge 1 l 9. Commitment 1 10. Enthusiasm 1 I ll. Flexibility l I 12. Understanding l 13. Dedication l 14. Good insights 1 15. Low level of sentimentality 1 I 16. Articulate l I I 17. Common sense 1 18. Ethical person 1 I In Questionnaire B the panel members were asked to rate their degree of agreement or disagreement with the 121 statements listed for topics (5a), time frames (5b), methods (5c), and qualifications of instructor (5d) on a five point Likert scale. The results of Questions 5a, 5b, 5c, and 5d are compiled in Tables 4.26, 4.27, and 4.28. - Table 4. 26 Panel Member Agreement on Listed Topic 1 iii 'jAreas based on a Five Point Likert Scale. Results cf_jg7} P Questionnaire 8, Question s;.+,-gr, 'p: _ _ ~{g.,1 : fimnb snub 1 As"! Al"! IWHUfl Dhqmn linome Iflmn 1 5 4 3 2 1 Score 1 1 1 Topic 1 3 2 o o o 4.6 1 1 Topic 2 4 1 O O O 4.8 1 . 1 1 Topic 3 S O O O 0 5.0 Topic 4 S O O O O 5.0 1 Topic 5 S O O O O 5.0 Topic 6 4 1 o o o 4.8 1 Topic 7 1 3 o o 1 3.6 I Topic 8 3 l 1 0 O 4.4 1 ITOpiC 9 1 2 2 O O 3.8 1 Topic 10 2 1 2 o o 4.0 1 lTopic 11 1 3 o 1 . o 3.8 1 Topic 12 3 2 o O O 4.6 1 Topic 13__ ”3 _1_ _1 _o _9 4,1 _1 I | | I | 1 | 1 1 122 TPoint Likert Scale., fQuestions Sb, 5c.:.;.,,, lTable 4.27 Panel Member Agreement on Time Frame for ”A: A" m III-I'- 3 Nu man u 5 4 3 3 1 I... lose Question 5b Tine Frames for Teaching Ethics I Statement 1 3 1 O O O 1 4.75 Statement 2 4 O O O O 1 5.0 l Statement 3 4 O O O O 1 5.0 I Question 5c Educational Methods Method 1 3 1 O O O 1 4.75 Method 2 3 1 O O O 1 4.75 Method 3 3 1 O O O 1 4.75 Method 4 1 1 2 O O 1 3.75 Method 5 3 O 1 O O 1 4.5 Method 6 1 2 1 O O 1 4.0 Method 7 1 2 O 1 O 1 3.75 IVMethod 8 1 1 1 1 O 1 3.5 Method 9 2 1 1 O O 1 4.25 I Method 10 1 3 O O O 1 4.25 n Method 11 2 1 O 1 O 1 4.0 I Method 12 1 O 3 O O 1 3.5 Method 13 1 O 1 2 O 1 3.0 Method 14 3 O 1 0 O 1 4.5 Method 15 O O 3 1 O 1 2.75 Method 16 1 1 1 1 O 1 3.5 11, ==éaauu==n 123 Table 4.28 Panel Member Agreement on Qualifications of ngnetructor based on a Five Point Likert Sca le.. Resul ta of ;?Que8t ionnaire 8, Question 5d. ' . eeeeeeee For Question 5a , "A: A" W Mlle"- m N- um 5 4 3 2 1 m lows - Qualification 1 2 3 0 0 0 0 4.4 I Qualification 2 2 1 2 0 0 0 4.0 o alification 3 0 0 2 2 1 0 2.2 I g alification 4 0 2 2 0 0 1 3.5 Qualification 5 0 0 1 3 1 0 2.0 I Qualification 6 2 2 0 1 0 0 4.0 I Qualification 7 3 0 1. 1 0 0 4.0 Qualification 8 3 2 0 0 0 0 4.6 Qualification 9 3 2 0 0 0 0 4.6 Qualification 10 3 2 0 1 0 0 4.0 Qualification 11 3 2 0 0 0 0 4.6 Qualification 12 4 1 0 0 0 0 4.8 Qualification 13 3 1 0 1 0 0 4.0 Qualification 14 2 3 0 0 0 0 4.4 I Qualification 15 2 0 1 1 l l 3.2 a Qualification 16 3 2 0 0 0 0 4.6 I ' Qualification 17 3 1 0 1 0 0 4.2 fl 1 aifia __3__=1_==1=I 0 0 0 4.4 10 of the topic areas showed a Likert Score of 4.0 or above. In these ten topic areas, none of the panel members disagreed with the topic being 124 included in ethical education for physical therapists. The ten topic areas in order of preference are listed in Table 4.29 Ebased on a Five Peint Likert Scale., Results of _ 1 Questionnaire B,-Question 53.sggfiggg,_,l_rwwfimxflmag§ Topic number Topic Area Likert Score 1 1 Topic 3 Ethicalproblem solving 5.0 Topic 4 Code of ethics 5.0 1 Topic 5 Specific ethical issues 5.0 1 Topic 2 Ethical principles 4.8 1 1 Topic 6 Decision making process 4.8 1 ' Topic 1 Philosophical theories 4.6 of ethics 1 3 Topic 12 Awareness of personal 4.6 1 ethical convictions Topic 8 Legal relationships 4.4 (Laws) Individual and collective responsibility Patient’s Bill of Rights Topic ;Topic 10 The results in Table 4.29 show a good agreement among the panel members on what topics need to be included in instruction. 125 For Question 5b which dealt with the time frame for teaching ethics in a physical therapy curriculum, all the panel members responding to the question strongly agreed or agreed with the three statements. The three statements are listed. in 'Table 4.23. Statement 1 received a Likert score of 4.75 while statements 2 and 3 received scores of 5.0. These results show a strong consensus of agreement among the panel members with the statements listed' in. Table 4.23. The results for Question 5c of Questionnaire 8 showed a Likert score of 4.0 or above on nine of the sixteen methods of instruction listed. in. Table 4.24. For these nine methods, none of the panel members disagreed with the statement. The nine methods are listed in order of preference in Table 4.30. 126 gkrabiég.;3o*Rankjoraer'or‘uethoasgf¢r_:hstinctionfart; 1vphysica1,Therapists»inEthics;basedlon*ajFiVePointiq; 1,Likert,Scale..,ReSultsof.Questionnaire:B,;Question;;; 1;5¢.¢ ';*n$§7aij- 'm~* Method Likert 1 number Method Score Method 1 Case studies 4.75 1 Method 2 Discussion 4.75 ' *Method 3 Lecture 4.75 _ Method 5 Problem solving 4.50 Method 14 Decision making instruction 4.50 Method 9 Seminars 4.25 1 Method 10 Activity to investigate 4.25 1 personal philosophies 1 Method 6 Simulations 4.00 1 Wei“ __ 4 ~ 00 The results listed in Table 4.30 show good agreement among the panel members on nine of the 16 methods. These methods were considered to be consensus statements for methods of teaching ethics in physical therapy curricula. The results of Question 5d of Questionnaire 8 showed 14 of 18 qualifications to have a Likert score of 4.0 or above. 0f the 14 characteristics with a 4.0 or 127 above Likert score, 10 issues showed no disagreement among the panel and the other four had only one panel member in disagreement. The qualifications of the instructor are listed in order of preference in Table 4.31. These results show excellent consensus among the panel members on the characteristics needed to teach ethics. The results listed in Table 4.31 tended to emphasize the personal characteristics of the instructor rather than the experience in ethics or formal training. Table 4 31 Rank Order of Qualifications for “5'1 gTeaching Ethics in Physical Therapy Curricula based §aon a Five Point Likert Scale. Results of ' ;,; liQuestionnaire 8, Question 5d.,,-1,w 1 j_,,_v Qualification Likert 1 number Quality Score I 12 Understanding 4.8 1 8 Knowledge 4.6 | 9 Commitment 4.6 11 Flexibility 4 . 6 16 Articulate 4 . 6 ' 1 Formal preparation in 4.4 1 ethics 1 14 Good insights 4 . 4 1 18 Ethical person 4.4 1 17__1__ _Common sense _ __ 1 H 4.2 128 2 Continuing education courses 4.0 6 Expertise in decision making process 4.0 7 Competent physical therapist 4.0 10 Enthusiasm 4.0 Dedication The consensus among the panel members was so high in Questionnaire 8, Questions 5a, 5b, 5c, and 5d that this area was omitted from the third round of the study. The fourth. topic {area of 'this study showed. good consensus among the panel members in all four of its areas. There were 10 topic areas which were identified as important topics by the panel of experts. They also showed agreement on the statements describing the time table for instruction within a curriculum. There was agreement on nine methods of instruction and on 14 characteristics of instructors. The implications of these results within physical therapy curricula will be discussed in Chapter V. 129 CHAPTER V SUMMARY In Chapter I the original goal of this study was stated as: 1) to identify the specific ethical issues facing physical therapists today, 2) to identify ethical issues which will be faced by physical therapists in the future, 3) to identify practice issues which contain ethical considerations, and 4) to provide information on how to incorporate professional ethics into physical therapy educational curriculum. The results of the study can be summarized by evaluating the extent to which these four goals have been achieved. Each goal will be examined individually to determine the success of the study in the four areas. In Chapter IV the results of the study were divided into four topic areas. These four topic areas relate directly to the four initial goals of the study. The four topic areas discussed in Chapter IV are: 1) current ethical issues in physical therapy, 2) 130 future ethical issues in physical therapy, 3) practice issues which present ethical questions, and 4) educational issues in instruction of ethics within physical therapy curricula. §9g1_ii IQ identify current gthicai issues facing physical therapists. The first topic area in this study is current ethical issues in physical therapy. This area was dealt with in Question 1 of each of the three rounds of the study. Progression of the study through rounds 1, 2, and 3 served to identify a large number of ethical issues, clarified the individual issues, and finally determined 15 specific ethical issues. The procedure followed is outlined in Chapter'IIIQ The 15 issues listed.below'were identified by the panel of experts in the final round of the study as either consensus choices, near consensus choices or majority choices. Issue i: The overutilization of physical therapy services. The identification of the factors which E constitute informed consent. I§§B§__ 131 The. protection of the patient’s right to confidentiality in interactions with therapists, personnel under the supervision of therapists, and physical therapy students. The justification of appropriate fees charged for the services rendered by physical therapists. The maintenance of truth in advertising. The identification and prevention of sexual (abuse) misconduct with patients by physical therapists. The tmaintenance of clinical competence by physical therapists. The adherence to ethical guidelines for the use of human subjects in clinical research. The endorsement of equipment or products in which the physical therapist has a financial interest. 1889: 1]. 132 The determination of the appropriate level of training, utilization and supervision of supportive personnel other than physical therapists who assist in the delivery of physical therapy treatments. The involvement. of physical therapists in business relationships which have the potential for patient exploitation. The identification.and.elimination.of fraud in billing for physical therapy services. The responsibility of physical therapists to provide adequate physical therapy services to all patients according to their need for care without regard to the patient's personal or social characteristics. The responsibility of physical therapists to provide for fair' distribution. of physical therapy services within the health care delivery system to meet the health needs of the population being served. 133 Issue i5: The professional qualifications and competence of physical therapists to serve as an entry point into the health care system. The initial goal of identifying a group of current ethical issues facing physical therapists has been accomplished by this study. Some questions which needed to be examined concerning these results were: 1. Have issues been included which are not ethical issues? 2. , Have important issues been excluded? 3. Are the issues included stated clearly enough to facilitate further study? In answer to Question 1 the researcher needed to address the procedure followed to identify the ethical issues included in the final results. The investigator utilized the Delphi Method to determine the views of the panel of experts and define the ethical statements to be included in each round of the study. Each issue needed to be agreed upon by all members of the panel for the issue to be a consensus issue. The consensus issues needed to pass the scrutiny of five to six panel members through 134 three rounds of the study to be included in the final list of issues” 'That did not assure that issues included in the list did not also have other problems associated with them such as the legal issues discussed in Chapter IV. It was felt by the investigator that the procedure followed does assure that the issues included in the final list do have ethical content. The researcher is confident that each issue listed is an important ethical issue facing physical therapists. The second question of whether all the important ethical issues facing physical therapists are included on the list is a more difficult question to answer. The initial questionnaire requested that six members of the panel list the most important ethical issues facing physical therapists. The panel was also asked in subsequent questionnaires to identify any important issues omitted from the lists. This gave opportunities for the panel to identify all ethical issues which they considered important. The small size of the panel and the amount of time which they had available to consider the issues could be factors which would allow for 135 omission of issues. The investigator felt it was likely that some important ethical issues facing physical therapists were not included on the final listing. This was not considered a major problem with the study as the intent was not to establish a static listing of issues, but to develop a foundation on which to build and to which other issues can be added. The ‘third. question. of ‘the. clarity' of ‘the issues presented will need to be addressed with each individual statement. The initial statements went through evaluation and.revision in each.round of the study by the panel as well as by the investigator. Even after that procedure, the investigator felt that further definition and.study of the individual issues.is strongly indicated. It was the intent of the study to provide impetus and direction for further' study’ on 'the specific issues identified. With additional analysis the individual ethical issues should undergo further clarification. The ethical issues as stated in the results of this study may not constitute the final form in which they will appear in future studies, but it was felt that they do provide 136 statements which identify the issues clearly enough to direct future studies. In summary, the goal of identifying current ethical issues facing physical therapy has been accomplished. The limitations of the study’ may' have allowed for omission of some important issues and for a need to clarify the statements of the issues. These limitations were not considered by the author to be major detractors from the study, but areas where further study is indicated. Qoa; 2. 0 'de ' eth'ca 'ssues c '1 ace s'ca t e 'sts ' the u ur . The second topic area, future ethical issues, builds on the first area. This area was investigated in Question 2 of each round of the study. The procedure used to determine the final listing of ethical issues is outlined in Chapter III. The final listing of future ethical issues from Table 4.11 is: ssu : The responsibility of physical therapists to respond to the environmental issues of pollutants and health hazards associated with physical therapy treatment. 137 ssu The duty of physical therapists to report misconduct in colleagues. issue 3: The need for therapists to define the limits *““ of personal relationships within the professional setting. Issue 4: The sexual and/or physical abuse of patients by physical therapists or those supervised by physical therapists. The statements listed above were all consensus choices by the panel members. The goal of identifying future issues facing physical therapists was then met by these four statements. The questions which were asked concerning the list of current issues also must be asked concerning the future issues. As in topic area one, the procedure that was followed to determine the future issues gives some assurance that the issues identified are ethical issues to be faced by physical therapists in the future. There are reasons to question whether the list of future issues is a complete list of all the future issues facing physical therapists. There are two major reasons.to question the completeness 138 of the final list. The first reason is that with a limited number of panel members there is a chance that issues will be excluded from the list. This seems likely in this instance due to the limited number of responses by the panel members. Some panel members indicated that the issues listed as present issues will remain in the future. It‘also appears likely that the issues listed as future issues are issues that are seen at the present time as well. An example of this is that Issue 4 of the future issues which addresses sexual and physical abuse of patients can also be found in the listing of current issues as Issue 6. The second reason to question the completeness of the results is that it is difficult for individuals to identify the issues of the future. It is difficult to differentiate present and future issues. In this study there appeared to be much overlap between current and future issues. In summary, the researcher felt that four issues were identified as future ethical issues facing physical therapists. The investigator did not believe that these issues represent all the future issues facing physical 139 therapy. The issues listed as future issues are also current issues and could reasonably be added to the list of current issues facing physical therapy. The four future issues identified in this study could provide some direction for further study, but it is likely that many of the future issues need yet to be identified. Gggl g. o e i h sica t e a ac ce 'ssues w ’c contain et ' al c ns d t' s. The third topic area of this study was the identification of practice issues which contained ethical content. This area was considered in Questions 3 and 4 of Questionnaires A and B and in Question 3 of Questionnaire C. The method followed is described in Chapter III. Twelve current and future practice issues were identified and defined through the three rounds of the study. The following list of current and future practice issues was taken from Table 4.21. Issue i: The delivery of physical therapy services in a setting which involves physician ownership (full or part) of the physical therapy practice. sue Issue 4: ss 7: l§§2§_23 140 The increase which has been seen in the responsibility of the therapist in total patient care. The increased opportunity for investment by physical therapists in health care products and services such as equipment companies and nursing homes. Changes in the types,of business relationships 'which physical therapists become involved with. The current.and.projected manpower shortage in physical therapy. Increase in the questioning of the efficacy 6 some accepted and marginal treatment techniques. Increase in insurance contracts that may limit access to care. The payment systems being utilized for the reimbursement of physical therapy services. Independent practice without referral will become the common mode of practice. 141 Igsgg i0: The increase in the conduction and use of research to support clinical practice in physical therapy. SLEEP—1.1: Increase in the demands of physical therapists to be more involved in quality assurance, fiscal planning, documentation of care, and the community. s e 2: Increased scrutiny of reimbursement and documentation of physical therapy services by outside agencies. igsge 1.3: The current trend wherein physical therapists are leaving institutions and establishing practice in the private arena. This final listing of practice issues places them in order of perceived importance by the panel members. This list of 13 practice issues accomplishes the goal of identifying practice issues which have ethical considerations. The procedure described in Chapter III which was utilized to compile the list of practice issues was comprehensive and identified important practice issues. As in topic areas 1 and 2 there is some question 142 as to whether some practice issues have been omitted from the list. It was difficult to project all the possible practice issues that will emerge in the future and it is likely that some future practice issues may have been omitted. The investigator believes that the list is comprehensive and identifies many issues which need to be analyzed. Many of these issues will need to be further defined and the ethical issues more clearly identified. The results of this study indicate that the goal of identifying practice issues which have ethical content has been reached. Additional practice issues may be identified and these can be added to the list developed in this study. Go . Tp provide ipformation on how to incopporate s ' t ' s ' to sica t e a educatipnal curpiculum. The fourth topic area dealt with educational issues and was investigated in Question 5 of Questionnaires A and B. The procedure followed is outlined in Chapter III of this study. The investigator addressed the following 143 areas: topics to be studied, when to teach ethics, methods to be used, and qualifications of the instructor. The first educational question dealt with the topics to be included in teaching ethics to physical therapists. The results of the study identified ten topics. These topics are taken from Table 4.29 of this study. Ippips pp ipciude in physical ppepapy cpppicuipp, 1. Ethical problem solving 2. Code of ethics 3. Specific ethical issues 4. Ethical principles 5. Decision making process 6. Philosophical theories of ethics 7. Awareness of personal ethical convictions 8. Legal relationships 9. Individual and collective responsibility 10. Patient's Bill of Rights These topics are listed in order of importance based on the responses of the panel of experts. This list of topics gives a good indication of the topics which should be included in a physical therapy curriculum. 144 The second educational issue questioned when to teach ethics within a physical therapy curriculum. From the responses of the panel members, three statements were developed.which received consensus approval by the panel members. The three statements were taken from Table 4.23. Time Frame fpp Ethical lhstpuctioh ih Physical Thepapy Quprigulpp. Statement 1. Training in ethics and ethical decision making for physical therapy students should begin very early in the professional education of the students. Statement 2. Training in ethics should be integrated throughout the entire curriculum. Statement 3. Ethical instruction should be related to the clinical portion of the curriculum. These consensus statements by the panel give clear indication that ethics should be integrated through the entire curriculum including the clinical portion. The third educational question dealt with which educational methods to use in teaching ethics within 145 physical therapy curriculum. Through the procedure outlined in Chapter III, nine methods were identified which had strong support by the panel. These methods which are taken from Table 4.30 include: hephods pf lhsppuction Method 1 Case Studies Method 2 Discussions Method 3 Lecture Method 4 Problem Solving Method 5 Decision making instruction Method 6 Seminars Method 7 Activities to investigate personal philosophy Method 8 Simulations Method 9 Testing These issues are listed in order of the preference of the panel members. The methods identified by the panel include most of the methods currently being utilized in ethics courses. To identify more clearly the importance of each method further investigation of the amount of time that should be devoted to each method is needed. 146 The last question in the education section dealt with the qualifications needed to teach ethics to physical therapists. The panel of experts came to good agreement on the 14 characteristics listed in Table 4.31. The qualifications are listed in rank order of the panel's perceived importance of these qualities. These qualifications include: 1. Understanding 2. Knowledge 3. Commitment 4. Flexibility 5. Articulate 6. Formal preparation in ethics 7. Good insights 8. Ethical person 9. Common sense 10. Continuing education courses in ethics 11. Expertise in decision making process 12. Competent physical therapist 13. Enthusiasm 14. Dedication 147 It may be noted that 10 out of 14 of the qualifications are personal characteristics which are not associated with any particular training. Only the four qualifications of formal preparation in ethics, continuing education, expertise in decision making, and attaining competency as a physical therapist would require any special training. The highest ranked of those four characteristics was formal preparation in ethics which was only the sixth highest characteristic in order of importance. This would appear to indicate that formal training in ethics and competence in physical therapy was not considered to be as critical as personal characteristics such as understanding, knowledge, commitment and common sense in an instructor. It may also indicate that two separate categories of first formal qualifications and secondly personal characteristics are being identified. Within the category of formal qualifications the ranking was: 1. Formal preparation 2. Continuing education 3. Expertise in decision making 4. Competent physical therapist 148 The personal characteristics consisted of: 1. Understanding 2. Knowledge 3. Commitment 4. Flexibility 5. Articulate 6. Good insight 7. Ethical person 8. Common sense 9. Enthusiasm 10. Dedication Looking at these as two separate categories gave a better indication of what qualifications and qualities the instructor should possess. The information which was received in the four areas of the question on educational issues does begin to achieve the goal of providing information on how to incorporate ethics into a physical therapy curriculum. There are questions of whether some topics or methods may have been missed. Considering the small size of the panel it is likely that some education methods or topics 149 have been excluded. The important educational questions of effectiveness and use need to be investigated in each of the methods identified. These would appear to be good areas for further research. The investigator believed that, this study achieved. its goal by' assisting in identifying issues which need to be discussed, identifying topics, identifying methods, indicating a time frame for instruction and compiling some qualifications and characteristics of the instructor. It is clear' that each. of these lareas need. additional investigation. The methods used in instruction appear to be a particularly important area for future research. The overall goal of this study was to provide a foundation for the continued study of ethics in physical therapy. The investigator believes that the goal was accomplished through meeting the above four goals. Each of the topic areas discussed needs further discussion and additional study. The information which was received in the study provides direction on which ethical issues and practice issues need examination and study. It also provided some guidance on what topics to incorporate in 150 educational curricula and how to present the material. Results of this study indicate a need for additional studies on the many specific ethical issues facing physical therapy. e c ' s o t ce Stud The importance of this study is emphasized by the changes in physical therapy which were discussed in Chapter I. Physical therapy is a rapidly growing health care profession which has extensive and direct personal contact and an expanding technology. Changes in health care delivery have increased the responsibility and autonomy of the profession. With all the changes in technology, autonomy and responsibility have come a greater need to protect and safeguard the well being of the patient. One important way to protect the patient is through the ethical behavior of the professional. The profession of physical therapy has a limited literature which discusses ethical issues. With the rapid changes taking place within the profession which require greater training, more technical skills and more autonomous 151 decision making, the need to identify and address the ethical issues contained in these changes becomes urgent. A lack of study on ethical issues within physical therapy is demonstrated by the sparsity of literature addressing these issues. In order to initiate an examination of ethics within physical therapy a broad study was needed to identify both the ethical issues facing physical therapists and the practice issues which have ethical ramifications. This study was conducted to fill that need. Through this study the investigator has begun the process of identifying a) current ethical issues; b) future ethical issues; c) practice issues with ethical considerations; and d) educational topics and methods. As discussed earlier in this chapter the goals outlined in Chapter I have been met. This study is an initial study of the ethical issues in physical therapy. It presents many areas and directions for further studies. With the rapid changes taking place within the profession of physical therapy, it is important to begin a systematic examination of the ethical implications of 152 those changes. This study can serve as the beginning of that examination. MW Fromlthe current study'many additional areas of future research have been identified. The first area of study would consist of a systematic examination of each identified issue to determine the prevalence, the importance of each issue and the difficulty which clinicians have in addressing the issue. In a study conducted by Guccione (1980) seven primary and 11 secondary issues were identified. Guccione asked physical therapists in New England to score ethical issues according to the frequency with which they encountered an issue and the difficulty they experienced in reaching a decision on how to act in those issues. For an issue to be ranked as a priority issue it needed to be scored as both frequently encountered and difficult to deal with based on the criteria set by Guccione (1980). This study and its results were discussed in Chapter II of this dissertation. The method of inquiry 153 used by Guccione would again be valuable in determining the incidence and difficulty of the issues identified in the current study. A problem noted in Chapter II was that no subsequent follow-up studies were designed to examine the individual issues identified as important by Guccione. It is also important to follow the identification of important ethical issues with further study on the specific difficulties and effects of those issues on practice. A systematic examination of the individual issues as to content, context, and outcomes is a further important area of investigation which follows from the current study. A list of ethical violations and resolutions compiled by the Judicial Committee of the American Physical Therapy Association for the last two years identified sixteen areas in which complaints have been made (See Appendix M) . Listed in order of number of alleged violations these include: 154 Alleged Actim Violations Taken 1. Inadequate supervision 23 14 2. Unprofessional conduct 13 5 3. Misleading advertising 11 8 4. Fraud-Insurance/Medicaid 10 9 5. Excessive fees 7 2 6. Unauthorized treatment 7 2 7. Documentation 6 2 8. Sexual misconduct 5 2 9. Felony/Battery 4 3 10. Overutilization 3 3 11. Drug/Alcohol abuse 2 1 12. Equipment endorsement 1 0 13. Physician employer 1 O 14. Receiving kickbacks 1 0 15. Failure to release records 1 O 16. Education loan unpaid 1 0 0f the 10 issues most commonly reported by the Judicial Committee as alleged ethical violations, during the past ten years, six were identified in the current study as important ethical issues. These included: 155 Issue 1: The overutilization of physical therapy services. I§§Q§;$: The justification of appropriate fees charged for the services rendered by physical therapists. Issue 5: The maintenance of truth in advertising. ss 6: The identification and prevention of sexual (abuse) misconduct with patients by physical therapists. Issue 19: The determination of the appropriate level of training, utilization and supervision of supportive personnel other than physical therapists who assist in the delivery’ of physical therapy treatment. Issue 12: The identification and elimination of fraud in billing for physical therapy services. The issues which appeared in both the list of most commonly alleged ethical violations and the list determined in the current study through consensus of experts are important issues and can be considered priority issues for further analysis. 156 Another important area of study would consist of an examination of the effects of various methods of instruction in ethics on the moral development of physical therapy students. This line of research has been examined in numerous studies in medicine and nursing. The investigator has identified various content areas and methods of instruction which were considered by the panel of experts to be appropriate in physical therapy education. Additional studies are needed to examine the effects which the various methods have on the moral development and behavior of the student. This important area of inquiry has been absent in physical therapy literature. Another area of needed research is an examination of the process by which physical therapists make ethical decisions. Ethnographic studies need to be undertaken to identify the process which physical therapists follow when confronted with an ethical problem. Nolette (1991) in a dissertation study interviewed six physical therapists to determine how they view their practice from a moral perspective. His study examined the factors 157 which molded the virtuous practitioner and the behaviors which characterized his/her actions. This method of ethnographic investigations into the daily stories, actions and decisions of practitioners needs further exploration. Further study is needed to understand how therapists act in ethical situations. Study in these areas will. help in directing methods for assisting students to understand ethical choices in clinical practice. A further area of inquiry suggested is an examination of practice issues and trends to identify ethical considerations. Each change in practice brings new challenges to a profession. Among these challenges is the need to identify how these practice issues impact on interactions with all aspects of society. Interactions with society can be changed to the benefit or detriment of various portions of that society. It is important to identify the ethical implications of changes in practice to assist the professional to respond to those changes. The investigator has identified some changes in practice which require further analysis. Study of these 158 practice issues should be conducted to identify the ethical and moral issues associated with these practice issues. The decisions made regarding practice issues should be guided by an ethical analysis of the issue. In summary, the goals of the study were to: 1) identify the specific ethical issues facing physical therapists today, 2) to identify ethical issues which will be faced by physical therapists in the future, 3) to identify practice issues which contain ethical content, 4) to provide information on how to incorporate professional ethics into physical therapists educational curricula. The investigator believes that these goals have been met as discussed earlier in Chapter V. The results of the study indicated a need for further studies on ethical issues and instruction in physical therapy. These areas of study take on additional importance due to the changes currently experienced in physical therapy practice. Although ethical decision making has long been considered an important component of professional development, discussion of ethical issues has been 159 largely absent from physical therapy literature. This deficit needs to be addressed as physical therapy develops as an autonomous profession. The integrity and diligence with which the profession examines its unique ethical issues, understands its ethical interactions, and determines methods for ‘educating its students will largely determine the moral position of that profession. Physical therapists have begun that process, but additional study is needed to understand and clarify these areas“ It is the author's hope and belief that the current study has assisted in this process. The recommendations presented for further study are also important to develop a better understanding of the ethical issues in physical therapy and to direct the moral development of the profession. The results of the current study combined with future investigations can create a nucleus for dialogue and understanding of the ethical issues facing physical therapy and provide guidance for the development of the profession. APPENDIX A AMERICAN PHYSICAL THERAPY ASSOCIATION CODE OF ETHICS II. III. 160 The American Physiotherapy Association Code of Ethics and Discipline (Adopted at A.P.A. Convention, Atlantic City, June 1935) PROFESSIONAL PRACTICE a. b. C. Diagnosing, stating the prognosis of a case __ .. "M droid-FF“ and “prescribing treatment shall be entirely _the responsibility of the physician. Any assumption of this responsibility by one of our members shall be considered unethical. The patient shall be referred back to the physician for periodical examinations. A member shall not attempt to criticize the physician or dictate techn1que grflprgcedure. ADVERTI SING a. Members shall not procure patients by means of solicitors, agents, circulars, displays, or advertisements inserted in commercial periodicals. Announcements in medical journals or business cards, not stating fees, are permissible. A statement that the work is medically supervised should appear on the announcement. A member may use the term "Physiotherapist” or (Physical Therapist" on an office door. BEHAVIOR a. Members shall not indulge, before patients, in QM§Q _ 9f 1..---c199tors: co-worker s__ "___or assslesess9rs;_w_h° have handled- the __c. a...s___e- It is well to bear in mind that our reputation as individuals and a group depends upon professional accomplishments and upon adherence to the standards of our organization. IV. 161 DISCIPLINE A. Charges and evidence against offenders will be weighed and acted upon by the Executive Committee. 162 AMERICAN PHYSICAL THERAPY ASSOCIATION Code of Ethics Principles (Adopted by the House of Delegates, June 1977) PREAMBLE The physical therapist member of the American Physical Therapy Association accepts this Code of Ethics as the basis for the practice of his profession. Individually and collectively, these members of the Association are responsible for promoting and maintaining the highest ethical standards. There shall always be a Guide for Professional Conduct to assist in the interpretation of the Code of Ethics. This guide, taking reference from the code, shall be subject to monitoring and timely revision by the Association's Judicial Committee. This Code of Ethics and the Guide for Professional Conduct shall be binding on the physical therapist members. PRINCIPLE 1 The physical therapist should respect the dignity offlgach individual with whom he islassoCiated in_ the_pr§9t1ce_of his profession_. PRINCIPLE 2 The physical therapist should qgmply with the law and_ Association poligiesfiqugrning_thg_practice of physicalfltherapy. PRINCIPLE 3 The physical therapist should.accept.responsibility for the exercise of professional judgment. —._..._. _. __m 163 PRINCIPLE 4 The physical therapist should. maintain optimal standards of professional practice. PRINCIPLE 5 The physical therapist should respect the confidences imparted to him in the course of professional activities. MW PRINCIPLE 6 The physical therapist should seek reasonable, deserved l_andfiscally sound remunerationmfor his serv1ces. " PRINCIPLE 7 The physical therapist should provide accurate information to the consumer about the profession and serv1ces proV1ded PRINCIPLE 8 The physical therapist should not ___enqage in «any form of self-aggrandizement. PRINCIPLE 9 The physical therapist should.accept.responsibilit for, _reporting‘ alleged 1 incompetence, ille ega éESiYities. and/9r.-un§thical conduct to the appropriate authority. PRINCIPLE 10 The physical therapist should so conduct himself in all of his affairs as to avoid discredit to 1:113 Association and to the profess1on. PRINCIPLE 11 The physical therapists should give his loyalty and support - to the American Physical Therapy ikssociation in its efforts to attain its objectives. 164 AMERICAN PHYSICAL THERAPY ASSOCIATION Code pf Ethics Preamble This Code of Ethics sets forth ethical.principles for the physical therapy profession. Members of this profession are responsible for maintaining and promoting ethical practices. This Code of Ethics, adopted by the American Physical Therapy Association, shall be binding on physical therapists who are members of the Association. Principle 1 Physical therapists respectuthe. rights and__d,igni.tx..9§.2l_1 Ediv_i§hé_l§9 “ Principle 2 Physical therapists cpmply with the laws ulations 9!-mh. Principle 3 Physical therapists accept responsibility for the _exercise of sound judgment. - ~ 1" Principle 4 Physical therapists maintain andflprgmgtemhighpstandapgs in the provision of physical therapy services. Principle 5 Physical therapists sgggppgmuneratipn_for their services. that is deserved and reasonable. " ' and. "-‘Hllw‘h m -——..-‘_1 Principle 6 Physical therapists Winfomation to the cpnsnmes~aboutwthehprofession_and about those services -wfimp q... , they provide. 165 Principle 7 Physical therapists accept the responsibility to protect the public and the profession from un‘éthi'caf, incompetent, or illegal acts. Principle 8 Physical therapists participate in effi9¥}s_£9_add£§,ssth£ health needs of theipublic ’”*"“” '" .Adopted; American Physical Therapy Association, House of Delegates 1981, Amended 1987. APPENDIX B LETTER TO JUDICIAL COMMITTEE MEMBERS 166 Herm Triezenberg, M.S., P.T. 3645 Reeds Lake Blvd. Grand Rapids MI 49506 I am writing to you as a current or former member of the Judicial Committee of the APTA to request your assistance in the initial stages of my doctoral studies at Michigan State University School of Education. My dissertation topics is the Identification of Current and Future Ethical Issues in Physical Therapy and their Applications in Curriculum Development. The purpose of this study is to identify categories of ethical issues and specific issues that are important for members of our profession to address. As a profession it is necessary for us to begin to identify in a systematic way specific ethical issues which directly impact our profession. To conduct this study I have chosen to use a Delphi Technique. The Delphi Technique consists of a series of questionnaires (usually four questionnaires) which are given to a panel of experts. Each questionnaire is developed based on the responses the investigator receives on the previous questionnaire. The purpose is to obtain consensus of opinion among the panel of experts by the final round. To identify individuals who have knowledge on ethical issues within physical therapy I am requesting that current and past members of the APTA Judicial Committee each identify five individuals whom they consider to be knowledgeable in ethical issues facing physical therapy. From the names which I receive from the Judicial Committee members, I hope to identify a panel of five to ten individuals with knowledge in ethical issues within physical therapy. Criteria which should be utilized for determining individuals with expertise in this area include: 1. Publication of articles or books on ethical issues in physical therapy. 2. Presentations at the state or national level on ethical issues in physical therapy. 167 3. Teaching of ethics within physical therapy curriculi. 4. Membership on state or national Judicial or Ethics Committees. 5. Advanced study on ethical issues at the graduate level. I request your assistance in identifying this panel of experts by' your listing on the enclosed form five individuals who meet two or more of the above criteria. If you feel that you.meet these criteria, please include your own name. Your responses will be kept confidential. I request that you do not sign the form or identify in any way who completed it. I have enclosed for you: 1. Form A: Survey of Judicial Committee Members 2. Addressed envelope Please complete form A and return it in the enclosed envelope by February 28, 1991. thank you for your assistance in this project. I apologize for the length of this correspondence, but I felt knowledge of both the substance and method of the study would be important for you. I hope this has not taken too much of your time and I thank you again for your assistance. Sincerely, H. Triezenberg, M.S., P.T. APPENDIX C FORM A SURVEY OF JUDICIAL COMMITTEE MEMBERS 168 FORM A: SURVEY OF JUDICIAL COMMITTEE MEMBERS List below five individuals who you consider to have expertise in ethical issues within physical therapy. 1. Name: Address (if known): or Worksite 2. Name: Address (if known): or Worksite 3 . Name: Address (if known): or Worksite 4 . Name: Address (if known): OI' Worksite 5 . Name: Address (if known): OI' Worksite Please complete and return by February 28, 1991 APPENDIX D LETTER TO EXPERTS 169 H. Triezenberg, M.S., P.T. 3645 Reeds Lake Blvd. Grand Rapids MI 49506 Thank you for consenting to participate in this study as a panel member in the area of ethical issues within physical therapy. During my phone conversation with you, I described: 1) the. purpose of the study, 2) the methodology to be used, 3) the specific time table and expected time involvement by panel members, and 4) the procedures to protect anonymity of participants. I have enclosed for your review a written outline of that information. I have enclosed a consent form which states that you understand the procedures and method of this study and are a voluntary participant. I have also included in this packet the first questionnaire of the study. The first questionnaire contains questions which are very broad and are designed to elicit open responses. Please complete the enclosed questionnaire and return with the signed consent form in the addressed envelope by March 27, 1991. Thank you again for consenting to participate in this study. If you have questions or concerns, please contact me: Home: 3645 Reeds Lake Blvd Grand Rapids MI 49506 (616) 956-0974 Work: Grand Valley State University Physical Therapy Department 150 Fieldhouse Allendale MI 49401 (616) 895-3562 Sincerely, H. Triezenberg, M.S., P.T. APPENDIX E FORM B-l OUTLINE OF STUDY GIVEN TO PANEL MEMBERS 170 FORM B-l OUTLINE OF INFORMATION GIVEN TO PANEL MEMBERS I. II. ose The purpose of this study is to: 1. Identify the specific issues facing physical therapists. 2. Provide information to direct further study of specific ethical issues. 3. Provide information for educators to utilize in the development of courses in biomedical ethics for physical therapy students. W m To identify the important ethical issues in physical therapy practice, a four-round Delphi technique will be used. A panel of individuals with knowledge concerning ethical issues within physical therapy will be used to identify current and future ethical issues facing physical therapy. e e ' e ' e The Delphi Technique was chosen as a method of bringing together the views of experts from throughout the profession of physical therapy to fonm a consensus on what issues are important in physical therapy. In this study it will also be used to determine what issues are currently facing the profession. The Delphi Technique consists of a series of questionnaires which are given to a selected panel of experts. The purpose is to achieve consensus among this group but avoid the psychological distractions of group dynamics. Typically the Delphi Technique consists of four rounds of questionnaires with each questionnaire providing the material for the development of the subsequent questionnaire. III. 171 The first questionnaire is composed of broad questions which will elicit open responses from panel members. The composition of the questions in the second round is based on the responses from the initial broad questions. The second questionnaire will provide the panel with a compilation of the results of the initial questionnaire and contain. questions which. will clarify -the vocabulary and terms used by the individual members. It will also attempt to identify specific areas of consensus and areas of disagreement. The third questionnaire will provide the experts with additional data on the responses of the other panel members. This questionnaire will outline areas of agreement between the experts but will also give minority views. This questionnaire gives the panel an opportunity to make revisions and respond to the information obtained in an attempt to obtain consensus among the panel of experts. If consensus is not obtained following the third questionnaire, a fourth round will be used to obtain greater consensus among the experts. We The choice of the panel of experts is an important step in the Delphi Technique. In this study the panel of experts is composed of 5-10 members. These experts were chosen by a method of polling members of the Judicial Committee of the American Physical Therapy Association. Each member who has served on the judicial Committee during the last 10 years was asked to identify five individuals whom they consider to be experts in ethical issues for physical therapy. The experts who were listed most frequently by the members of the Judicial Committee were contacted and asked to participate as panel members. ia 't The following procedure will be followed to protect the confidentiality of the participants. 172 The panel of experts will be selected in the method outlined above. The Judicial Committee members will be asked not to identify themselves when they submit their list of experts. The identified experts will be contacted individually to request their participation in the study. They will be informed of the method utilized in identifying them as experts. The experts will be given a complete description of the methods and purpose of the study. The individuals who consent to participate in the study will then be assigned a random number between one and ten. All data will be collected in a system that identifies the response of each expert by the assigned number. The investigator will not have access to the code which identifies the number with a specific panel member. All correspondence will be received and sent out through a secretary who will have access to the code. The secretary will address envelopes and receive questionnaires. The questionnaires will be removed from their envelope by the secretary upon receipt and the questionnaire with only a number designation will be given to the investigator. Participants in the study have the right to refuse to participate in any phase of the process or to withdraw from the study. IV. V. 173 B§§Bl£§ The names of the panel members will be listed in the final results of the study as part of my dissertation. The responses will not be identified with any specific panel member. The names of the panel members will not be identified in any subsequent publications or presentations unless prior written consent is given by the panel member at the completion of the study. The results of the study will be available to all panel members within two months of the completion of the study. s_ch_ecl‘_11e The study will be conducted beginning on March 7, 1991 and completed by June 15, 1991. During that time you will be requested to complete 3-4 questionnaires. It is difficult to determine the exact amount of time which will be required to complete each questionnaire. The questionnaires are designed to allow the panel to write as little or as much as they feel necessary. I would estimate that they will take approximately one hour each to complete. APPENDIX F FORM B-2 CONSENT FORM 174 FORM B-2 CONSENT FORM TOPIC: Identification of Ethical Issues within Physical Therapy and their Applications in Physical Therapy Education. INVESTIGATOR: H. Triezenberg, M.S., P.T. Doctoral Candidate, Michigan State University School of Education I have received an outline of: 1. The purpose of the study 2. Methods to be used 3. Procedures for confidentiality to be used 4. Schedule for study These have been explained to my satisfaction. I understand what will be required of me to participate in this study. I further understand that I have the right to withdraw from the study at any time and to not complete any section of the study that I choose. I voluntarily participate in this study as outlined: Name: (Please Print) Signed: Date: APPENDIX G FORM D-l INSTRUCTIONS FORM D-2 QUESTIONNAIRE A 175 FORM D-l Instructions for Questionnaire A Questionnaire A was designed to consist of a series of broad questions. You are encouraged to include explanations of your answers if you feel that they are needed. You may also bring up questions that you feel need to be asked in that particular question area. If you do not feel qualified or comfortable answering any question or portion of a question, leave them blank or provide an explanation. Use as much paper as necessary to complete the questions and attach additional sheets to the back of the questionnaire. l 7 5 a FORM D-2 QUESTIONNAIRE A 1. List the ethical issues which you feel are currently most important for physical therapists to address. 176 2. List any other ethical issues which you feel will become important for physical therapists in the next 10 years. 3 177 What current practice issues affect the physical therapist's need for competence in ethical decision making? 178 Are there future practice issues which you feel will present ethical issues for physical therapists in the next five years and what are those practice issues? NOTE: 179 This question and its subparts concerns the educational component of ethics in physical therapy. If you do not feel qualified to respond to questions concerning educational methodology, please leave the question or subpart of the question blank. What topic areas should be included in ethical instruction for physical therapists? (Examples of topic areas include: philosophical theories of ethics, ethical principles, ethical problem solving, Code of Ethics, specific ethical issues, etc.) b) 180 At what point in physical therapy education do you feel ethical instruction should be presented? Please discuss your reasons for the choices that you made. d) 181 What methods of teaching do you feel are most appropriate for instruction in ethical decision making for physical therapists? (Examples of teaching methods include: lecture, discussion, case studies, clinical, etc.) What should be the qualifications of the instructor? APPENDIX H FORM E-l INSTRUCTIONS FORM E-2 QUESTIONNAIRE B 182 FORM E-l INSTRUCTIONS FOR QUESTIONNAIRE B Questionnaire B is designed to clarify the specific issues and to develop statements which accurately represent the various issues. It is intended to give panel members information on the views of the other members of the panel, to assist them in responding to further questions. Reach each statement as presented and make any appropriate changes. Specific instructions are given for each question and subquestion. Write as little or as much as you feel is necessary for each section. If any clarification is needed, please contact me at: H. Triezenberg 3645 Reeds Lake Blvd Grand Rapids MI 49506 Home phone: (616) 956-0974 Work phone: (616) 895-3562 Please return by May 15, 1991. 1833 Form E-Z QUESTIMHAIRB 13 Question #1 The following statement of ethical issues are based on the specific statements made by the panel members. I have listed the specific statements of the panel nembers below each ethical issue. Please answer the questions listed for each issue. Issue #1: The inequity of the provision of physical therapy services within the current health care system. Statements of Panel: 1. Inequity in the provision of services in the health care system, including physical therapy 2. Limiting services based on reimbursement 3. Allocation of health services 4. Insurance contracts (PPO's, HHD's, etc.) that limit access to care 1-1a Do you agree with the statement of the ethical issue as written? Yes no With Modification l-lb What changes are needed to correct or clarify the statement? 1-1c Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. 1-1d Rephrase the statements which you feel do not fit to clarify their distinctiveness from the ethical issue as written Form 53-2 1184 rage 4 Issue #2: The determination of the appropriate utilization and supervision of personnel other than physical therapists (i.e. P.T.A., aide, A.T.C.) in the treatment of physical therapy patients. Statements of Panel: 1. Delegation of direction and supervision of treatment of patients to personnel other than physical therapists Supervisory relationships and the use of P.T.A. for active treatment programs Supervision of supportive personnel Utilization of supportive personnel Proper supervision of assistants and aides Proper assignment of assistants and aides Appropriate use of non-physical therapy personnel in P.T. clinics 1-2a no you agree with the statement of the ethical issue as written? Yes lo With Modification 1-2b What changes are needed to correct or clarify the statement? 1-2c Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. 1-2d Rephrase the statements which you feel do not fit to clarify their distinctiveness from the ethical issue as written 1£35 Form E-2 Page 3 Issue #3 The involvement of physical therapists in business relationships which limit professional autonomy or have the potential for financial abuse. Statements of Panel: 1. Disclosure in referral for profit situations 2. . . . physician owned physical therapy practice and other professional autonomy issues 3. Professional autonomy 4. Relations with referral sources that involve economic incentives to maintain the referral network l-3a Do you agree with the statement of the ethical issue as written? Yes No With Modification 1-3b What changes are needed to correct or clarify the statement? 1-3c Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. 1-3d Rephrase the statements which you feel do not fit to clarify their distinctiveness from the ethical issue as written Issue #4: The overutilization of physical therapy services. Statements of Panel: 1. Overutilization of services (stated by 2 members) 2. overutilization 1836 Form E-2 Page 4 1-41a Do you agree with the statement of the ethical issues as written? Yes No With Modification 1-41b What changes are needed to correct or clarify the statement? 1-41c Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. 1-4d Rephrase the statements which you feel do not fit to clarify their distinctiveness from the ethical issue as written lgggg_g§: The qualification of physical therapists as the entry point into the health care system. Statements of Panel: 1. Credibility as entry to the Health Care System 2. Independent practice without referral with regards to diagnosis and referral l-Sa Do you agree with the statement of the ethical issues as written? Yes No With Modification 1-5b What changes are needed to correct or clarify the statement? 1-5c Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. 1-5d Rephrase the statements which you feel do not fit to clarify their distinctiveness from the ethical issue as written 2187 Form E-2 rug: 9 Issue #6: The delineation of professional expertise and practice in relationship to other health providers. Statements of Panel: 1. Credentialing based on fairness and predicted on protection of the public 2. Validation of professional 'turf' 1-6a Do you agree with the statement of the ethical issue as written? Yes We With Modification 1-6b What changes are needed to correct or clarify the statement? 1-6c Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. 1-6d Rephrase the statements which you feel do not fit to clarify their distinctiveness from the ethical issue as written lgggg_!1: The accountability of physical therapy educational programs to develop physical therapy students in the skills needed as professionals. Statements of Panel: 1. Educational accountability 2. Ethics in education 1-7a Do you agree with the statement of the ethical issue as written? Yes No With Modification 1-7b What changes are needed to correct or clarify the statement? 1-7c Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. 2188 Form E-Z Page 0 1-7d Rephrase the statements which you feel do not fit to clarify their distinctiveness from the ethical issue as written Issue #8: The identification of what constitutes informed consent for physical therapy evaluation and treatment. Statements of Panel: 1. Implied consent 2. Patient autonomy and explicit informed consent for physical therapy evaluation and treatment 1-8a Do you agree with the statement of the ethical issue as written? Yes No With Modification l-ab What changes are needed to correct or clarify the statement? 1-Bc Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. I-ad Rephrase the statements which you feel do not fit to clarify their distinctiveness from the ethical issue as written 1§§gg_gg: The protection of the patient's right to confidentiality in interactions with therapist, personnel under the sapervision of therapists, and physical therapy students. Statements of Panel: 1. Confidentiality of records, especially with respect to student needs gg; patient needs 2. Confidentiality 1639 Form E-2 Page 7 1-9a Do you agree with the statement of the ethical issue as written? Yes No With Modification 1-9b What changes are needed to correct or clarify the statement? 1-9c Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. 1-9d Rephrase the statements which you feel do not fit to clarify their distinctiveness from the ethical issue as written The following statements were presented by only one panel member or by the investigator. Please seasider each of these issues and answer the questions. £§§QE_112: Justifiability of fees charged for services and reasonable rate of return. 1-10a Do you feel the above issue should be included as an important ethical issue for physical therapy? Yes NO Explain answer (optional) 1-10b Should it be included under any of the previous issues? Yes No Which one? Explain answer (optional) 1-10c Restate issue if you feel it needs clarification. 1S30 Form 3-2 Page 8 Issue #11: Defining the proper ethical limits of intervention: when doing . everything possible may not be in the best interests of the patient. l-lla Do you feel the above issue should be included as an important ethical issue for physical therapy? YES NO Explain answer (optional) 1-11b Should it be included under any of the previous issues? Yes no Which one? Explain answer (optional) 1-11c Restate issue if you feel it needs clarification. Issue #12: Truth in advertising. 1-12a Do you feel the above issue should be included as an important ethical issue for physical therapy? Yes NO Explain answer (optional) 1-12b Should it be included under any of the previous issues? Yes no Which one? Explain answer (optional) 1-12c Restate issue if you feel it needs clarification. 1531 Form E-2 Page 9 Issue #13: Fraud in billing. 1-13a Do you feel the above issue should be included as an important ethical issue for physical therapy? Yes No Explain answer (optional) 1-13b Should it be included under any of the previous issues? Yes Do Which one? Explain answer (optional) 1-13c Restate issue if you feel it needs clarification. Issue #14: Sexual abuse by physical therapists. 1-14a Do you feel the above issue should be included as an important ethical issue for physical therapy? Yes no Explain answer (optional) 1-14b Should it be included under any of the previous issues? Yes no Which one? Explain answer (optional) 1-14c Restate the issue if you feel it needs clarification. 2192 Form E-2 Page I U Issue #15: The treatment or non-treatment of AIDS patients by physical therapists. 1-14a Do you feel the above issue should be included as an important ethical issue for physical therapy? Yes No Explain answer (optional) 1-15b Should it be included under any of the previous issues? Yes No Which one? Explain answer (optional) 1-15c Restate the issue if you feel it needs clarification. Issue #16: Maintaining of clinical competency by physical therapists. 1-16a Do you feel the above issue should be included as an important ethical issue for physical therapy? Yes No Explain answer (optional) 1-16b Should it be included under any of the previous issues? Yes No Which one? Explain answer (optional) 1-16c Restate the issue if you feel it needs clarification. Form E-2 1533 Page 11 Issue 1-17a 1-l7b 1-17c #17: Compliance of physical therapists with the need for supportive documentation for services and/or charges rendered. Do you feel the above issue should be included as an important ethical issue for physical therapy? Yes No Explain answer (optional) Should it be included under any of the previous issues? Yes Mo Which one? Explain answer (optional) Restate the issue if you feel it needs clarification. #18: Resolving the conflicts that sometimes occur between what is Issue 1-18a 1-18b 1-18C permitted by law and not permitted by the Code of Ethics. Do you feel the above issue should be included as an important ethical issue for physical therapy? Yes NO Explain answer (optional) Should it be included under any of the previous issues? Yes no Which one? Explain answer (optional) Restate the issue if you feel it needs clarification. Form E-2 I 88118 1-19C 1-19b 1-19C ISSUE 1-20a 1-20b 1-20c 2194 Page 12 #19: The lack of research evidence to support clinical practice techniques. Do you feel the above issue should be included as an important ethical issue for physical therapy? Yes No Explain answer (optional) Should it be included under any of the previous issues? Yes No Which one? Explain answer (optional) Restate the issue if you feel it needs clarification. #20: The lack of cultural diversity within the physical therapy profession. Do you feel the above issue should be included as an important ethical issue for physical therapy? Yes No Explain answer (optional) Should it be included under any of the previous issues? Yes No Which one? Explain answer (optional) Restate the issue if you feel it needs clarification. 1595 norm 12.-4 rug: 1.) Issue #21: Adhering to the ethical guidelines for the use of human subjects in clinical research. 1-21a Do you feel the above issue should be included as an important ethical issue for physical therapy? Yes No Explain answer (optional) 1-21b Should it be included under any of the previous issues? Yes No Which one? Explain answer (optional) 1-21c Restate the issue if you feel it needs clarification. Issue #22: The endorsement of equipment, products, in which the physical therapist has a financial interest. 1-22a Do you feel the above issue should be included as an important ethical issue for physical therapy? Yes No Explain answer (optional) 1-22b Should it be included under any of the previous issues? Yes No Which one? Explain answer (optional) 1-22c Restate the issue if you feel it needs clarification. 1536 Form E-2 Page 14 Issue #23: The use of ethics and the disciplinary process to achieve personal gain. 1-23a Do you feel the above issue should be included as an important ethical issue for physical therapy? Yes No Explain answer (optional) 1-23b Should it be included under any of the previous issues? Yes We Which one? Explain answer (optional) 1-23c Restate the issue if you feel it needs clarification. Please list any other ethical issues which have been excluded from this list. 1537 Form E-2 Page 13 Question #2 The following statements of future ethical issues are based on the specific statements made by panel members. Please answer the questions listed for each issue. Mote: Many panel members stated that all the issues listed in Question #1 also pertain to the future. In the final compilation of future issues I will include all present issues as well. Issue #1: The response of physical therapists to environmental issues of pollutants and health hazards associated with specific treatment modalities. 2-1a Do you agree that the above issue is an important future issue for physical therapists? Yes We Explain response (optional) : 2-1b Restate the issue if you feel it needs clarification. Issue #2: Discrimination in employment opportunities within physical therapy private practices. 2—2a Do you agree that the above issue is an important future issue for physical therapists? Yes no Explain response (optional): 2-2b Restate the issue if you feel it needs clarification. Issue #3: The duty of physical therapists to report misconduct in colleagues. 2-3a Do you agree that the above issue is an important future issue for physical therapists? Yes NO Explain response (optional) : 2-3b Restate the issue if you feel it needs clarification. 1538 Form E-2 Page lb Issue #4: Defining the limits of personal relationships within the professional setting. 2-4a Do you agree that the above issue is an important future issue for physical therapists? Yes No Explain response (optional): 2-4b Restate the issue if you feel it needs clarification. Issue #5: How to address the issue of encroachment of other disciplines into the practice of physical therapy. 2-5a Do you agree that the above issue is an important future issue for physical therapists? Yes NO Explain response (optional): 2-5b Restate the issue if you feel it needs clarification. Issue #6: The utilization of treatment techniques without research to verify the degree of effectiveness. 2-6a Do you agree that the above issue is an important future issue for physical therapists? Yes No Explain response (optional): 2-6b Restate the issue if you feel it needs clarification. 1539 Form E-2 Page 1: Issue #7: The use of advertising in physical therapy practice. 2-7a Do you agree that the above issue is an important future issue for physical therapists? Yes No Explain response (optional): 2-7b Restate the issue if you feel it needs clarification. Issue #8: The sexual and physical abuse of patients by physical therapists or those supervised by physical therapists. 2-8a Do you agree that the above issue is an important future issue for physical therapists? Yes NO Explain response (optional): 2-8b Restate the issue if you feel it needs clarification. 2(30 Form 8-2 Page 18 Question #3 The following statement of practice issues are based on the specific statements made by the panel members. I have listed the specific statements of the panel nembers below each practice issue. Please answer the questions listed for each issue. Issue #1: Most states have currently passed legislation which allows for direct access to physical therapy services. Statements of Panel: 1. Direct access 2. Entry point to health care direct access - referral relationships 3. Independent Practice 4. Independence - increased autonomy as a profession 5. Direct access; i.e., practice without mandated need for a physician referral presents the opportunity for the physical therapist to function as the initial decision-maker in the health care system 3-1a Do you agree with the statement of the ethical issue as written? Yes No With Modification 3-1b What changes are needed to correct or clarify the statement? 3-1c Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. 3-1d Rephrase the statement(s) which you feel do not fit to clarify their distinctiveness from the practice issue as written. I§§§g_#2: The current reimbursement system for physical therapy services. Statements of Panel: 1. Reimbursement plans for physical therapy services and the injustices they may perpetuate 2. Reimbursement problems 2(31 Form h-Z Page 19 3-2a Do you agree with the statement of the ethical issue as written? Yes No With Modification 3-2b What changes are needed to correct or clarify the statement? 3-2c Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. 3-2d Rephrase the statement(s) which you feel do not fit to clarify their distinctiveness from the practice issue as written. Issue #3: The change in the method for provision of services from hospital . based and physical therapist owned practice to business relationships which involve physician ownership of physical therapy pract1ce and joint business ventures. Statements of Panel: 1. Provision of services - business arrangements 2. Physician and other's ownership of physical therapy practices 3. Continuation of the trend wherein more physical therapists are moving away from institutional settings and establishing themselves in the pr1vate practice arena 3-3a Do you agree with the statement of the ethical issue as written? Yes No With Modification 3-3b What changes are needed to correct or clarify the statement? 3-3c Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. 3-3d Rephrase the statement(s) which you feel do not fit to clarify their distinctiveness from the practice issue as written. 2(32 Form E-2 Page 20 Issue #4: The change in the role of the physical therapist from a direct treatment mode to one requiring increased delegation and supervision of other personnel such as P.T.A.'s, aides and A.T.C.'s. Statements of Panel: 1. Provision of services - delegation, direction and supervision 2. Use of PTA's and Aides 3-4a Do you agree with the statement of the ethical issue as written? Yes 80 With Modification 3-4b What changes are needed to correct or clarify the statement? 3-4c Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. 3-4d Rephrase the statement(s) which you feel do not fit to clarify their distinctiveness from the practice issue as written. Issue #5: The consumer is becoming more aware and sophisticated regarding their own health. Statements of Panel: 1. Awareness and sophistication of consumer 2. Consumer involvement and sophistication re: their own health and health care 3-5a Do you agree with the statement of the ethical issue as written? Yes We With Modification 3-5b What changes are needed to correct or clarify the statement? 3-5c Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. 3-5d Rephrase the statement(s) which you feel do not fit to clarify their distinctiveness from the practice issue as written. 2(33 Form E—2 Page 21 Issue #6: The aging of the patient population. Statements of Panel: 1. The aging of the patient population 2. Increase in age of patients 3-6a Do you agree with the statement of the ethical issue as written? Yes No With Modification 3-6b What changes are needed to correct or clarify the statement? 3-6c Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. 3-6d Rephrase the statement(s) which you feel do not fit to clarify their distinctiveness from the practice issue as written. Issue #7: Increase in the demands on physical therapists to be involved in: —___'-"' quality assurance, documentation of care, fiscal planning, management and the community. Statements of Panel: 1. Quality assurance 2. Documentation 3. Fiscal planning, management and accountability 4. Community responsibilities 3-7a Do you agree with the statement of the ethical issue as written? Yes 80 With Modification 3-7b What changes are needed to correct or clarify the statement? 2(34 Form E-2 Page 22 3-7c Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. 3-7d Rephrase the statement(s) which you feel do not fit to clarify their distinctiveness from the practice issue as written. The following issues were presented by only one panel member or by the investigator. Please consider each of these issues and answer the questions under each issue. Issue #8: Current challenge to licensure as a means to protect health professional privilege. 3-8a Do you feel that the above issue should be included as an important practice issue for physical therapy? Yes NO Explain reasons for answer (optional) 3-8b Should it be included under any of the previous issues? Yes No Explain reasons for answer (optional) 3-8c Restate the issue if you feel it needs clarification. Issue #9: The current and projected manpower shortage in physical therapy. 3-9a Do you feel that the above issue should be included as an important practice issue for physical therapy? Yes NO Explain reasons for answer (optional) 3-9b Should it be included under any of the previous issues? Yes No Explain reasons for answer (optional) 3-9c Restate the issue if you feel it needs clarification. 2(35 Form E-Z Page 23 Issue #10: Increase in the conduction and use of research to support clinical practice in physical therapy. 3-10a Do you feel that the above issue should be included as an important practice issue for physical therapy? Yes No Explain reasons for answer (optional) 3-10b Should it be included under any of the previous issues? Yes, No Explain reasons for answer (optional) 3-10c Restate the issue if you feel it needs clarification. Issue #11: The increase in high technology in what has been a traditionally low-tech profession. 3-11a Do you feel that the above issue should be included as an important practice issue for physical therapy? Yes No Explain reasons for answer (optional) 3-11b Should it be included under any of the previous issues? Yes No Explain reasons for answer (optional) 3-11c Restate the issue if you feel it needs clarification. Issue #12: The increase in the responsibility of physical therapists in overall patient care. 3-12a Do you feel that the above issue should be included as an important practice issue for physical therapy? Yes No Explain reasons for answer (optional) Form E-Z 3-12b 3-12C 2(36 Page 24 Should it be included under any of the previous issues? Yes No Explain reasons for answer (optional) Restate the issue if you feel it needs clarification. #13: The increase in the sophistication of information gathering and Issue 3-138 3-13b 3-13c information flow in health professions. Do you feel that the above issue should be included as an important practice issue for physical therapy? Yes NO Explain reasons for answer (optional) Should it be included under any of the previous issues? Yes No Explain reasons for answer (optional) Restate the issue if you feel it needs clarification. #14: Increased scrutiny of the qualifications and credentials of the Issue 3-148 3-14b 3-14C individuals providing health services. Do you feel that the above issue should be included as an important practice issue for physical therapy? Yes NO Explain reasons for answer (optional) Should it be included under any of the previous issues? Yes No Explain reasons for answer (optional) Restate the issue if you feel it needs clarification. 2(37 Form E-2 Page 25 Issue #15: Increased opportunities for physical therapists to become involved in highly successful business ventures with the accompanying risk that the profit motive will become primary and supplant the focus on quality patient care. 3-15a Do you feel that the above issue should be included as an important practice issue for physical therapy? Yes No Explain reasons for answer (optional) 3-15b Should it be included under any of the previous issues? Yes No Explain reasons for answer (optional) 3-15c Restate the issue if you feel it needs clarification. 2(38 Form E-2 Page 20 Question #4 The following statements of future practice issues are based on the specific statements made by the panel members. I have listed the specific statements of the panel members below each practice issue. Please answer the questions listed for each issue. Mote: Many panel members stated that all the issues listed in question #3 also pertain to the future. In the final compilation of future issues I will include all present issues as well. Issue #1: Independent practice without referral will become a common mode of practice. Statements of Panel: 1. Independent practice without referral 2. Independent practice 4-1a Do you agree with the statement of the ethical issue as written? Yes Mo With Modification 4-1b What changes are needed to correct or clarify the statement? 4-1c Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. 4-1d Rephrase the statement(s) which you feel do not fit to clarify their distinctiveness from the practice issue as written. Issue #2: Changes in business relationships which physical therapists will become involved in. Statements of Panel: 1. Business relationships 2. Conflict of interest in the kinds of business relationships physical therapists enter into with non-physicians, e.g. ATC's and psychologists 2(39 Form 8-2 Page 2/ 4-2a Do you agree with the statement of the ethical issue as written? Yes No With Modification 4-2b What changes are needed to correct or clarify the statement? 4-2c Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. 4-2d Rephrase the statement(s) which you feel do not fit to clarify their distinctiveness from the practice issue as written. Issue #3: Increased scrutiny of reimbursement and documentation of physical therapy services by outside agencies. Statements of Panel: 1. Reimbursement problems 2. Credibility in areas of documentation and reimbursement 4-3a Do you agree with the statement of the ethical issue as written? Yes No ‘ With Modification 4-3b What changes are needed to correct or clarify the statement? 4-3c Are there any statements which do not fit in this issue? If so, identify which statements do not belong and describe why. 4-3d Rephrase the statement(s) which you feel do not fit to clarify their distinctiveness free the practice issue as written. 2113 Form E-2 Page 28 The following issues were presented by only one panel member or by the investigator. Please consider each of these issues and answer the questions under each issue. Issue #4: Investment by physical therapists in health care products and services such as equipment companies and nursing homes. 4-4a Do you feel that the above issue should be included as an important practice issue for physical therapy? Yes No Explain reasons for answer (optional) 4-4b Should it be included under any of the previous issues? Yes No Explain reasons for answer (optional) 4-4c Restate the issue if you feel it needs clarification. Issue #5: Increase in the manpower shortage. 4-5a Do you feel that the above issue should be included as an important practice issue for physical therapy? Yes NO Explain reasons for answer (optional) 4-5b Should it be included under any of the previous issues? Yes No Explain reasons for answer (optional) 4-5c Restate the issue if you feel it needs clarification. Issue #6: Increase in the age of the patient population. 4-6a Do you feel that the above issue should be included as an important practice issue for physical therapy? Yes No Explain reasons for answer (optional) Form E-Z 4-6b 4-6C 21L1 Page 29 Should it be included under any of the previous issues? Yes No Explain reasons for answer (optional) Restate the issue if you feel it needs clarification. #7: Increase in the questioning of the efficacy of some accepted and Issue 4-78 4-7b 4-7C marginal treatment techniques. Do you feel that the above issue should be included as an important practice issue for physical therapy? Yes NO Explain reasons for answer (optional) Should it be included under any of the previous issues? Yes No Explain reasons for answer (optional) Restate the issue if you feel it needs clarification. #8: Increase in professional accountability and liability. Issue 4-8a 4-8b 4-8C Do you feel that the above issue should be included as an important practice issue for physical therapy? Yes No Explain reasons for answer (optional) Should it be included under any of the previous issues? Yes No Explain reasons for answer (optional) Restate the issue if you feel it needs clarification. 2112 form E-z rage :u Issue #9: Increase in insurance contracts that may limit access to care. 4-9a Do you feel that the above issue should be included as an important practice issue for physical therapy? Yes NO Explain reasons for answer (optional) 4-9b Should it be included under any of the previous issues? Yes No Explain reasons for answer (optional) 4-9c Restate the issue if you feel it needs clarification. Issue #10: Additional unspecified changes in the health care system. 4-10a Do you feel that the above issue should be included as an important practice issue for physical therapy? YES NO Explain reasons for answer (optional) 4-10b Should it be included under any of the previous issues? Yes No Explain reasons for answer (optional) 4-10c Restate the issue if you feel it needs clarification. Issue #11: Increased awareness and sophistication of consumer. 4-11a Do you feel that the above issue should be included as an important practice issue for physical therapy? Yes NO Explain reasons for answer (optional) 2113 Form E—Z rage 51 4-1lb Should it be included under any of the previous issues? Yes I No Explain reasons for answer (optional) 4-11c Restate the issue if you feel it needs clarification. 1§§QE_113: Increase in the number of AIDS patients seen by physical therapists. 4-12a Do you feel that the above issue should be included as an important practice issue for physical therapy? Yes "D Explain reasons for answer (optional) 4-12b Should it be included under any of the previous issues? Yes No Explain reasons for answer (optional) 4-12c Restate the issue if you feel it needs clarification. Issue #13: Increasing need to determine what our own identify is and develop autonomy as a profession. 4-13a Do you feel that the above issue should be included as an important practice issue for physical therapy? Yes No Explain reasons for answer (optional) 4-13b Should it be included under any of the previous issues? Yes No Explain reasons for answer (optional) 4-13c Restate the issue if you feel it needs clarification. 21u4 Form E-Z rage :4 Issue #14: Increase in the use of advertising by physical therapists. 4-14a Do you feel that the above issue should be included as an important practice issue for physical therapy? YES NO Explain reasons for answer (optional) 4-14b Should it be included under any of the previous issues? Yes No Explain reasons for answer (optional) 4-14c Restate the issue if you feel it needs clarification. Please list any other practice issues which were excluded fr:- this list. Form 52-2 2115 Page 33 Question #5 a) The following topic areas for ethical instruction were listed by one or more panel members. The number of times a response was given is in parentheses. Please indicate if you agree or disagree with the topic area by circling the appropriate number. Strongly Strongly Agree Agree Neutral Disagree Disagree Philosophical theories of ethics (3) 5 4 3 2 1 - Reasons for choice (optional) Ethical principles (3) 5 4 3 2 1 - Reasons for choice (optional) Ethical problem solving (4) 5 4 3 2 1 - Reasons for choice (optional) Codes of ethics (5) 5 4 3 2 1 - Reasons for choice (optional) Specific ethical issues (3) 5 4 3 2 1 - Reasons for choice (optional) Decision making process (2) 5 4 3 2 1 - Reasons for choice (optional) History of ethics (1) 5 4 3 2 1 - Reasons for choice (optional) Legal relationships - Laws (1) 5 4 3 2 1 - Reasons for choice (optional) Bioethical issues (1) 5 4 3 2 1 - Reasons for choice (optional) 21.6 Form E-Z rage .w 10. Patient's Bill of Rights (1) 5 4 3 2 - Reasons for choice (optional) 11. Resolution of personal and professional differences (1) 5 4 3 2 - Reasons for choice (optional) 12. Awareness of personal ethical convictions in relation to the role of health professional (1) 5 4 3 2 - Reasons for choice (optional) 13. Individual and collective obligations and responsibilities (1) 5 4 3 2 - Reasons for choice (optional) Please list any additional topic areas that were excluded. 21f7 Form E—2 Page 3: 5b. The statements made by the panel on the point at which ethics should be taught within a physical therapy curriculum did not clearly define a time, but it did present three considerations. I will condense the comments into three statements and give the supporting views of the panel members. Please answer the questions. Statement 1: Training in ethics and ethical decision making for physical therapy students should begin very early in the professional education of the students. Statements of Panel: 1. Day one and should be a thread throughout the curriculum 2. The first day 3. Ethical attitude through the entire curriculum 4. Early in the training - basic approaches and principles with some case material to highlight 5. Must know principles prior to first clinical experience Sb-la Do you agree with the above statement? Strongly Agree Agree neutral Disagree Strongly Disagree 5 4 3 2 l Sb-Ib Make any changes which you feel are needed to clarify the statement. Statement 2: Training in ethics should be integrated through the entire curriculum. Statements of Panel: 1. Day one and should be a thread throughout the curriculum 2. Ethical attitudes through entire curriculum 3. I don't feel there is a specific time and although I feel it needs individual attention, it should be reinforced throughout the educational process 4. Early in training - basic approaches and principles with some case material to highlight. During clinical education - small group discussions .focused on ethical and paradigmatic cases. Graduate school - seminar in ethical issues related to business aspects of ethics, leadership, administration, research. 5b-2a Do you agree with the above statement? Strongly Agree Agree Neutral Disagree StronglyIDisagree 5 4 3 2 5b-2b make any changes which you feel are needed to clarify the statement. 2113 Form 52-2 Page so Statement 3: Ethical instruction should be related to the clinical portion of the curriculum. Statements of Panel: 5c 1. Integrated with clinical component 2. During clinical education small group discussions focused on actual and paradigmatic cases 3. Discussion of clinical issues after clinical experiences with advanced bioethical problem solving focus 4. Must know principles prior to first clinical experience 5b-3a Do you agree with the above statement? Strongly Agree Agree Neutral Disagree Strongly Disagree 5 4 3 2 1 5b-3b Make any changes which you feel are needed to clarify the statement. The methods of instruction which were listed by one or more of the panel members are presented below. The number of times that each method was given is in parentheses. Please indicate whether you agree or disagree with the method by circling the appropriate number. Methods Strongly Strongly Agree Agree Neutral Disagree Disagree 1. Case studies (5) 5 4 3 2 1 - Reasons for choice (optional) 2. Discussion (5) 5 4 3 2 1 - Reasons for choice (optional) 3. Lecture (4) s 4 3 2 1 - Reasons for choice (optional) 4. Clinical Observations (4) 5 4 3 2 1 - Reasons for choice (optional) 5. Problem solving (2) 5 4 3 2 1 - Reasons for choice (optional) Form 3'2 10. 11. 12. 13. 14. 15. 16. Please list any additional methods which were excluded from this list. 2119 Simulations (1) - Reasons for choice (optional) Research (1) - Reasons for choice (optional) Presentations (1) - Reasons for choice (optional) Seminar (1) - Reasons for choice (optional) Activity to investigate and probe own philosophy (1) - Reasons for choice (optional) Testing (1) - Reasons for choice (optional) Attend Hearings (1) - Reasons for choice (optional) Personal log entries (1) - Reasons for choice (optional) Decision making process (1) - Reasons for choice (optional) Newspaper clippings (1) - Reasons for choice (optional) Interview assignments (1) - Reasons for choice (optional) Page 31 2220 Form E—Z Page on 5d. The qualifications to teach ethics that were listed by one or more panel members are presented below. The number of times that each qualification was given is in parentheses. Please indicate if you agree or disagree with the qualification by circling the appropriate number. Strongly Strongly Qualifications Agree Agree Neutral Disagree Disagree 1. Formal preparation in ethics (3) 5 4 3 2 1 - Reasons for choice (optional) 2. Continuing education course in ethics and teaching techniques for ethics (1) 5 4 3 2 1 - Reasons for choice (optional) 3. One term as a state board of physical therapy member (1) 5 4 3 2 1 - Reasons for choice (optional) 4. Ethics trained person and physical therapist should team teach (I) 5 4 3 2 1 - Reasons for choice (optional) 5. One term on APTA Judicial Committee (1) 5 4 3 2 1 - Reasons for choice (optional) 6. Expertise in decision making process (1) 5 4 3 2 1 - Reasons for choice (optional) 7. Competent physical therapist (1) 5 4 3 2 1 - Reasons for choice (optional) The following qualifications are personal characteristics that were listed by one or more pane11melbers. 8. Knowledge 5 4 3 2 1 - Reasons for choice (optional) Form E-Z 10. 11. 12. 13. 14. 15. 16. 17. 18. 2221 Commitment - Reasons for choice (optional) Enthusia- - Reasons for choice (optional) Flexibility - Reasons for choice (optional) Understanding - Reasons for choice (optional) Dedication - Reasons for choice (optional) Good insights - Reasons for choice (optional) Low level of sentimentality - Reasons for choice (optional) Articulate - Reasons for choice (optional) Common Sense - Reasons for choice (optional) Ethical person - Reasons for choice (optional) Page 39 APPENDIX I LETTER TO PANEL TO CHANGE TIMETABLE 222 3645 Reeds Lake Blvd Grand Rapids MI 49506 November 19, 1991 I apologize for the delay in sending you the third round of the Delphi study' on Ethical Issues in. Physical Therapy. I hope that the change in the time table for this study does not inconvenience you or make your participation more difficult. Many factors added together to prevent progress on the study until fall semester began at Michigan State University. The new time table for this study is: a) completion of analysis of Questionnaire C by December 31, 1991. b) If a fourth questionnaire is found to be necessary it will be sent out by January 15, 1992. c) The final results of the study will be available by March 15, 1992. I appreciate your contributions of ideas and time toward the completion of the initial rounds of the study. I hope that you are able to continue to participate in the final rounds of the study. Thank you and I apologize again for the unforseen delay. Sincerely, H. Triezenberg HLT:sc APPENDIX J FORM F-l INSTRUCTIONS FORM F-Z QUESTIONNAIRE C 2223 FORM F-l Instructions for Questionnaire C: Questionnaire C is designed to allow the panel to reach consensus on which statements to include in a listing of ethical issues facing physical therapy. It is intended to give panel members additional feedback on the views of the other panel members and to give panel members an opportunity to make comments on the issues. Please read each statement and make any changes or additions which you feel are necessary. The specific instructions for each question are presented with the question. Please write as much or as little as you feel is necessary on each section and each issue. If any additional clarification or assistance is needed, please contact me at: E. Triezenberg 3645 Reeds Lake Blvd. Grand Rapids NI 49506 Home: (616) 956-0974 Hark: (616) 895-3562 Please return by December 20, 1991 Form F-2 QUESTIONNAIRE C me 2224 1a. The following (9) statements of ethical issues were chosen by all members (100%) of the panel as important ethical issues facing physical therapists today. Please coment on any changes you wish to make on these issues in the space provided. Issue #1: Issue #2: Issue #3: Issue #4: Issue #5: Issue 46: Issue 47: Issue #8: Issue #9: The overutilization of physical therapy services. Comment: The identification of the factors which constitute informed consent. Comment: The protection of the patient's right to confidentiality in interactions with therapists, personnel under the supervision of therapists, and physical therapy students. Comment: The justification of appropriate fees charged for the services rendered by physical therapists. . Comment: The maintenance of truth in advertising. Comment: The identification and prevention of sexual (abuse) misconduct with patients by physical therapists. Comment: The maintenance of clinical competence by physical therapists. Chmment: The adherence to ethical guidelines for the use of human subjects in clinical research. Comment: The endorsement of equipment, products, in which the physical therapist has a financial interest. Comment: 2225 lb. The following statements of ethical issues were considered by greater than 50% of the panel to be important issues facing physical therapists today. If you feel that this issue should not be included as an important ethical issue indicate by marking re'ect and if you feel it should be included, mark acce t. I have provid a representative list of coments from panel members Issue #1: Reject Accept Issue #2: Reject Accept Issue #3: Reject Accept a space for your additional comments. The professional qualifications and competence of physical therapists to serve as the entry point into the health care system. Representative Comments: 1) At the root of the issue is professional competence. 2) Relative to state law and APTA Code of Ethics. Determining the appropriate limits of therapeutic intervention when doing everything possible may not be in the best interests of the patient. Representative Cemmemts: 1) Relates to patient's rights and overutilization. 2) It is already covered by Code of Ethics. The identification and elimination of fraud in billing for physical therapy services. Representative Comments: 1) Dishonesty is unethical. 2) This is addressed in the Code and Guide. Issue #4: Reject Accept Issue #5: Reject Accept Issue #6: Reject Accept 2226 The responsibility of physical therapists to provide for fair distribution of physical therapy services within he health care delivery system to meet the health needs of the population being served. Representative Comments: Investigator Note: All comments related to deletion of use of ”inequitable“ in original statement and replacing it with a more neutral phrase. I have substituted “fair . . . to meet the health needs' COMMENTS: The determination of the appropriate level of training, utilization and supervision of supportive personnel other than physical therapists who assist in the delivery of physical therapy treatments. Representative Comments: 1) Does not distinguish between professional and non-professional non-P.T.‘s. COMMENTS: The involvement of physical therapists in business relationships which have the potential for patient exploitation. Representative Comments: Investigator Note: The comments were primarily directed toward removing “professional autonomy“ from the original statement of this issue and include it in the statement of a new issue. I have done that in the section 1d. New Issues #2. COMMENTS: Issue #7: Reject Accept Issue #8: Reject Accept Issue #9: Reject Accept 22?? The accountability of physical therapy educators to impart to their students the necessary skill, knowledge, and behavior for the safe and effective practice of physical therapy. Representative Comments: 1) I believe that certification of P.T. programs is not the responsibility of the APTA. COMMENTS: The responsibility of physical therapists to provide appropriate physical therapy services to all patients according to their need for care without regard to the patient's personal or social characteristics. Representative Comments: Investigator Note: This issue was originally directed at the treatment or non-treatment of AIDS patients. Many comments by the panel requested a broadening of the statement to include other conditions. The responsibility of physical therapists to provide adequate supportive documentation for the services and/or charges given. Representative Comments: 1) It is a part of practice standards. 2) Can be included with fraud in billing. COMMENTS: 2228 1c. The following statements of ethical issues were rejected by greater than 50% of the panel. If you feel this issue should not be included in a list of important ethical issues mark Re'ect and if you feel it should be included mark Acce t. I have includga a representative list of comments from panel membérs and room for additional statements. Issue #1: Reject Accept Issue #2: Reject Accept Issue #3: Reject Accept The delineation of professional expertise and practice in relationship to other health providers. Representative Comments: 1) I feel the code and guide adequately address the practice of physical therapy and we have no control of others relative to turf. Resolving the conflicts that occur between what is permitted by law and not permitted by the Code of Ethics. Representative Consents: 1) State laws differ and the associations Code and Guide have to consider all lawful practice. 2) Therapists need to continue to refine their understanding and relationship between law and ethics. 3) It is a procedural issue not an ethical one. 4) Since the code of ethics requires that you abide by the law, then what is the law is inherent in the code of ethics. 5) This is just the difference between law and ethics. COMMENTS: The lack of adequate research evidence to support some often used clinical practice techniques. Representative Comments: 1) In my mind this could be when someone was found guilty of malpractice. Much of what we do is not supported by research. 2) This seems to be a practice validation issue rather than an ethical one. . . 3) This issue relates to informed consent and truth telling in advertising. Issue #4: Reject Accept Issue #5: Reject Accept 2229 The lack of cultural diversity within the physical therapy profession. Representative Comments: 1) Cultural diversity is a social issue not a professional ethics issue. 2) Cultural diversity is not the issue. Racial discrimination is. (Culture # race!). This relates to systematic bias in admissions and is not an issue that arises from P.T. but education in general. COMMENTS: The use of ethics and the disciplinary process to achieve personal gain. Representative Coments: 1) Issue involved is not clear. 1d. 2230 The following statements of ethical issues were not included on the last questionnaire but are new issues which were suggested by panel members. Please indicate if you feel these issues should be added to the list of ethical issues. Issue #1: Establishing policies for the credentialing of health professionals based on fairness and pedicated on the protection of the public safety. Reject COMMENTS: Accept Issue #2: The involvement of physical therapists in business relationships which limit or has potential to limit the professional autonomy of the therapist. Reject COMMENTS: Accept Question #2 2331 Future Ethical Issues 2a. The following statements of ethical issues were chosen by all members (100%) of the panel as important ethical issues facing physical therapists in the next five years. Please comment on any changes which you wish to make on these issues in the space provided. Issue #1: Issue 42: Issue #3: Issue #4: The responsibility of physical therapists to respond to the environmental issues of pollutants and health hazards associated with specific treatment modalities. Comment: The duty of physical therapists to report misconduct in colleagues. Comment: The need for therapists to define the limits of personal relationships within the professional setting. Comment: The sexual and/or physical abuse of patients by physical therapists or those supervised by physical therapists. Comment: 2232 2b. The following (2) statements of ethical issues were chosen by a majority (more than 50%) of the panel as important ethical issues facing physical therapy in the next g years. If you feel that this issue should not be included as an important ethical issue indicate by marking Reject and if you feel it should be included mark Acce t. I have provided a representative list of comments from panel rs and a space for your additional comments. Issue #1: Reject Accept Issue #2: Reject Accept The responsibility of physical therapists to truthfully represent the degree of effectiveness of treatment techniques based on the empirical research data available to support its use. Representative Comments: 1) verification in the absolute sense is probably impossible for some techniques - it would limit the benefits for some patients. Maintaining truth and high standards in physical therapy advertising. Representative Comments: 1) Note: The statement was changed to address truth in advertising and not just advertising itself. COMMENTS: 2233 2c. The following (2) statements of ethical issues were rejected by a majority (more than 50%) of the panel as important ethical issues facing physical therapy in the next 5 years. If you agree that this issue should not be included as an important ethical issue indicate that choice by marking Reject and if you feel it should be included mark Accept. I have provided a representative list of comments from panel members and a space for your additional comments. Issue #1: The encroachment of other professions into the practice of physical therapy. Representative Comments: . 1) Safeguarding the public with qualified practitioners. 2) Future issue: yes. Future ethical issue: no. 3) Issue maybe, but ethical no. Reject Accept COMMENTS: Issue #2: Discrimination in employment opportunities within physical therapy private practices. Representative Comments: 1) Social issue not related to professional ethics. 2) Why is private practice singled out? 3) Is this an ethical issue? Reject Accept 2:34 QUESTIONNAIRE C Question #3 The following statements of present or future practice issues were considered by greater than 80% of the panel members to contain ethical ramifications for physical therapists . For each of these statements: a. Identify on a continuum of 5 to 0 how important you feel it is in that the practice issue receive a careful ethical analysis. The scale is set with 5 being critical and 0 being unimportant. b. Identify any ethical principles or issues which must be considered in analysis of this practice issue. Question PRACTICE Issue #1 Issue #2 Issue 33 Issue #4 Issue #5 2235 ISSUES SCALE The payment systems being utilized for the reimbursement of physical therapy services a) Practice Issue 41 b) Ethical considerations: The delivery of physical therapy services in a setting which involves physician ownership (full or part) of the physical therapy practice. a) Practice Issue 92 b) Ethical considerations: The increase which has been seen in the responsibility of the therapist in total patient care. a) Practice Issue #3 b) Ethical considerations: The current and projected manpower shortage in physical therapy. a) Practice Issue #4 b) Ethical considerations: The increased opportunity for investment by physical therapists in health care products and services such as equipment companies and nursing homes. a) Practice Issue #5 b) Ethical considerations: Issue #6 Issue 47 Issue #8 Issue #9 Issue #10 Issue #11 2:36 The current practice trend wherein more physical therapists are leaving institutions and establishing practice in the private practice arena. a) Practice Issue #6 b) Ethical considerations: Independent practice without referral will become the common mode of practice. a) Practice Issue #7 b) Ethical considerations: Increase in the demands of physical therapists to be more involved in quality assurance, fiscal planning, documentation of care, and the community. a) Practice Issue 48 b) Ethical considerations: The increase in the conduction and use of research to support clinical practice in physical therapy. a) Practice Issue #9 b) Ethical considerations: Changes in the types of business relationships which physical therapists become involved with. a) Practice Issue #10 b) Ethical considerations: Increased scrutinizing of reimbursement and documentation of physical therapy services by outside agencies. a) Practice Issue #11 b) Ethical considerations: 2237 Issue 412 Increase in the questioning of the efficacy of some accepted and marginal treatment techniques. a) Practice Issue #12 5 4 3 2 1 0 b) Ethical considerations: Issue #13 Increase in insurance contracts that may limit access to care. a) Practice Issue 413 5 4 3 2 1 0 b) Ethical considerations: APPENDIX K THANK YOU LETTER TO PARTICIPANTS 238 3645 Reeds Lake Blvd Grand Rapids MI 49506 February 9, 1992 Thank you for participating in this study of Ethical Issues in Physical Therapy. I hope that the information attained through this process will assist in identifying issues that need to be addressed by our profession and in our educational programs. I have compiled and analyzed the results of the first three rounds of the study and do not believe that a fourth round is necessary. If you have not completed the third questionnaire, please do so as soon as possible. Y our participation in the final round would be greatly appreciated. It would improve the study to have 100% participation through the final round. If you need an additional copy of the final questionnaire to be sent to you, please return the enclosed card in the envelope provided. I have also included a general questionnaire which will provide me with feedback on the procedure used in this Delphi study. Your feedback and suggestions on this questionnaire are not included in the body of the study, but will provide me with a means to analyze the process used and improve the effectiveness of future studies. Thank you again for the extensive time you have given to this project. I will send you a copy of the results of the study when they are compiled in their final form. If you have questions please contact me. Phone: (616) 956-0974 (home) (616) 895-3562 (work) Sincerely, H. Triezenberg HLT:sc APPENDIX L FOLLOW-UP QUESTIONNAIRE 239 FOLLOW-UP QUESTIONNAIRE Did you understand the purpose and procedure followed in this study? Were the questions and directions clearly stated? Did you receive sufficient feedback to complete subsequent questionnaires? Did you feel that the process was of value and worth the time needed for completion? Are there areas which you feel needed to be addressed in this study which were not included? Do you have any suggestions or general areas of concern? APPENDIX M AMERICAL PHYSICAL THERAPY ASSOCIATION ETHICAL VIOLATIONS AND RESOLUTIONS (1981-1991) 240 coca—am 329.3502 4 ESE: Sc.— ect-8.6m m—zcooz owes—om c. 95:.»— ioeaéoi 9:383. SAGE—cm. 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