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Approval of physical therapy continuing education credit varies by state. Confirm approval with your state's licensing agency before you take the course for CE credit. See Physical Therapy CE Approval for more information.
Course Availability: Expires March 1, 2018. You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity. Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care. Medical Disclaimer Legal Disclaimer Disclosures
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COURSE OBJECTIVE: The purpose of this course is to prepare physical therapists and physical therapist assistants to incorporate professional association standard-based ethical principles and behaviors into their practice.
Upon completion of this course, you will be able to:
Why are ethics so important to consider, both in the practice of healthcare in general and physical therapy in particular? As physical therapists and physical therapist assistants assume a more autonomous role in healthcare, ethical judgments play an important role in the scope of sound clinical decision-making. In addition to potential legal consequences, unethical behavior risks loss of trust among the public, both for individual physical therapists and/or physical therapist assistants as well as for the profession as a whole (FSBPT, 2014a).
Ethics are broadly defined as the division of philosophy that deals specifically with questions concerning the nature of values in regards to matters of human conduct. In considering ethical judgments and decisions, this branch of philosophy is primarily concerned with the ability to:
In order to clarify why what is considered to be “right” or “good” actually is right or good, philosophers engaged with questions of ethics have generally sought to formulate and justify ethical theories. These theories are intended to explain the fundamental nature of that which is “good,” why it is “good,” and why the ethical principles most commonly used to evaluate human conduct follow (or do not follow) from these theories. Ethical theories may be presented for different purposes, as described below:
There are four fundamental ethical principles generally accepted and applied to the practice of healthcare as a whole.
While explicit ethical principles specific to the practice of physical therapy are detailed below, the preceding four fundamental ethical principles are applicable and implicit in the components of the APTA’s Code of Ethics for the Physical Therapist (discussed later in this course).
The responsibility held by healthcare providers to ensure and respect a patient’s right to autonomy is also legally enforced by the federal Patient Self-Determination Act (PSDA) of 1991. The PSDA mandates that any Medicare- and/or Medicaid-certified healthcare institution must actively work to educate adult patients and the community as a whole about the rights of a patient to accept or refuse healthcare interventions. The PSDA obligates healthcare providers to ensure that patients are informed of their legal rights, under individual state law, to make decisions about their own healthcare, as well as to create an advance directive for themselves.
This law mandates that patients admitted to healthcare facilities be asked whether they have an advance directive in place; that healthcare facilities maintain policies and procedures regarding advance directives; and that this information be provided to patients when they are admitted. (The PSDA defines an advance directive as a “written instrument, such as a living will or durable power of attorney for healthcare, recognized under state law, relating to the provision of such care when the individual is incapacitated.”) Advance directive laws were put into place in response to several highly visible legal cases in order to protect the right of a patient to predetermine whether or not to receive life-sustaining healthcare interventions.
Sources: Castillo et al, 2011; Washington State Hospital Association, 2014.
Bioethics explores those ethical questions specific to the life sciences. Bioethical analysis assists people in making decisions about their behavior and about policy questions that governments, organizations, and communities must face when they consider how best to use new biomedical knowledge and innovations.
The primary difference between scientific and bioethical inquiry is that scientists seek to understand concrete phenomena in the world (what is), while bioethicists strive to determine what people should do. For example, a scientist might ask, “How might we genetically modify a mouse to produce human antibodies for use in cancer treatment?” A bioethicist, in contrast, would be more likely to ask, “Should we genetically modify a mouse to produce human antibodies at all?” (NIH, 2014).
While the terms ethics and values are often used interchangeably, they are actually quite different in meaning. Ethics constitutes a broadly accepted collection of moral principles; values are much more individualized and relate to an individual’s personal set of standards regarding what is right, important, and valuable (Townsville Community Legal Services, 2014).
Originally proposed by Raths (1979) and still widely used in classroom and clinical settings, values clarification is a seven-step process that seeks to allow individuals to examine their lives and clearly articulate their values. The process follows the subsequent stepwise progression:
Source: Modified from Raths et al., 1979.
An ethical dilemma arises when a practitioner becomes caught between two conflicting duties that mutually exclude one another but that would each be ethically viable if considered separately. In order to protect the best interests of the patient and to minimize the risk of ethical and/or legal complaints, it is of utmost importance that practitioners develop the skills and are aware of the resources available for the successful resolution of ethical dilemmas.
Resolution of ethical dilemmas in the clinical setting requires a thoughtful and careful decision-making process and may include any or all of the following steps:
Tyler works as a physical therapist on the post-operative orthopedic floor of a large urban hospital. When Tyler arrives at the room of Mr. Akhinga, who has had bilateral total knee replacements, to begin his scheduled morning physical therapy session, he finds the patient still in bed in his hospital gown. When Tyler inquires about this at the nurse’s station, he is told that Mr. Akhinga stated that he did not want any P.T. today “because I’m in too much pain.” This is the third time this has happened this week.
Tyler now faces an ethical dilemma. While the ethical principle of autonomy dictates that Mr. Akhinga does indeed have the right to accept or refuse physical therapy interventions, Tyler is concerned that continued missed therapy sessions may lead to a poorer overall functional outcome for Mr. Akhinga in the long term. This would run counter to the ethical principle of beneficence, or acting in a clinical manner that would positively affect a patient’s well being.
Tyler documents the missed visit for the morning and goes immediately to his rehab director to discuss the dilemma. Tyler and the rehab director consult with the nursing staff, a social worker, and Mr. Akhinga’s surgeon, as well as with Mr. Akhinga and his wife. It is eventually discovered that Mr. Akhinga’s post-operative pain has not been sufficiently managed by his currently prescribed medication, but that he has been hesitant to discuss his discomfort with his nurses because, “I didn’t want to bother them, they’re already so busy.”
It is decided that Mr. Akhinga’s surgeon will adjust his medication to better manage his pain and that his nursing personnel will verbally ask Mr. Akhinga to rate his pain at regular intervals throughout the day. The rehab director offers to make Mr. Akhinga’s physical therapy schedule available to the nursing staff on the post-op floor several days in advance so that his medication schedule and therapy schedule may be coordinated.
The consultations and agreed-upon course of action are documented in Mr. Ankinga’s medical record and Mr. Akinga seems pleased with the plan of action. Within one day, he is reporting significantly less pain and is once again willing to participate in physical therapy.
Codes of ethics are formal statements that set forth standards of ethical behavior for members of a specific group. One of the hallmark characteristics of a profession is that its members subscribe to a code of ethics. Every member of a profession is expected to read, understand, and abide by the specific ethical standards of that profession.
In order to assert the values and standards expected of members of the profession of physical therapy, the American Physical Therapy Association (APTA) publishes the Code of Ethics for the Physical Therapist, Standards of Ethical Conduct for the Physical Therapist Assistant, APTA Guide for Professional Conduct, and APTA Guide for Conduct of the Physical Therapist Assistant. These four documents are regularly revised and updated, with the latest codes and standards effective July 2010 (APTA, 2010a).
Portions of these documents are provided here. (See also “Resources” at the end of this course.)
[Material in this section is reprinted from the APTA Code of Ethics for the Physical Therapist, with permission of the American Physical Therapy Association. This material is copyrighted, and any further reproduction or distribution is prohibited.]
The Code of Ethics for the Physical Therapist delineates the ethical obligations of all physical therapists as determined by the House of Delegates of the American Physical Therapy Association. The purposes of this Code of Ethics are to:
No code of ethics is exhaustive nor can it address every situation. Physical therapists are encouraged to seek additional advice or consultation in instances where the guidance of the Code of Ethics may not be definitive.
This Code of Ethics is built upon the five roles of the physical therapist (management of patients/clients, consultation, education, research, and administration), the core values of the profession, and the multiple realms of ethical action (individual, organizational, and societal). Physical therapist practice is guided by a set of seven core values: accountability, altruism, compassion/caring, excellence, integrity, professional duty, and social responsibility. Throughout the document the primary core values that support specific principles are indicated in parentheses. Unless a specific role is indicated in the principle, the duties and obligations being delineated pertain to the five roles of the physical therapist.
Fundamental to the Code of Ethics is the special obligation of physical therapists to empower, educate, and enable those with impairments, activity limitations, participation restrictions, and disabilities to facilitate greater independence, health, wellness, and enhanced quality of life.
The APTA’s Code of Ethics for the Physical Therapist delineates five roles, seven core values, and three realms of ethical action to which physical therapists are expected to adhere.
Roles assumed by physical therapists in professional practice include:
Core values which physical therapists are expected to exemplify include:
Realms of ethical action for physical therapists include:
Marisol is a physical therapist in a midsize outpatient facility. She has recently noticed that Alex, a young man recovering from an ACL repair who is on her current caseload, seems to be developing feelings for her that go beyond the usual clinician-patient relationship. He always requests to work with Marisol and frequently compliments her appearance. One morning, Marisol returns from lunch to find a bouquet of flowers on her desk. The card reads, “Thanks to you, I feel ready to go dancing again! Will you have dinner with me on Friday? –Sincerely, Alex.”
While she is attracted to Alex and feels flattered by his attention, Marisol quickly realizes the potential ethical problem inherent in accepting a date with him. Marisol schedules a meeting with the rehab director to discuss the situation and to weigh her options.
Is it all right for Marisol to accept a date with a current patient? No. As clearly stated in Principle 4E of the Code of Ethics for the Physical Therapist,“Physical therapists shall not engage in any sexual relationship with any of their patients/clients, supervisees, or students.” If Marisol wishes to pursue a relationship with Alex, the ethical choice would be to explain to Alex that she cannot do so while he is still a patient of the clinic where she is employed. She and Alex may pursue a relationship after he completes rehab and is discharged. Alternatively, if Alex chooses to complete his rehab at a different facility, this would also allow him and Marisol to begin dating without creating a dilemma of a professional nature for Marisol.
Ibi is completing her final clinical rotation for her DPT program. Her rotation site is located at a small, critical-access hospital in rural Alaska. Ibi is excited about the wide variety of patients and conditions that she has had the opportunity to encounter in this generalist setting. In the second week of her rotation, Ibi’s clinical instructor (CI) informs her that three patients were admitted to the hospital the previous night with frostbite, and it is expected that they will all require wound care, possibly including sharp debridement, over the next several days.
Having grown up and attended school in Florida, Ibi has never encountered frostbite in a clinical setting. While Ibi has learned about wound care in her didactic program and performed various types of wound care under direct supervision from CIs during earlier student rotations, she has never performed sharp debridement. Ibi does not want to disappoint her CI and wants to receive a positive evaluation for this clinical, yet she does not feel confident in her ability to treat these patients on her own. What should Ibi do?
Principle 6B of the Code of Ethics of the Physical Therapist clearly states that physical therapists should “take responsibility for their professional development based on critical self-assessment and reflection on changes in physical therapist practice, education, healthcare delivery, and technology.” Likewise, Principle 3C states that physical therapists “shall make judgments within their scope of practice and level of expertise and shall communicate with, collaborate with, or refer to peers or other healthcare professionals when necessary.”
Even though she wants to please her CI, Ibi should not perform procedures that are outside the scope of her experience, especially if she is not confident in her ability to perform them safely. Ibi should discuss her concerns with her supervisor at once, explaining that all of her prior rotations were in warm-weather locations and that she has never had the opportunity to treat frostbite or to practice sharp debridement. Ibi should respectfully request that her CI provide her with guidance and appropriate training in these areas.
Sanjay is a physical therapist working in extended-care rehab in a skilled nursing facility setting. Recently, there has been a sharply increased focus on department profitability, and the rehab therapists have felt increasing pressure from administration to significantly increase their daily treatment minutes with Medicare patients. Like the other staff therapists, Sanjay has felt a growing level of concern over this recent pressure and wonders if it is in the best interests of the patients.
During a staff meeting, the rehab director announces that she has been informed by administration that all incoming Medicare A patients must be placed in an “ultra-high” RUG (resource utilization group) level regardless of whether the evaluating therapist feels that this maximal level of rehab intensity is safe or appropriate for each patient. Sanjay voices his concerns over the ethics of this new policy and argues that each patient’s rehab intensity level should be determined on an individual basis by the evaluating therapist.
After the meeting is over, the rehab director pulls Sanjay aside. “Look, I know it’s not the best option,” she says, “but my hands are tied here and I can’t afford to lose my job. If a patient can’t tolerate that level of therapy, we can find some modalities to use on them, or else just pad the minutes a little bit. I can count on you to help me out here, can’t I?”
At home that evening, Sanjay explains to his wife, Jhoti, the situation at work. They discuss his dilemma and refer to the Code of Ethics for Physical Therapists to help clarify his best course of action. They realize that what Sanjay is being asked to do—to provide potentially unnecessary treatment to his patients at the same level of intensity despite their individual needs—is in direct violation of principle 3A (“Physical therapists shall demonstrate independent and objective professional judgment in the patient’s/client’s best interest in all practice settings”).
In addition, if Sanjay were to do as instructed by his rehab director and not voice his ethical concerns about this company’s intended policy, he would be in violation of principle 4C (“Physical therapists shall discourage misconduct by healthcare professionals and report illegal or unethical acts to the relevant authority when appropriate”).
Sanjay decides that he cannot continue to work for a facility that asks him to practice in a manner that violates his professional ethics and potentially puts patient welfare at risk. The next day, he meets privately with his rehab director and explains his decision to resign his position and why. He encourages the director to seriously consider the potential ramifications of what the administration is asking her and the entire rehab department to do. At lunchtime, Sanjay announces his decision to leave and, when asked why he is leaving, politely explains that his sense of professional ethics does not allow him to comply with the new facility policy.
[Material in this section is reprinted from the APTA Standards of Ethical Conduct for the Physical Therapist Assistant, with permission of the American Physical Therapy Association. This material is copyrighted, and any further reproduction or distribution is prohibited.]
The Standards of Ethical Conduct for the Physical Therapist Assistant delineate the ethical obligations of all physical therapist assistants as determined by the House of Delegates of the American Physical Therapy Association. The Standards of Ethical Conduct provide a foundation for conduct to which all physical therapist assistants shall adhere. Fundamental to the Standards of Ethical Conduct is the special obligation of physical therapist assistants to enable patients/clients to achieve greater independence, health, and wellness, and enhanced quality of life.
No document that delineates ethical standards can address every situation. Physical therapist assistants are encouraged to seek additional advice or consultation in instances where the guidance of the Standards of Ethical Conduct may not be definitive.
For the past six months, Rowan has had increasing difficulty in trying to avoid his new neighbor. Ever since she learned that Rowan is a licensed physical therapist assistant, the neighbor has constantly pestered him about her many aches and pains in hopes of getting some free treatment. After the neighbor’s fourth unannounced visit to his home, Rowan finally gives in and agrees to look at his neighbor’s sore neck. After all, he has often watched the physical therapists complete cervical spine evaluations and establish treatment plans at the clinic where he works. Rowan examines his neighbor’s cervical range of motion and, finding a limitation in left-sided rotation, he performs some muscle-energy techniques to address this.
Has Rowan done anything wrong? Definitely. Rowan has violated two specific standards from the Standards of Ethical Conduct for the Physical Therapy Assistant:
As a physical therapist assistant, Rowan is under no circumstances allowed to perform an evaluation on a patient or to select specific treatment options without direct supervision from and/or in consultation with a physical therapist.
Vinh is a physical therapist assistant and has just started a new job in a busy manual therapy practice. On her fourth day at work, a client phones in to cancel her mid-morning appointment. The rehab director tells Vinh to document the treatment as if it had taken place. When Vinh questions the ethics of doing so, the rehab director states, “We reserved the time, so it counts as an appointment.” Should Vinh do as the rehab director asks?
Absolutely not. To do so would be a clear violation of Standard 7D of the Standards of Ethical Conduct, which states, “Physical therapist assistants shall ensure that documentation for their interventions accurately reflects the nature and extent of the services provided.”
As a new employee, Vinh may feel especially unsure about questioning her rehab director’s instruction. Nevertheless, it is very important that she meets with the rehab director and explains that knowingly recording false information violates what she understands to be professional ethical standards. If the rehab director still insists upon the false documentation, Vinh should consult immediately with her state’s APTA chapter, follow their advice, and possibly seek other employment if necessary.
In order to help physical therapists and physical therapist assistants interpret and apply the Code of Ethics and the Standards of Ethical Conduct, the ethics and judicial committee of the American Physical Therapy Association has published the APTA Guide for Professional Conduct and the APTA Guide for Conduct of the Physical Therapist Assistant. These guides address each portion of the Code and Standards and are intended to provide a framework by which PTs and PTAs may determine the propriety of their conduct and to guide the development of students. (See “Resources” at the end of this course for a link to these documents.)
Physical therapists and physical therapist assistants practice within a society governed by state and federal law. For that reason, it is important that physical therapy professionals understand the basis of law (jurisprudence) in the United States, its sources and types, and the relationship of law to ethics in the practice of physical therapy.
Laws flow from ethical principles and are limited to specific situations and codified by detailed language. These rules of conduct are formulated by an authority with power to enforce them. As such, laws change with time and circumstances. In the United States, law is based on the Old English system wherein the monarch held supreme power over the land and its people, acting according to “divine right.” The ruler’s decisions became the law of the land and eventually were known as common law, or case law. These case-by-case decisions set precedent and shaped future laws.
In the United States, the U.S. Constitution is the supreme law of the land, filling the role once held by the monarch. The first ten amendments to the Constitution, called the Bill of Rights, place restrictions on the power of government and establish specific individual freedoms, such as the right to free speech and assembly. When residents of the nation believe they have been denied any of these rights, they can seek redress in the courts (Hamilton, 1996).
The U.S. Constitution established three separate branches of government within the federal system—executive, legislative, and judicial—and granted specific powers to the federal government. These are called express powers. Under the Tenth Amendment, all other powers are retained by the states, including licensure of healthcare professionals such as physical therapists and physical therapist assistants. As a result, both the federal government and the state governments create and enforce laws.
In the states, the division of power mirrors that of the federal government:
|Source: Adapted from Hamilton, 1996.|
|Source||U.S. Constitution, the supreme law of the nation|
|Functions||Establishes executive, legislative, judicial branches of government|
|Source||Laws passed by legislative bodies of federal, state, and local governments|
|Functions||Protects and provides for the general welfare of society|
|Examples||Controlled Substances Act of 1970 created a schedule of controlled substances, ranking them according to their potential for abuse from high (I) to low (V).|
|Source||Executive power of federal, state, and local government, delegated by the legislative branch|
|Functions||Carries out special duties of various agencies|
|Common (Case) Law|
|Source||Precedent, custom, tradition, court-made|
|Functions||Avoids duplication and unnecessary expense of litigating issues many times|
|Examples||Amendment 14 grants “equal protection of the law,” but because of Plessy v. Ferguson, an 1896 decision of the Supreme Court, several states continued to segregate children by race in public schools. In 1954, the Brown v. Board of Education decision said, “Separation of children in public schools solely on the basis of race deprives children of a minority group equal educational opportunities, even though physical facilities and other tangible factors may be equal.”|
There are two major divisions of law: civil and criminal.
The purpose of civil law is to make restitution for injury suffered by one or more individuals. Civil law is further divided into contract law and tort law.
The purpose of criminal law is to protect society from actions that directly threaten the order of society. Because some crimes are more serious than others and children are considered less responsible for their acts than adults, there are three categories of criminal offenses:
Criminal law is concerned with harm against society—that is, with action that directly threatens the orderly existence of society. Criminal acts, while causing harm to individuals, are offenses against the state. Thus, in criminal cases the government attorney acts as the prosecutor on behalf of the people. When a guilty verdict is returned, the victim usually does not receive redress (compensation) even though the person who commits the crime is punished in some way, such as being sentenced to jail, fined, or placed on probation. To receive compensation, the victim must bring a civil suit against the accused perpetrator (Hamilton, 1996).
|Source: Adapted from Hamilton, 1996.|
|Function||To redress wrongs and injuries suffered by individuals|
|Proof||By a preponderance of the evidence; adjudicated by a judge or jury; a jury decision need not be unanimous|
|Function||To protect society from actions which directly threaten its orderly existence. Criminal acts, while aimed at individuals, are offenses against the state, thus perpetrators are punished by the state (imprisoned, fined, performance of hours of work); victims usually are not compensated but may initiate civil action against perpetrators to recover monetary damages for injury or loss.|
|Proof||Beyond a reasonable doubt; jury decision must be unanimous|
Though healthcare regulation has historically been managed by individual states, the federal government has become increasingly involved in recent years. Of particular relevance to the practice of physical therapy are several specific acts of Congress, including:
The Americans with Disabilities Act (ADA, 2014) of 1990 is a broad-reaching civil rights statute. Amended in 2008 to broaden protections for workers with disabilities, it protects the rights of people with a variety of ailments, including persons infected with human immunodeficiency virus (HIV) and those with respiratory and musculoskeletal disorders. Its provisions include measures of particular interest and relevance to physical therapists, such as access to public buildings, equal legal protection of persons living with disabilities, and nondiscrimination in employment situations.
The Health Insurance Portability and Accountability Act of 1996 limits the extent to which health insurance plans may exclude care for pre-existing conditions and creates special programs to control fraud and abuse within the healthcare system. The most well-known provision of the act is its standards regarding the electronic exchange of sensitive, private health information. Known as privacy standards, these rules 1) require the consent of clients to use and disclose protected health information, 2) grant clients the right to inspect and copy their medical records, and 3) give clients the right to amend or correct errors. Privacy standards require all hospitals and healthcare agencies to have specific policies and procedures in place to ensure compliance with the rules.
The Patient Protection and Affordable Care Act of 2010 initiated a series of healthcare reforms to give Americans new rights and benefits by “helping more children get health coverage, ending lifetime and most annual limits on care, allowing young adults under 26 to stay on their parents’ health insurance, and giving patients access to recommended preventive services without cost” (Healthcare.gov, 2014).
Other new benefits include 50% discounts on brand-name drugs for seniors in the Medicare “donut hole” and tax credits for small businesses that provide insurance to employees. Each year until 2018, it is planned that additional rights, protections, and benefits will be instituted. These benefits will be paid for by an individual mandate requiring individuals not covered by Medicaid, Medicare, or other government program to maintain insurance or pay a penalty, unless they are a member of a recognized religious sect (Healthcare.gov, 2011).
In the United States, physical therapist licensure is required in all 50 states as well as in the District of Columbia, Puerto Rico, and the Virgin Islands. Licensure is required in each state in which a physical therapist practices. All physical therapy licenses must be renewed on a regular basis (which varies by state), and most states require the completion of some level of continuing education in order for a licensee to qualify for license renewal.
Physical therapists must practice within the scope of physical therapy practice defined by individual states’ physical therapy practice acts. A state’s physical therapy practice act includes rules and requirements for educational institutions and practitioners regarding:
Each state practice act may have language that differs from other states in regard to evaluations/reevaluation, delegation and supervision of physical therapist assistants and/or physical therapy aides, specific areas of practice restriction, or issues of direct access.
The goal of physical therapy practice acts and their administrative boards is to protect the public by setting standards for physical therapy education and practice. It is the responsibility of practitioners to know and abide by the provisions of these acts and abide by the rules and regulations of the state(s) in which they are licensed (APTA, 2014; FSBPT, 2014b).
It is a criminal offense to violate provisions of a state’s physical therapy practice act. When individuals or agencies believe a physical therapist or physical therapist assistant has violated a provision of a state’s physical therapy practice act, they may complain to the administrative board of the pertinent state. This board will investigate the allegations, and if sufficient evidence is found to support the complaint, state attorneys may file a complaint against the licensee.
Because a state license cannot be taken away without due process, licensees have the right to a public hearing before the board, to be represented by an attorney, and to present witnesses on their own behalf. Following such a hearing, the board may: 1) take no action, 2) reprimand the licensee, 3) suspend or revoke the individual’s license, or 4) place the licensee on probation.
Although physical therapy practice acts do vary from state to state, they contain similar grounds for complaints, such as:
It is the responsibility of license holders to know, understand, and obey the rules and regulations of the state in which they are licensed to practice. (See “Resources” at the end of this course for a link to physical therapy practice acts by state.)
All fifty U.S. states, as well as the District of Columbia, Puerto Rico, and Virgin Islands, belong to the Federation of State Boards of Physical Therapy (FSBPT). This organization develops and administers the National Physical Therapy Examination (NPTE) for both physical therapists and physical therapist assistants. These examinations evaluate the basic entry-level competence for first-time licensure of a physical therapist or physical therapist assistant within the aforementioned 53 jurisdictions. The NPTE also helps regulatory authorities to evaluate potential licensure candidates and provide standards that are comparable from jurisdiction to jurisdiction.
In addition to the NPTE, the organization has developed a number of relevant documents, including the following:
Alexa is a physical therapist and works in an outpatient pediatric clinic. Though she excels in her professional and clinical responsibilities, she has lately been struggling with some personal issues, including a health crisis with her elderly father and a recent acrimonious divorce. She also just found out that her teenaged son dropped out of high school.
With all the recent upheaval in her personal life, Alexa accidentally misplaced the letter from the state physical therapy board that contained the forms for her upcoming licensure renewal deadline. Three weeks after the renewal deadline had passed, the director of the pediatric practice where Alexa works requested updated copies of state licenses for all therapist employees. Alexa realized that she had forgotten to renew her license, which was now expired. To make matters worse, Alexa also realized that she had not completed sufficient continuing education to be eligible for license renewal. Alexa was extremely upset and embarrassed and became tearful in her manager’s office as she described the recent stressors in her life that had contributed to her forgetting to complete her license renewal requirements.
Alexa’s manager, Jade, was a very supportive employer and knew Alexa to be a loyal employee and highly competent therapist who had simply made a mistake. Jade gently explained to Alexa that she would have to cease practicing immediately and begin the process of reinstating her lapsed license in accordance with the practice act specific to their state, including payment of applicable penalties and completion of requisite paperwork. In addition, they would need to call the state physical therapy board in order to explain the situation and to determine if Alexa were liable for any disciplinary action due to having inadvertently practiced with a lapsed license for three weeks.
They discussed Alexa’s other recent personal stressors, and Jade suggested that Alexa use some of her accrued paid time off to take a pediatric continuing education course that was being offered out of state. Jade assisted Alexa in finding some respite care for her elderly father and arranged for Alexa’s son to stay with relatives temporarily, allowing Alexa to enjoy some much-needed down time while simultaneously completing the continuing education that she needed to reinstate her license.
Civil law is concerned with harm against individuals, including breaches of contracts and torts. A civil action is considered a wrong between individuals. Its purpose is to make right the wrongs and injuries suffered by individuals, usually by assigning monetary compensation. It is important to be aware that an action can potentially be both criminal and civil in nature (Stanford & Connor, 2012).
A contract is a legally binding agreement between two or more parties. Breaking such an agreement—such as a written employment agreement between a healthcare agency and a physical therapist—is called a breach of contract. Both parties to a contract must do exactly what they agreed to do or they risk legal action being taken against them. For that reason, it is vital that each party clearly understands all the terms of a contractual agreement before signing it (Hamilton, 1996).
A tort is a wrong against an individual. Torts may be classified as either intentional or unintentional.
Assault is doing or saying anything that makes people fear they will be touched without their consent. The key element of assault is fear of being touched, for example, threatening to force a resistant patient to get out of bed against his/her will.
Battery is touching a person without consent, whether or not the person is harmed. For battery to occur, unapproved touching must take place. The key element of battery is lack of consent. Therefore, if a man bares his arm for an injection, he cannot later charge battery, saying he did not give consent. If, however, he agreed to the injection because of a threat, the touching would be deemed battery, even if he benefited from the injection and it was properly prescribed.
Except in rare circumstances, clients have the right to refuse treatment. Other examples of assault and battery are:
False imprisonment is confining people against their will by physical or verbal means. Some examples of false imprisonment are:
Defamation of character is communication that is untrue and injures the good name or reputation of another or in any way brings that person into disrepute. This includes clients as well as other healthcare professionals. When the communication is oral, it is called slander; when it is written, it is called libel. Prudent healthcare professionals: 1) record only objective data about clients, such as data related to treatment plans and 2) follow agency policies and approved channels when the conduct of a colleague endangers client safety (Hamilton, 1996; Stanford & Connor, 2012).
Invasion of privacy includes intruding into aspects of a patient’s life without medical cause. Invasion of privacy is a legal issue separate from violations of HIPAA’s privacy rule due to the fact that invasion of privacy goes beyond protected health information.
Riley, a physical therapist at the local hospital, was chatting with her neighbor, Sonja, an occupational therapist who works in home health, while they did yard work together. When they were finished digging up a flowerbed, Sonja shook out her wrists and said, “Wow, I feel like I just gave myself carpal tunnel syndrome from all that digging!”
“That reminds me,” Riley said. “You’ll never guess who I saw at the hospital today—remember Manny, who used to date your sister? Well, he was just referred to our outpatient clinic for treatment of carpal tunnel symptoms! I always thought he was pretty tough, but it turns out that he’s a real wimp when it comes to pain. Makes you wonder if he’s all that good a mechanic, really.” Suddenly, Riley realized she had violated a core value of her professional code of ethics by disclosing confidential client information without authorization, as well as voicing personal and non-objective opinions about this client.
Riley violated principle 2E in the Code of Ethics for the Physical Therapist, stating, “Physical therapists shall protect confidential patient/client information and may disclose confidential information to appropriate authorities only when allowed or as required by law.”
Not only had Riley violated a principle of the Code of Ethics by disclosing confidential information, if the matter were to become known to her client, a legal suit of slander could be realistically be brought against Riley. Even though it may be tempting to discuss clinical aspects of client care with friends who are also healthcare professionals, the Code of Ethics expressly prohibits sharing of confidential patient information with unauthorized individuals.
Fraud includes deceitful practices in healthcare and can include the following:
Embezzlement is the conversion of property that one does not own for his or her own use, such as when an employee appropriates funds from a company bank account (Stanford & Connor, 2012).
It is the legal responsibility of all healthcare professionals to uphold a certain standard of care. This standard is generally measured against an established norm of what other similarly trained professionals would do if presented with a comparable situation.
In the case of negligent care, four components must be present in order to establish a successful unintentional tort claim.
Professional negligence (malpractice) is the improper discharge of professional duties or failure to meet standards of care, resulting in harm to another person. Four important principles affect malpractice actions: individual responsibility, respondeat superior, res ipso loquitor, and standard of care.
Aron Cohen, PT, DPT, a newly licensed physical therapist, helped Mr. Singh get out of bed to attempt ambulation for the first time since his recent hip ORIF. When Aron had assisted Mr. Singh to standing, the patient in the other bed suddenly asked Aron to get her a glass of water. Aron, thinking that Mr. Singh was steady on his feet, left him standing alone and went across the room to the other patient. Mr. Singh lost his balance and fell to the floor, sustaining a significant head laceration.
Mr. Singh sued Aron for negligence on the basis of res ipso loquitor. All three necessary legal elements were present:
Mr. Singh won the case and Aron was held liable for his injury.
Because today’s healthcare consumers are more likely to take an active role in their care, more likely to question the quality of healthcare services, and more apt to take legal action against providers, physical therapists must take precautions to minimize the risk of malpractice claims being brought against them. Below are some suggested actions that may help prevent malpractice claims. (This information is in no way intended to be a substitute for professional legal advice.)
Seamus works as an independent physical therapist in a joint practice with another physical therapist. Besides taking patients on a direct-access basis, they also receive referrals from various physicians in the local healthcare community. One day Seamus received a referral from an orthopedic surgeon for Ms. Olanna, who had just undergone an R-sided carpal tunnel release. At her physical therapy evaluation, Ms. Olanna told Seamus how much she had suffered with the injury, how long she had waited for care, that she had once sued her employer, and how angry she was with the entire medical establishment.
Seamus had never dealt with a suit-prone client before but realized that he should be especially cautious and thoughtful in his interactions with Ms. Olanna. Seamus checked his professional liability insurance policy to be sure it was in effect, established consistent two-way communication with the referring surgeon, and meticulously documented the evaluation and all subsequent physical therapy treatments provided. At Ms. Olanna’s second visit, Seamus listened attentively to the client, discussed his recommended treatment plan with her in detail, and involved Ms. Olanna in decision-making in regards to every aspect of her care.
After several visits, Ms. Olanna began to trust and respect Seamus. She gradually regained the strength and mobility in her wrist and verbalized pleasure at being able to return to her hobby of playing the cello. Upon her discharge from physical therapy, Ms. Olanna told Seamus how frightened and powerless she had felt and how much she appreciated the care that Seamus had given her, particularly the considerate way that he had actively sought her opinion and listened to and validated her thoughts and feelings.
Professional liability insurance shifts the cost of a suit and its settlement from a person to an insurance company. Such insurance covers acts committed by an individual when he or she is functioning in a professional capacity.
Employer policies cover healthcare professionals only while they are on the job working for that employer within the scope of the employer’s job description. Individual policies give named holders more power to control decisions than if they are insured only under the policy of the employer. Physical therapists in independent practice need to know if an insurance policy covers them as independent practitioners or if they are only covered when they are employed by a healthcare agency.
Many policies exclude coverage of criminal acts, such as intentional torts (assault, battery, false imprisonment, etc.) and disciplinary actions brought by licensing boards against physical therapists and physical therapist assistants.
A liability insurance policy is a legal contract between an insurance company and a policyholder. False information on the application may void the policy.
No policy is limitless. Some important limitations include:
Liability insurance policies are contracts that are renewed or canceled each year. The policy usually states how it is to be canceled and how many days’ notice must be given.
Physical therapists and physical therapist assistants need to know if an insurance policy gives them the right to decide about the settlement of a case or if the insurance company has that right. This is an important issue because settlements become matters of public record and may adversely affect future opportunities.
If served with a summons and complaint, healthcare professionals are well-advised to act promptly. Doing nothing (i.e., failing to answer the complaint) could result in a default judgment. The following are some suggested do’s and don’t’s for responding to this type of situation. (Every case is unique, and the information in this course is in no way intended to be a substitute for professional legal advice.)
For professionals who are personally insured:
For professionals who are not personally insured:
Whether insured or not, individuals named in a complaint should not:
Francisco, a physical therapist assistant, has worked in a busy outpatient clinic for several years. One day, as he walked to his car, a stranger stepped up to him and asked if he was Francisco Acal. When he said yes, the man handed him a legal summons. Francisco was stunned and confused. He opened the envelope and read the enclosed documents. He did not recognize the name of the person who was bringing the “complaint,” and he did not remember the described incident. Francisco was unsure of what to do. He had never purchased professional liability insurance for himself, but he was sure that the clinic where he worked had malpractice insurance for its employees.
The following morning everyone in the clinic was talking about the pending suit, but no one had any concrete information. The rehab director suggested that Francisco contact the clinic’s legal department. Francisco did so, and the secretary who answered the phone asked him to come to the office. When Francisco arrived in the legal department, he was met by a man who introduced himself as the facility’s attorney. He explained that a former patient had brought charges against everyone in the department who had had any contact with him, including Francisco. The attorney told Francisco that he would represent the agency and its employees and instructed him not to talk to anyone about the case or sign any written statement without his advice and counsel.
After several months, the attorney informed Francisco that the case had been settled out of court. Francisco was enormously relieved but decided that he would purchase his own professional liability insurance so that in the future he would not be solely dependent on an employer’s legal counsel.
As physical therapy providers assume an increasingly autonomous role in the delivery of rehabilitative services, it is of vital importance that they adhere strictly to existing laws and ethical principles. Physical therapists and physical therapist assistants are responsible for maintaining the highest standards of professional conduct. These standards arise from ethical principles, fundamental concepts by which people gauge the rightness or wrongness of behavior, and laws, which flow from ethical principles and are limited to specific situations, codified by detailed language and formulated by an authority with power to enforce them.
Ethical standards of behavior for physical therapy professionals have been identified by the American Physical Therapy Association and codified into law in the physical therapy practice acts of individual states and other jurisdictions within the United States. Continuing competence in both ethics and jurisprudence is vital for all practicing physical therapy professionals, regardless of experience level or practice setting.
Licensing Authorities Contact Information (Federation of State Boards of Physical Therapy)
Practice Acts by State (APTA)
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).
American Physical Therapy Association (APTA). (2014).Practice acts by state. Retrieved from http://www.apta.org
American Physical Therapy Association (APTA). (2013). Core ethics documents. Retrieved from http://www.apta.org
American Physical Therapy Association (APTA). (2010a). Code of Ethics for Physical Therapists. Retrieved from http://www.apta.org
American Physical Therapy Association (APTA). (2010b). Standards of Ethical Conduct for the Physical Therapist Assistant. Retrieved from http://www.apta.org
Americans With Disabilities Act. (2014). Retrieved from http://www.ada.gov
Castillo LS, Williams BA, Hooper SM, et al. (2011). Lost in translation: the unintended consequences of advance directive law on clinical care. Ann Intern Med, 154(2), 121–8.
Centers for Medicare and Medicaid Services. (2013). HIPAA—General Information. Retrieved from http://www.cms.gov
Federation of State Boards of Physical Therapy (FSBPT). (2014a). Ethics articles. Retrieved from https://www.fsbpt.org
Federation of State Boards of Physical Therapy (FSBPT). (2014b). Ethics articles: learn about standards of ethical behavior. Retrieved from https://www.fsbpt.org
Federation of State Boards of Physical Therapy (FSBPT). (2014c). Free resources: access valuable information. Retrieved from https://www.fsbpt.org
Fremgen BF. (2011). Medical law and ethics (4th ed.). Paramus, NJ: Prentice-Hall.
Hamilton PM. (1996). Realities of contemporary nursing (2nd ed.). Menlo Park, CA: Addison-Wesley Nursing.
Loyola University New Orleans. (2014). Some fundamental concepts in ethics. Retrieved from http://www.loyno.edu
National Association of Social Workers, Illinois Chapter. (2013). Ethics corner: resolving ethical dilemmas. Retrieved from http://naswil.org
National Institutes of Health (NIH). (2014). Exploring bioethics. Retrieved from http://science.education.nih.gov
Raths LE, Harmin M, Simons SB. (1979). Values and teaching (2nd ed.). Columbus, OH: Merrill.
Stanford CC & Connor VJ. (2012). Ethics for health professionals. Burlington, MA: Jones and Bartlett Learning.
Townsville Community Legal Services. (2014). Community workers and the law. Retrieved from http://www.tcls.org.au
University of Ottawa. (2014). Basic ethical principles. Retrieved from http://www.med.uottawa.ca
Washington State Hospital Association. (2014). End of life care manual. Retrieved from http://www.wsha.org