The Ethical Triangle of the PT,
PTA, and Patient Relationship
Melanie Heffington, PT, DPT, APTA Education Leadership Institute Fellow
Greetings and Salutations
But seriously…
Let’s say the average PT or PTA works 40 hours/week from the age of
26 until 65 and gets two weeks of vacation every year. In that time, the
average clinician will have worked a total of
78,000 hours
1/3 of a human life is spent working…
Top 3 Factors for Employee Satisfaction
1.Appreciation for your work
2.Good relationships with colleagues
3.Good work-life balance
(Morgan 2014)
When we aren’t happy at work?
• RESIGN
• High turnover rates have been reported by OSHA as a workplace violence risk factor
• 2015 NSG Solutions, Inc. found that turnover in first year allied health professionals and RNs
outpaced other workplace categories and can make up over 50% of hospital turnover in a
year (2016 looked better for Allied)
• Costly to employers in terms of recruiting/hiring/training and coworkers who are tasked with
more responsibilities
• Difficult to accomplish patient satisfaction and budget goals with revolving door of
employees
When we aren’t happy at work
• Complain
• Slow productivity, reach only for the minimum- clock watch
• Lack of problem solving, feedback, or new ideas
• Secrecy, conspiracy
• Reluctant to engage
Who do we do we work for?
PT returns individuals to their life roles
PT, PTA, and Patient Relationship Matters
Patient
PTA
PT
Pollev
Name some famous couples.
• Pollev instructions
What are characteristics of
healthy relationships?
What are characteristics of bad
relationships?
pollev
Describe in ONE word, the
relationship with your PT(s)or
PTA(s)
pollev
Perceptions of Roles of PTA
(Robinson
1994, 1995)
• Despite documents from APTA, State Practice Acts, and
education institutional standards- perceptions of the role of
the PTA differ from PT to PT and PTA to PTA
• This strains the relationship between the PT and PTA and
ultimately the patient
Perceptions of the PTA continued
Skill
% PTAs
yes role
% PTs
MMT
84
67
Determine assistive
device/orthotic device
52
10
Determine wc type/features
71
30
yes role
Perceptions of the PTA
Skill
% PTAs
yes role
% PTs
Design POC
16
5
Change PT goals/RX
31
8
Select US method/settings
52
32
yes role
Perceptions of the PTA
Skill
% PTAs
yes role
% PTs
Execute therapeutic exercise
100
98
Respond to acute physiological
changes
97
95
Administer gait training
100
99
Measure/adjust canes/crutches
100
97
Administer heat/cold
100
99
Perform therapeutic massage
99
99
yes role
SUCCESS
Develop a plan AHEAD of patient care time that takes into
account differences in personality types as well as skill
levels/experience levels and how the quality of the PT/PTA
and Patient relationship MATTERS to patient outcomes
Jenny and Forest
Jenny is a 15 year veteran PTA with experience treating adults in an acute care
setting. She moves to a new town and finds the utilization of the PTA at her new
hospital much below her perceived level of skill. Jenny feels very comfortable
advancing gait/pregait skills and determining appropriate assistive devices for a
patient in preparation to return home. Her PT, Forest, often times asks her to stick
solely to training functional tasks that have been evaluated by the PT and insists on
being contacted everytime Jenny wants to advance the patient from a RW to a cane
etc.. .
How does this effect the Patient????
Thor
• Thor is a PT with 2 years of experience. He has difficulty maintaining
his documentation and often has a PTA see a patient without initial
evaluations or goals completed. When his PTAs complain he says
“well I tell you everything you need to know verbally, so you are
covered”.
• How does this effect the patient???
Utilization
Overutilization
Underutilization
• PTAs working outside scope of practice
especially in areas of predicting/goal
setting/equipment recommendations
• Bored PTAs acting and getting paid
highly to function essentially as techs
• Employee satisfaction
• Patient efficiency of care/budget
• Animosity
• Patient loses benefit of the PT skill level
• PT and PTA taking risks with everyone’s
licenses
Utilization
• Today’s healthcare environment is much more dynamic and complex requiring a
higher level of decision making from PTAs and PTs
• Development of the DPT creating the pathway for the autonomous provider
• Charge would be that we would all “up our game” to include acknowledgment of
need to perfect our intraprofessional communication, delegation, and respect to
maximize patient outcomes
What do we do to maximize relationship to
best serve our patients?
Medical Ethical Principles
Nonmaleficence
Justice
Autonomy
Beneficence
FIDELITY AND DUTY
Non maleficence and Beneficence
Justice
Autonomy or Respect for Persons
Ethical principle defined as
Acting in ways that are loyal
FIDELITY
fidelitas fidem constantia castitudo
Within a particular professional
designation
Perhaps the most common
source of ethical conflict
Fidelity…
Building trusting relationships
At any one time, clinician may find themselves in conflict between what the
patient wants, what the clinician thinks is right and what another member of
health care team thinks
Getting out of that one is all about relationship, communication,
delegation, and respect
Harley and Davidson
• Harley is a PT with 30 years experience working with an outpatient orthopedic patient population.
Davidson is a PTA with 5 years of experience working in a variety of settings to include HH, acute,
and SNF. They are sharing a patient who has undergone a TKA 8 weeks ago and still hasn’t met
ROM goals set at eval after 8 visits. Harley knows Davidson is not pushing the patient to end
range. Davidson hates making his patient hurt. The patient is unhappy with his progress, but
likes Davidson better than Harley because he sympathizes with his pain more.
See relationships, fidelity, communication, delegation, and respect in
this scenario?
Purtilo 2005 “Fidelity” What Patients Expect
1.Treat them with respect
2.Competent and capable in your role
3.Adhere to a professional code of ethics
4.Follow the policies and procedures of your organization and
applicable laws
5.Honor agreements
APTA Professionalism Core Values
Accountability
Altruism
Compassion/caring
Excellence
Integrity
Professional Duty
Collaborative Practice Competencies APTA
HOD 2014
1. Values/ethics: work with others to maintain a climate of mutual respect and
shared values
2. Roles: Use knowledge of one’s own role and those of others to appropriately
address needs of patients
3. Interprofessional communication: Responsive, responsible
4. Teams: Apply relationship-building values to effectively deliver patient centered
care
Do we do that inTRAprofessionally?
• Are we demonstrating the concept of FIDELITY to those in our profession?
• Do we keep our “promises” to each other in our profession? How well? How
often?
• Does it depend on how busy we are or other factors?
• How can the concept of duty to our PTA/PT team maximize work environment
and patient outcomes?
Duty based ethics
• Deontological ethics
• Immanuel Kant 1778: “act only on maxims that treat each person involved as the
end and not a means to an end”
• Kant used “categorical imperatives” : a rule that is true in all situations (Gabard and Martin
2011)
Duty Based Ethics Theory
• Duty based ethics focuses on the ACT and NOT
the CONSEQUENCE
• These approaches are heavy on obligations
Duty Based Ethics Theory
• Kant 4 famous examples that assume all living beings :
1. Desire to continue living
2. Desire to develop their talents
3. Desire to NOT have insincere promises made to them
4. Desire necessary help when in severe hardship
Duty Ethics
• These approaches in workplace tend to be heavy on “following the
policy” regardless of the outcome
• Equal respect to all human beings
• Do we have a moral obligation to treat our coworkers with fidelity and
respect regardless of the outcome?
Duty Ethics
• An evolvement of Kant occurred in David Ross as most can agree that
sometimes there might be an exception to a moral rule ie. Lie to keep
someone alive
• David Ross would say that there might be a prima facie duty in the
above case which helps us rationalize an alteration in following a
moral rule
Duty Ethics and Prima Facie Duties
• Duty to maintain confidentiality, but also a duty to protect others from harm
• Patient has hepatitis C loses balance in hall and drain falls out with blood leaking in hallway.
Other health care providers arrive to help. Primary therapist has a duty to maintain
confidentiality, however the prima facie duty would be to avoid harm to others and she discloses
contact precautions are crucial to assisting this patient.
Pop culture associations
Doing “good for goodness sake”
Duty ethics vs. Outcome based ethics
Duty based
• Moral perspective on the action
Outcome based
• Most benefit to the most individuals
• action
• consequence
The Golden Rule
Common to most major religions
The Golden Rule/Law of Reciprocity
• Concept occurs in every major religion, examples:
• ~664 BC in Egypt “That which you hate to be done to you, do not do to
others”
• ~500 BC China/Confucius “Never impose on others what you would not
choose for yourself”
• Judaism “You shall not take vengeance upon yourself…Love your neighbor as
yourself…”
• Christianity “Do onto others as you would have done unto you”
Think back to “ideal relationship” poll
• APTA videos on PT/PTA
• http://www.apta.org/SupervisionTeamwork/SuccessStories/
APTA Code of Ethics
A ‘Code of Ethics’ is necessary for an occupation to be considered a profession
A Profession “regulates itself” and has a “service rather than a profit orientation enshrined in its
code of ethics”
“Regulating of itself” is a social contract between a profession and the public
(Starr 1982)
APTA Code of Ethics
• “Vocabulary for intraprofessional argument, self-criticism, and
reform”
• “Stimulates a moral self-understanding”
• “Collective conscience”
(Fullinwider 1996)
APTA Code of Ethics/Standards
• Principle 1:
• Principle 2:
• Principle 3:
• Principle 4:
Ethical obligations to all people
Duties owed to patients and clients
Accountability for making sound professional judgments
Integrity in relationships with other people
Principles Code of Ethics/Standards continued
• Principle 5: Fulfilling legal and professional obligations
• Principle 6: Lifelong acquisition of knowledge, skills, and abilities
• Principle 7: Promoting organizational and business practices to
benefit patients/society
• Principle 8: Meeting the health needs of people locally, nationally, or
globally
Code/Standards
• Duties owed to others
Patient
• Integrity in relationships
PTA
PT
Values Based Behaviors APTA for the PTA
• “Promoting positive working relationship with PT/PTA team”
• “Demonstrating respect for roles and contributions of both the PT
and PTA in achieving optimal patient outcomes…”
• http://www.apta.org/PTPTATeamToolkit/
Benefits of the PT/PTA Team
• Extending the reach of the PT to improve access to physical therapy care
• Consistency of care where patients can expect to see at least one of their PT “team” at each visit
• Opportunities for collaborative care that may result in increased efficiency and effectiveness
• Cost conscious care where both providers are able to work at the top of their license
• http://www.apta.org/SupervisionTeamwork/SuccessStories/
Dolly and Kenny
• Dolly is a PT in a SNF and works with a PTA named Kenny. In their facility, the PT evaluates and
delegates select interventions to the PTA. Dolly the PT is only immediately on site available to
Kenny the PTA 3 days/week. The remaining 2 days a week Dolly and Kenny must rely on
telecommunications to effectively manage their shared patients. Establishment of formal
communication processes have been key in ensuring quality patient care. Dolly and Kenny meet
for 15 minutes every day (either in person or by phone) to discuss progress and any needed
revisions to POC or new patients. Once weekly, Dolly and Kenny meet for 30 minutes over lunch
to formally and thoroughly manage shared documentation and participate in ongoing training and
education.
What does Dolly the PT consider?
• Are the interventions within the scope of the PTA?
• Is the patient’s condition sufficiently stable?
• Are the intervention outcomes sufficiently predictable?
• Is the intervention within the PTA’s personal knowledge, skills, and abilities?
• Are there risks and liabilities that should be considered prior to delegation?
• Would any payer requirements be affected by a PTA in the POC?
APTA Algorithm for Direction and Supervision of the PTA
What Does Kenny need to consider?
• Does he have questions about the initial eval that need clarification?
• What data should he collect first and every visit that he can compare to
initial eval?
• Does he have the personal skills, knowledge to perform the delegated
interventions?
• Is patient safe/comfortable with interventions? If not can he modify?
• Does the patient data he collects (ROM, gait etc.) support progress towards
goals?
• When must he stop RX and communicate with Dolly?
• APTA Problem Solving Algorithm Utilized by PTAs in Patient Interventions
State Practice Act
• This is law, not a suggestion.
• Skills, Re-evaluations, Supervision
PTA Limits of Practice OK Practice Act
• (1) Specify, other than to the Physical Therapist of Record, perform or interpret
definitive (decisive, conclusive, final) evaluative and assessment procedures.
Definitive evaluation procedures may not be recommended to anyone other than
the patient's physical therapist, unless previously approved by the physical
therapist.
• (2) Alter overall treatment, goals and/or plan.
PTA Limits of Practice OK Practice Act
• (3) Recommend adaptive equipment, assistive devices, or alterations
to architectural barriers to persons other than a physical therapist.
• (4) File discharge documents for permanent record until approved by
a physical therapist.
• (5) Perform duties or tasks for which he/she is not trained.
http://www.okmedicalboard.org/physical_therapists/download/456/PTRULES.pdf
PT and PTA Reevaluations OK Practice Act
This will be performed no less frequently than:
• (A) every 30 days in acute care, outpatient, inpatient rehabilitation and long term
care settings with documented case consultation no less frequently than every 15
days;
• (B) every 60 days in home health settings with documented case consultation no
less frequently than every 30 days;
• (C) every 90 days in consultative DDSD with documented case consultation no
less frequently than every 45 days;
Reevaluations NO less frequently than:
• (D) very 10th visit for DDSD for patients under 21 years of age with documented
case consultation no less frequently than every 5th visit;
• (E) every 60 days in educational settings with documented case consultation no
less frequently than every 30 days;
http://www.okmedicalboard.org/physical_therapists/download/456/P
TRULES.pdf
Standards for Entry Level PTAs
CAPTE PTA Educational Institutional Standards and Required Elements
http://www.capteonline.org/AccreditationHandbook/
PT-PTA Team: A Tool Kit , Sept. 2014 page 40
http://www.apta.org/PTPTATeamToolkit/
Both places…
Information on how PTAs should be able to review POC
Which interventions they should be competent in at entry level
What appropriate modifications to a RX plan within a RX plan a PTA can do
• i.e. use a wedge under a patient with reflux who needs supine ther. ex.
Communication, Delegation, Respect
Many ethical dilemmas in the PT/PTA/Patient can be
categorized as issues with
• Communication
• Delegation
• Respect
Communication: Bruno and Adele
• Adele is tired of working with Bruno and it has only been 2 months. Bruno is a
weak PTA in her view. His patients never seem to progress to meet the goals she
sets when he is their PTA. Adele leaves notes for Bruno suggesting exercises that
would progress her patients, but it seems Bruno ignores them or doesn’t know
how to do them. Adele doesn’t feel like “raising” a new PTA anymore. Her
outpatient clinic has had quite a bit of turnover in PTAs and it seems to always be
left to Adele to train them. Adele resolves to stop passing patients to Bruno and
makes excuses to her manager everytime it is suggested Adele pass a patient.
Bruno and Adele
• Passive aggressive
• Creating underlying hostility
• Does Adele have a responsibility to Bruno?
• Does Bruno have a responsibility to Adele?
• What about the patient?
Communication
Ineffective communication
• Indirect, too much, too little, not specific, not timely
• No follow up
• Conflict avoidant
• No formal routes in processes/policies of facility
• Incomplete documentation
Communication: Kathy Lee and Hoda
• Kathy Lee has called Hoda 4 times since her last visit with Mr. Lauer and still no
answer. Mr. Lauer’s BP dropped last visit to 100/60 when he stood and Kathy Lee
is unsure whether to continue RX cautiously or insist on Mr. Lauer returning to his
PCP since the new addition of a beta blocker for HTN. Kathy is due at Mr. Lauer’s
house this morning. She resolves to do bed exercises and put in another call if his
BP is low again and just document.
Communication
No communication
• Delaying effective execution of POC
• Creates apathy
• Team splitting
• What are Kathy and Hoda’s responsibilities to each other?
• What are their responsibilities to Mr. Lauer?
Communication: Freddy and Jason
• Freddy sees Jason the PT of record on Ms. Sybill down the hall at their CIRE
facility. Freddy has asked for new goals for the past 3 days and Jason still hasn’t
written them. Freddy has had it and charges towards Jason. Freddy: “I REFUSE
to see this patient until you write me new goals! You do this to me every time
and I am sick of waiting for you to do your job! You are a lousy PT! “ Jason:
“Well I think you are a lousy PTA and what do you know anyway? I am balancing
twice as many patients as you and there are only so many hours in the day! Get
off my back!”
Communication
Disrespectful communication
• Creates hostility and resentment
• Personal not professional
• Often times is a product of ineffective or no communication
• Workplace? Patients? Manager? Cost of
coaching/counseling/rehiring?
Communication
Relate directly to APTA Code of Ethics/Standards
• Principle 2 Duties owed to patients
• Principle 4 Integrity in Relationships with other people
Communication
Practice Act lays out expectations of reevaluations and limitations of licenses
• Facility communication standards should be derived from
• Quality handoff communication is imperative
• Patient has right to expect clinicians follow the Practice Act in a way that
maximizes their RX
Communication
Study in Canada (Jelley, Larocque, and Borghese 2013) demonstrated
PTs and PTAs as a group identify as high competency elements
• Demonstrates active listening, using verbal and nonverbal
• Expresses ideas and viewpoints in a respectful, confident, and
concise manner
• Shares and exchanges information effectively
Delegation: Woodward and Bernstein
Woodward, PT just completed an initial eval of a patient in an
outpatient setting with schizophrenia (on meds), hepatitis C due to
former IV drug use, referred for LBP. To say the patient was odd was
putting it mildly. The patient was also unclean with strong smells of
body odor and urine. While walking the patient out, Woodward tells
the receptionist please schedule this patient with Bernstein our PTA.
Delegation: Russell and Andre
• Russell is a PT working in HH. He just finished an eval in a
roach infested home of a patient who will need at least 2
weeks of PT s/p left tibia fx for gait training with device NWB.
Russell calls his agency and says please schedule all the f/u
with this patient with Andre our PTA.
Delegation: Vivian and Edward
• Vivian sighs as she transfers her new pt. back into her wc. Vivian is a
PT working in a CIRE and she has just finished her last eval session of
a patient who is max assist for transfers, wc propulsion and the
biggest “pusher”/worst left hemi Vivian has seen for awhile. Vivian is
t.i.r.e.d of lifting patients. She goes to Edward’s (the PTA) schedule
and begins to arrange for Edward to take over daily RXs.
Delegation
• How often do PTs delegate based off of emotions/work fatigue?
• How would you feel if your entire day was filled with schizophrenics, total assist
pushers, and roach infested homes?
• What is our duty to demonstrate fidelity to the PTA?
• The APTA PTA Direction and Supervision Algorithm (Delegation to the PTA)
• Key components include: stable condition, interventions within scope of
practice, outcomes predictable, payer requirements
Delegation
• No or limited intent to f/u with PTA or patient regarding
progress other than in “formality”
• We cannot delegate away our responsibilities as PTs to
progress patients/reevaluate
• Duty to patient and duty to PTA
Delegation
• Every time we share a patient- we lose a bit of our own
autonomy
• Autonomy drives us and teamwork requires us to
share/collaborate/yield
• Recognizing strengths/weaknesses can help ward off the
dilemmas
Respect:
• Respect your elders
• Respect must be earned
• Respect yourself
RESPECT
Respect for
Autonomy
Personal autonomy…
• Cultural differences
• Gender differences
• Religious differences
• Introvert/Extrovert/Mixed
• Generational differences
Generational differences
• Today’s workplace is comprised of Baby Boomers, Gen X, and Gen Y (Millennials)
• Creates challenges as each of these generations were shaped by different forces
• Assist each other, appreciate each other, collaborate with each other
Generational differences
Baby Boomers Gen X
Gen Y
Work Ethic
Workaholics
Work efficiently
Desire quality
Self reliant
Want structure
Skeptical
Multitasking
Tolerant
What’s next
Work Is…
Motivated by
Exciting adventure
A contract
Means to an end
You are valued
Do it your way
Working with creative
others
Respect: Different roles
Different roles
Same goal: Patients
Communication dilemmas
• First- let’s try to avoid them by increasing our
communication skills
• What tools?
Tools for increasing communication
Perfecting the Hand-Off
health care
another
Definition: transition of patient care from one
provider to
Often reliant on interpersonal communication skills
errors
In physicians, it is a leading cause of preventable
Perfecting the Hand-Off
Clinical environments are dynamic and complex with many challenges to effective
communication
NSG/physicians fouled up hand-off result in med errors, deaths, wrong site surgery,
patient safety
PT fouled up hand-offs result in precautions/contraindications blown, ineffective RX
Perfecting the Hand-Off
• How many patients are you “handing off” in a work week?
• In a shift? If you work prn, could the argument be all of them?
• How much effort is going into the hand-off? Do we assume the chart
speaks for itself?
Perfecting the Hand-Off
Common issues with handoffs in NSG (consider some units
transfer 40 -70% of their patients daily)
• Incomplete information
• Inaccurate information
• Communication issues
Perfecting the Hand-Off
• JCAHO has required formal standardized processes for hand-offs
• Meta analysis in 2016 found that across provider type, regardless of clinical focusstandardized hand-off protocols improved patient, provider, and organizational
outcomes
(Keebler et al 2016)
Perfecting the Hand-off
• Practicing teamwork has positive effects on workplace culture and clinicians, beneficial for all
clinicians
• Recommend specifically:
• Training in specific teamwork education on how effective teams function
• These events have an opportunity for constructive debriefing
• Scenarios and simulation are effective in training team work/communication
(Eddy et al 2016
)
Communication: IPASS
Illness severity: one word “complicated”, “typical”, “healthy”
Patient summary: DX, RX plan
Action list: things the receiver needs to do
Situation awareness/contingency list: “if this happens, then”
Synthesis by receiver: opportunity to ask questions and
synthesize info
IPASS
• IPASS study demonstrated a 23% reduction in preventable errors in 9
pediatric residency programs
• Standardized hand-off training and full engagement of clinicians
(Starmer et al 2012)
Communication: IPASS
•
•
•
•
Uncomplicated
72 y/o female with Right THA 1 week post op, PMH of HTN, hypothyroidism
Action needed: advance gait distance to community as tolerated ASAP
If she meets that goal, let’s talk about transition to outpatient, If she doesn’t by
visit 3 call me
• “So what approach is her THA? How is she with her TH precautions?”
What do we tell the patient?
Another take on the Hand-Off
What do we tell patients when we hand them off?
• Should reassure the patient they will be taken care of
• Increase the level of trust with the whole team
• Make your patient feel understood
• Set the stage for compliance and comfortable RX
Who What Where Why: The Patient
• Who: Jerry (patient), this is my assistant Tom.
• What: Tom is a part of our PT team and we work closely together on
patient care.
• Where: For the next few weeks, visits, minutes… Tom will be working
with you on the goals you and I set today. Specifically, your goal of
picking up your grandson pain free (patient feels understood, some
restatement of personal goal)
• Why: Be honest. “Much of my job here at the clinic is to assess and
reassess.” “I only work weekends, I will be on vacation”. “We share
patients, so you get two brains for the price of one”
Tools for increasing communication
Situation
Background
Assessment
Recommendation
Communication: SBAR
• Situation: brief clear definition of the situation
• Background: relevant background info such as age, dx,
referring doc
• Assessment: your professional conclusion
• Recommendation: “please tell me your recommendation,
what to do”
SBAR
• Shown to increase self-confidence and attitudes with interprofessional
collaboration
(Kostoff 2016)
• Shown to increase quality of communication and patient safety
(Velgi 2008)
Communication: SBAR
Situation: “Hermione fell out of bed last night and is complaining of
right knee pain”
Background: “She is our 68 y/o patient of Dr. Potter who is s/p left
TKA”
Assessment: “I think it is only bruised, but I cannot be sure”
Recommendation: “I need you to tell me Ron if it is okay for me to
proceed with our regular RX plan”
Communication and Fidelity
• Communication is key to trusting relationships
• Think back to Poll
• Ethical duty to enter into Kant’s assumptions of humans
Kant’s Assumptions
1. Desire to continue living
2. Desire to develop their talents
3. Desire to NOT have insincere promises made to them
4. Desire necessary help when in severe hardship
Communication: Personality
Who reads their email?
Who prefers direct in person communication?
What about phone calls?
What about written notes?
Shouldn’t the chart do this anyway?!?!
Communication by Generations
• Baby boomers: tend to prefer face to face or phone calls, less likely to
like communication after business hours
• Gen X: tend to be tied to their phones, feel as if they must be in
touch at all times, dislike meetings, do not tend to mind after hours
contact
• Gen Y: tend also to be tied to their phones, prefer working in groups,
even less concerned about after hours contact(Morris 2013)
Communication dilemmas
• Reflective listening
• Self-Assessment
• Accept the role of teacher, mentor, collaborator
• Assertive communication
Assertive Communication
Assertive Communication
Assertive Communication
WHEN you don’t finish the evaluations in the EMR…
I FEEL uncomfortable
BECAUSE I’m not getting the full picture of the patient with an
unwritten evaluation. I learn a lot from reading your evals. The State
Practice Act and best practice standards would direct me towards not
initiating my RX without a full and complete evaluation.
WHAT I NEED FROM YOU is to complete the written eval with goals
and an outlined POC so I can best serve this patient. Is there another
patient I can see for you so you can get caught up on your
documentation?
Delegation Dilemmas
• Avoid by using APTA Algorithm for Direction and Supervision
• Avoid by using APTA PTA Supervision Algorithm
• Avoid by knowing State Practice Act
• Avoid by knowing Entry Level Expectations of PTA
Delegation dilemma other strategies
•
•
•
•
•
•
Review charts together
RX patient together
CEUs together
Sit in on part of initial eval
Match personalities with patient personalities
Develop complementary skill sets- PT develops vertigo assessment skills, PTA
develops balance ther. ex. skills
Respect Dilemmas
• Avoid by accepting we all desire our own autonomy
• Avoid by developing appreciation for differences
• Avoid by understanding our different roles
• Avoid by Golden Rule, duty, fidelity
Case Study: Julia, Richard, and Mr. Lovett
Julia is a 10 year veteran PTA working in an acute care setting with Richard a PT
with the same experience. Julia has been working with their shared patient Mr.
Lovett for 3 days and needs new goals as Mr. Lovett has achieved the last ones set
at min assist. At lunch, Julia tells Richard this and Richard says “just write down in
the chart that I said new goals set for independent with extra time” and he runs off
to see his afternoon patients.
Julia feels uneasy with this, but says nothing. She trusts Richard, but feels this is
asking her to step outside of her scope of practice.
Julia, Richard, Mr. Lovett
• Which issue is causing Julia distress? Communication, delegation, respect?
• What supporting documents could assist Julia in decision making and justification for talking with
Richard?
Direction and Supervision Algorithm, Delegation Algorithm, State Practice Act etc.
• What strategies could she use to address with Richard?
Reflective listening, IPASS, SBAR, Golden Rule, assertive communication, self-reflection
Justin, Brittany, Taylor
Justin is a 21 y/o patient s/p MVA with multiple fractures and NWB right LE and left
LE . He confides in Brittany, his PTA in CIRE that he was using meth while driving his
car. He hasn’t talked to anyone about his drug use including Taylor the evaluating
PT. Brittany knows a tox screen was run at admit and revealed + for
amphetamines. She doesn’t know if his family knows. Must Brittany discuss this
revelation with Taylor? What are Brittany’s choices? Who should she talk to? Are
there issues with communication, delegation, respect? What are the outcomes of
Brittany’s decisions on the patient? Does duty or outcome based ethics inform a
“better” decision?
Peter and Gladys, Paul or Mary
Peter has just evaluated two patients: Paul and Mary. Paul is a delightfully
interesting WWII Vet s/p right BKA. Mary is a HOH, low pain tolerance individual
s/p right BKA. It is Peter’s turn to pass Gladys the PTA in their SNF a patient. Which
patient should he pass and why?
What ethical principle could assist him in making the decision?
Kit, Sage, Josefina
Kit writes in a POC for a patient “sharp debridement” as indicated. Although Sage,
PTA realizes the State Practice allows a PTA with training to perform this skill, Sage
does not feel competent to address this on a patient. Josefina, PTA has spent
several years studying with Kit and does feel competent in limited sharp
debridement. Which elements of the PT/PTA relationship (communication,
delegation, respect) weigh the most here on patient care? How can Sage best
address the POC given the resources outlined in the scenario? What documents
support her position?
Beyoncé, Kelly, Michelle
Beyoncé, PTA wears a head wrap covering her hair daily to work in her outpatient clinic as a part of
her religious tradition. Kelly, PT resents this as it seems to be out of line for typical PT dress code
and as a result never passes patients to Beyoncé. Michelle, PT doesn’t have issue with Beyoncé's
dress, but several patients have complained to Michelle about Beyoncé's dress being off putting.
What strategies could be employed by Beyoncé, Kelly, and Michelle to address these issues?
Which element of the PT/PTA relationship (communication, delegation, respect) is in play here?
What are the possible effects if this issue is not addressed?
Gracie, Lily, and Lola
Lily PTA has called and left a message for Gracie PT. AGAIN. This is the third call
this morning and it is only 10 am. At first Gracie recognized that Lily would need
some extra supervision and guidance as a transfer to HH setting. However, it is now
the 6th month and Lily still calls about every.little.thing. And a phone call from Lily
is never a direct question- it is more a complaint session about patients. Gracie
fires off a text to Lily giving general directions addressing Lily’s message and goes to
her next house to reeval Lola. Gracie finds little progress towards the goals she set
60 days ago. Gracie knows if she would have kept Lola, this patient would have
been discharged.
Gracie, Lily, Lola
• What elements of the PT/PTA relationship are in play here?
Communication, respect, delegation?
• What strategies or document could assist Gracie? Could assist Lily?
• How does Lola fair as a result?
References
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References
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References
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Online document links
http://www.apta.org/PTinMotion/2010/9/PTADirectionAlgorithmChart/
http://www.apta.org/PTinMotion/2010/9/PTASupervisionAlgorithmChart/
http://www.okmedicalboard.org/physical_therapists#laws-rules
http://www.apta.org/PTPTATeamToolkit/
http://www.capteonline.org/AccreditationHandbook/
http://www.apta.org/SupervisionTeamwork/SuccessStories/
Online document links
http://www.nsinursingsolutions.com/Files/assets/library/retentioninstitute/NationalHealthcareRNRetentionReport2016.pdf
http://www.apta.org/uploadedfiles/aptaorg/about_us/policies/hod/et
hics/codeofethics.pdf
http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/
Ethics/Standards.pdf