1. The Ethical Triangle of the PT, PTA, and Patient Relationship
Melanie Heffington, PT, DPT, APTA Education Leadership Institute Fellow

2. Greetings and Salutations

3. But seriously… 78,000 hours 1/3 of a human life is spent working…
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…

4. Top 3 Factors for Employee Satisfaction
Appreciation for your work
Good relationships with colleagues
Good work-life balance
(Morgan 2014)

5. 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

6. 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

7. Who do we do we work for?

8. PT returns individuals to their life roles

9. PT, PTA, and Patient Relationship Matters

10. Pollev

11. Name some famous couples.
Pollev instructions

12. What are characteristics of healthy relationships?

13. What are characteristics of bad relationships?
pollev

14. Describe in ONE word, the relationship with your PT(s)or PTA(s)
pollev

15. 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

16. Perceptions of the PTA continued
Skill
% PTAs yes role
% PTs yes role
MMT 84 67
Determine assistive device/orthotic device 52 10
Determine wc type/features 71 30

17. Perceptions of the PTA Skill % PTAs yes role % PTs yes role Design POC16 5
Change PT goals/RX 31 8
Select US method/settings 52 32

18. Perceptions of the PTA Skill % PTAs yes role % PTs yes role
Execute therapeutic exercise
100 98
Respond to acute physiological changes 97 95
Administer gait training 99
Measure/adjust canes/crutches
Administer heat/cold
Perform therapeutic massage

19. 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

20. 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????

21. 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???

22. Utilization Overutilization Underutilization
PTAs working outside scope of practice especially in areas of predicting/goal setting/equipment recommendations
Patient loses benefit of the PT skill level
PT and PTA taking risks with everyone’s licenses
Bored PTAs acting and getting paid highly to function essentially as techs
Employee satisfaction
Patient efficiency of care/budget
Animosity

23. 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

24. What do we do to maximize relationship to best serve our patients?

25. Medical Ethical Principles
Nonmaleficence
Justice
Autonomy
Beneficence
FIDELITY AND DUTY

26. Non maleficence and Beneficence

27. Justice

28. Autonomy or Respect for Persons

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

30. 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

31. 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?

32. Purtilo 2005 “Fidelity” What Patients Expect
Treat them with respect
Competent and capable in your role
Adhere to a professional code of ethics
Follow the policies and procedures of your organization and applicable laws
Honor agreements

33. APTA Professionalism Core Values
Accountability
Altruism
Compassion/caring
Excellence
Integrity
Professional Duty

34. 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

35. 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?

36. 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)

37. Duty Based Ethics Theory
Duty based ethics focuses on the ACT and NOT the CONSEQUENCE
These approaches are heavy on obligations

38. Duty Based Ethics Theory
Kant 4 famous examples that assume all living beings :
Desire to continue living
Desire to develop their talents
Desire to NOT have insincere promises made to them
Desire necessary help when in severe hardship

39. 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?

40. 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

41. 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.

42. Pop culture associations

43. Doing “good for goodness sake”

44. Duty ethics vs. Outcome based ethics
Duty based
Outcome based
Moral perspective on the action
action
Most benefit to the most individuals
consequence

45. The Golden Rule
Common to most major religions

46. 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”

47. Think back to “ideal relationship” poll
APTA videos on PT/PTA

48. 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)

49. APTA Code of Ethics
“Vocabulary for intraprofessional argument, self-criticism, and reform”
“Stimulates a moral self-understanding”
“Collective conscience”
(Fullinwider 1996)

50. APTA Code of Ethics/Standards
Principle 1: Ethical obligations to all people
Principle 2: Duties owed to patients and clients
Principle 3: Accountability for making sound professional judgments
Principle 4: Integrity in relationships with other people

51. 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

52. Code/Standards Duties owed to others Patient
Integrity in relationships
PT PTA

53. 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…”

54. 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

55. 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.

56. 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

57. 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

58. State Practice Act This is law, not a suggestion.
Skills, Re-evaluations, Supervision

59. 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.

60. 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.

61. 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;

62. 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;
TRULES.pdf

63. Standards for Entry Level PTAs
CAPTE PTA Educational Institutional Standards and Required Elements
PT-PTA Team: A Tool Kit , Sept page 40

64. 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.

65. Communication, Delegation, Respect
Many ethical dilemmas in the PT/PTA/Patient can be categorized as issues with
Communication
Delegation
Respect

66. 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.

67. 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?

68. 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

69. 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.

70. 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?

71. 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!”

72. 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?

73. Communication Relate directly to APTA Code of Ethics/Standards
Principle 2 Duties owed to patients
Principle 4 Integrity in Relationships with other people

74. 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

75. 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

76. 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.

77. 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.

78. 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.

79. 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

80. 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

81. 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

82. Respect:
Respect your elders
Respect must be earned
Respect yourself

83. R E S P E C T

84. Respect for Autonomy Cultural differences Gender differences
Religious differences
Introvert/Extrovert/Mixed
Generational differences
Personal autonomy…

85. 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

86. 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…
Exciting adventure
A contract
Means to an end
Motivated by
You are valued
Do it your way
Working with creative others

87. Respect: Different roles
Same goal: Patients

88. Communication dilemmas
First- let’s try to avoid them by increasing our communication skills
What tools?

89. Tools for increasing communication

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

91. 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

92. 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?

93. Perfecting the Hand-Off
Common issues with handoffs in NSG (consider some units transfer % of their patients daily)
Incomplete information
Inaccurate information
Communication issues

94. 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 focus- standardized hand-off protocols improved patient, provider, and organizational outcomes
(Keebler et al 2016)

95. 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)

96. 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

97. 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)

98. 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?”

99. What do we tell the patient?

100. 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

101. 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”

102. Tools for increasing communication
Situation
Background
Assessment
Recommendation

103. 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”

104. SBAR
Shown to increase self-confidence and attitudes with interprofessional collaboration
(Kostoff 2016)
Shown to increase quality of communication and patient safety
(Velgi 2008)

105. 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”

106. Communication and Fidelity
Communication is key to trusting relationships
Think back to Poll
Ethical duty to enter into Kant’s assumptions of humans

107. Kant’s Assumptions Desire to continue living
Desire to develop their talents
Desire to NOT have insincere promises made to them
Desire necessary help when in severe hardship

108. Communication: Personality
Who reads their ? Who prefers direct in person communication? What about phone calls? What about written notes? Shouldn’t the chart do this anyway?!?!

109. 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)

110. Communication dilemmas
Reflective listening
Self-Assessment
Accept the role of teacher, mentor, collaborator
Assertive communication

111. Assertive Communication

112. Assertive Communication

113. 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?

114. 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

115. 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

116. 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

117. 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.

118. 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

119. 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?

120. 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?

121. 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?

122. 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?

123. 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.

124. 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?

125. References
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129. Online document links   

130. Online document links
institute/NationalHealthcareRNRetentionReport2016.pdf
hics/codeofethics.pdf
Ethics/Standards.pdf