Professional and Ethical Issues in United States Acute Care Physical Therapists Treating Patients With COVID-19: Stress, Walls, and Uncertainty.

OBJECTIVE: To the authors' knowledge, no peer-reviewed research has explored professional and ethical issues encountered by physical therapists in treating patients with COVID-19. The purpose of this study was to explore the experiences of physical therapists regarding the professional and ethical issues they encountered during the COVID-19 pandemic. METHODS: The current study used reflexive thematic analysis, a qualitative research design developed by Braun and Clarke, to analyze individual interviews. RESULTS: Analysis of the coded interviews produced 6 primary themes (uncertainty, physical therapist's role, ethical dilemmas and moral distress, emotions, providing care and working conditions, and management and leadership influence) and associated subthemes. CONCLUSION: Physical therapists reported numerous professional and ethical issues across the individual, organizational, and societal realms during the COVID-19 pandemic. This study highlights the need for education and resources to prepare physical therapists for professional and ethical issues encountered during pandemics. Specifically, there is a need to define the physical therapist's role in pandemics and prepare physical therapy personnel for dealing with ethical issues, stress, uncertainty, and organizational changes associated with pandemics. Ethical guidelines would support organizations in delineating fair processes for triage and allocation of scarce resources for acute care physical therapy during health care emergencies. IMPACT: The COVID-19 pandemic has produced significant changes in health care and physical therapist practice. This study reports results of the first, to our knowledge, research study focusing on professional and ethical issues experienced by physical therapists in acute care during the COVID-19 pandemic. As the United States faces an unprecedented spike in COVID-19 cases and deaths, results of this study may contribute to physical therapists' preparation for and response to professional and ethical issues encountered in acute care during the pandemic.

Particularizing an Internal Morality of Physical Therapy.

While the American Physical Therapy Association has upheld a code of ethics since 1935, the philosophical underpinnings of physical therapist practice have yet to be robustly explicated. Theoretical work in the field of philosophy of medicine can be engaged to study physical therapist practice. Modifying the phenomenological and teleological framework of Edmund Pellegrino, a physician and prominent bioethicist, the purpose of this theoretical paper is to particularize Pellegrino's philosophy of medicine to construct an internal morality of physical therapy. Acknowledging that the internal morality of health care professions is founded in the relationship between a patient and a health care professional, this paper analyzes the nature and telos, or end, of physical therapy through 3 phenomena of physical therapy-the fact of disability, the act of profession, and the act of physical therapy. This paper claims that, rather than medicine's clinical truth of a good treatment decision, physical therapy's clinical truth is a good process that capacitates patients. This relational approach to an internal morality robustly underpins a philosophy and ethics of physical therapy.

Physical therapists' perspectives on using contextual factors in clinical practice: Findings from an Italian national survey.

BACKGROUND: Contextual factors (CFs) represent a potential therapeutic tool to boost physiotherapy outcomes, triggering placebo effects. Nevertheless, no evidence about the use of CFs among physical therapists is currently available. OBJECTIVE: To investigate the use of CFs and the opinion of Italian physical therapists specialized in Orthopaedic Manual Therapy (OMTs) on their therapeutic benefits. DESIGN: An exploratory cross-sectional online survey. METHODS: A 17-item questionnaire and 2 clinical vignettes assessed the perspective of OMTs on the adoption of CFs in daily clinical practice. The target population was composed of 906 OMTs. An online survey was performed in 2016 using SurveyMonkey Software. Data were analyzed by descriptive and inferential statistics. RESULTS: A total of 558 volunteers (61.6% of the target OMT population) participated in the study. Half of the participants (52.0%) claimed to use CFs frequently in their practice. More of 50% of OMTs valued the therapeutic significance of CFs for different health problems as determined by a combined psychological and physiological effect. OMTs considered the use of CFs ethically acceptable when they exert beneficial therapeutic effects and their effectiveness has emerged in previous clinical experiences (30.6%). They disagreed on the adoption of CFs when they are deceptive (14.1%). Moreover, OMTs did not communicate the adoption of CFs to patients (38.2%), and CFs were usually used in addition to other interventions to optimize clinical responses (19.9%). Psychological mechanisms, patient's expectation and conditioning were believed to be the main components behind CFs (7.9%). LIMITATIONS: Considering that the data collected were self-reported and retrospective, recall and response biases may limit the internal and external validity of the findings. CONCLUSIONS: OMTs used CFs in their clinical practice and believed in their therapeutic effect. The knowledge of CFs, placebo and nocebo mechanisms and their clinical effects should be included in physical therapists' university studies.

Informed consent in physiotherapy practice: it is not what is said but how it is said.

This paper discusses the concept of informed consent in the context of contemporary biomedical ethics. A change in UK law regarding what information should be provided to patients has brought to the fore the role of physiotherapists in the process of gaining informed consent. It is important that physiotherapists are aware of how this change in the law will affect their practice. For an individual to consent, they need to have both the capacity and freedom to exercise rational thought. These concepts are challenged in contemporary biomedical ethics. An individual's ability to make rational decisions has been increasingly questioned by empirical evidence from behavioural psychology. In addition, the concept of freedom in contemporary neoliberal societies has also been critically examined. Liberal paternalism has been advocated by some as a means of helping patients to make better decisions about their care. Actualised as a 'nudge', liberal paternalism has been influential in a number of health policies, and has recently been discussed as a means of gaining consent from patients for assessments and treatments. Physiotherapists engage directly with patients and, through this engagement, construct a therapeutic environment that aims to build mutual trust. This paper questions the legitimacy of informed consent, and presents the argument that, through communicative actions, physiotherapists nudge patients into consenting to assessments and treatments.

The active engagement model of applied ethics as a structure for ethical reflection in the context of course-based service learning.

PURPOSE: The purpose of this case report is to explore the active engagement model as a tool to illuminate the ethical reflections of student physical therapists in the context of service learning in a developing country. METHODS: The study participants were a convenience sample of six students. The study design is a case report using a phenomenological perspective. Data were collected from students' narrative writing and semi-structured interviews. The steps of the active engagement model provided the structural framework for student responses. The analysis process included open coding, selective coding, and member checking. RESULTS: Results showed the emergence of two main themes: 1) gathering rich detail and 2) developing independent moral identity. Students' descriptions of their relationships were detailed and included explanations about the complexities of the sociocultural context. Independent and deliberate agency was evident by the students' preparedness to be collaborative, to raise ethical questions, to identify ethically important aspects of their practice and to describe their professional roles. The students noted that the use of the model increased their engagement in the ethical decision-making process and their recognition of ethical questions. CONCLUSIONS: This case report illustrates attributes of the active engagement model which have implications for teaching ethical reflection: scaffolding for ethical reflection, use of narrative for reflection, reflection in action, and illumination of relevant themes. Each of these attributes leads to the development of meaningful ethical reflection. The attributes of this model shown by this case report have potential applications to teaching ethical reflection.

[Not Available]. / Il consenso informato in Terapia Occupazionale: proposta di una modulistica.

UNLABELLED: The legislative developments that led to the Three-year Degree of the Health Professions poses any health professional in the position of having to comply with the ethical and legal duty to obtain valid informed consent from the patient prior to treatment. In the present work, attention was focused on the figure of the occupational therapist. MATERIALS AND METHODS: Informed consent forms have been developed according to the specific disease from which the patient undergoing occupational therapy is affected. The following categories of sick were identified: amputation, developmental age, orthopedy, spinal cord injury, neurology, psychiatry, geriatry and oncology. RESULTS AND CONCLUSION: The consent forms are particularly well suited to obtaining valid consent from the patient and, at the same time, allow the occupational therapist to obtain all the information he/she needs to carry out the treatment in safety. This results improved patient compliance to therapy by facilitating a better empathic relationship with the therapist.

Ethics of physiotherapy practice in terminally ill patients in a developing country, Nigeria.

Physiotherapy has been widely defined as a healthcare profession that assesses, diagnoses, treats, and works to prevent disease and disability through physical means. The World Confederation for Physical Therapy describes physiotherapy as providing services to people and populations to develop, maintain, and restore maximum movement and functional ability throughout the lifespan. Physiotherapists working with terminally ill patients face a myriad of ethical issues which have not been substantially discussed in bioethics especially in the African perspective. In the face of resource limitation in developing countries, physiotherapy seems to be a cost-effective means of alleviating pain and distressing symptoms at the end-of-life, ensuring a more dignified passage from life to death, yet referrals to physiotherapy are not timely. Following extensive literature search using appropriate keywords, six core ethical themes related to physiotherapy in terminally ill patients were identified and using the four principles of bioethics (patient's autonomy, beneficence, nonmaleficence, and justice), an ethical analysis of these themes was done to highlight the ethical challenges of physiotherapists working in a typical African setting such as Nigeria.

An ethical approach to health promotion in physiotherapy practice.

ISSUE ADDRESSED: With increased emphasis on reducing the global burden of non-communicable disease, health professionals who traditionally focused on the individual are being encouraged to address population-level health problems. While physiotherapists are broadening their clinical role to include health promotion strategies in their clinical practice, the ethical foundations of this practice focus have received less attention. METHODS: We use a physiotherapy clinical scenario to highlight different physiotherapeutic approaches and to analyse underpinning ethical values and implications for practice. RESULTS: We suggest there are potential harms of incorporating health promotion into physiotherapy management of individuals if the population-based research does not resonate with an individual's particular circumstances, capacity to change or view of what counts as important and meaningful. We propose that critical reasoning and ethical judgment by the physiotherapist is required to determine how health promotion messages applied in primary care settings might work to benefit and enhance a client's well being rather than impose burdens or cause harm. CONCLUSION: We suggest four ethical reasoning strategies designed to assist physiotherapists to frame and understand fundamental ethical principles of beneficence, harm, autonomy and justice when implementing health promotion and self-management approaches in clinical practice.

An in-depth analysis of ethics teaching in Canadian physiotherapy and occupational therapy programs.

PURPOSE: The purpose of this study was to examine current approaches and challenges to teaching ethics in entry-level Canadian physiotherapy (PT) and occupational therapy (OT) programs. METHODS: Educators responsible for teaching ethics in the 28 Canadian PT and OT programs (n = 55) completed an online survey. RESULTS: The quantity of ethics teaching is highly variable, ranging from 5 to 65 h. Diverse obstacles to ethics teaching were reported, relating to the organization and structure of academic programs, student issues and the topic of ethics itself. Specific challenges included time constraints, large class sizes, a lack of pedagogical tools adapted to teaching this complex subject, a perceived lack of student interest for the subject and a preference for topics related to clinical skills. Of note, 65% of ethics educators who participated in the survey did not have any specialized training in ethics. CONCLUSION: Significant cross-program variation in the number of hours dedicated to ethics and the diversity of pedagogical methods used suggests that there is little consensus about how best to teach ethics. Further research on ethics pedagogy in PT and OT programs (i.e. teaching and evaluation approaches and effectiveness of current ethics teaching) would support the implementation of more evidence-based ethics education. Implications for Rehabilitation Ethics educators in Canadian PT and OT programs are experimenting with diverse educational approaches to teach ethical reasoning and decision-making to students, including lectures, problem-based learning, directed readings, videos, conceptual maps and clinical elective debriefing, but no particular method has been shown to be more effective for developing ethical decision-making/reasoning. Thus, research on the effectiveness of current methods is needed to support ethics educators and programs to implement evidence-based ethics education training. In our survey, 65% of ethics educators did not have any specialized training in ethics. Ensuring that educators are well equipped to support the development of necessary theoretical and applied competencies can be promoted by initiatives including the creation of tailored ethics teaching and evaluation tools, and by establishing communities of practice among ethics educators. This survey identified heterogeneity in ethics teaching content, format and duration, and location within the curriculum. In order to be able to assess more precisely the place accorded to ethics teaching in PT and OT programs, careful mapping of ethics content inside and across rehabilitation programs is needed - both in Canada and internationally. These initiatives would help advance understanding of ethics teaching practices in rehabilitation.

Theoretical frameworks used to discuss ethical issues in private physiotherapy practice and proposal of a new ethical tool.

In the past, several researchers in the field of physiotherapy have asserted that physiotherapy clinicians rarely use ethical knowledge to solve ethical issues raised by their practice. Does this assertion still hold true? Do the theoretical frameworks used by researchers and clinicians allow them to analyze thoroughly the ethical issues they encounter in their everyday practice? In our quest for answers, we conducted a literature review and analyzed the ethical theoretical frameworks used by physiotherapy researchers and clinicians to discuss the ethical issues raised by private physiotherapy practice. Our final analysis corpus consisted of thirty-nine texts. Our main finding is that researchers and clinicians in physiotherapy rarely use ethical knowledge to analyze the ethical issues raised in their practice and that gaps exist in the theoretical frameworks currently used to analyze these issues. Consequently, we developed, for ethical analysis, a four-part prism which we have called the Quadripartite Ethical Tool (QET). This tool can be incorporated into existing theoretical frameworks to enable professionals to integrate ethical knowledge into their ethical analyses. The innovative particularity of the QET is that it encompasses three ethical theories (utilitarism, deontologism, and virtue ethics) and axiological ontology (professional values) and also draws on both deductive and inductive approaches. It is our hope that this new tool will help researchers and clinicians integrate ethical knowledge into their analysis of ethical issues and contribute to fostering ethical analyses that are grounded in relevant philosophical and axiological foundations.

Código de ética para fisioterapeutas e terapeutas ocupacionais revela conteúdos relacionados à autonomia do profissional / Code of ethics for physical and occupational therapists reveals contents related to professional autonomy / Código de ética para fisioterapeutas y terapeutas ocupacionales revela contenidos relacionados a la autonomía del profesional

Apesar de já existir código mais recente, estudo que revele os conteúdos do antigo pode contribuir para melhor compreensão do papel social do fisioterapeuta. Assim, este estudo procurou verificar as proporções de enfoques deontológicos e bioéticos presentes no código, identificando predomínios de conteúdos para subsidiar interpretações deste documento. Utilizou-se análise textual e interpretativa do código comparando-o com dois conjuntos de textos. O primeiro apresentava referencial teórico deontológico e o segundo referencial bioético. Para o código de ética e para cada conjunto de textos foram identificadas unidades textuais em categorias de enfoques bioético (principialismo) e/ou deontológico (técnica e virtude). Para conteúdos textuais do código de ética e para os dois respectivos conjuntos de textos identificou-se 54,4, 55,7 e 57,7% de unidades com enfoque deontológico nos seus conteúdos. No código de ética, para as unidades de enfoque bioético, considerando unidades de autonomia separadas entre profissional e cliente, observou-se razão de 2,15:1 (profissional:cliente). Esta razão foi menor que a observada nos textos de referencial deontológico (5,07:1 - profissional:cliente) e inversa à razão de 1,32:1 (cliente:profissional) dos textos de referencial bioético. Conclui-se que o predomínio de conteúdos, tanto no código de ética quanto nos textos deontológicos, mostraram concepções corporativistas e legalistas, prevalecendo uma visão de autonomia profissional. Esta característica divergiu dos textos com referencial teórico bioéticos em que se constatou predominância de valor para autonomia focada no cliente...

Despite the existence of a recent code of ethics, a study revealing the content inside the previous one could contribute for the better comprehension of the physical therapist's social function. Therefore, the present study verified proportions of deontological and bioethical approaches that are present in this code identifying the predominance of contents to support the interpretation of the document. Textual and interpretative analyses were used to compare the code with two other sets of documents. The first set showed deontological approaches, while the second one presented bioethical ones. Textual units were identified for all documents and classified by bioethical (principles) and/or deontological (technique and virtue) approaches. For the code of ethics and each set of documents, 54.4, 55.7 and 57.7% of deontological contents were identified. The textual units classified in the code of ethics as professional or client autonomy had ratio of 2.15:1 (professional:client). The ratio previously presented was lower than the one observed in the set of documents with deontological approach (5.07:1 - professional:client) and it was the opposite for the documents regarding the bioethical approach (1.32:1 - client:professional). It was concluded that inside the codes of ethics and the set of deontological information there are corporate and law conceptions, resulting in the majority of contents reveling professional autonomy. This characteristic was different from the set of documents presenting the bioethical approach, in which there was more content related to client autonomy...

A pesar de que ya existe código más reciente, estudio que revele los contenidos del antiguo puede contribuir para mejor comprensión del papel social del fisioterapeuta. Así, este estudio procuró verificar las proporciones de enfoques deontológicos y bioéticos presentes en el código, identificando predominios de contenidos para apoyar interpretaciones de este documento. Se utilizó análisis textual e interpretativo del código comparándolo con dos conjuntos de textos. El primero presentaba referencia teórica deontológica y el segundo referencia bioética. Para el código de ética y para cada conjunto de textos fueron identificadas unidades textuales en categorías de enfoques bioético (principialismo) y/o deontológico (técnica y virtud). Para contenidos textuales del código de ética y para los dos respectivos conjuntos de textos se identificó 54,4, 55,7 e 57,7% de unidades con enfoque deontológico en sus contenidos. En el código de ética, para las unidades de enfoque bioético, considerando unidades de autonomía separadas entre profesional y cliente, se observó razón de 2,15:1 (profesional:cliente). Esta razón fue menor que la observada en los textos de referencia deontológica (5,07:1 - profesional:cliente) e inversa a la razón de 1,32:1 (cliente: profesional) de los textos de referencia bioética. Se concluye que el predominio de contenidos, tanto en el código de ética como en los textos deontológicos, mostraron concepciones corporativistas y legalistas, prevaleciendo una visión de autonomía profesional. Esta característica divergió de los textos con referencia teórica bioética en que se constató predominancia de valor para autonomía enfocada en el cliente...

Discipline, desire, and transgression in physiotherapy practice.

Therapeutic touch has played an important part in human civilization and continues to contribute to our social relations and individual identities. Therapeutic touch has been a vital component in the development and definition of physiotherapy practice and continues to be one of the profession's principal distinguishing competencies. It is surprising then that while so much has been written about how to perform therapeutic touch techniques, little has been written about the role that these techniques have played in defining physiotherapy's professional identity. Drawing on the work of three postmodern philosophers, we offer a critique of physio-therapeutic approaches to therapeutic touch, examining why certain modes of touch were adopted by the profession in the past and not others; how the innate sensuality of touch had to be managed; and how the disciplinary technologies that surrounded the practice of massage came to define physiotherapy's professional identity. Our thesis is that the disciplinary technologies adopted by the profession in the 1890s endure today and that the profession's heavily disciplined approach to touch is now constraining new therapeutic possibilities that may be necessary if the profession is to respond to the demands of twenty-first century health care.

Physical therapy students' willingness to report misconduct to protect the patient's interests.

This article presents a study on the ethical dilemma of whistleblowing in physical therapy, and suggests some lines for further research on this topic as well as ways for integrating it in the physical therapy curriculum. The study examines the self-reported willingness of physical therapy students to report misconduct, whether internally or externally, to protect the patient's interests. Internal disclosure entails reporting the wrongdoing to an authority within the organisation. External disclosure entails reporting the offence to an outside agency, such as the police, professional organisation, or press. The findings indicate that the students view the acts that are detrimental or cause injustice to the patient in a very serious light. In dilemma situations such as these, the students reported a willingness to act. The students also report considerably greater likelihood of whistleblowing internally than externally. The pattern reveals a desire to correct the misconduct coupled with a marked decline in the willingness to blow the whistle as this act moved from the workplace to an external authority.

Addressing conflicts in research ethics: consent and risk of harm.

This paper explores some ethical conflicts that may arise in physiotherapy-related research, focusing particularly on the issues of informed consent and avoidance of harm. These central issues in research ethics are defined and related to fundamental moral principles such as respect for autonomy, respect for persons and non-maleficence, and their implications are examined through a set of hypothetical case studies, encompassing both quantitative and qualitative research approaches. It is argued that these ethical requirements may legitimately be traded off against each other, so that a prima facie need to gain informed consent or to avoid a risk of harm to participants may - within certain limits - be outweighed by other ethical requirements.

Moral reasoning among physical therapists: results of the Defining Issues Test.

BACKGROUND AND PURPOSE: Although there is extensive literature in other health care fields about the ability to make ethical judgements (moral reasoning), there is a paucity of research addressing the moral reasoning of practising physical therapists. The purposes of this research were to 1) identify the types of moral reasoning used by practising physical therapists as measured by the Defining Issues Test; 2) identify differences in moral reasoning among physical therapists based on educational background, demographic variables, clinical experience, practice setting or expertise in ethics; and 3) compare the moral reasoning of physical therapists with that of other professional groups. METHODS: The Defining Issues Test of James Rest was used to evaluate moral reasoning. Five hundred thirty-seven physical therapists responded to a mail survey sent to a random sample of 2,000 American Physical Therapy Association members. Twelve physical therapists with expertise in ethics or professionalism completed the same survey. RESULTS: The mean postconventional score for the random sample was 41.93. This score was lower than the mean scores of physicians, nurses, medical students, nursing students and dental students established in previous research. Females, ethics experts and those in academic settings had higher postconventional scores. CONCLUSIONS: Physical therapists scored lower in postconventional moral reasoning than some other professional groups with similar educational background. Factors that may inhibit or enhance the development of moral reasoning among physical therapists and possible consequences of high or low moral reasoning scores in physical therapy require further research. These findings may raise concerns about the entry-level educational curriculum and professional development opportunities in the area of ethics and moral reasoning. Results of this research may also highlight the challenges of evaluation, scholarship and research in physical therapy ethics. Further research and theory development is needed to address the relationships between moral theory and descriptive or empirical research within physical therapy.

Beyond a code of ethics: phenomenological ethics for everyday practice.

Physical therapy, like all health-care professions, governs itself through a code of ethics that defines its obligations of professional behaviours. The code of ethics provides professions with a consistent and common moral language and principled guidelines for ethical actions. Yet, and as argued in this paper, professional codes of ethics have limits applied to ethical decision-making in the presence of ethical dilemmas. Part of the limitations of the codes of ethics is that there is no particular hierarchy of principles that govern in all situations. Instead, the exigencies of clinical practice, the particularities of individual patient's illness experiences and the transformative nature of chronic illnesses and disabilities often obscure the ethical concerns and issues embedded in concrete situations. Consistent with models of expert practice, and with contemporary models of patient-centred care, we advocate and describe in this paper a type of interpretative and narrative approach to moral practice and ethical decision-making based on phenomenology. The tools of phenomenology that are well defined in research are applied and examined in a case that illustrates their use in uncovering the values and ethical concerns of a patient. Based on the deconstruction of this case on a phenomenologist approach, we illustrate how such approaches for ethical understanding can help assist clinicians and educators in applying principles within the context and needs of each patient.