Ethics and Jurisprudence for the Physical Therapy Professional Licensed in Wisconsin

Learning Outcomes

After this course, participants will be able to:

• List basic principles of ethics and their application to rehabilitation and physical therapy.
• Identify codes of ethics that govern discipline-specific therapy practice.
• Analyze ethical dilemmas through case scenarios to illustrate how to apply a Code of Ethics to real-world issues.
• Identify ethical issues commonly experienced in healthcare settings.
• Identify 3-4 sources of rules and laws governing physical therapy practice in Wisconsin. 
• Explain how to access the most recent Wisconsin Physical Therapy Practice Act and apply the clinical scope of practice in Wisconsin.
• List the key supervision requirements for physical therapist assistants and physical therapy aides.
• Examine the Wisconsin Practice Act to determine requirements for physical therapists and physical therapist assistants to maintain and renew their licenses, including continuing competence requirements.  

Introduction

What is jurisprudence exactly?  Jurisprudence is the philosophical study of law, encompassing its nature, origins, interpretation, and application within society.  Jurisprudence requirements for physical therapists vary across states in the United States, with each state's physical therapy licensing board or regulatory agency establishing its own rules and regulations, including any jurisprudence requirements. Jurisprudence courses and/or exams assess therapists' knowledge of the laws and regulations governing physical therapy in a specific state. 

You may ask why jurisprudence?  Why do I need to take a course on this each renewal period?   

Therapists must stay informed about and adhere to their practice acts for several reasons:

1. Legal and Ethical Compliance: Understanding and following the regulations outlined in practice acts ensures therapists comply with legal and ethical standards, maintaining a high standard of professional conduct.

2. Patient Safety and Quality of Care: Practice acts often include guidelines and standards to protect patients' well-being and safety.  Staying updated on these regulations enables therapists to implement best practices for their patients' safety.

3. Professional Accountability: Adhering to the Practice Act demonstrates professional accountability, ensuring therapists can be held responsible for maintaining the highest standards of care through their actions and decisions.

4. Licensing and Certification Requirements: Practice acts govern licensing and certification requirements. To maintain professional credentials, therapists must be aware of continuing education, renewal, and other requirements specific to the state or states practicing in.

5. Professional Development: Staying current with the practice act allows therapists to engage in ongoing professional development, attending conferences or training sessions to enhance their skills and knowledge for optimal client care.

6. Adaptation to Changes: Practice acts may undergo updates or changes over time. Staying informed about these changes enables therapists to adapt their practices, incorporating new evidence-based practices and aligning with evolving standards.

Today, we will go through the jurisprudence and the ethical aspects of physical therapy practice in Wisconsin. 

Physical Therapy and the Law

There are multiple laws that govern the practice of physical therapy. Federal laws come from the federal government out of Washington, DC, and are followed by all healthcare providers. There are also specific state laws for each state in the United States and common law or case laws (laws that go to court and are usually the source of malpractice law).  
Physical therapy practice and licensure occur in each state, and laws governing practice are established by the specific state practice act. There are 50 different states, meaning 50 different practice acts exist. Your ability to practice as a physical therapist or physical therapist assistant is different in each state. The state legislature decides the State Practice Act but with administrative input. It is governed and interpreted by an administrative body, usually called the State Board of Physical Therapy. 

Licensure is the primary regulatory mechanism within the domain of physical therapy. It mandates that individuals cannot identify as physical therapists or offer physical therapy services without a valid physical therapy license. Each jurisdiction's state practice act in the United States outlines the prerequisites for obtaining and retaining a license. You cannot be a physical therapist or physical therapy assistant and practice without a license. State licensure used to be limited to the state that you were practicing in for the most part.  The Physical Therapy Licensure Compact is now in effect for over half of the states. Thirty-two states have gained this option, with seven additional member states working on implementing the requirements to become active jurisdictions.  Compact privileges are now available for the state of Wisconsin. The official start date was Monday, October 3, 2022. As a licensed therapist, you may be able to join the compact and practice in member states. The Physical Therapy Licensure Compact was officially enacted in April 2017. The Physical Therapy Licensure Compact will be discussed later in this course. 

The realm of physical therapy practice is also influenced by federal laws, which emanate from the central government in Washington, DC. Notably, these federal laws possess jurisdictional impact across all states. Several prominent federal laws are of relevance within clinical practice, including:

1. Health Insurance Portability and Accountability Act (HIPAA): HIPAA is a pivotal confidentiality law. It establishes guidelines for safeguarding patient medical information and personal data. Accompanying HITECH, it ensures the confidentiality of electronic health records.

2. HITECH (Health Information Technology for Economic and Clinical Health Act): This law complements HIPAA by addressing technology-related confidentiality concerns. It supports the secure exchange of electronic health information while upholding patient privacy.

3. Medicare Rules and Regulations: Guidelines established by the Centers for Medicare & Medicaid Services (CMS) that dictate reimbursement policies, documentation requirements, and standards of care for physical therapy services provided to Medicare beneficiaries.

4. Americans with Disabilities Act (ADA): This law ensures the protection of individuals with disabilities against discrimination in various spheres, including employment and access to public service, healthcare services, and facilities.

5. IDEA (Individuals with Disabilities Education Act). IDEA is a federal law that governs how states and public agencies provide early intervention, special education, and related services to children with disabilities. IDEA covers early intervention services for infants and toddlers with developmental delays or disabilities and their families. Children with disabilities must be educated with non-disabled children to the maximum extent possible. Parents must be included in the IEP process, and older students are also involved in developing their educational plans. The main purposes of IDEA are to ensure all children with disabilities have access to a free and appropriate public education, protect their rights, and provide early intervention services.

6. Stark Law: Prohibits physicians from referring Medicare patients to entities with which they have a financial relationship, which can impact physical therapists who have referral relationships with physicians.

7. Anti-Kickback Statute: This statute prohibits the exchange of remuneration in exchange for referrals for services reimbursed by federal healthcare programs, which can affect relationships between physical therapists and other healthcare providers.

These federal laws extend their influence beyond state boundaries, making it imperative for physical therapists to comprehend and adhere to their provisions.

HIPAA

In 1996, HIPAA was introduced as a crucial confidentiality law to safeguard patient identifiers and protected health information (PHI). Protected health information encompasses any data that could potentially identify an individual, including details like name, address, social security number, and diagnosis. Even defining characteristics, like in the case of a high-profile patient, can be considered within the scope of PHI. The primary focus of HIPAA revolves around the secure transmission of information and the methods by which such information is shared.

Protected Health Information (PHI) encompasses any information related to a patient's past, present, or future physical and/or mental health or condition, regardless of its form, including written (such as documentation, electronic communication), spoken (like hallway discussions), or even notes left for colleagues. However, spoken and electronic texts are particularly prone to causing issues.

For example, consider a scenario where individuals in a public setting, clearly from the healthcare field, inadvertently disclose patient information in conversation, potentially breaching confidentiality. Similarly, online forums, including social media groups, can inadvertently expose PHI when discussing cases. Physical therapists must remain vigilant across all communication channels, ensuring confidentiality and avoiding HIPAA violations.

PHI Identifiers

There are 18 specific identifiers.  Those identifiers include: 

• Name
• Address
• All elements (except years) of dates related to an individual
• Telephone numbers
• Fax number
• Email address
• Social Security Number
• Medical record number
• Health plan beneficiary number
• Account number
• Certificate or license number
• Any vehicle or device serial number
• Web URL
• IP Address
• Finger or voice print
• Photographic images
• Any other characteristic that could uniquely identify the individual ie. tattoo   

How Can We Use and Share Patient Information? 

We can use it for treatment, payment, or operations.

Treatment (T)

Physicians, nurses, therapists, and other providers may access a patient’s record for treatment.  Health information may also be shared with other healthcare providers outside of the facility to decide on the best treatment or to coordinate care.   

Payment (P)

Health information is shared with Medicare, Medicaid, insurance plans, and other payers to determine claims payments and benefits. 

Operations (O)

Health information is used for quality assurance, training, and audit purposes.  This would include working in an organization where they have a quality assurance committee or performance improvement plans that utilize training, and internally auditing chart reviews. 

For purposes Other than TPO

Unless required or permitted by law, you must obtain written authorization from the patient to use, disclose, or access patient information. Where I see us get into trouble sometimes with this is related to research first and foremost, as well as marketing.

Even positive stories about patient outcomes or new equipment require authorization to be shared publicly, as they are not considered treatment, payment, or healthcare operations. Well-intentioned aggregated data could still indirectly identify individuals, so caution is needed. Sales and marketing teams may propose ideas that breach TPO, requiring therapists to ensure proper protections remain in place. The minimum necessary standard also applies - only essential PHI should be used or disclosed. Openly discussing patients without a job-related purpose violates HIPAA, even if de-identified. When unsure if PHI use aligns with TPO, consult compliance staff rather than risk violations. Their guidance helps therapists avoid missteps while still being able to appropriately leverage data or stories in practice enhancement or referral development. The key is obtaining patient consent and limiting PHI outside immediate care team needs.

Except for Treatment, the Minimum Necessary Standard Applies

HIPAA does not restrict healthcare providers' use and disclosure of PHI for patient care and treatment. Exceptions: psychotherapy information, HIV test results, and substance abuse information.

For everything else, HIPAA requires users to access the “minimum necessary” amount of information to perform their duties and only disclose it to those who need to know. 

You may not discuss any patient information with anyone unless required for your job.

Keep Health Information Secure is Part of Your Job

This includes: 

• Secure Faxing
• Safe Emailing
• No texting of PHI
• Safe Internet use
• Password Protection
• Conversations-Conversations are to be held in a private place
• Department Security
• Social Media
• Discarding Papers
• Computer Security
• Know where you left your paperwork. Check your printers, fax machines, copiers, etc. If you have soft charts, bring them back to the appropriate area.
• Removal of Records- We don't remove records from our facilities unless required or requested by a government agency, an intermediary, or a carrier.
• Storage of Records- Store records in a secure location that is not available for public viewing or access.
• Building Access- How often have you used your swipe card to enter a facility, and somebody comes behind you? If you don't know that individual, don't allow him or her to enter a secure facility if they're not authorized to do so.
• Verification of Requests- Ensure you know your policy on verifying those requests. Don't disclose PHI unless you have the written authorization to do so
• Sharing PHI
• Disclosure of PHI

Several excellent points for therapists to ensure HIPAA compliance and safeguard protected health information:

• Avoid transmitting PHI via unsecured methods like plain email/text
• Use strong passwords, never share credentials, and properly secure computers
• Have private conversations away from public areas
• Shred documents and utilize locked cabinets/rooms to limit exposure
• Log off computers when stepping away and confirm printer/fax documents aren't left out
• Do not post any patient details or photos on social media
• Verify identity and authorization before releasing records. Make sure you know your policy for verifying those requests. We don't disclose PHI unless we have written authorization to do so.
• Do not allow building access to unknown people
• Check state privacy laws, as penalties for violations are substantial

Even when communicating with a patient's friends or family, the patient must have the capacity to consent to disclosing their protected health information. Therapists cannot share details with loved ones without the patient's explicit authorization, even if they intend to keep them informed. It's an important distinction, as family dynamics can make assumptions of implied permission risky. As you noted, HIPAA violations carry substantial penalties, so obtaining express patient consent before any PHI disclosure is essential to avoiding hefty fines or potential legal consequences.

Internet is an Electronic Billboard

You may expect electronic messages to remain private, but once you send or post them, you lose all control over them. 

Deleting an electronic message does not make it invisible or undiscoverable.

NO Social media! Do not post patient-related or sensitive information on a website or social networking site.

Online communications like texts, emails, and social media posts are discoverable even after "deletion." While encrypted networks provide some protection, the best practice is to avoid any patient-related information online. Therapists should assume that anything posted could potentially become public, regardless of privacy settings or quick retractions. Violating patient privacy through digital channels can generate HIPAA violations and legal consequences. 

Texting

When is texting appropriate at work?

If your message is urgent or short & sweet:

• “Call Me”
• Say, “I just sent you an email and need a response.”
• Logistical communications: Travel information, dates, times, and locations of meetings are okay (if no names are provided). However, do not include protected health information in a text.

Voice Mail 

Don't leave a detailed voicemail unless absolutely necessary.  Never leave substantive patient-related messages on unfamiliar phone numbers.  Instead, say, "Hey, this is Kathleen from therapy. I need to speak with you. Call me at your earliest convenience. 

Do not use a speaker phone unless privacy is assured.  When using your phone through the car's Bluetooth system, the audio can be heard by people outside of the car. It's important to be mindful of this, especially when parked. To maintain privacy, it's a good practice to use earphones or AirPods if you need to have a private conversation or maintain discretion.

Don't forget that voice mails are easily forwarded, passed along, and otherwise shared. 

Best Practices for Voice Communication

Do not give PHI over the phone unless you confirm the listener's identity and authority to receive PHI.  

Be aware of your surroundings and who is around to hear any discussions concerning PHI.     

Refrain from discussing PHI in public areas such as coffee shops, airports, elevators, restrooms, and reception areas. 

Recommendations for Email

Email PHI only to a known party (e.g., patient, health care provider).

Do not email PHI to a group distribution list unless individuals have consented to such a method of communication.

In the subject heading, do not use patient names, identifiers, or other specifics; consider the use of a “confidential” subject line.

Again, I don't put any PHI into my emails. I would say, "Please contact me. I need to speak with you." Oftentimes, I do this within my own organization. If I need to speak with somebody about something that could be compliance-related, I'll email, "Hey, I have that information; I'm following up. Can you give me a shout?" And that's kind of my code to say, I need to talk to you, but I'm not putting that in writing. Always consider what you put in writing.

Medicare Rules and Regulations

Distinguishing between resources for healthcare providers and consumers, inquiries from professionals are directed to the cms.gov website, while patient queries are referred to the medicare.gov website.

Medicare, originally comprised of Parts A and B denoting inpatient and outpatient categories, has expanded to encompass Parts C and D. Part C represents a new version of Medicare resembling an HMO or PPO, and Part D pertains to pharmaceutical coverage. The distinctions among these parts can significantly influence coverage and care. Unlike Medicaid, which is managed at the state level, Medicare is federally funded and administered. The funds originate from federal taxes and are distributed nationwide from Washington, DC.

The American Physical Therapy Association (APTA) is a valuable and comprehensive resource for navigating Medicare rules and regulations. APTA also provides advocacy resources for private practice owners, aiding in optimizing reimbursement. The significance of Medicare regulations on physical therapy practice cannot be overstated. Since many patients treated fall under Medicare, understanding reimbursement policies is pivotal for financial sustainability.

Furthermore, Medicare policies often set the precedent for other third-party payers. For example, the concept of direct access, allowing patients to seek physical therapy without a physician referral, has varying degrees of acceptance by third-party payers. Medicare's stance on reimbursement influences the decisions of these payers. If Medicare were to support reimbursement for direct access care, other payers would likely follow suit, enhancing the financial feasibility of direct access care within the physical therapy practice.

Americans with Disabilities Act

The impact of federal laws on our clinical practice extends to ensuring accessibility for all individuals. Common inquiries arise regarding accommodations for patients with specific needs. While the answers might seem straightforward, local and state regulations often influence them. Consider these examples:

1. Accommodations for Deaf Patients: Providing a sign language interpreter is a common accommodation for deaf individuals. While using a family member might not always be ideal, seeking a professional translator is preferable.

2. Service Animals in Clinics: Determining which service animals to permit in outpatient clinics can be challenging due to the absence of clear guidelines. Developing well-defined clinic policies and procedures becomes crucial. Generally, service animals should be accommodated with appropriate documentation from a medical professional.

3. Wheelchair Accessibility in Clinics: While promoting wheelchair accessibility aligns with the principles of physical therapy, the financial feasibility is considered. While full accessibility is ideal if implementing it poses a significant financial burden, complete wheelchair accessibility might not be mandated.

Viewing the Americans with Disabilities Act (ADA) from the perspective of PTs and PTAs involves more than meeting legal requirements. It also serves as a tool for patient advocacy. Our responsibility extends beyond compliance; it's about empowering patients to live life fully in their most accessible communities. By adhering to ADA standards, we ensure legal compliance and champion our patients' rights and inclusivity.

Wisconsin State Practice Act/Administrative Code/Statutes

It is important to note that laws, rules, standards, and policies can change at any time. It is the licensee's responsibility to stay abreast of these changes, and the best way to do this is through the Wisconsin Physical Therapy Examing Board and the American Physical Therapy Association.  

In Wisconsin, three different sources of law bring about the full set of rules and regulations that PTs and PTAs must follow. First, the Wisconsin Administrative Code section deals specifically with the Wisconsin Physical Therapy Examining Board and physical therapy practice. Next is the Wisconsin Administrative Code, which deals with the entire Department of Safety and Professional Services Administrative Procedures. Those rules cover more than just physical therapy; They also cover other professions in the state.  Finally, specific statutes have been enacted in Wisconsin in chapters 15, 48, 252, 440, 448, and 940 of the state code that also impact physical therapy. A statute is a formal, written law enacted by a legislative body, following the required legal processes to become part of the state's official law. Legislative acts declare what the practice of physical therapy is, including what actions therapists can perform and what actions are prohibited.  

If you are licensed and working in the state of Wisconsin, you should read and familiarize yourself with the three sources that apply to PTs and PTAs in Wisconsin; this course will provide an overview and touch on key highlights and recent changes.  

Physical Therapy Examining Board

According to Chapter 15 of the Wisconsin Statutes, a physical therapy examining board is under the Wisconsin Department of Safety and Professional Services.  The board consists of three licensed physical therapists, one licensed physical therapy assistant, and one public member appointed for staggered 4-year terms. Each member is appointed by the governor and, with the consent of the senate, is appointed. Members of examining boards are to be residents of Wisconsin. Terms shall expire on July 1. No member may serve more than two consecutive terms. No member of an examining board may be an officer, director, or employee of a private organization that promotes or furthers the PT profession regulated by that board.

Public members have the same powers and duties as the other physical therapy examining board members, except that they are not allowed to prepare questions for or grade licensing examinations. They are also not allowed to be involved with any profession or occupation concerned with the delivery of physical or mental health care.

Public members are not to be licensed (past or present) in any profession regulated by the Physical Therapy Examining Board, be married to any person licensed, and shall not employ, be employed by, or be professionally associated with any person so licensed by the Physical Therapy Examining Board. 

A chairperson, vice chairperson, and, unless otherwise provided by law, a secretary will be elected among the members of the board at its first meeting each year.   

The examining board is to meet annually and may meet at other times on the call of the chairperson or of a majority of its members.

A majority of the members of an examining board are required to form a quorum to conduct official business. Once a quorum is established, a majority of that quorum can make decisions and take action on matters within the board’s jurisdiction.

An affirmative vote of 2/3 of the voting membership of the examing board is required to suspend or revoke a person licensed to practice.   

General powers 

• It may require the attendance of witnesses, administering oaths, taking testimony, and receiving proof concerning all matters within its jurisdiction.
• Promulgate rules for its own guidance and for the guidance of the physical therapy profession, define and enforce professional conduct and unethical practices not inconsistent with the law relating to the physical therapy profession.
• May limit, suspend, revoke, or reprimand the license of a PT or PTA. 
• Foster the standards of education or training pertaining to its own trade or profession, not only in relation to the PT profession to the interest of the individual but also in relation to the government and to the general welfare. 
• Each member of an examining board will be paid a per diem of $25 for each day on which the member performs examining board duties. The member shall also be reimbursed for the actual and necessary expenses incurred in performing examining board duties.
• Every member of an examining board shall take and file the official oath before assuming office.
• Every examining board submits to the head of the department in which it is created an annual operation report.

Webpage, Annual Report, Meeting Minutes and Agendas

The Physical Therapy Examining Board webpage may be found here.  On this page, the members of the board are listed, and there are many useful links that you may want to use. You may access the statutes and administrative codes, suggest an agenda item, review the annual report, and view the meeting minutes/agenda for past meetings as well as the calendar of the upcoming meetings. Any orders or disciplinary actions may be viewed, and the process of making a claim is also accessible on this page. 

Professional Assistance Procedure

Another important link on this page is the Professional Assistance Procedure (PAP).  The PAP is a non-disciplinary program for professionals with substance abuse issues who are committed to their own recovery.  The procedure is designed to protect the public by promoting early identification of chemically dependent professionals and encouraging rehabilitation.  It is designed to promote identification and encourage rehabilitation while protecting the public.  It allows qualified participants the opportunity to continue practicing without public discipline while complying with the terms of a contract that is closely monitored by the Department. An application and further terms are included on this site.  

In their resource section, a link is also provided to view any pending rules related to physical therapy. When I checked in January 2025 there was a rule drafted regarding telehealth and the supervision of PTAs.  

Definitions (448.50)

Physical therapy is defined in the statute as:

• Examining, evaluating, or using standardized methods or techniques for gathering data about a patient in individuals with mechanical, physiological, or developmental impairments, functional limitations related to physical movement and mobility, disabilities, or other movement-related health conditions in order to determine a diagnosis, prognosis, or plan of therapeutic intervention or to assess the ongoing effects of the intervention. 
• Instructing patients or designing, implementing, or modifying therapeutic interventions to alleviate impairments or functional limitations.
• Promoting or maintaining fitness, health, or quality of life in all age populations to reduce the risk of injury, impairment, functional limitation, or disability.
• Engaging in administration, consultation, or research that is related to any activity specified in the first three bullets above.

"Physical therapy" does not include using roentgen rays or radium for any purpose, except that “physical therapy" includes ordering X-rays to be performed by qualified persons (which will be discussed later), and using X-ray results to determine a course of care or to determine whether a referral to another health care provider is necessary.  Physical therapy also does not include using electricity for surgical purposes, including cauterization or prescription of drugs or devices.  

Physical therapists and massage therapists are not prohibited from performing activities within their respective scopes of practice, even if those activities extend to some degree into the field of chiropractic science. 

License required (448.51)

No person may practice physical therapy in the state of Wisconsin or designate himself or herself as a physical therapist or physical therapist assistant unless the person is licensed as a physical therapist or holds a valid physical therapist compact privilege.  

A person may not refer to themselves or use any of the following titles unless properly licensed:

• Physical therapist
• Physiotherapist
• Physical therapy technician
• Licensed physical therapist
• Registered physical therapist
• Master of Physical Therapy
• Master of Science in Physical Therapy
• Doctorate in Physical Therapy

Additionally, individuals may not use or append the following letters to their name unless licensed:

• P.T.
• P.T.T.
• L.P.T.
• R.P.T.
• M.P.T.
• M.S.P.T.
• D.P.T.

This restriction ensures that only qualified and licensed professionals represent themselves as physical therapists, protecting patients and maintaining professional standards.

Applicability (448.52)

If the person does not claim to render physical therapy or physiotherapy services, a license is not required for the following:

• A person lawfully practicing within the scope of a license granted by Wisconsin or the federal government
• A person who is exempt from licensure as a physician 
• A person assisting a physical therapist in practice under the direct, on-premises supervision of the physical therapist (such as a physical therapy aide).
• A physical therapy student or a physical therapist assistant student performing physical therapy procedures and related tasks within the scope of the student's education or training (and under the correct level of supervision rules). 
• A physical therapist who is licensed to practice physical therapy in another state or country and provides consultation or demonstration with a licensed physical therapist in Wisconsin.

A licensed chiropractor in the state of Wisconsin is not required to have a PT license when claiming to render physical therapy if the physical therapy is provided by a physical therapist employed by the chiropractor.

A license is also not required for a licensed chiropractor in Wisconsin claiming to render physical therapy modality services.

Manipulation services (448.522)

A physical therapist may not claim that any manipulation service he or she provides is a chiropractic adjustment employed to correct a spinal subluxation.

License and Compact Privilege to Practice Physical Therapy (Chapter 1)

Definitions

• Direct, immediate, on-premises supervision requires face-to-face contact between the supervisor and the individual being supervised. The supervisor must be physically present in the same building while the service is being performed.

• Direct, immediate, one-to-one supervision involves one-on-one, face-to-face contact between the supervisor and the individual being supervised. The supervisor may assist the individual as needed.

• General Supervision: This requires the supervisor to have direct, on-premises contact with the physical therapist, physical therapist assistant, student, or temporary licensee being supervised as needed. The supervisor must maintain indirect, off-premises telecommunication availability between direct contacts, ensuring the supervised individual can establish direct telecommunication with the supervisor within 24 hours.

• Physical Therapist Assistant Student: A person enrolled in a board-approved physical therapist assistant educational program. This individual performs physical therapy procedures and related tasks in line with their education, training, and experience under a physical therapist's direct, immediate, on-premises supervision or, as permitted by s. PT 5.03(2) is under the supervision of a physical therapist assistant, where the PT delegates supervision to the physical therapist assistant.

  Physical Therapist Student: A person enrolled in a board-approved physical therapist educational program. This individual performs physical therapy procedures and related tasks in line with their education, training, and experience under a physical therapist's direct, immediate, on-premises supervision.

• Temporary Licensee: A graduate of an accredited physical therapy program who has met the qualifications and been granted a temporary license to practice as a physical therapist or physical therapist assistant, as outlined in ch. PT 3.

• Unlicensed Personnel: An individual who is not a physical therapist, physical therapist assistant, or student but performs patient-related tasks. These tasks must align with the individual’s education, training, and experience and be conducted under a physical therapist's direct, immediate, on-premises supervision.

• Supervisor: A supervisor is an individual who holds either:

  • A regular license as a physical therapist or

  • A physical therapist compact privilege granted by the board.

A supervisor does not include individuals holding licenses issued under temporary licenses or locum tenens licenses. 

The supervisor must be competent to coordinate, direct, and evaluate the work of another physical therapist, physical therapist assistant, student, or temporary licensee.

Informed Consent: This refers to a client's voluntary, informed agreement to the service provided by a physical therapist, physical therapist assistant, temporary licensee, candidate for reentry, or student. Informed consent requires the following:

1. Provision of Information: The licensee must explain reasonable alternatives for diagnosis and treatment and the risks and benefits of each to enable the client to make an informed decision.
2. Documentation:
   • Informed consent is typically documented by the client’s written signature, the signature of a guardian, or a power of attorney for healthcare.
   • Alternatively, a notation in the patient’s healthcare record (as defined in s. 146.81(4), Stats.) is acceptable.
   • If circumstances prevent signed documentation, the licensee may record verbal consent in the patient’s healthcare record.
3. Right to Withdraw: A client may withdraw consent verbally or in writing at any time before a service is completed.
4. Chaperone Option: Clients must be informed of their right to request a chaperone during services.
5. Cost Transparency: Clients must be informed of the general nature of costs associated with the service or provided with contact information to address billing concerns.
6. No Service Without Consent: Services or any part of them cannot be provided without the client’s informed consent or if consent is withdrawn.

Licensure requirements

All initial applicants applying for any class of license to provide physical therapy services are to complete and submit appropriate application forms provided by the board (including the Authorization for Release of FBI Information form and fingerprints must be submitted), pay the current fee, a photograph, and provided evidence of graduation from a school of physical therapy for a PT licensee applicant and evidence of graduation from a physical therapist assistant educational program for a PTA licensee applicant.  The board approves schools of physical therapy and physical therapist assistant education programs that are recognized and approved by the Commission on Accreditation in Physical Therapy Education at the time of the applicant's graduation. All license applicants are required to successfully complete an online, open-book exam on the Wisconsin Statutes and Rules relating to PT and PTA practice.  Applicants cannot take this exam until after an application has been received and processed by the Department. 

Application forms are available from the Department of Safety and Professional Services' website at www.dsps.wi.gov.

The board may waive the requirement for verified evidence of graduation from a PT or PTA school for an applicant who:

• Is a graduate of a physical therapy school or a physical therapist assistant educational program,
• Is licensed as a physical therapist or physical therapist assistant by another licensing jurisdiction in the United States in which that jurisdiction requires the applicant to be a graduate of a school or educational program approved by the licensing jurisdiction (or of a school or educational program that the licensing jurisdiction evaluated for educational equivalency).
• Has actively practiced as a physical therapist or physical therapist assistant under the license issued by the other licensing jurisdiction in the United States for at least three years immediately preceding the date of application.

If an applicant for licensure is a graduate of a foreign school of physical therapy or physical therapist assistant educational program, verification of educational equivalency to a board-approved school of physical therapy or physical therapist assistant educational program must be obtained from a board-approved foreign graduate evaluation service. The following has to be submitted to the evaluation service:  

• A verified copy of transcripts from the schools from which secondary education was obtained.
• A verified copy of the diploma from the school or educational program at which professional physical therapy or physical therapist assistant training was completed.
• A record of the number of class hours spent in each subject for both preprofessional and professional courses, hours detailed for laboratory and lecture time, a syllabus that describes course material covered, and at what course level (entry or advanced) the class was taught.

Evidence of successful completion of the examination is also required.  

Educational Equivalency for Non-Approved Programs
If the applicant’s program is not board-approved, the board will evaluate educational training for equivalency. This may include evaluations from a board-approved service, with the applicant bearing the costs. The board regularly reviews and approves foreign graduate evaluation services. A list of board-approved evaluation services can be obtained upon request by contacting the board.

Compact Privilege Requirements

Every applicant for compact privilege must submit the following to the board:

• A completed application form provided by the board
• A fee specified in the materials
• Proof of successful completion of the required examination

Examinations (Chapter 2)

General Examination Requirements

All applicants must complete written examinations, including the National Physical Therapy Examination (NPTE) for physical therapists or physical therapist assistants, and a state-specific examination on statutes and rules. An oral examination may also be required if the applicant meets certain conditions, which are detailed below. All exams are conducted in English. The passing grade for the statutes/rules exam is determined by the board based on minimum acceptable competence. Passing scores for the NPTE are those recommended by the Federation of State Boards of Physical Therapy (FSBPT).

Conditions Requiring Oral Examination

In addition to the national physical therapy examination or national physical therapist assistant examination, Wisconsin utilizes oral examinations in some circumstances. An applicant may be required to take an oral examination if one of the following is true:

• Has a medical condition and or uses chemical substances that impair or limit the applicant's ability to practice physical therapy with reasonable skill and safety.

• Diagnosed as suffering from pedophilia, exhibitionism, or voyeurism.

• Engaged in the illegal use of controlled substances within the past two years.

• Subject to adverse formal action during the course of physical therapy education, postgraduate training, hospital practice, or other physical therapy employment.

• Disciplined or had licensure denied by a licensing or regulatory authority in Wisconsin or another jurisdiction.

• Convicted of a crime in which the circumstances thereof substantially relate to the practice of physical therapy.

• Not practiced as a physical therapist or physical therapist assistant for a period of 3 years prior to application unless the applicant has graduated from a school of physical therapy or a physical therapist assistant educational program within that period.

• Graduated from a physical therapy school or a physical therapist assistant educational program not approved by the board.

• Voluntarily limited the scope of his or her practice as a physical therapist or physical therapist assistant after being the subject of an investigation by a credentialing authority or employer.

Applications with any of the above conditions are reviewed by a panel of at least two board members. The panel determines if an oral examination is necessary. Written and oral exams are scored separately. Applicants must pass all required exams to qualify for licensure. Oral exams are scored as pass or fail. The board notifies applicants about the time and place for oral examinations. Failure to appear for an exam without prior arrangements may void the application.

Special Requirements for Non-English Programs

Graduates from non-English programs must pass additional language proficiency tests, including the Test of English as a Foreign Language (TOEFL), the Test of Written English (TWE), and the Test of Spoken English (TSE).

Conduct of Examinations 

At the beginning of the exam, applicants will receive a set of rules to follow. If an applicant breaks these rules, their results may be withheld, and after a review, the board may decide they failed the exam.

Failure and reexamination of statutes and rules exam 

Applicants who do not pass the statutes and rules exam can retake it by paying a reexamination fee.

Temporary License, Initial Licensure (PT Chapter 3)

A temporary license is for a new graduate who's eligible to take the licensing exam. An applicant for a regular license to practice as a physical therapist or physical therapist assistant can apply to the board for a temporary license to practice under supervision. 

To apply for a temporary license as a physical therapist or physical therapist assistant, the following requirements have to be met

• the individual has never held a license or granted a compact privilege to practice in Wisconsin as a physical therapist or physical therapist assistant, respectively,   
• A graduate from an approved school of PT or PTA school and not required to take an oral examination
• Has applied to take the national physical therapist examination or physical therapist assistant examination and is awaiting results
• Not required to take an oral examination per Chapter 2 (discussed below)

Applications and required documents for both regular and temporary licenses are reviewed by two members of the board. If these members determine that the applicant meets the qualifications for admission to the examination for a regular license, the board, acting through these two members, may issue a temporary license, allowing the applicant to practice under supervision.

A holder of a temporary license to practice physical therapy may engage in physical therapy practice only under a licensed physical therapist's direct, immediate, on-premises supervision. Similarly, a holder of a temporary license to practice as a physical therapist assistant may provide physical therapy services consistent with their education, training, and experience, provided their entire practice is conducted under the same level of supervision (direct, immediate, on-premises supervision) by a licensed physical therapist.

A temporary license to practice physical therapy under supervision is valid for three months or until the license holder receives failing examination results, whichever occurs first unless an extension is granted by the board. The temporary license may be renewed for an additional three months and, in cases of hardship, may be renewed a second time for another three months. However, the total duration of practice under a temporary license cannot exceed nine months.

A physical therapist providing supervision may supervise no more than a combined total of 4 physical therapists and physical therapist assistants who hold temporary licenses.  This number is reduced by the number of physical therapist assistants and unlicensed personnel being supervised by the physical therapist.  This will be discussed more when we get to supervision (Chapter 5).

Locum Tenens (Chapter 4)

Locum tenens may be utilized in a traveling PT scenario where the applicant is licensed in a different state but will practice for a short term in Wisconsin.  Application forms are available from the Department of Safety and Professional Services’ website at www.dsps.wi.gov. 

To apply, the applicant must include a completed and verified application, the required fees, a letter of recommendation from a physician, supervisor, or present employer stating the applicant’s professional capabilities, a copy of a license to practice physical therapy issued to the applicant by another licensing jurisdiction of the United States, and a letter requesting the applicant’s services from a Wisconsin licensed physical therapist, an individual who holds a physical therapist compact privilege granted by the board, or an organization or facility located in Wisconsin.

The board will review and grant a locum tenens license to practice physical therapy if it determines that the applicant is qualified. The typical expiration date is 90 days, but the board can approve up to 12 months. A locum tenens license is not renewable.

Licensure by Reciprocity
The examination requirement can be waived for PTs/PTAs who have successfully graduated from PT/PTA school, have a valid license in another jurisdiction, have actively practiced for 3 years in that jurisdiction prior to application in Wisconsin, and can provide proof to the board of (30 for PT /20 for PTA hours) continuing competence activities in the previous two years. 

Physical Therapy Licensure Compact (448.985)

The purpose of the compact is to facilitate the interstate practice of physical therapy with the goal of improving public access to physical therapy services. The practice of physical therapy occurs in the state where the patient is located at the time of the patient encounter.

Definitions

Some helpful definitions for understanding the rules regarding the licensure compact 

• "Compact privilege” according to this statute means the authorization granted by a remote state to allow a licensee from another member state to practice as a physical therapist or work as a physical therapist assistant in the remote state under its laws and rules.
• "Home state” means the member state that is the licensee's primary state of residence.
• "Member state” means a state that has enacted the compact.
• "Remote state” means a member state other than the home state, where a licensee is exercising or seeking to exercise the compact privilege.

The reason why states are excited to do this is it reduces regulatory barriers to physical therapy. It allows more people that need physical therapy to get physical therapy, especially in remote or rural areas. The physical therapy compact website, which is ptcompact.org has information about the licensure compact and an interactive map showing which states are participating and which states have brought that to their legislatures.

There are many rules required by the compact that the state must uphold to participate. You may find them in Subchapter XI of 448.

Compact Privilege Requirements

For the licensee to participate in compact privilege, the licensee needs to hold a license in the home state and have no limitations placed on his/her license in any state.  The licensee must be eligible for a compact privilege in any member state with no prior disciplinary action against any license or compact privilege within the prior two years.  The licensee must notify the commission that he/she is seeking compact privilege within a remote state(s).  Any fees, including any state fee, is to be paid by the licensee.  The licensee must meet any jurisprudence requirements established by the remote state(s) the member is seeking compact privilege and let the commission know if an adverse action is taken on his/her license by a non-state of the compact within 30 days of the adverse action.  

Chapter PT 1, specific to the state of Wisconsin, states that every person applying for the compact privilege must complete an application form provided by the board, including the fee specified on the form, and show evidence of successful examination. 

The compact privilege is valid until the expiration date of the home license. To maintain compact privilege in the remote state, the licensee must abide by the requirements mentioned in the paragraph above.  

The licensee providing physical therapy in a remote state must abide by the laws and regulations of that state. The licensee is subject to that state's authority when practicing in that state, and the remote state may impose fines or take any necessary action to protect the health and safety of its citizens. Compact privilege is not allowed in any other state until removal action is satisfied by the state taking action on the license and all fines are paid.  

If a licensee's home state licensee is limited in any way by that board, compact privilege is lost in any remote state until the home state license is no longer limited and two years have elapsed from the date of the disciplinary action.  Once those requirements are satisfied, the licensee must meet the compact privilege requirements discussed above to obtain compact privilege in a remote state.  

If a licensee's compact privilege in any remote state is removed, the licensee will lose compact privilege in any remote state until all fines are paid, the specific period for which the compact privilege was removed has ended, and two years have elapsed from the date of the disciplinary action.  Once those requirements are satisfied, the licensee must meet the compact privilege requirements discussed above to obtain compact privilege in a remote state.  

Active Duty Military Personnel or Their Spouses 

A licensee who is active duty military or the spouse of someone who is active duty military can designate the home state as one of the following: home of record, permanent change of station (PCS), or state of current residence if it is different than the PCS state or home of record.  

Adverse actions

For the state of Wisconsin, a person holding a license who is convicted of a felony or misdemeanor anywhere shall notify the Department of Safety and Professional Services of the conviction within 48 hours after the judgment of conviction is entered. 

A home state has the exclusive power to impose adverse action against a license issued by the home state. The home state can take adverse action based on information from a remote state as long as it follows its own procedures for imposing adverse actions.  

A member state can decide to have the licensee participate in an alternative program instead of adverse action, and that participation can remain nonpublic if required by the member state's laws. Member states must require licensees who enter any alternative programs in lieu of discipline to agree not to practice in any other member state during the term of the alternative program without prior authorization from such other member state.

A member state may investigate actual or alleged violations of the statutes and rules authorizing the practice of physical therapy in any other member state in which a physical therapist or physical therapist assistant holds a license or compact privilege.

A remote state is able to take adverse actions against a licensee's compact privilege in the state, issue subpoenas for both hearings and investigations that require the attendance and testimony of witnesses, and the production of evidence. The issuing authority shall pay any witness fees, travel expenses, mileage, and other fees required by the service statutes of the state where the witnesses and/or evidence are located. If permitted by state law, the member state may recover the costs of investigations and disposition of cases resulting from any adverse action taken against that licensee from the licensee. 

Joint investigations

 A member state may participate with other member states in joint investigations of licensees.  They may share any materials in any joint or individual investigation initiated under the compact.

Physical Therapy Commission 

The Physical Therapy Commission was established by the compact member states.  Some of the commission's duties are establishing bylaws, establishing the fiscal year and maintaining financial records, create uniform rules to implement and administrate the Compact. The executive board consists of nine members, with seven voting members and two non-voting members. The commission will meet at least once annually and will prepare the budget, maintain financial records, monitor Compact compliance, establish committees if needed, and ensure Compact administration. Meetings are open to the public, and minutes are taken, while specific committees or the Executive Board may meet privately.   For further information on the Commission, please see Wisconsin statute 448.985. 

Supervision (Chapter 5)

Practice and Supervision of Physical Therapist Assistants.

A physical therapist assistant assists a physical therapist in delivering physical therapy services, operating under the general supervision and guidance of the PT.

Supervising PTs must adhere to the following guidelines:

• The PT retains primary responsibility for the care provided by the PTA.
• The PT must communicate directly face-to-face with the PTA at least once every 14 calendar days. This can be accomplished electronically via video conferencing, but audio-only phone calls, emails, text messages, faxes, or postal services do not meet this requirement.
• The PT must be accessible via telecommunications between direct contacts while the PTA provides patient care.
• The PT must establish written policies and procedures for written and oral communication with the PTA. These should detail supervisory activities and describe how the PT will manage all aspects of patient care. Supervision levels must match the care setting and the services provided.
• The PT must perform the initial patient examination, evaluate referrals, and create the initial patient record for every patient.
• The PT must develop and revise a written patient treatment plan as needed. Based on their education, training, and experience, the PTA can delegate appropriate portions of the plan.
• The PT must assess and reevaluate each patient on-site at least once per calendar month or every tenth treatment day, whichever is sooner. Adjustments to the treatment plan should be made as necessary.
• The PT must coordinate discharge planning and perform the final patient assessment in collaboration with the PTA.

Supervisory Limits: The PT must limit the number of PTAs supervised to ensure all patients receive care consistent with accepted standards and regulatory requirements. No PT may supervise more than two full-time equivalent PTAs under general supervision at any time.

A PT cannot supervise more than two physical therapist assistants (full−time equivalents) practicing under general supervision. A PT can only supervise four people in total, but it is limited to two PTAs. So, for example, the therapist could supervise four temporary licensees, two temporary licensees and two PTAs, or two PTAs and two physical therapy aides. 

Direct Immediate on-premises supervision

The physical therapist must always provide direct, immediate, on−premises supervision to unlicensed personnel. Physical therapy aides are unlicensed personnel and require direct, immediate, on-premises supervision. This is the same level of supervision as the temporary license holder. 

The physical therapist can not have unlicensed personnel perform tasks that require the decision−making or problem−solving skills of a physical therapist, including patient examination, evaluation, diagnosis, or determination of therapeutic intervention.  The physical therapist providing this level of supervision has full professional responsibility for patient-related tasks performed and has to be available at all times for direction and supervision of the person performing related tasks.

The physical therapist providing this level of supervision also has the following responsibilities: 

• Evaluating the effectiveness of patient-related tasks performed by those under direct supervision by assessing the client before and after the task performance and by observing and monitoring the client  
• Determine the competence of personnel to perform assigned tasks based on education, training, and experience. (f)  Verify the competence of unlicensed personnel with written documentation of continued competence in the assigned tasks
• Perform initial patient examination, evaluation, diagnosis, and prognosis; interpret referrals; develop and revise as appropriate a written patient treatment plan and program for each patient; and create and maintain a patient record for every patient the physical therapist treats.
• Provide interpretation of objective tests, measurements, and other data in developing and revising a physical therapy diagnosis, assessment, and treatment plan.
• Direct unlicensed personnel to provide appropriate patient-related tasks consistent with the education, training, and experience of the person supervised.  That direction includes a list of specific patient-related tasks, including dosage, magnitude, repetitions, settings, length of time, and any other parameters necessary for the performance of the patient-related tasks.

As mentioned previously, the supervision of PTAs and unlicensed personnel performing patient-related tasks under supervision (including temporary license holders) may not exceed a combined total of 4 for a licensed PT.   

Students

The PT provides direct, immediate, on−premises supervision of a physical therapist or physical therapist assistant student at all times unless that PT has delegated that supervision to a physical therapist assistant. 

The delegating physical therapist provides general supervision of the physical therapist assistant supervising the physical therapist assistant student.

A physical therapist assistant supervising a physical therapist assistant student will provide face−to−face contact with the student, as necessary, and be physically present in the same building when the student performs a service.

A physical therapist also has the following responsibilities: 

• Full professional responsibility for all physical therapy procedures and related tasks performed by the student he or she is supervising and shall delegate treatment plans and programs to the student in a manner consistent with the student’s education, training, and experience.
• When delegating the supervision of a PTA student to a PTA, the physical therapist delegating the supervision has full professional responsibility for all physical therapy procedures and related tasks performed by the physical therapist assistant and by the physical therapist assistant student and shall delegate treatment plans and programs to the physical therapist assistant student in a manner consistent with the student’s education, training, and experience.

Communication with the Department of Safety and Professional Services (440.03, 440.11)

Any licensee who is convicted of a misdemeanor or felony in any state is required to notify the Department of Safety and Professional Services in writing of the date, place, and nature of the conviction within 48 hours of the conviction.  Failure to notify may result in disciplinary action against your Wisconsin license. 

Any licensee who changes his or her name or moves from the last address provided to the department has 30 days from the name or address change to notify the department.  

Credential Denial (440.12-440.13)

The Department of Safety and Professional Services may deny a credential renewal (or initial credential) if the Department of Revenue determines that the license applicant is liable for delinquent taxes. In this case, a credential is the same as a license.  This is also noted in Chapter 9 of the Administrative Procedures of the Department of Safety and Professional Services.  The Wisconsin Department of Revenue (DOR) checks if applicants owe delinquent state taxes. If they do, they will get a notice and have 10 days to prove they’ve cleared their tax debt by submitting a tax clearance certificate. 

If other issues might cause a renewal denial, the Department of Safety and Professional Services (DSPS) will first handle the tax issue before looking into other concerns. 

A renewal will be denied if the applicant does not provide the required information or clear delinquent taxes. Applicants who are denied can request a hearing to challenge the decision.

A credentialing board shall also restrict, limit, or suspend a credential held by a person or deny an application for an initial credential when directed to do so by the Department of Safety and Professional Services. This applies to a license applicant or renewal applicant who is delinquent in paying child support or fails to comply after appropriate notice with a subpoena or warrant regarding support or paternity proceedings.  

Practice Requirements (448.56) and (Chapter 6)

Direct Access/Written Referral

Wisconsin has direct access, but there are some restrictive provisions. 

A physical therapist does not require a written referral to provide services in the following cases:

1. Schools: Services provided to children with disabilities as defined in s. 115.76 (5), following rules established by the Department of Public Instruction.
2. Home Health Care: Services provided as part of a home health care agency.
3. Nursing Homes: Services provided to patients in nursing homes as part of their care plans.
4. Athletics and Injury Prevention: Services related to athletic activities, conditioning, or injury prevention.
5. Previously Diagnosed Conditions: Services provided for a previously diagnosed medical condition as long as the physical therapist informs the diagnosing healthcare provider (e.g., physician, naturopathic doctor, physician assistant, chiropractor, dentist, podiatrist, or advanced practice nurse

In addition, PT Chapter 6 also states that a written referral is not required to provide conditioning, injury prevention, and the treatment of musculoskeletal injuries, with the exception of acute fractures or soft tissue avulsions. 

In Wisconsin, referral sources include physicians, naturopathic doctors, physician assistants, chiropractors, podiatrists, dentists, and advanced practice nurses. A physical therapist providing services under a referral must communicate with the referring physician, chiropractor, dentist, or podiatrist as necessary to ensure continuity of care.

Duty to Refer

The physical therapist must refer a patient to a physician, chiropractor, dentist, podiatrist, or another healthcare practitioner when the patient requires healthcare services that are beyond the scope of physical therapy practice.

Patient Records

A physical therapist must create and maintain a detailed patient record for every patient they examine or treat, ensuring accurate documentation of assessments, treatments, and progress.

Fee Splitting

Physical therapists and compact privilege holders are strictly prohibited from:

• Giving or receiving any payment, commission, rebate, or compensation of any kind (directly or indirectly) in exchange for:
  1. Referring a person to communicate with them professionally.
  2. Services that were not personally provided by the therapist or supervised by them.

This rule ensures that all referrals and services are made in the best interest of the patient and not influenced by financial incentives.

Billing by Professional Partnerships and Corporations

If two or more physical therapists form a legitimate partnership or establish a service corporation for practicing physical therapy, they cannot issue a single bill under the partnership or corporation's name unless the bill clearly identifies each physical therapist who provided services and specifies the services rendered by each therapist.

Responsibility

A physical therapist is responsible for managing all aspects of the physical therapy care of each patient under his or her care.  A physical therapist shall create and maintain a patient record for every patient the physical therapist examines or treats.

Ordering X-rays (Chapter 10 and 448.56(7)

Most states do not allow physical therapists to order X-rays. In Wisconsin, it is explicitly allowed.  However, not every PT can order an x-ray. You have to satisfy one of the following requirements to be allowed to order X-rays:

A physical therapist may order X-rays to be performed by qualified individuals if they meet one of the following qualifications:

• The therapist holds an entry-level or transitional clinical doctoral degree in physical therapy from a program accredited by the Commission on Accreditation in Physical Therapy Education or its successor.

• The therapist has a specialty certification from the American Board of Physical Therapy Specialties or an equivalent national organization, provided the certification program includes training in X-ray ordering and meets specified competency and education criteria.

• The therapist has completed a residency or fellowship accredited by the American Board of Physical Therapy Residency and Fellowship Education or an equivalent national organization, which includes training in x-ray ordering and satisfies required educational standards.

• The therapist has successfully completed a formal x-ray ordering training program that:

  • Directly enhances professional competency in ordering X-rays
  • Covers subjects integrally related to the practice of ordering X-rays
  • Conducted by qualified instructors, including those with demonstrated physician involvement
  • Meets pre-established goals and objectives
  • Provides proof of attendance
  • Includes a final assessment to evaluate competency in ordering X-rays.

The physical therapist is to communicate with the patient's primary care physician or an appropriate health care practitioner to ensure coordination of care after ordering an X-ray unless all of the following apply:

• A radiologist has read the X-ray and has not identified a significant finding, and
• The patient does not have a primary care physician, and
• The patient was not referred to the physical therapist by another health care practitioner to receive care from the physical therapist.

Sharps Debridement

The Wisconsin State Practice Act does not explicitly address sharps debridement. To ensure compliance, it is advisable to seek clarification directly from the Wisconsin Physical Therapy Examining Board.

According to the American Physical Therapy Association (APTA), selective sharp debridement is considered a component of wound management and falls within the scope of physical therapy practice. However, the APTA specifies the following:

• Who Can Perform It: Sharps debridement should be performed exclusively by a licensed physical therapist due to the complexity of the intervention.
• Why: The procedure requires continuous examination, evaluation, and synthesis of information to make real-time clinical decisions during the intervention.

Dry Needling

The Wisconsin State Practice Act does not specifically address dry needling. This absence of guidance means there is currently no official position on whether dry needling falls within the scope of physical therapy practice in the state. Physical therapists should consider consulting the Wisconsin Physical Therapy Examining Board for clarification. The American Physical Therapy Association (APTA) has consistently supported dry needling as a skilled intervention that physical therapists are trained to perform when they have appropriate education and training.

Treatment Discrimination (252.14)

Physical therapists and physical therapist assistants must not discriminate against individuals with HIV or related medical conditions. They are prohibited from refusing to treat such individuals if their condition falls within the therapist's scope of practice. Care must be provided at the same standard as that offered to other patients with similar medical needs, and individuals with HIV cannot be isolated unless medically necessary. Physical therapists and all healthcare providers must also avoid subjecting these patients to any form of indignity, including humiliating, degrading, or abusive treatment. If a patient declines an HIV test, this decision cannot be used as a reason to deny other treatments or services. Additionally, healthcare providers are required to have procedures in place to ensure continuity of care if a patient’s condition exceeds their scope of practice, making appropriate referrals when necessary. Violations of these standards can result in liability for actual damages, court costs, and up to $10,000 in exemplary damages for intentional misconduct.

Biennial License Renewal (PT Chapter 8)

All licensees are required to renew their licenses every two years by completing a renewal application form and submitting it along with the required fee before March 1 of the following odd-numbered year. If you receive your initial credential in the months leading up to this date, you are still required to renew your license by the defined date.  

Your license will expire if it is not renewed before March 1 of each odd-numbered year, except for temporary licenses. 

If your license expires because you did not renew it on time, here’s how you can renew or reinstate it:

Renewal Before 5 Years

If your license has been expired for less than 5 years, you can renew it by paying the renewal fee and completing any required continuing education.

Renewal After 5 Years or More 

If your license has been expired for more than 5 years, the board will assess your ability to safely practice. This may include taking an open-book exam on state laws and rules (the same exam given to new applicants). The board may also require additional steps, such as an oral exam.

This process does not apply to licenses with unmet disciplinary actions or those that have been surrendered or revoked.

Reinstatement 

If your license was revoked, surrendered, or not renewed for more than 5 years, and there are unmet disciplinary actions, you can apply for reinstatement by meeting these requirements:

• Complete the steps listed under the "Renewing After 5 Years" section.
• Fulfill any outstanding disciplinary requirements.
• Provide proof of rehabilitation or changes in circumstances that justify reinstatement.

Continued Competence (Chapter 9)

PTs are required to have 30 hours of continuing competence activities every two years, four of which must be in ethics, jurisprudence, or both. PTAs are required to have 20 hours of continuing competence activities every two years, with four hours in ethics, jurisprudence, or both. One contact hour equals at least 50 minutes a licensee spends in actual attendance at or completion of acceptable continuing education. The biennium is defined as 3/1/odd - 2/28/odd year.

Continuing education hours are applicable only to the registration period in which they are earned. If a license has lapsed, the board may allow continuing education hours acquired after the lapse to be applied to a prior biennial period where the required hours were not completed. However, continuing education hours cannot be applied to more than one biennial period.

Applicants for renewal must certify the completion of required continuing education hours. The board will audit any licensee currently under investigation for alleged misconduct.

A licensee may request a postponement or waiver of continuing education requirements from the board due to prolonged illness, disability, or other extreme hardships. Each request is evaluated individually, and the board may grant a postponement, partial waiver, or total waiver based on the circumstances.

You must stop practicing if you do not request a postponement or waiver and fail to complete the required continuing education hours by February 28 of an odd-numbered year. The law explicitly requires licensees to cease and desist clinical practice if continuing education requirements are not met. To avoid this, ensure your continuing competence hours are completed or submit a request for postponement or waiver before the deadline, as practicing beyond March 1 without compliance is prohibited.

One exception to the continuing competence requirement is that continuing education is not required during the biennium when the license was first issued.  

Continuing Education Requirements for Out-of-State Applicants

• Physical therapists applying for a license in this state from another state must provide proof of completing at least 30 hours of board-approved continuing education within the two years prior to their application.

• Physical therapist assistants applying for a license in this state from another state must provide proof of completing at least 20 hours of board-approved continuing education within the two years prior to their application.

Specific Approval Requirements for Continuing Education Programs

A continuing education program must meet all of the following criteria:

• The program must be structured to enhance the licensee’s knowledge, skills, behaviors, and abilities relevant to the practice of physical therapy.
• The content must be integrally related to the practice of physical therapy.
• Conducted by individuals who have specialized education, training, or experience by reason of which the individuals should be considered qualified concerning the subject matter of the activity or program.
• Fulfills pre-established goals and objectives.
• Provides proof of attendance by licensees.

None of these activities are available for continuing education hours:

• Meetings for the purpose of policy decisions
• Non-educational meetings at the annual association, chapter, or organization meetings
• Entertainment or recreational meetings or activities
• Visiting exhibits

In addition to academic courses or continuing education courses, a wide variety of activities can earn continued competence hours, including teaching, presenting, publishing/authoring a book, or acting as a CI. The table below shows those activities. Per Chapter 9, all activities have to "integrally relate to the practice of the profession" to be accepted.  

Table 1. Approved Continuing Education Activity and contact hour limits (if applicable)

Disciplinary Actions and Loss of Licensure (448.57 and Chapter 7)

Definitions

Negligence in physical therapy occurs when a physical therapist or physical therapist assistant fails to provide the level of care and skill that a reasonably competent practitioner would offer in similar circumstances. Importantly, negligence can be identified even if the act does not result in actual harm to the patient.

Sexually explicit conduct means actual or simulated:

• Sexual intercourse, including vulvar penetration, cunnilingus, fellatio, or anal intercourse between persons, any other intrusion, however slight, of any part of a person’s body or an object into the genital or anal opening, either by a person or upon the person’s instruction. Note: The emission of semen is not required.
• Bestiality
• Masturbation
• Sexual sadism or sexual masochistic abuse, including but not limited to flagellation, torture, or bondage

• Lewd exhibition of intimate parts.

Sexual contact refers to the following intentional actions:

• Touching someone’s intimate parts, either directly or through clothing, for the purpose of sexually degrading, humiliating, arousing, or gratifying. This includes:

  • Touching someone’s intimate parts using any body part or object, either by the person committing the act or by someone else under their instruction.
  • Touching the intimate parts of the person committing the act, or the intimate parts of another person, as instructed by them.
  • Touching bodily fluids, such as ejaculate, urine, or feces, as instructed by the person committing the act, especially if force or threats are involved.

• Intentionally ejaculating or releasing urine or feces onto another person’s body, whether clothed or unclothed, for the purpose of sexually degrading, humiliating, arousing, or gratifying.

• Intentionally causing another person to ejaculate or release urine or feces onto any part of the person committing the act’s body, whether clothed or unclothed, for the same purposes.

Unprofessional Conduct

We are guided by core values such as accountability, altruism, compassion, caring, excellence, integrity, professional duty, and responsibility. As representatives of our profession, we are responsible for empowering, educating, and supporting patients in achieving greater independence, improved health, wellness, and a better quality of life.

To uphold these principles, physical therapists and physical therapist assistants must consistently act with honesty, adhere to legal and ethical standards, exercise reasonable judgment, demonstrate competence, and respect the dignity of every patient.

Any unethical or unprofessional conduct will call your license into question. The examining board may make investigations and conduct hearings to determine whether a violation has occurred. The examining board may reprimand a licensee or compact privilege holder or may deny, limit, suspend, or revoke a license or a compact privilege if it finds that the applicant, licensee, or compact privilege holder has violated, aided, abetted, or conspired to engage in any of the following:

• Advertised in a manner that is false, deceptive, or misleading
• Made a material misstatement in an application for a license or for renewal of a license
• Interfere with an investigation or disciplinary proceeding by using threats, harassment, or intentional misrepresentation of facts
• Advertised, practiced, or attempted to practice under another's name
• Practicing under the influence of drugs or alcohol
• Convicted of an offense that substantially relates to the practice of PT
• Found to be mentally incompetent
• Practicing beyond the scope of any professional credential issued by the board 
• Engaged in unprofessional or unethical conduct in violation of the code of ethics
• Failed to complete your continuing competence requirements in the time frame required
• Practiced outside the scope of practice, which includes not properly supervising PTAs, aides, or those on a temporary license
• Negligent in your practice, regardless of whether the patient was actually injured
• Practicing physical therapy with a mental or physical condition that impairs the ability of the licensee to practice within the standard of minimal competence or without exposing the patient to an unacceptable risk of harm
• Providing treatment intervention unwarranted by the condition of the patient or continuing treatment beyond the point of reasonable benefit.
• Disclose confidential patient health care information except as required or permitted by state or federal law.
• Performing physical therapy on any patient without the patient’s informed consent or after the patient has withdrawn informed consent, whether verbally or in writing. 
• Failure to document informed consent or failure to inform the patient that any act of physical therapy may or will be performed by unlicensed personnel.
• Permitting or assisting any person to perform acts constituting the practice of physical therapy without sufficient qualifications, necessary credentials, adequate informed consent, or adequate supervision as
  It is the PT's responsibility to determine whether general, direct, or one−on−one supervision is necessary to protect the patient from unacceptable risk of harm.  The physical therapist retains responsibility for delegated or supervised acts unless the board determines that the delegate knowingly and willfully violated the supervisor’s direction or instruction.
• Failure to establish and maintain accurate and timely patient health care records as required by law and professional standards.  Patient health care records are presumed to be untimely if not completed and signed within 60 days of the date of service.
• Failure to timely transfer patient health records to any person or practitioner authorized by law to procure the patient health care records.  Failure to comply with any lawful request for patient health care records within 30 days of receipt of the request is presumed to be a violation of this subsection.
• Failure, within 30 days, to report to the board any adverse action by another licensing or credentialing jurisdiction, whether final or temporary, taken against the licensee to practice physical therapy as follows. 
• Failure to report within 30 days to the board any adverse action by any division of the state or federal government that results in limitation or loss of authority to perform any act constituting the practice of physical therapy or as a physical therapist assistant.
• Failure, within 30 days, to report to the board any voluntary agreement to limit, restrict, or relinquish the practice of physical therapy or as a physical therapist assistant entered into with any court or agency of any state or federal government.
• Failure to report to the board any incident in which the licensee has direct knowledge of reasonable cause to suspect that a physical therapist or physical therapist assistant has committed any unprofessional, incompetent, or illegal act in violation of state or federal statute, administrative rule, or orders of the board. Reports shall be made within the time necessary to protect patients from further unacceptable risk of harm, but no more than 30 days after the required reporter obtained knowledge of the incident.

• Engaging in sexually explicit conduct, sexual contact, exposure, gratification, or other inappropriate sexual behavior with or in the presence of a patient, a patient’s immediate family member, or a person responsible for the patient’s welfare is strictly prohibited. The following clarifications apply to this guideline:

  • Sexual Motivation: Sexual motivation may be inferred from the totality of the circumstances and is presumed when a physical therapist or physical therapist assistant makes contact with a patient’s intimate parts without legitimate professional justification.

  • Adult Patients: An individual who has received treatment is considered a patient for six months following the termination of professional services.

  • Minor Patients: A minor remains a patient for two years after the termination of services or until two years after reaching the age of majority, whichever is longer.

  • Inability to Consent: It is a violation for a physical therapist or physical therapist assistant to engage in any sexual contact or conduct with or in the presence of a patient or former patient who is unable to consent due to factors such as age, medication, psychological conditions, or cognitive disabilities.

As a licensee, you can voluntarily surrender your license to the examining board.  However, the board may refuse to accept it if they have received allegations of unprofessional conduct. The examining board may negotiate stipulations for accepting the surrender of licenses. The examining board has the ability to restore a license that had been voluntarily surrendered. 

The examining board prepares and makes public an annual report that describes the final disciplinary action taken against licensees and compact privilege holders during the preceding year. The board may report final disciplinary action taken against a licensee or compact privilege holder to any national database that includes information about disciplinary action taken against health care professionals.

Injunctive Relief (448.58)

If the examining board believes someone is violating this subchapter or its related rules, it may take action. The board, the department, the attorney general, or the district attorney of the appropriate county can investigate the matter. In addition to other available remedies, they may file a legal action on behalf of the state to stop the person from continuing the violation.

Penalties (448.59)  

Any person who violates any rule promulgated by the board may be fined up to $10,000, imprisoned for up to 9 months, or both.

Disciplinary Process and Procedures for Physical Therapists (SPS 2)

Handling Complaints and Disciplinary Actions

The Department of Safety and Professional Services (DSPS) oversees disciplinary actions against licensed professionals, including physical therapists. Patients, employers, or colleagues can file complaints, which may lead to an investigation if the issue involves a violation of professional standards.

Types of Complaints and Investigations

Complaints fall into two categories:

1. Informal Complaints – Written concerns submitted about a licensee’s behavior or practice. These are screened to determine if further investigation is needed.
2. Formal Complaints – If a violation appears serious, an official disciplinary proceeding may begin, leading to possible penalties.

The Division of Legal Services and Compliance (DLSC) reviews all complaints and determines if a case requires a formal hearing.

Disciplinary Hearings and Settlement Conferences

• Settlement Conferences – Before formal action begins, a meeting may be held to resolve minor complaints without going to a full hearing.
• Formal Hearings – If the issue is not resolved, a disciplinary proceeding is initiated, and the case is heard by an Administrative Law Judge.

Licensees facing disciplinary action are notified in writing and given a chance to respond.

Potential Disciplinary Actions

If a licensee is found guilty of a violation, possible consequences include:

• Reprimands – Formal warnings about conduct.
• License Limitations – Restrictions on practice.
• Suspension or Revocation – Temporary or permanent loss of a license.
• Fines – Monetary penalties for violations.

Appeal Process and Legal Rights

• Licensees have the right to appeal disciplinary decisions.
• If found guilty of cheating on an exam or violating security protocols, restrictions may include a failing grade, bans on retaking exams, or denial of licensure.
• Failure to appear at a hearing results in an automatic ruling based on available evidence.

Administrative and Legal Procedures

• Notice of Hearing – Licensees receive a written notice at least 10 days before their hearing.
• Filing Complaints and Responses – Licensees must respond to formal complaints within 20 days of receiving them.
• Discovery and Evidence – Both sides can present evidence and witnesses.

Orders and Disciplinary Actions

Public access to the Wisconsin Department of Safety and Professional Services Reports of Decision includes any orders and disciplinary actions relating to PTs or PTAs licensed in Wisconsin. These records are made available under Wisconsin's Open Records Law, sections 19.31–19.39 of the Wisconsin Statutes, and are open for public viewing.

Wisconsin Act 210

There are state laws beyond the Physical Therapy Practice Act. Wisconsin has a specific law for military personnel that applies to PTs and PTAs. Wisconsin Act 210, which became effective in June 2012, created special assistance for military personnel in keeping their license. This act extends the license of the service member who is on active duty in the US Armed Forces, a reserve unit of the US Armed Forces, or the National Guard of any state, provided their primary residence is in Wisconsin 180 days from the date of discharge or until the next credentialing biennium whichever date comes first.  This act also includes the spouse of the active duty member if the spouse does not practice as a PT or PTA because the service member is on active duty.  

Service members or their spouses may also request an extension past 180 days of discharge and may request a waiver or extension of time to complete continuing education requirements due to hardship.  
 

Key Points for Wisconsin Mandatory Reporting

Child Abuse or Neglect

Under Wisconsin Statute 48.981, physical therapists are mandated reporters and must report suspected cases of child abuse or neglect, as well as abuse of unborn children, if they have reasonable cause to believe such abuse has occurred or is at risk of occurring. This obligation includes situations identified during professional interactions where the therapist observes signs of physical, emotional, or sexual abuse, neglect, or conditions suggesting that an unborn child may be harmed by the actions of a pregnant individual. Physical therapists must report their suspicions to the local child protective services (CPS) agency, law enforcement, or the appropriate authorities as soon as possible. Reports should include any known details about the child, the suspected abuse or neglect, and identifying information about the individuals involved. Reports made in good faith are confidential and protect the reporter from legal liability. Not fulfilling the mandatory reporting duties can result in legal consequences, including fines or professional disciplinary action.

Elder or Adult-at-Risk Reporting

Under Wisconsin Statute 46.90, mandatory reporting also applies to elder abuse or adults at risk (vulnerable adults), particularly if the individual is unable to advocate for themselves. Elder abuse includes physical abuse, emotional abuse, sexual abuse, neglect, and financial exploitation. Physical therapists should report any reasonable suspicion of elder abuse, neglect, or exploitation to the appropriate county Elder Abuse Agency or Adult Protective Services (APS) as soon as possible. Reports must include details of the suspected abuse and the individuals involved. Therapists who report in good faith are protected from civil or criminal liability, and their identity is kept confidential, except in court proceedings if disclosure is required. Failure to report, when required, may result in professional disciplinary action. Once a report is made, the agency investigates and takes appropriate action to ensure the elder’s safety. Physical therapists should be vigilant for signs of abuse, such as unexplained injuries, emotional distress, malnutrition, or financial irregularities, and familiarize themselves with their reporting obligations and facility policies to support the safety and dignity of their elderly patients.

Malpractice

Malpractice means that a professional has been negligent. This is because a professional has a fiduciary duty to the patient that carries more responsibility than a regular relationship. This fiduciary duty is hierarchal, and it's because the professional has power. We have an education, a skillset, a research base, and evidence that the patient doesn't have, and we need to hold that patient in our care. And when we break that care, it's malpractice.
Malpractice most commonly occurs after there's some injury to the patient. For malpractice actions to be successful, they have to show that there is a duty. As a PT or PTA, there's always a duty to your patient. That duty has to be breached, and that breach of that duty has to cause harm or loss.
As a PT or PTA, unfortunately, you may not have immediate knowledge of this claim. There's generally a two-year statute of limitations in each state. Now, it's rare for a case like this to go to court, as less than 1% do. Most cases settle.

We know the most about physical therapy malpractice from what we learned through insurance settlements or professional liability settlements. CNA/HPSO is the company that ensures most physical therapists. They publish a report every so many years, the last being January 2021. Their most recent report is titled Physical Therapy Professional Liability Exposure Claim Report, 4th Edition.  During the time of Jan 1, 2015 -December 31, 2019, there were 2,232 professional liability closed claims and incidents for those insured by CNA/HPSO.  The report found that the most common allegation regarding PTAs was the failure to supervise or monitor a patient during treatment, which resulted in a patient fall. Three out of every five license protection matters involved allegations related to the professional conduct of a PT or PTA. Improper management over the course of treatment was the area where the highest average total in a lawsuit occurred ($166,874) and comprised the most closed claims in 2020 claim data.

Over a five-year study period, malpractice claims against physical therapists (PTs) insured through the HPSO Program totaled $46 million. The average cost of a malpractice lawsuit, including legal defense expenses, was $134,761. The most common malpractice allegation against PTs was improper management of a patient’s treatment, with fractures being the most frequently reported injury in these claims. Additionally, defending a PT against a state licensing board complaint incurred an average legal cost of $6,420. These findings underscore the importance of risk management and adherence to best practices in physical therapy to minimize legal exposure.

Malpractice and Licensure Infraction

It's important to understand that malpractice and a license infraction are different. Malpractice is a civil lawsuit through the judicial branch, and it has no impact on the ability to practice. Even if you're being sued under a malpractice claim, you can continue to practice as a PT. The allegations in a civil lawsuit relate to your professional responsibilities and clinical practice. 

A license infraction is carried out through the administrative branch of government, and the state examining board usually governs this type of activity. Now, if you're a PT or PTA, you could be reported for both (licensure infraction and malpractice). One could lead to another, but usually, they remain separate.  License infractions are typically nonclinical, such as physical abuse, unprofessional behavior, or fraud.  However, allegations can also be related to clinical practice and professional responsibility. According to CNA/HPSO's latest report from their cases, three out of five licensure infractions (protection cases) involve an allegation related to the professional conduct of the PT or PTA.  With malpractice, when we talked about the breach of duty, cause, and harm, you have to have harm to the patient. With a license infraction, no harm to the patient is necessary. So, a PT or PTA can be reported to the state board for negligence even if a patient isn't harmed.

Licensure infractions related to Wisconsin physical therapists and physical therapist assistants are of public record and can be reviewed on the Orders and Disciplinary Actions page on the State of Wisconsin Department of Safety and Professional Services website.   

CNA/HPSO also provides some information or data about defending PT's and PTA's licenses when they are reported to the board. According to the CNA/HPSO report, about 52 percent of licensing board matters led to some type of action against a PT's or PTA's license.  

In Wisconsin, multiple sources of law govern physical therapy practice, including the State Practice Act, administrative code, relevant statutes from various disciplines, and official information from the state website. Additionally, professional organizations such as the APTA (American Physical Therapy Association) provide guidance. However, there are situations where no specific laws exist. In such cases, organizational policies and procedures become crucial. When legal guidance is unclear or the standard of practice is not well established, it is essential to ensure that your actions align with organizational expectations, provided they are ethical, legal, and clinically sound.

Following established policies and procedures demonstrates compliance within your organization and adherence to professional standards. If you are using specialized interventions or techniques, compliance also helps establish competency. For example, splinting the wrist and hand may not be common in a general outpatient physical therapy clinic. However, in an outpatient setting with a high volume of post-operative hand patients, a Certified Hand Therapist (CHT) may use splinting as a recognized standard of practice. In situations where no specific law defines your scope of practice, adherence to organizational policies can serve as a defense in malpractice litigation. However, you should never follow organizational policies or procedures that involve fraud, abuse, illegal activities, or actions beyond your scope of practice.

Risk Management Through Competency and Documentation

Maintaining clinical and specialty competencies through ongoing education and training is highly recommended to minimize legal risks. Staying current with best practices ensures that patient care remains effective and defensible in legal or regulatory reviews.

Additionally, documentation is a critical risk management tool. Accurate and thorough documentation should include:

• Patient assessments before and after treatment sessions.
• Changes in patient status and modifications to care plans.
• Informed consent and proper handover of care to another provider (including PTAs).
• Evidence of clinical competence, including the rationale for interventions.
• Communications with the care team, especially regarding changes in a patient’s condition.
• Patient concerns and the steps taken to address them.

Reporting Adverse Events

If an adverse event occurs, it should be reported immediately to a supervisor in accordance with company risk management and business policies. Adverse events may include:

• A patient being injured during care or discovering an injury after treatment (e.g., in-home care or a skilled nursing facility).
• Events with potential clinical significance, even if no immediate harm is apparent.
• An unexpected outcome where the intervention results differ significantly from anticipated results.
• A sudden safety crisis requiring an urgent response.

By following these guidelines, physical therapists can protect their patients, professional practice, and legal standing while maintaining high-quality, ethical care.

Professional Resources/References 

• The Wisconsin chapter of the American Physical Therapy Association is found at wpta.org
• State of Wisconsin, Department of Safety and Professional Services
• State of Wisconsin, Physical Therapy Examining Board
• US Department of Health and Human Services at hhs.org
• The American Physical Therapy Association (APTA) is a good resource on a lot of professional issues under the "Your Practice" and "Advocacy" sections.
• The Federation of State Boards of PT, found at FSBPT.org, has a really extensive state section that tells you what's happening in each state and provides guidance for the scope of practice in each state, including supervision and practice-related issues, to compare differences across states.
• CNA/HPSO Professional Liability Exposure Claim Report: 4th Edition

That completes our review of the Wisconsin jurisprudence for physical therapists and physical therapist assistants. 

Principles of Ethics

Physical therapists and physical therapist assistants are guided by core values, including accountability, altruism, compassion, caring, excellence, integrity, professional duty, and responsibility. As representatives of our profession, we are committed to empowering, educating, and enabling patients to achieve greater independence, improved health, wellness, and an enhanced quality of life. To uphold these principles, we must consistently act with honesty, adhere to the law, exercise reasonable judgment, maintain competence, and respect the dignity of every patient.

Ethics are crucial in guiding our decisions about what is morally right and wrong, extending seamlessly from our personal lives into our professional conduct as physical therapists. Our choices in the professional realm are intricately tied to the unique context in which we practice. In this discussion, we will delve into fundamental principles of ethics. As we progress, we hope you will find alignment with these principles, affirming that your practices align seamlessly. However, you may also encounter ethical gray areas that prompt further consideration and reflection within your clinic or practice area.

Autonomy

Let's start with the basic ethical principles, starting with autonomy. Autonomy refers to the moral right to make choices about one's own actions—in other words, it's the right to self-determination. For practitioners, respecting autonomy means refraining from interfering with patients' choices. We allow and enable patients to make their own choices. That said, we can still educate patients about the risks, benefits, and consequences of choices without diminishing autonomy. 

In our approach to patient education, we prioritize providing information to empower individuals to make informed decisions regarding their therapy. However, it's essential to acknowledge that within the health and rehabilitation sector, our dedication to helping others can inadvertently overshadow the principle of respecting autonomy.

For instance, when a patient declines therapy, it's crucial to communicate the potential risks and benefits of their decision. However, persistent attempts to convince or pressure them could undermine their autonomy and demonstrate a lack of respect for their choices and preferences.

It is paramount to maintain a delicate balance between offering guidance and honoring an individual's autonomy. By providing comprehensive information and fostering open communication, we create an environment where patients can confidently exercise their autonomy in making choices about their care.

Nonmaleficence

This principle embraces the timeless guidance from the Hippocratic Oath - "do no harm." As healthcare practitioners, it reminds us that if we cannot provide direct assistance to our patients, we must, at the very least, ensure we do not cause harm or exacerbate their condition. When we examine harm, we must recognize its diverse manifestations, encompassing physical, psychological, social, mental, reputational, or even harm to one's liberty, property, and more.

The nuanced nature of harm leads us to question both the recipient and the nature of the harm, especially when working with patients who may lack decision-making capacity, such as those with advanced dementia. Understanding harm in this context requires a delicate approach, considering differing interpretations and perspectives on what constitutes harm.

Furthermore, it's vital to acknowledge that our perception of harm may diverge from the patient's own assessment. For instance, we may believe that non-participation in physical therapy could harm the patient, while the patient may not perceive it as detrimental. Hence, we must carefully consider whose perspective of harm we are referencing.

Beneficence

In alignment with nonmaleficence, we delve into the principle of beneficence, representing our duty to prevent harm and promote the greater good. This duty involves the act of removing harm and actively fostering positive outcomes. However, it's essential to recognize that this moral obligation has its limits, especially when our actions, aimed at benefitting the patient, may inadvertently cause harm to ourselves as healthcare providers. Balancing the pursuit of benefit with preserving our well-being is critical to this ethical consideration.

Beneficence in healthcare centers on promoting the patient's overall well-being. However, a crucial and complex aspect is navigating the potential disparity in perspectives regarding what constitutes the patient's "good" or best interest. As healthcare providers, we often have a professional understanding of what interventions may optimize a patient's health and quality of life.

Yet, it's paramount to acknowledge and respect each patient's individualized perspectives. What we might perceive as a beneficial treatment or intervention may be viewed differently by the patient based on their unique experiences, pain thresholds, fears, and personal circumstances. For instance, encouraging a patient to walk for their health may conflict with their personal experiences of pain and fear of falling, causing them to consider it against their best interest.

The essential approach lies in effective patient education, open dialogue, and collaborative decision-making. Providing comprehensive information about risks, benefits, and potential outcomes empowers patients to make informed choices aligned with their values and concerns. It's about balancing promoting the patient's well-being and respecting their autonomy and individual perceptions of what benefits them.

Justice

The principle of justice in healthcare is becoming increasingly significant as the demand for limited healthcare resources continues to rise. Justice emphasizes the fair distribution of both burdens and benefits in society, aiming to provide individuals with their rightful due. In healthcare decision-making, this principle is pivotal in determining who should receive essential resources, examining whether some individuals deserve these resources more than others, and identifying the stakeholders responsible for these allocation decisions.

However, achieving justice in healthcare is a complex challenge, as it involves addressing various contextual factors, including religious beliefs, professional ethics, legal frameworks, institutional policies, and more.

My mother's story highlights the importance of advocating for the fair and equitable distribution of healthcare resources, irrespective of personal connections or influential networks. My mother just recently had back-to-back emergency surgeries, and she's doing very well right now. She was in the intensive care unit, and we were trying to get her into an inpatient rehab facility as opposed to a skilled nursing facility. I knew the case manager at that particular large teaching hospital. I was able to ask her what she would be able to do to get my mom whatever she needed.  We got what we wanted, and we got what we asked for. Was that justice? No, not necessarily. I thought, how do we fairly and equitably distribute resources such as discharge location and therapy? It shouldn't be necessary to know someone to get what is needed.  I was a very strong advocate. What about those individuals who are receiving care who don't have advocates in their families like me? 

Healthcare professionals must uphold the principles of justice by advocating for all patients, particularly those without strong advocates. By doing so, we contribute to a system where healthcare decisions are made fairly and ethically, guided by the best interests of the patients and the community.

Informed consent

Informed consent is a fundamental ethical and legal principle in healthcare. It requires healthcare professionals to provide patients with comprehensive and easily understandable information about their proposed intervention strategies. This includes outlining the potential benefits, risks, potential risks, side effects, alternatives, and any other relevant details associated with the proposed course of action.

Informed consent is more than just a checkbox to complete a procedure or evaluation. It embodies a vital opportunity for genuine communication and understanding between healthcare providers and their patients. It's about engaging in a meaningful conversation, ensuring that patients fully comprehend the proposed evaluation or treatment, its potential benefits, risks, alternatives, and what is expected from them throughout the process.

This process of obtaining informed consent should be conducted with care, empathy, and a genuine concern for the patient's well-being and understanding. We establish a foundation of trust and collaboration with the patient by explaining and addressing any concerns, questions, or uncertainties. This, in turn, enhances patient satisfaction, compliance, and overall outcomes.

Moreover, by approaching informed consent in this way, we uphold ethical principles, such as autonomy and beneficence, by respecting the patient's right to make informed decisions about their own healthcare. It's an opportunity to empower patients with knowledge and involve them in the decision-making process regarding their own health, promoting a sense of ownership and engagement in their care.

Veracity

Informed consent, an ethical cornerstone, hinges on the principle of veracity. Veracity dictates our duty to convey truth and integrity in all patient communications. Let me pause momentarily to clarify that I will use patient, resident, and individual client interchangeably. Now, diving deeper into veracity, its significance becomes apparent as we delve into case examples later.

Confidentiality

Confidentiality, deeply rooted in the Hippocratic Oath, is paramount. The oath asserts, "Anything I see or hear of the life of men, whether in a professional capacity or otherwise, which should not be passed on to others, I will hold as professional secrets and not divulge them." Hence, we possess a duty to restrict access to treatment-related information, maintaining a strict confidentiality boundary between us and our patients.

Yet, stepping back and acknowledging exceptions grounded in justice and beneficence is crucial. Certain laws mandate breaching confidentiality to protect citizens, such as reporting child abuse or elder abuse in specific states. We function as mandated reporters, adhering to distinct timeframes, notably in elder abuse cases. Nevertheless, upholding confidentiality remains vital.

Allow me to elaborate. In my role as an occupational therapist, patients often confide personal details during daily activities. Perhaps a past trauma or a family-related matter. If it doesn't necessitate reporting, I frequently express gratitude for their openness. I ask, "May I have your permission to share this with the healthcare team? It will aid in devising the best plan of care and course of action for you." While not obligatory, seeking this permission cultivates trust and reinforces the patient's faith in us as practitioners. Confidentiality, once again, emerges as an immensely significant principle.

Fidelity

Fidelity, closely intertwined with confidentiality, embodies our moral duty to uphold promises and fulfill commitments made to our patients.

Patients rightly expect us to honor both explicit and implicit promises. The explicit promises, such as scheduled appointments like, "We'll meet you at 9:30 for your physical therapy session," are clear commitments. Simultaneously, implicit promises, rooted in regulations like HIPAA and confidentiality, assure patients that we will preserve the privacy of shared information and provide the services prescribed by the physician.

Continuing to explore fidelity, we recognize five crucial expectations patients reasonably hold regarding healthcare contexts. These expectations encompass:

1. Treating them with fundamental respect and dignity,
2. Demonstrating competence and capability in performing our professional duties (a topic we'll delve into shortly),
3. Adhering to a professional code of ethics,
4. Following organizational policies, procedures, applicable laws, and licensure regulations,
5. Honoring any agreements made with the patient or client.

Duty

This underscores the obligations we hold toward others within society. Often, these duties stem from the nature of relationships between parties. In the context of therapy, initiating a patient-therapist relationship entails specific duties toward the patient. These encompass obligations to deliver a defined standard of care and maintain confidentiality, among other responsibilities. Establishing and upholding these obligations forms the foundation of ethical practice and professional conduct within the healthcare domain.

Rights

We will now discuss rights to a certain extent. Rights pertain to the ability to exercise a moral entitlement to either perform an action or refrain from doing so. In the realm of healthcare, a variety of rights come into play. The Patient's Bill of Rights, introduced some time ago, is a fundamental document. Additionally, individual healthcare facilities or communities may adopt their own Bill of Rights, outlining specific rights within their organizational context.

These rights encompass various aspects, including the right to health insurance irrespective of preexisting conditions—an evolving right. Federal statutes also delineate specific patient rights concerning privacy, such as the Health Insurance Portability and Accountability Act (HIPAA). Moreover, different states may have their unique Bill of Rights. Hence, we must understand and adhere to these rights as mandated by our respective organizations and regions of practice.

Paternalism

While not a distinct ethical principle, paternalism is a significant concept to address. Paternalism occurs when an individual, often a healthcare provider, disregards a person's autonomy and substitutes their own beliefs, opinions, or judgments for the judgment of the individual involved, typically a patient. They may act without obtaining informed consent or going against the patient's wishes under the pretext of seeking to benefit the patient.

In cases of paternalism, individuals rationalize their actions by asserting that they acted in the person's best interest. This often happens when someone believes they know better or what's best for the person in question without adequately considering the desires and wishes of the patient. Paternalism is sometimes observed in healthcare, particularly when dealing with families, such as in end-of-life care, where family members may have differing opinions on the care plan compared to the patient. In long-term care settings, involving the family in decision-making instead of the patient can also be a form of paternalism, especially in cases of dementia where the patient's capacity to make decisions may be intact.

Recognizing and addressing paternalism is crucial in promoting patient-centered care and upholding the principle of autonomy. Respecting and honoring patients' wishes and involving them in decision-making processes is essential to providing care that aligns with their values, preferences, and autonomy. 

Physical Therapy Ethics

Professional Ethics

Professional ethics incorporates values, principles, and morals into professional decision-making within our respective professions. Without this guidance, we risk falling into pitfalls that can harm ourselves, others, and society at large.

An insightful perspective shared by a friend emphasizes the importance of intuition, that gut feeling, as a guide for ethical decisions. However, it's crucial to recognize that not everyone possesses the same intuition or gut instincts. Therefore, relying solely on individual feelings may not always lead to universally ethical decisions.

We often witness the consequences of ethical lapses within our professional circles—colleagues facing sanctions or making headlines in the newspaper or online social networks for the wrong reasons. It makes you cringe.  How did that person allow that to happen? Why did they do that? These instances remind us of the critical need for a strong ethical foundation. Professional ethics act as a safeguard against such missteps, aiming to prevent these issues from occurring in the first place.

We must tap into our training, knowledge, and ethical obligations in our professional roles. These resources guide our actions and behaviors, helping us make informed and morally sound decisions in our respective fields.

Code of Ethics

Our code of ethics incorporates a set of rules or principles intended to express the profession's values as a whole.

Licensing boards and/or credentialing agencies incorporate professional codes of ethics into licensure regulations or credentialing rules. This ethical framework isn't confined to association membership; it universally applies to all practitioners within the field. Whether at the state or national level, adherence to the strictest code of ethics should be a priority, ensuring you maintain a strong ethical foundation in your practice.  It may mean, for example, using evidence-based practice or a certain quality measure or maybe incorporating something very specific into our rules. 

The code of ethics plays a pivotal role in promoting the basic tenets of the profession. It codifies our fundamental beliefs of the professions and the common moral values the profession chooses to protect patients and clients from harm. It gives meaning to the distinctiveness of your role as a physical therapist or physical therapist assistant. It serves as a unifying bond between professionals, fostering a common standard and shaping the very essence of being a practitioner in this field. These values become integral to your moral and behavioral repertoire, akin to how you integrate social, cultural, and other personal values.

Furthermore, courts reference the code of ethics to gauge appropriate professional behavior and as a component of the standard of care expected from practitioners. In legal scenarios, the code of ethics can significantly impact the outcome, acting as a measuring stick for proper conduct.

It's important to acknowledge that the code of ethics isn't a comprehensive guide that dictates behavior or decision-making with absolute certainty. Rather, it's a foundational starting point, reference point, and aspiration to steer professional practice. While it offers invaluable guidance, gray areas may still necessitate careful consideration and ethical discernment.

Unethical Practice

Unethical practice in healthcare refers to actions that deviate from established professional standards. This deviation spans from unreasonable, unjustified, or ineffective practices to those that are outright immoral, harmful, or knowingly wrong. Evaluating ethicality often involves a litmus test, a gut check, where practitioners assess their discomfort or unease with a certain practice.

Ethical analysis is multifaceted and influenced by various social, religious, and cultural perspectives. Acknowledging that not everyone will share the same ethical analysis, and disagreements are part of the ethical discourse is important. Often, as practitioners, we arrive at our ethical analysis from many different views, and not everybody will agree with our analysis, and that's okay.

We have to recognize what we will or won't do. Sometimes, it's a matter of discussing it with your supervisor or somebody on your compliance team. Unethical practice has a profound impact, primarily on the patient, but it also extends to the practitioner, the employing organization, insurers, society, and more. Instances of unethical behavior can lead to loss of professional license and credibility, highlighting the substantial risk unethical practices pose to one's professional investment and the credibility of the healthcare system at large.

Considering the investment of time, effort, and resources put into acquiring professional qualifications, it becomes imperative to safeguard one's ethical standing and uphold the profession's integrity. Maintaining ethical practice is not only a moral duty but also a strategic decision safeguarding the individual practitioner and the healthcare system. Somebody said to me one day, and it just resonated with me: Gosh, I spent so much money and time to get through school; why would I place that at risk to do anything that I would consider unethical? So, I think of it in that regard as well.

Core Values for the Physical Therapist and Physical Therapist Assistant

The core values of physical therapy form the foundation for high-quality care and professional conduct. These principles guide physical therapists and their assistants in all aspects of practice, ensuring that patient needs remain at the forefront. Physical therapists are responsible for delivering safe, accessible, cost-effective, and evidence-based services, while physical therapist assistants provide crucial support under their direction and supervision.

When examining the code of ethics in-depth, it's structured around the five fundamental roles of a physical therapist: patient management, consultation, education, research, and administration. This ethical framework revolves around the core values that underpin the profession, navigating the intricate landscape of ethical action across multiple realms. 

In physical therapy, practice is fundamentally shaped by seven core values, each playing a significant role in guiding practitioners' actions and decisions. These core values form the ethical compass of the profession, anchoring the practice within a strong ethical foundation and ensuring the delivery of patient-centric, responsible, and morally sound care.

Those core values are:

1. Accountability
2. Altruism
3. Compassion or caring
4. Excellence
5. Integrity
6. Professional duty
7. Social responsibility

Central to these values is accountability, which involves embracing responsibility for one's professional roles and actions. This includes self-regulation and behaviors that positively impact patients, the profession, and society's health needs. Altruism emphasizes putting patients' interests first above personal concerns. Collaboration entails working effectively with patients, families, communities, and other health professionals to achieve common goals. Collaboration in the physical therapy team means leveraging each member's strengths to optimize patient outcomes.

Compassion and caring are intertwined values that involve empathizing with patients' experiences and considering their needs and values. Duty reflects a commitment to providing effective services, advancing the profession, and contributing to societal health. Excellence in physical therapy requires consistent application of current knowledge and skills, recognition of personal limitations, integration of patient perspectives, embracing progress, and striving for continuous improvement.

Inclusion is vital in creating a welcoming environment for all. It involves providing safe spaces, amplifying diverse voices, acknowledging personal biases, and actively opposing discrimination. Integrity underpins all these values, demanding adherence to high ethical standards, honesty, fairness, and transparency in professional actions and decision-making.

Social responsibility extends these principles beyond individual patient care. It involves fostering mutual trust between the profession and the broader community by actively addressing societal health and wellness needs. This value underscores the profession's commitment to public health, preventive care, and community engagement.

These core values shape a framework for physical therapy practice that prioritizes patient well-being, professional growth, positive societal impact, and responsiveness to broader public health concerns. They guide physical therapists and their assistants in delivering care that is not only clinically effective but also ethically grounded and socially conscious.

APTA Guide for Professional Conduct

The APTA Guide for Professional Conduct helps physical therapists interpret the Code of Ethics for the Physical Therapist in matters of professional conduct. The revised Code of Ethics, adopted in 2009 and effective July 1, 2010, provides a framework for ethical decision-making and applies to all physical therapists. Additionally, the Guide supports the professional development of physical therapy students. Since the healthcare field is constantly evolving, these guidelines may be updated to reflect changes in professional practice and patient care.

Key Points of the Guide

• Application: The Guide applies to all physical therapists and is updated as the profession evolves and new healthcare practices emerge.
• Interpretation: The Ethics and Judicial Committee (EJC) provides opinions and advice to help therapists apply ethical principles to specific situations.

The APTA Guide for Professional Conduct is a dynamic document, evolving with the profession. It provides a clear ethical framework for physical therapists to follow, ensuring they deliver high-quality, ethical care to their patients and clients.

Respect in Physical Therapy (Principle 1A)

Physical therapists must treat all individuals with respect, regardless of age, gender, race, nationality, religion, socioeconomic status, sexual orientation, health condition, or disability.

Interpretation. Respect can vary across cultures and individuals. For example, direct eye contact may be seen as courteous in some cultures but inappropriate in others. Physical therapists must be mindful of cultural differences and assess what is appropriate in each situation to ensure inclusive and respectful interactions.

Altruism in Physical Therapy (Principle 2A)

Physical therapists must prioritize the well-being of their patients over their own personal or financial interests, adhering to the core values of the profession.

Interpretation. Altruism is often instinctive, but in challenging moments—such as when a therapist is tired at the end of the day—it requires a conscious decision. For example, a therapist may have to choose between leaving on time or staying late to accommodate a patient who arrived late. Upholding patient-centered care is a key ethical responsibility of physical therapists.

Patient Autonomy in Physical Therapy (Principle 2C)

Physical therapists must provide patients or their surrogates with the necessary information to make informed decisions about their care or participation in clinical research.

Interpretation. Respecting patient autonomy means clearly communicating exam findings, diagnosis, prognosis, and treatment options. Therapists must use professional judgment to explain potential risks and work collaboratively with patients to set treatment goals and plans. Ultimately, patients have the right to consent, modify, or refuse treatment, and therapists must honor those choices while ensuring ethical and effective care.

Professional Judgment in Physical Therapy (Principles 3, 3A, 3B)

Physical therapists are responsible for making sound, independent, and objective clinical decisions based on professional standards, evidence-based practice, experience, and patient values.

Interpretation. Therapists must apply clinical reasoning and ethical decision-making in all aspects of patient care, including:

• Conducting examinations, evaluations, and diagnoses

• Developing and modifying treatment plans

• Supervising interventions and maintaining accurate records

If a condition falls outside their scope of expertise, therapists must refer the patient to an appropriate provider. Additionally, therapists must not provide unnecessary treatments for financial gain and should discontinue services when they are no longer beneficial to the patient. Ethical practice requires avoiding overutilization of services while ensuring high-quality patient care.

Supervision in Physical Therapy (Principle 3E)

Physical therapists must provide clear direction and effective communication when supervising physical therapist assistants (PTAs) and support staff to ensure quality patient care.

Interpretation. Supervision requires sound professional judgment to delegate tasks appropriately while maintaining legal and ethical responsibility for patient outcomes. Therapists must follow local, state, and federal regulations, as well as APTA guidelines, to ensure compliance with scope of practice and supervision standards. Additional supervision resources are available through APTA policies and state practice acts.

Integrity in Relationships (Principle 4)

Physical therapists must uphold honesty, trust, and ethical behavior in all professional relationships, including those with patients, families, colleagues, students, employers, and the public.

Interpretation. Integrity extends beyond patient interactions to include collaboration with healthcare teams, accountability in professional roles, and ethical decision-making. Therapists should demonstrate professionalism, take responsibility for their actions, and foster a culture of respect and teamwork in all aspects of their practice.

Reporting Misconduct in Physical Therapy (Principle 4C)

Physical therapists must discourage misconduct among healthcare professionals and report illegal or unethical behavior to the appropriate authority when necessary.

Interpretation. Therapists can help prevent misconduct by:

• Leading by example and maintaining high ethical standards.

• Promoting ongoing training on legal, ethical, and best practices (e.g., billing, privacy, harassment prevention).

• Encouraging a positive, professional, and civil work environment.

• Reviewing policies and procedures regularly to ensure compliance.

Determining When to Report

• Reporting should be based on facts and legal requirements.

• If laws mandate reporting, therapists must act accordingly.

• Therapists should evaluate the situation, internal policies, and potential risks if no legal obligation exists before proceeding.

• When reporting, therapists must identify the relevant authority, which may include:

  • Supervisors, HR, licensing boards, legal counsel, regulatory agencies, or government hotlines.

Post-Reporting Considerations

• Reporting misconduct does not end involvement—therapists may be required to testify or provide written statements in legal or regulatory proceedings.

• The primary goal is to prevent unethical behavior and uphold professional integrity in healthcare settings.

Sexual Harassment in Physical Therapy (Principle 4F)

Physical therapists must not engage in any form of harassment, including verbal, physical, emotional, or sexual harassment.

Interpretation. The APTA has a zero-tolerance policy for harassment of any kind. Physical therapists are legally and ethically required to comply with all applicable laws prohibiting sexual harassment. This principle applies to all professional interactions, including those with patients, colleagues, students, and employees.

Key Takeaway. Harassment in any form is unacceptable and strictly prohibited in physical therapy practice. Therapists must uphold a safe, respectful, and professional environment at all times.

Exploitation in Physical Therapy (Principle 4E)

Physical therapists must not engage in sexual relationships with patients, clients, supervisees, or students due to the inherent power imbalance and ethical obligation to protect individuals from exploitation.

Interpretation

• Therapists hold positions of trust and authority and must act in the best interests of those under their care or supervision.

• Sexual relationships with individuals in these roles create ethical conflicts and can lead to exploitation.

• If a therapist has personal feelings of attraction toward a patient, they must set those feelings aside to maintain professional integrity.

Relationships with Former Patients

• There is no clear rule on when, if ever, a romantic relationship with a former patient is ethically permissible.

• In some cases, it may be acceptable soon after treatment ends, while in others, it may never be appropriate.

Key Takeaway. To maintain trust, professionalism, and ethical integrity, physical therapists must avoid any form of exploitation and refrain from romantic or sexual relationships with those under their professional care.

Colleague Impairment in Physical Therapy (Principles 5D & 5E)

Physical therapists must take action when a colleague’s impairment affects their ability to practice safely.

Interpretation

• Encouraging Assistance (Principle 5D): If a colleague shows signs of physical, psychological, or substance-related impairment, therapists should encourage them to seek help before it affects their professional responsibilities.

• Mandatory Reporting (Principle 5E): If a colleague is clearly unable to perform their duties safely and competently, therapists have an ethical obligation to report the issue to the appropriate authority.

Key Considerations

• Factual Determination: Therapists must assess whether an impairment affects professional performance before taking action.

• Reporting Decisions: While reporting is necessary for serious cases, the appropriate authority may vary (e.g., supervisor, licensing board, HR, or regulatory agencies).

Key Takeaway. Inaction is not an option. Therapists must either encourage assistance or report impairments to protect patients, colleagues, and the integrity of the profession.

Professional Competence in Physical Therapy (Principle 6A)

Physical therapists must achieve and maintain professional competence throughout their careers to ensure high-quality patient care.

Interpretation

• Competence is an ongoing process that includes:

  • Self-assessment of strengths and areas for improvement.

  • Continuous learning to acquire new knowledge and skills.

  • Reflection and reassessment of clinical performance.

• Factors influencing professional competence include practice setting, patient population, personal interests, and advancements in evidence-based practice.

Key Takeaway. Lifelong learning is essential for delivering safe, effective, and ethical care. Physical therapists should actively pursue professional development and continuing education to stay up to date with best practices. Additional resources are available on the APTA website.

Professional Growth in Physical Therapy (Principle 6D)

Physical therapists must foster an environment that supports professional development, lifelong learning, and clinical excellence.

Interpretation

• Therapists are responsible for promoting ongoing education and skill development, even if their employer does not provide support.

• A culture of learning benefits patients, colleagues, and the profession by ensuring high standards of care.

• Professional growth may include mentorship, continuing education, evidence-based practice, and collaboration with peers.

Key Takeaway. Regardless of workplace policies, physical therapists must take initiative in their professional development to maintain competence, innovation, and excellence in patient care.

Charges and Coding in Physical Therapy (Principle 7E)

Physical therapists must ensure that documentation and billing accurately reflect the services provided.

Interpretation

• Therapists are responsible for proper coding and billing to ensure transparency, accuracy, and compliance with legal and ethical standards.

• Documentation must align with services rendered, preventing fraud, errors, or misrepresentation.

• Additional resources on billing, documentation, and coding are available on the APTA website.

Key Takeaway. Accurate documentation and coding are essential for ethical billing, insurance claims, and maintaining trust in the profession.

Pro Bono Services in Physical Therapy (Principle 8A)

Physical therapists should contribute to meeting the health needs of economically disadvantaged, uninsured, and underinsured individuals by providing pro bono services or supporting organizations that do so.

Interpretation

• Direct pro bono care: Therapists can offer free or reduced-cost services to underserved populations.

• Indirect support: If unable to provide services, therapists can contribute through:

  • Volunteer work

  • Financial donations

  • Advocacy for healthcare access

  • Educational outreach

  • Promoting pro bono initiatives

Key Takeaway​​​​​​. Supporting equitable healthcare is an ethical responsibility. Physical therapists can fulfill this obligation either by providing direct care or supporting organizations dedicated to underserved communities. Additional guidelines and resources are available on the APTA website.

APTA Code of Ethics for the Physical Therapist

The Code of Ethics for physical therapists serves as a comprehensive guide for professional conduct, yet it acknowledges its own limitations. It cannot address every possible scenario, and physical therapists are encouraged to seek additional guidance when faced with ambiguous situations. The APTA Guide for Professional Conduct and Core Values for the Physical Therapist and Physical Therapist Assistant offer supplementary direction in such cases.

This ethical framework encompasses the multifaceted roles of physical therapists, including patient management, consultation, education, research, and administration. It addresses ethical actions at individual, organizational, and societal levels, reflecting the profession's core values: accountability, altruism, collaboration, compassion and caring, duty, excellence, integrity, and social responsibility. Throughout the Code, specific principles are linked to these supporting core values.

The Code of Ethics applies universally to all roles of a physical therapist unless a specific role is mentioned. Central to this code is the commitment of physical therapists to support individuals with impairments, activity limitations, and disabilities. This commitment involves empowering, educating, and enabling these individuals to achieve greater independence, health, wellness, and an improved quality of life. Central to its philosophy is the unique obligation of physical therapists to empower, educate, and enable individuals with impairments, activity limitations, participation restrictions, and disabilities. This commitment aims to foster greater independence, improve health and wellness, and enhance these individuals' overall quality of life.

Purpose

The code of ethics, as determined by the House of Delegates of the American Physical Therapy Association (APTA), has a few purposes.

They include:

1. Define the ethical principles that form the foundation of physical therapist practice in patient and client management, consultation, education, research, and administration.
2. Provide standards of behavior and performance that form the basis of professional accountability to the public.
3. Provide guidance for physical therapists facing ethical challenges, regardless of their professional roles and responsibilities.
4. Educate physical therapists, students, other health care professionals, regulators, and the public regarding the core values, ethical principles, and standards that guide the professional conduct of the physical therapist.
5. Establish the standards by which the American Physical Therapy Association can determine if a physical therapist has engaged in unethical conduct. 

Principle #1

Physical therapists shall respect the inherent dignity and rights of all individuals.

This principle relates back to the core values of Compassion and Integrity.

It means that physical therapy practitioners must act respectfully toward each person, regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability. 

Acknowledging and addressing personal biases is a critical principle reiterated in numerous codes of ethics across various professions. Recognizing biases is foundational to providing all individuals fair, just, and equitable care. In the contemporary landscape, extensive training and emphasis on implicit bias, diversity, equity, and inclusion aim to bring these biases to light and ensure they do not influence treatment, consultation, education, research, or administrative decisions.

Principle #2

Physical therapists shall be trustworthy and compassionate in addressing the rights and needs of our patients.

This principle relates back to the core values of Altruism, Collaboration, Compassion, and Professional duty.

You shall adhere to the profession's core values and act in the best interests of patients and clients over the interests of the physical therapist. It emphasizes the need to provide physical therapy services with a compassionate and culturally sensitive approach, valuing individual differences and backgrounds. Furthermore, it is crucial to ensure that patients and their surrogates have access to necessary information for informed decision-making. Collaborative decision-making with patients and clients empowers them in matters concerning their healthcare. Additionally, safeguarding confidentiality and respecting patient privacy are integral components of ethical practice, with disclosures made to appropriate authorities in line with legal and ethical guidelines.

Principle #3

Physical therapists should be accountable for making sound professional judgments.

This principle relates back to the core values of Collaboration, Duty, Excellence, and Integrity.

Physical therapy practitioners should demonstrate independent and objective professional judgment in the patient's best interests and professional judgment informed by professional standards, evidence, experience, and patient values. Physical therapists should make judgments within their scope of practice and their level of expertise. Communicate, collaborate with, or refer to peers or other healthcare professionals when necessary and avoid conflict of interest. Provide appropriate direction and communication with physical therapist assistants and other support personnel. 

Principle #4

Physical therapists shall demonstrate integrity in their relationships with patients, families, colleagues, students, research participants, other healthcare providers, employers, payers, and the public. 

This principle relates back to the core value of Integrity, which brings us back to veracity.

It emphasizes the importance of providing accurate and truthful information, avoiding any misleading representations, and refraining from exploiting individuals under a supervisory relationship, be it students, patients, or employees. Moreover, it underscores the responsibility to discourage and report misconduct and illegal or unethical acts among healthcare professionals, highlighting the imperative to protect vulnerable individuals from abuse.

This principle's unequivocal stance against engaging in any form of sexual relationship with patients, supervisees, or students reinforces the critical importance of maintaining professional boundaries and ensuring a safe and ethical environment. Additionally, the strong stance against harassment, whether verbal, physical, emotional, or sexual, reinforces the commitment to a respectful and inclusive professional atmosphere. Altogether, this principle underscores a profound dedication to upholding the highest standards of ethical conduct and fostering a culture of accountability and integrity within the healthcare community.

Principle #5

Physical therapists shall fulfill their legal and professional obligations.

This principle relates back to the core values of Accountability, Duty, and Social Responsibility.

This principle includes complying with applicable local, state, and federal laws and regulations. Physical therapists must have primary responsibility for supervising assistance and support personnel. They should encourage colleagues struggling with physical, psychological, or substance-related impairments that could negatively impact professional responsibilities to seek assistance or counseling. Furthermore, if aware that a colleague is unable to perform duties with reasonable skill and safety, physical therapists should report this to the appropriate authority, whether that is a licensing board, organizational leadership, or other governing body. In the event that a physical therapist terminates a provider relationship while the patient still needs services, the physical therapist ought to notify the patient and provide information about alternative care options.

Principle #6

Physical therapists shall enhance their expertise through lifelong acquisition and refinement of knowledge, skills, abilities, and professional behaviors.

This principle relates back to the core value of Excellence.

This principle encompasses maintaining and improving professional competence through continued professional development based on critical self-assessment and reflection. Physical therapists should evaluate the strength of evidence and applicability of content presented in professional development activities before integrating that knowledge into practice. They ought to cultivate practice environments supportive of professional growth, lifelong learning, and excellence. Lifelong learning is crucial—physical therapists must move beyond checking boxes to satisfy continuing education requirements. Instead, they should actively broaden their skills and knowledge throughout their careers.

Principle #7

Physical therapists shall promote organizational behaviors and business practices that benefit patients, clients, and society.

This principle relates back to the core values of Integrity and Accountability.

This principle involves fostering practice settings that enable autonomous, accountable professional judgment. Physical therapists should seek fair and reasonable service remuneration, refrain from accepting gifts influencing professional decisions, and disclose any financial stakes in products or services recommended to patients. For instance, they should reveal ownership interests in durable medical equipment companies or other healthcare businesses. Physical therapists must ensure documentation and coding accurately conveys the nature and extent of services furnished. They should avoid employment arrangements that prevent the fulfillment of professional obligations to patients. Billing, coding, HIPAA, and social media merit particular attention, as lapses in these areas frequently lead to disciplinary action.

Principle #8

Physical therapists shall participate in efforts to meet the health needs of people locally, nationally, and globally.

This principle connects to physical therapy's core values of Social Responsibility.

Practitioners can actualize this by providing pro bono services to the economically disadvantaged, uninsured, and underinsured, if feasible in their setting. They should advocate reducing health disparities, improving healthcare access, and addressing wellness and preventive services. Though physical therapists often treat existing disabilities and impairments, focusing on health promotion and disease prevention remains crucial.

Physical therapists ought to steward healthcare resources responsibly, avoiding over- and under-utilization. Another key facet is educating the public about physical therapy's benefits and the profession's unique role. Getting involved with advocacy organizations and meeting with legislators to promote the field allows practitioners to embody this principle fully. Sitting at the policymaking table helps ensure the profession's perspectives are heard.

Part of this speaks to me; as mentioned in my bio, I am part of the American Occupational Therapy Association Political Action Committee, one of my other roles with Select Rehabilitation. When I am on Capitol Hill, I'm in front of our senators and our representatives in Congress. That might be an opportunity for you to really enact this principle by getting in front of people and promoting who you are and what you do. Make sure that you have a seat at the table. We always have a saying: if you don't have a seat at the table for dinner, you are probably on the plate for a meal.

As I said earlier, while a code of ethics is a robust guiding framework, it's important to acknowledge its limitations. No code can comprehensively cover every situation or circumstance encountered in practice. In straightforward situations, aligning actions with the code is relatively clear-cut. However, the true challenge lies in navigating the gray areas, where careful consideration of the principles and core values becomes crucial in making ethically sound decisions.

Standards of Ethical Conduct for Physical Therapist Assistants

The Standards of Ethical Conduct outline the ethical obligations of physical therapist assistants (PTAs) as determined by the American Physical Therapy Association (APTA). These standards provide a foundation for the behavior expected of all PTAs, guided by core values like accountability, altruism, collaboration, compassion, duty, excellence, integrity, and social responsibility. PTAs are crucial in enabling patients to achieve greater independence, health, wellness, and quality of life.

Key Points

• Application: The Standards apply to all PTAs and are subject to change as the profession evolves.
• Guidance: The APTA Guide for Conduct of the Physical Therapist Assistant and Core Values for the Physical Therapist and Physical Therapist Assistant provide additional guidance.

Ethical Standards

Standard #1: Respect (Core Values: Compassion and Caring, Integrity)

• 1A: Act respectfully towards everyone, regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability.
• 1B: Recognize and overcome personal biases to avoid discrimination in providing services.

Standard #2: Trustworthiness and Compassion (Core Values: Altruism, Collaboration, Compassion and Caring, Duty)

• 2A: Prioritize patients' and clients' interests over personal interests.
• 2B: Provide interventions with compassionate and culturally sensitive behaviors.
• 2C: Inform patients and clients about the interventions provided.
• 2D: Protect confidential information and disclose it only when allowed or required by law, in collaboration with the physical therapist.

Standard #3: Sound Decisions (Core Values: Collaboration, Duty, Excellence, Integrity)

• 3A: Make objective decisions in the best interest of patients and clients in all settings.
• 3B: Follow best practices for interventions.
• 3C: Make decisions based on competence and patient/client values.
• 3D: Avoid conflicts of interest.
• 3E: Provide services under the direction and supervision of a physical therapist and communicate necessary modifications to the plan of care.

Standard #4: Integrity in Relationships (Core Value: Integrity)

• 4A: Provide truthful, accurate, and relevant information.
• 4B: Avoid exploiting those under their authority.
• 4C: Do not engage in sexual relationships with patients, clients, supervisees, or students.
• 4D: Avoid any form of harassment.
• 4E: Discourage misconduct and report illegal or unethical acts when appropriate.
• 4F: Report suspected abuse of children or vulnerable adults to the appropriate authority.

Standard #5: Legal and Ethical Obligations (Core Values: Accountability, Duty, Social Responsibility)

• 5A: Comply with local, state, and federal laws and regulations.
• 5B: Support the supervisory role of the physical therapist to ensure quality care and patient safety.
• 5C: Adhere to standards for protecting research participants.
• 5D: Encourage colleagues with impairments to seek assistance.
• 5E: Report colleagues who are unable to perform their duties safely.

Standard #6: Lifelong Learning (Core Value: Excellence)

• 6A: Maintain clinical competence.
• 6B: Engage in lifelong learning to stay current with advancements in physical therapy.
• 6C: Promote environments that support career development and learning.

Standard #7: Organizational Behavior (Core Values: Integrity, Accountability)

• 7A: Promote work environments that support ethical decision-making.
• 7B: Avoid accepting gifts that may influence decisions.
• 7C: Disclose any financial interests in recommended products or services.
• 7D: Ensure documentation accurately reflects services provided.
• 7E: Avoid employment arrangements that prevent fulfilling ethical obligations.

Standard #8: Community Health (Core Value: Social Responsibility)

• 8A: Support organizations that address the health needs of disadvantaged groups.
• 8B: Advocate for the participation of people with disabilities in the community and society.
• 8C: Collaborate with physical therapists to manage healthcare resources effectively and avoid overutilizing or underutilizing services.
• 8D: Educate the public about the benefits of physical therapy.

The Standards of Ethical Conduct for PTAs provide a clear ethical framework to ensure that PTAs deliver high-quality, ethical care. PTAs are encouraged to seek additional guidance when needed to navigate complex situations and to continually strive for excellence in their practice.

Licensure

While we've discussed national standards, licensure is state-specific, and each jurisdiction has its own code of conduct. States control licensure through individual laws, regulations, and physical therapy practice acts. Requirements vary, though many states have adopted licensure compacts. Regardless, therapists must understand their specific state's legal and ethical parameters.

Licensure laws aim to protect the public by outlining expected behaviors and minimum competence standards for initial licensure and renewal. Professional association codes of ethics often integrate within state practice acts. Importantly, these laws also detail disciplinary actions and penalties for prohibited behaviors and activities. Though the process differs by state, the intent is to handle infractions to uphold standards. Therapists must familiarize themselves with their state's licensure laws and disciplinary procedures.

The disciplinary process could range from a fine, a slap on the wrist with a warning, to a suspension or revocation of one's license. For example, I remember coming across a HIPAA-related story a few years ago. A clinician was working in the clinic and witnessed or saw across the room somebody who looked familiar to them. The individual wasn't their patient, and they were not actively treating this individual. However, this clinician went to the nurse's station and found this person's chart. The clinician discovered that this person was, in fact, a childhood friend's mother who had been estranged from her family for upwards of 20 years. 

The clinician tried to approach the person and then called the friend and said, "Hey, I found your mother; she is here in our hospital," several states away. There was a reason this woman was estranged. There was a reason she didn't want to be found. This particular clinician completely violated HIPAA. The clinician not only lost their license to practice in that particular state, but because that state had a certain level of reciprocity with other states, they could not be licensed in other states. 

Therapists must thoroughly comprehend their state's licensure law and practice act provisions. These documents warrant close study and outline documentation frequency, supervisory visit timing for assistants, assistant supervision ratios, continuing education requirements, and more.

Do not rely on employers to convey licensure details - go straight to the licensing board with questions and get interpretations in writing. Recently, a therapist encountered ambiguity around allowable wound care modalities and debridement. The board clarified upon request. However, the practice act itself was unclear. Therapists should proactively join listservs and stay updated on changes to ensure they comply. Though employers may have information, therapists must ultimately know their license's parameters.

Behaviors Subject to Disciplinary Action

Behaviors subject to disciplinary action will vary by state. Some behaviors that could be subject to disciplinary action include but are not limited to the following:

1. Abuse of drugs or alcohol
2. Conviction of a felony
3. Conviction of a crime of moral turpitude, such as a sex offense, DUI, extortion, or embezzlement, are just a few examples.
4. Conviction of a crime related to the practice of the profession for which you hold a license
5. Practicing without a prescription or a referral if that is required by your state practice act or by the payer that you're utilizing.
6. Practicing outside of the scope of your practice or using interventions that you've not been certified to use or trained to use.
7. Obtaining a license using fraud or deception. For example, purposefully giving an incorrect address.
8. Gross negligence in practicing physical therapy
9. Breaching patient confidentiality
10. Failing to report a known violation of the licensure law by another licensee
11. Making or filing false claims or reports
12. Accepting kickbacks
13. Exercising undue influence over patients
14. Failing to maintain adequate records
15. Failing to provide adequate supervision
16. Providing unnecessary services
17. False, deceptive, misleading advertising
18. Practicing under another name
19. Failure to perform a legal obligation
20. Practicing medicine when you are not a physician 
21. Performing services not authorized
22. Performing experimental services without informed consent
23. Practicing beyond the scope permitted
24. Failure to comply with CE requirements  
25. Failure to notify the licensing board of an address change
26. Inability to practice competently

Licensure stipulations may seem excessive, but they exist due to real infractions. For instance, I was teaching continuing education live and didn't write out the names on the certificates. Someone actually took a blank certificate, photocopied it, and gave it to all of their friends. These therapists were using somebody else's CEs to get their licenses. That same individual utilized somebody else's address and name to get a different license type. While surprising, such situations demonstrate the need for rigorous standards.

Though seemingly improbable, the board documents these policies because such problems have happened. Therapists must take licensure provisions seriously, as they aim to uphold patient safety and care quality.

Fraud and Abuse

Abuse

Alongside licensure regulations, other laws impose legal duties on physical therapists, like mandated reporting of suspected child, spouse, or elder abuse. Most states designate health professionals as mandatory reporters to protect vulnerable groups. Physical therapists should familiarize themselves with reporting criteria, timeframes, and agencies in their jurisdiction. These requirements supersede patient confidentiality in cases of suspected abuse or harm. Though details vary by state, understanding mandated reporter status is crucial, given physical therapists' ethical and legal obligations to keep patients safe.

Fraud

Fraud generally involves deception to induce someone into action or inaction. In therapy, fraud often occurs in billing contexts. Common examples include:

• Billing for services never performed
• Billing for more units than furnished
• Billing non-covered services
• Backdating documentation
• Fabricating patient visit notes

These constitute true fraud versus colloquial use of the term. Medicare fraud specifically involves knowingly or willingly lying to get paid. Other insurers often follow Medicare policies, making their criteria significant.

The key distinction in fraud is purposeful deception to bill services inappropriately, not errors or misunderstandings. Physical therapists must ensure a thorough understanding of accurate coding and documentation to avoid fraudulent actions.

Medicare Fraud and Abuse

Abuse occurs when Medicare pays for services that should not be covered or anytime a provider bills Medicare for services that are not medically necessary.

Denials citing "not medically necessary" exemplify abuse. The Affordable Care Act expanded Medicare fraud and abuse oversight, establishing task forces and increasing audits. This receives extensive attention, with Presidents regularly addressing fraud reduction efforts in addresses.

If aware of fraudulent or abusive activities, physical therapists must report them. Failure to do so violates codes of ethics and practice acts while potentially incurring criminal charges for conspiracy in covering up Medicare fraud. Simply witnessing improper conduct triggers responsibility to take action. With increased scrutiny, therapists must ensure documentation proves medical necessity and accurately reflects services delivered.

Acts that Medicare specifically prohibits include the following:   

• Making false claims for payment.
• Making false statements again to receive payment.
• Billing for visits that were never made.
• Billing for non-face-to-face therapy services. Obviously, we have telehealth right now, and it is a billable service. However, this does not include telehealth. I'm referring to situations where the physical therapist bills for services never provided to a patient. 
• Billing for a one-to-one visit when perhaps group or concurrent was provided. We often see this, particularly in the Medicare world, with students when we look at a student involved in that therapy relationship.  If I'm the therapist and supervise a student, and we treat a patient simultaneously, that would be considered concurrent therapy for Medicare Part A. There is no such thing as concurrent for outpatient or Part B, but we would have to bill that as such. We can't call that one-on-one if truly that person was seen in a concurrent or group situation.
• Billing for therapy services not provided by a licensed provider. This comes up when we have a therapy aide/tech in our clinic who is working with a patient but is not technically licensed. 
• Billing for therapy codes reimburses at a higher rate than the provided code. This is upcoding. You may have heard others say you need to bill it under this code because that pays more than this, and this is how you justify it. That's not how it works. If you provide a therapeutic exercise, that's what you bill and document, and that is the code you use.  You don't bill it under something else just because you think you might get more money for that. 
• Paying or receiving kickbacks for goods or services.
• Soliciting from a physician and offering something to a physician so they can send you more referrals. This includes making offers for payment, receiving payment for patient referrals, or offering gifts in remuneration for receiving those referrals.  

Resident Rights and Elder Abuse

Resident Rights

The 1987 Nursing Home Reform Law established critical protections for long-term care residents, though these rights broadly apply across settings. Providers participating in Medicare/Medicaid must uphold resident dignity, self-determination, and well-being. The overarching right is to receive services enabling the highest possible physical, mental, and psychosocial health per an individualized care plan developed with patient and family involvement whenever practical. This landmark legislation obligates facilities to actively promote and safeguard rights through person-centered care planning and an environment fostering choice, inclusion, and purposeful living. While originating in long-term care, these principles today help shape contemporary practice expectations for empowering patients and optimizing quality of life across the healthcare continuum.

The Right to Be Fully Informed 

Individuals have the right to full disclosure regarding services, associated charges, governing rules and regulations, and a written copy of their rights. They must receive contact information for resources like the state ombudsman and applicable survey agencies. Facilities should provide access to survey reports and any plans of correction following deficiencies. Patients/residents deserve advance notice of room or roommate changes, along with appropriate assistance for sensory impairments. Importantly, they have the universal right to obtain all information in an understandable language or format, whether Spanish, Braille, or other accommodations tailored to their needs. Care settings must take steps to ensure transparent communication and cognizance of rights, including through translation or accessible means for diverse populations.

Right to Complain

Individuals have a right to present grievances without any fear of reprisal and a prompt effort by the community to resolve those grievances. They have a right to complain to the Ombudsman and file a complaint with a state survey or any other certification agency.

Right to Participate in One's Own Care

They have a right to participate in one's own care. That includes receiving adequate and appropriate care, being informed of any change in medical condition, and participating in their care planning, treatment, and discharge. They have a right to refuse medication, treatment, therapy, and restraints (chemical or physical). They have a right to review their medical record, and they have a right to be free from charges for services that might otherwise be covered by an insurance provider. 

Right to Privacy and Confidentiality

This right included private and unrestricted communication with anyone of their choice during treatment and care. The communication could be regarding medical, personal, or financial affairs.

Rights During Transfers and Discharges

This right is very specific to long-term care. Individuals need to know that whatever that transfer is, it's necessary to meet their welfare. Maybe they've improved, and now they no longer need care. It might be needed to protect other individuals, including the safety of other residents or staff, or they haven't paid their bill, quite honestly. Individuals are to receive a thirty-day notice that includes the reason, effective date, and location.

Right to be Treated with Dignity, Respect, Freedom, and Self-Determination

Individuals have a right to be treated with consideration, respect, and dignity and be free from abuse. 

Right to Visits (or refuse visits) 

Individuals have a right to visits, and that could be from anybody, including their physician, a representative from the state survey, the ombudsman, relatives, friends, other individuals, or organizations who might be providing social or legal services.

Right to Make Independent Choices

This goes back to autonomy, right? This right can include what they wear or how they spend their free time. It includes the right to choose their own physician and accommodations, to participate in community activities, and to manage their own financial affairs.

Again, this is very specific to long-term care. However, I think it applies to any setting that our patients might be in.

Your Role

So what's your role? Your role is to

• Know the rights of your patients wherever you're working.
• Respect their dignity and their privacy, 24 hours a day, seven days a week. That means knocking on the door before you enter and asking permission.
• Speak to individuals respectfully and in a positive manner
• Let them make choices about their care, giving them that informed consent we discussed.
• Respect their right to refuse therapy, to refuse care, medications, a specific diet, activity, or whatever that happens to be.
• Listen to them and their family members who might have concerns about their rights, treatment, and/or their plan of care. Refer individuals who may have questions or concerns to the appropriate person. 

Elder Abuse

Elder abuse is a growing geriatric concern. There are ethical issues related to this. We need to look beyond just protective services records. We need to look at financial, medical, social, and long-term care areas for any sort of breakdown, possible difficulties, and solutions.

Key definitions:

• Elder: 65 years or older
• Elder abuse: An act or omission by someone in a trusted relationship that harms or threatens an older adult's health/welfare
• Caregiver: Anyone with custody or control over an elder

Estimates suggest that 10-15% of elders experience abuse. While there is no single victim profile, 90% of perpetrators are known to the victim, mirroring child abuse dynamics. As therapists work closely with seniors and caretakers, we are well-positioned to detect and address signs of abuse through appropriate reporting and interdisciplinary collaboration. Education and advocacy regarding this often hidden issue are crucial.

Forms of Abuse

• Physical abuse
• Sexual abuse
• Emotional abuse
• Neglect
• Abandonment
• Financial exploitation
• Self-neglect

Elder Abuse Indicators

• Physical Abuse. Sprains, dislocations, fractures, or broken bones. Burns, internal injuries, abrasions, bruising. Injuries are unexplained or explanations are implausible. 
• Sexual Abuse. Fear of being touched/inappropriate modesty on evaluation. Inner thigh/breast bruising, tenderness. 
• Emotional Abuse. Depression, sleep, appetite disturbances, decreased social contact, loss of interest in self, apathy, and suicidal ideation. Evasiveness, anxiety, hostility. 
• Neglect and Self-Neglect. Inadequate, dirty, or inappropriate clothing, malnutrition, dehydration, odor and poor hygiene, and pressure sores. Misuse/disregard/absence of medicines, medical assistive devices, medical regimens. 
• Self-Neglect. Eccentric or idiosyncratic behavior, self-imposed isolation, marked indifference. 
• Financial Abuse. Fear, vague answers, and anxiety when asked about personal finances. Disparity between assets and appearance and general condition. Failure to purchase medicines, medical assistive devices, seek medical care or follow medical regimens. 

Some potential signs of elder abuse include depression, fear of being touched, and eccentric behavior. Importantly, many elder abuse indicators are very similar to bullying warning signs across age groups. As therapists, we must pay attention to these red flags wherever they occur and report them. Our skills in building trust, observation, and intervention enable us to identify concerning behaviors among vulnerable individuals at any age. 

Elder Justice Act

You have a duty to report any suspected acts involving resident mistreatment, neglect, abuse, crimes, misappropriation of resident property, or injuries of unknown source. The facility must report any reasonable suspicion of a crime against a resident or patient to the Secretary of the U.S. Department of Health and Human Services (HHS) and the law enforcement authorities in the political subdivision where the facility is located. 

There are very specific timeframes for reporting any elder abuse. If the events cause suspicion of a crime—suspicion is the key—we don't have to prove that truly elder abuse occurred. If we suspect it may have occurred, we have to report it.

• If the incident results in “serious bodily injury,” the facility must report it to HHS and law enforcement authorities immediately, but not later than two hours after forming the suspicion.  
• Do not result in “serious bodily injury.” The facility must report to HHS and law enforcement authorities no later than 24 hours after forming the suspicion.

Serious bodily injury is an injury  

• involving extreme physical pain or substantial risk of death;  
• involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty or
• requiring medical intervention such as surgery, hospitalization, or physical rehabilitation

Legal Issues

Malpractice

Most claims of malpractice surround negligence  

Negligence occurs when you, as the therapist, fail to follow the acceptable standard of care for the profession. The important piece with negligence is that you didn't need to intend to do something poorly. Negligence concerns itself with the conduct, not your state of mind. So it's not necessarily your intent; it's what your actual conduct was.

Negligence

Proving malpractice within the negligence framework presents challenges in a court of law. To substantiate such a claim, several critical elements must be met.

Firstly, there must be a clearly defined relationship between the involved parties, establishing a duty to act in a specific manner. Building on the foundational principle of ethical practice, this duty sets predetermined expectations, and failure to meet them signifies a breach of the established standards.

Secondly, the plaintiff, the individual alleging negligence, must show that your conduct fell below the accepted professional standards of care, thereby breaching your expected duty.

Thirdly, the plaintiff must establish a direct link between your breach of conduct and the resulting harm or damage. It is crucial to demonstrate that the breach directly contributed to the harm suffered by the patient.

Lastly, the plaintiff must present evidence of tangible harm or damages incurred. This requires illustrating the adverse consequences of the breach, emphasizing the actual and quantifiable impacts of the alleged negligence. While it is a demanding process, meeting these criteria is attainable with the right evidence and legal support.

Discrimination Laws

Discrimination laws raise many legal and ethical issues for us in relation to patient and student issues. We are aware that there are laws in place, and our code of conduct expressly prohibits discrimination based on a number of factors. Those include age, race, disability, religion, nationality, sexual orientation, gender, and marital status.

Whistleblowing

The term whistleblower is used to describe a person who exposes an activity that is illegal, unethical, or incorrect.

As a physical therapy practitioner, you are ethically obligated to act as a whistleblower when encountering such situations. Determining who to report the issue to can be complex, often involving multiple parties.

Acknowledging that many individuals hesitate to report due to fears of retaliation or prejudice from colleagues or supervisors is crucial. However, numerous protections are in place to encourage reporting without fear of repercussions. Nearly all states, if not all 50, have laws safeguarding whistleblowers. Additionally, companies have their own policies that emphasize protection against retaliation. At a federal level, the United States Congress passed the Whistleblower Protection Act in the late 1980s, providing protection for federal employees. The Sarbanes-Oxley Act in 2002 further fortifies protections for individuals who expose wrongdoing. The guiding principle remains: speaking up and taking appropriate action if you witness something wrong.

Mandatory Reporting

Most state-licensed healthcare workers are considered mandatory reporters. It's a fundamental obligation, and this holds true across all 50 states within the United States. However, the specifics regarding the types of abuse that necessitate reporting can vary from one state to another. Each state has its own set of explicit guidelines delineating the obligations and procedures for reporting. Additionally, the definition and parameters of abuse, as well as the required reporting language and formats, will exhibit unique variations in accordance with the particular state's regulations. Healthcare practitioners must familiarize themselves with the state's distinct reporting requirements, ensuring compliance with the specific language and procedures dictated by that jurisdiction.

Common Ethical Issues

Ethical Challenges vs. Ethical Dilemma 

In my readings within the nursing literature, I encountered a distinction that resonated with me: ethical challenges versus ethical dilemmas. Ethical challenges encompass a broad spectrum of ethical issues, ranging from the ordinary to the significant. These challenges permeate our everyday professional experiences.

On the other hand, ethical dilemmas represent a unique subset wherein we grapple with choosing between distinct options, both of which may have ethical merit. The complexity lies in the realization that in an ethical dilemma, no choice is unequivocally ideal. We find ourselves navigating the delicate balance of competing values when faced with such a dilemma. Regardless of the path we choose, we must accept that each option will bear its own set of consequences. 

Everyday Ethical Issues vs. Big Ethical Issues

When delving into the literature on ethics, it becomes evident that ethical issues can be broadly categorized into two major groups: everyday ethical issues and significant ethical dilemmas.

1. Everyday Ethical Issues:

   • These encompass a wide array of common ethical challenges encountered in daily practice. Examples include issues related to informed consent, respect for autonomy, patient refusal of services, addressing offensive behavior, and maintaining confidentiality. These issues are part of routine practice and require consistent attention and ethical decision-making.

2. Significant Ethical Dilemmas:

   • On the other hand, significant ethical dilemmas represent a more profound and intricate set of challenges. These encompass issues such as end-of-life care decisions, the delicate choices regarding withholding or withdrawing life-sustaining treatments, and the ethical considerations surrounding hospitalization. These dilemmas often involve critical and profound decisions, forcing healthcare professionals to weigh conflicting values and principles.

Reasons for Ethical Dilemmas

• Patients or their loved ones must make life-or-death decisions
• The patient refuses treatment
• Staffing assignments may contradict cultural or religious beliefs
• Peers demonstrate incompetence
• Inadequate staffing or resources

Patients are making potentially life-or-death decisions, and they are making choices in general. For example, the patient refuses some level of treatment, whether physical therapy, medication, or food. 

Moreover, healthcare professionals often encounter ethical challenges tied to cultural or religious beliefs, especially when these beliefs conflict with the assigned staffing arrangements. Such conflicts can raise dilemmas regarding balancing one's professional responsibilities with personal convictions.

Equally concerning are instances where healthcare professionals witness peers engaging in incompetent practices, potentially compromising patient safety and care quality. These situations force ethical deliberation on whether and how to address these concerns.

Inadequate staffing and resources, a pervasive issue in today's healthcare landscape, present a critical ethical dilemma. Healthcare professionals often grapple with delivering optimal care under strained conditions, where there's an ethical tension between providing the best care possible and dealing with resource limitations.

Common Ethical Issues in Healthcare Setting

We commonly encounter several ethical issues that deserve our careful attention in the healthcare profession. These encompass both the need for thorough and accurate documentation as well as navigating complex workplace demands:

• Documentation Lapses
  • Ensuring timely and accurate documentation of patient encounters is critical. We should document every single encounter as soon as it occurs or shortly thereafter, at least at a bare minimum, every day. Lapses in documentation, such as shortcuts, using Xs or dots, or cloning/copy-pasting records, can compromise patient care and credibility in legal situations. Documentation needs to accurately reflect what we did.
• Employer Demands and Productivity Quotas
  • Balancing productivity demands with ethical practice is essential. While efficiency and productivity are not inherently unethical, falsifying billing or misrepresenting services to meet quotas is unethical.
• Use and Supervision of Support Personnel
  • Utilizing support personnel within the boundaries of state practice acts is crucial. Clearly defining the roles and responsibilities of support staff to ensure they adhere to legal and ethical guidelines is vital.
• Impaired Practitioners
  • Recognizing and addressing impaired practitioners due to mental health issues or substance abuse is essential for patient safety and maintaining professional ethics. Prompt intervention and support are imperative in such cases.
• Student Supervision
  • Adequate supervision and mentorship for students during clinical placements are ethical responsibilities. Neglecting to provide proper guidance and supervision can compromise the learning experience and ethical conduct of students. I have heard students complain that their mentors didn't supervise them.  

Addressing these ethical challenges involves upholding professional standards, prioritizing patient care and safety, and ensuring compliance with legal regulations. It's incumbent upon healthcare professionals to maintain ethical conduct while navigating the demands and responsibilities inherent in their roles. I remember going on my fieldwork a long time ago, and I was just left to my own. I saw my supervisor the day I walked on the job and at the end of my fieldwork. That is reasonably unethical.

Common Ethical Issues in Student Supervision

• Patient welfare must come first
• Cannot delegate clinical decision-making
• Must inform client of qualifications/credentials
• Increase supervision based on knowledge, experience, competence
• Document the amount of supervision
• Protect client confidentiality
• It is unethical for therapists to sign for clinical hours they did not supervise

Patient welfare should always remain the top priority in healthcare settings. When supervising a student, the experienced practitioner, not the student, is responsible for clinical decision-making. The supervisor's role is to facilitate, guide, and collaborate with the student, but the supervisor is ultimately responsible for patient care and decisions.

Medicare and the setting can determine the level of supervision in the facilities I work in. It is also crucial to determine the appropriate level of supervision based on the student's competence. This supervision level may vary from direct onsite supervision to less direct supervision based on the student's abilities, experience, and current regulations. Clear documentation of the level of supervision provided is essential, ensuring transparency and compliance with guidelines.

Additionally, it's vital to inform the client about the presence of a student and share the supervisor's credentials and qualifications. This transparency fosters trust and allows for informed consent, maintaining the integrity of the patient-provider relationship. The supervising practitioner remains accountable for the entirety of the patient encounter, overseeing and ensuring the quality and safety of care provided.

Common Ethical Issues in Confidentiality

• Records management, storage, ownership, retention
• Information exchanged
• Disclosure/release of information
• Access to records
• Exchange of records between professionals

Common Ethical Issues in Client Abandonment

Examples of misconduct

• Failing to give sufficient notice
• Failing to provide an interim plan
• Failing to complete the paperwork
• Withholding paperwork
• Removing materials or records
• Maligning the facility or organization
• Recruiting clients

There is nothing unethical about leaving a place of employment.  You may be leaving for a family reason or find a better job or a position advancement; however, you still need to focus on ethics and the welfare of your client.

Key ethical considerations during a change of employment include:

Handling transitions in healthcare employment with ethics and patient welfare in mind is critical. Here are key ethical considerations during such transitions:

• Giving Adequate Notice
  •    Before leaving, provide sufficient notice to your employer to prevent treatment disruptions for your clients. Be mindful of the impact on patient care and work with the employer on a transition plan.
• Completing Paperwork and Orders
  • Ensure all necessary paperwork, including treatment orders, is completed before leaving. Do not withhold essential documentation, as it may adversely affect patient care during the transition.
• Maintaining Professionalism and Integrity
  • Refrain from maligning your previous employer or facility when leaving. Maintain professionalism and ethical conduct during your departure, and consider assisting in recruiting efforts if requested.
• Avoiding Client Recruitment
  • Avoid soliciting clients to follow you to a new practice. This can be seen as unprofessional and may compromise patient trust and continuity of care.
• Addressing Patient Abandonment
  • Take responsibility for patient care to prevent abandonment during transitions, especially in critical settings like nursing homes. Collaborate with appropriate authorities and healthcare professionals to ensure patient safety and continuity of care.
• Reporting Ethical Violations
  • if faced with severe ethical violations, such as client abandonment, consider reporting to the relevant boards or authorities to ensure accountability and protect patient well-being.

These ethical guidelines underscore the importance of maintaining patient welfare, professionalism, and integrity throughout career transitions within the healthcare field. Balancing personal or professional changes with ethical obligations is essential to uphold the standards of care and trust patients place in healthcare professionals.

Examples

Reflecting on past experiences, I vividly recall an incident when transitioning into a new contract. The preceding provider chose to discharge every therapy order before departing, potentially to inconvenience the incoming provider. However, the true consequence of this action was a disservice to the patients, who were left without the necessary therapy services. It reinforced the importance of considering patient welfare above all else.

As you leave prior employment, it's essential not to remove essential services or contribute to a negative environment. Maintaining professionalism and a sense of responsibility toward the facility and the patients is paramount. Additionally, refraining from recruiting clients away from the previous facility showcases good professional practice and helps build positive relationships within the healthcare community.

One incident that stands out in my career involved a nursing home experiencing a change in ownership. In an unexpected turn of events, almost all the nursing staff, except two CNAs, decided not to report for duty. This left therapists and the remaining staff in a difficult position, risking patient safety and care. Nobody was there to pass meds, making it a very unsafe situation. It was a stark case of client abandonment, necessitating immediate action and involving authorities to address the situation.

In challenging circumstances like these, reporting such cases to the relevant boards is an ethical obligation to uphold the profession's integrity and ensure accountability. This incident underscored the critical need to prioritize patient well-being and act in the best interest of those we serve, even in the face of unexpected and unprecedented challenges. In this case, the individuals were reported, and many of them did, in fact, lose their license to practice. 

Common Ethical Issues in Reimbursement for Services

• Misrepresenting information to obtain reimbursement
  • Accurate documentation is required
  • Must remain current with payer policies
• Providing service when there is no reasonable expectation of significant benefit
  • Cannot provide services when the prognosis is too poor to justify therapy
  • Cannot exaggerate the extent of improvement in obtaining reimbursement

Accurate and honest documentation is fundamental in healthcare. When delivering therapeutic activities, it's crucial to document correctly what was performed and bill accordingly. Misrepresenting services to obtain higher reimbursement is unethical and undermines the healthcare system's integrity. If you performed therapeutic activities, that's what you document; that's what you bill. It's just as easy as that.

Ethical practice necessitates ensuring that the services provided hold a reasonable expectation of benefiting the individual receiving care. It's essential to continuously evaluate the interventions' efficacy and modify the care plan if necessary. If a person reaches a plateau or the chosen interventions no longer yield benefits, adjustments must be made to the plan of care ethically and professionally. 

Exaggerating improvement or progress to increase payment is unethical and compromises the trust and accuracy required in healthcare practice. Upholding transparency and providing care based on genuine needs and benefits to the patient should always be the guiding principle in healthcare documentation and billing.

• Scheduling services not reasonably necessary
  • Must be based on clinical need
• Providing more hours of care than can be justified
  • Must be based on clinical need
• Providing complimentary care or discounted care
  • Fee alterations are not provided based on referral sources or personal relationships.

Scheduling and providing services that are not clinically necessary or justified is an ethical concern in healthcare. It's essential to base the scheduling and provision of services on a genuine clinical need and avoid unnecessary or excessive care that doesn't benefit the patient. Similarly, offering more hours of care than what is required can lead to overutilization of resources and may not align with the patient's best interests. It's important to ensure that the care provided is appropriate and in line with the patient's needs and treatment plan. 

Providing complimentary or discounted care that is typically billable can be ethically complex. Considering the overall impact on the healthcare system, patient expectations, and professional standards is essential when determining the appropriateness of offering care without reimbursement. This differs slightly from pro bono services that might apply to your setting. It's more like, "Hey, if you follow me to this practice, I'll discount your bill by 25%."

I'll make it worth your while." That's what we don't do. Or "I want to continue services. Do you mind doing those for free even though they can't be reimbursed?" We shy away from those.

Common Ethical Issues in Therapy with Children

When working with children, it's essential to prioritize the child's best interests. However, common ethical considerations often revolve around follow-up care for the child. These issues may include families failing to adhere to appointments, following your instructions, or sharing confidential information with non-family members. Sometimes, there can be ambiguity in the relationships and responsibilities involved in managing the therapeutic alliance with parents and caregivers.

Distrust or frustration regarding reimbursement limitations, concerns about parenting techniques, or potential neglectful behavior can also arise. In some cases, parents may misuse resources, not follow the care plan, or even threaten to withdraw the child from services. Privacy and confidentiality issues persist, particularly when conducting telephone follow-ups, where the caller's identity may not be clear or non-legal guardians seek information they're not entitled to. Parents might request confidential information they shouldn't have access to, further complicating these situations.

Common Ethical Issues

• Documentation lapses
• Employer demands/lack of resources
• Impaired practitioners
• Coercion

These are some of the common issues. To reiterate, ethical concerns among staff members are prevalent, with approximately 90% of clinicians acknowledging that they encounter ethical challenges in their daily work. These issues typically revolve around everyday matters, not necessarily major ethical dilemmas. A significant concern, reported by 79% of clinicians, is the lack of resources. This shortage can encompass various aspects, from the unavailability of durable medical equipment (DME) to the absence of leg rests for wheelchairs, among other things.

Coercion is another significant ethical concern. It's not limited to therapy but can extend to various situations. For example, you might have observed people secretly mixing medications into applesauce for someone without their knowledge. This act could easily be avoided by simply informing the person about the medication. Additionally, lapses in documentation, as previously discussed, are common ethical issues in healthcare.

Ethical Dilemma Examples

Now, I will share a few examples of ethical dilemmas, some of which may involve therapy and others that have arisen recently.

Inadequate Staffing Example: Nurse Cathy is working the evening shift. The SNF has established protocols that include nurse-patient ratios. There was a callout, leaving three staff to provide care for the whole unit.

So, I'm focusing on nursing here, but I think we could extrapolate this to therapy. 

Resource limitations and staffing shortages are common challenges in healthcare. Dealing with these issues may require creative solutions and proactive communication. Consider strategies such as:

1. Calling in PRN Staff: If available, part-time or PRN (as needed) staff can help cover shortages.

2. Overtime: Sometimes, asking existing staff to work overtime may temporarily alleviate staffing issues.

3. Supervisor Involvement: It is essential to report your concerns to your supervisor. They may have insights, and their involvement can help address resource challenges.

4. Prioritizing Care: While not ideal, prioritizing patients based on their needs may be necessary during staffing shortages.

5. Flexible Scheduling: Adjusting treatment schedules, including evening sessions if possible, can help manage patient loads more effectively.

6. Team Collaboration: Work closely with your team to share responsibilities and help each other during resource shortages.

It's crucial to address these challenges promptly to ensure patient care remains a top priority and ethical standards are upheld.

Inadequate Resources Example-Nurse Judy is the wound care nurse for a home health agency. She stopped by the office to pick up additional wound care supplies for her weekend visits. However, the charge nurse told her the wound care supplies delivery did not arrive. As a result, there are not enough supplies on hand for the visits Nurse Judy has scheduled.

Nurse Judy faces a challenging situation with a shortage of wound care supplies for her scheduled weekend visits. To handle this issue ethically, she can consider several approaches:

1. Purchase Supplies: As suggested, Nurse Judy could explore local pharmacies or medical supply stores to purchase essential wound care supplies. While this may be an added cost, it ensures that patient care remains uninterrupted.

2. Physician Consultation: Nurse Judy can contact the physicians for patients with wound care needs. She can discuss the supply shortage issue with them and request adjustments in orders based on the current supplies available.

3. Supply Allocation: Based on the remaining supplies prioritize the most critical cases. Ensure that patients with more severe conditions receive the limited available resources.

4. Notify Patients: If it's unavoidable that some visits will need to be postponed due to supply shortages, Nurse Judy should contact the affected patients as soon as possible. She should explain the situation honestly and reschedule their visits.

5. Resource Management: She will collaborate with her team and the agency's management to develop future strategies for better resource management and supply monitoring.

Open and honest communication is crucial in all these actions. Nurse Judy's primary ethical responsibility is to maintain patient safety and ensure that their care is not compromised.

Keep in Mind

Ethical issues in healthcare, including those related to resource shortages, patient care, and professional conduct, remain consistent regardless of the payer or healthcare setting. The fundamental ethical principles and values that guide healthcare professionals apply universally. Whether one works in a private practice, a public hospital, a home health agency, or any other healthcare context, the obligation to prioritize patient well-being, maintain confidentiality, and adhere to professional standards remains constant. Understanding and addressing these ethical challenges is a critical part of delivering quality healthcare services.

In ethics, it is essential to emphasize the role of evidence-based practices. Specifically, when considering treatment protocols for various diagnoses or clinical considerations, we must rely on empirical evidence. Questions that demand our attention include the frequency of treatment for a given patient, the duration of treatment (in weeks), the number of visits, time allocation, and the selection of appropriate modalities.

Within my practice, which primarily focuses on long-term care and involves Medicare, it's worth noting that Medicare administrative contractors often incorporate evidence into their guidance. This evidence-based approach determines which treatments are eligible for reimbursement and which are not. In cases where the evidence does not support a specific treatment, they clarify that reimbursement is not feasible.

Ideally, they define the recommended number of treatments, the appropriate timeframe for treatment delivery, and the associated guidelines. However, exceptions are acknowledged and justified through thorough documentation. It is imperative to highlight that quantifiable, measurable changes resulting from treatment interventions play a pivotal role in justifying the continuation of care. It's important to remember that our compensation typically hinges on the treatments we provide in each session. Exceptions arise only when a treatment session faces a challenge, such as a denial. In such cases, the accurate presentation of information is of utmost importance.

Cultural Biases

We need to be able to examine our own biases and change them in our daily practice.

• Stereotyping is common
  • Examine your own beliefs and values about aging
  • How do you react to bias or stereotyping?
• Values and beliefs impact care
  • •What care is provided, when, where, why, and how it is provided
  • E.g., the frail elderly stereotype may mean we do not provide the necessary therapy
• Practitioners must treat with respect, dignity, worth, and individual uniqueness, unrestricted by social/economic status, personal attributes, or the nature of health problems. 

If you haven't explored this before, various cultural bias inventories available online can help you assess and understand your own potential biases. This is a crucial step because acknowledging and addressing our biases is essential. It's a recognized fact that biases exist within us; the challenge is not allowing them to influence how we deliver treatment. We are not immune to making assumptions and stereotypes even as healthcare professionals. We must take a closer look at our own beliefs and reactions.

For instance, consider how you respond when you hear statements like, "They're old; they've earned it; they can manage on their own," or, "I'm highly focused on this issue, so I'm less concerned about that one." Our biases, values, and beliefs undoubtedly impact how we provide care. This includes decisions about when and where care is delivered and the methods used.

So, let's give an example of a bias related to, again, the elderly. If we stereotype the elderly as frail and in need of protection, we might inadvertently overlook the full spectrum of therapy or treatment necessary to address their unique issues. Thus, it is imperative to approach care provision with unwavering respect, dignity, recognition of their self-worth, and a celebration of their individuality, all while consciously considering and mitigating our biases. 

Ethical Dilemma Example

Nurse Gloria is instructed by the attending physician to have Mr. Isaac sign a consent form before a scheduled colonoscopy. As she reviews the form with the patient, she notices that he seems confused and unsure where or how to sign the paperwork.

Various factors can contribute to this situation, and it's worth considering that it's not exclusive to the nursing profession. We may encounter similar scenarios when explaining the potential benefits of a treatment, such as aquatic therapy. The patient's confusion may stem from a genuine lack of understanding. In such cases, the fault may not lie with the patient but rather with how information has been conveyed. Perhaps medical jargon or overly complex language was used. Cultural factors could also come into play; English might not be the patient's first language, further complicating comprehension. In such instances, an interpreter or a cultural broker may be necessary.

The paramount concern here is to avoid any form of coercion. The patient must be fully informed about their options and the procedures involved. When in doubt, the principle of caution should guide our actions. Re-engaging the physician, presenting the information differently, or bringing in a translator, among other possible solutions, may be required to ensure the patient's understanding and informed decision-making.

These are everyday ethical issues. It is important for someone to understand us. Sometimes, we don't see those big ethical issues, but our ethical obligation, as outlined in our professional code of ethics, is to educate and ensure informed decision-making.

Education

• Ethical duty to educate the public and ourselves
  • Are you as educated as you should be about long-term care?
  • Do you listen for and correct misperceptions?
• Staying current in one’s profession is an ethical duty to the constituency the profession serves
  • Formal education, clinical competence, personal growth

It is essential to continuously educate the public while also maintaining our own knowledge base. A fundamental question we should ask ourselves is whether we are as well-informed as we need to be in our specific clinical setting. This involves being aware of the rules and regulations governing our practice, staying updated on legislative developments in Congress relevant to our field, and understanding the dynamics with our payers.

How often have we heard someone say, "I simply don't grasp the complexities of insurance," or witnessed a divide between those in acute care and long-term care, each harboring misconceptions about the other's domain? As professionals, we have a duty to address such misperceptions. Whether it's debunking the idea that a particular care setting is only for end-of-life care or correcting misunderstandings between colleagues, it falls upon us to ensure clinical competence and foster personal growth.

Competence is not merely a goal in physical therapy; it is an expectation. We trust that our colleagues are competent, and it is our responsibility to uphold and contribute to this competence as well.

Ethical Dilemma Examples

• Incompetence among peers
• Asked to perform a treatment for which you are not trained or competent
• Questioning MD orders (e.g., order written for medication to which patient is allergic)

Nobody wants to entertain the thought of someone being incompetent to provide care. However, the reality is that issues of incompetence do exist and can present significant ethical dilemmas in therapy. What should we do when confronted with a situation where we are asked to perform a treatment for which we lack training or competence? Ideally, we should respond by acknowledging our limitations and readily admit that we are not qualified for the task while suggesting a more suitable colleague who can address it effectively. For example, if it involves a specialized treatment like lymphedema therapy, we should avoid attempting it ourselves, assuming we can manage it or misrepresenting our capabilities.

Another vital aspect of our professional duty is to question physician orders when we have concerns. If we encounter a treatment plan or modality that raises doubts or poses a risk to the patient's well-being, it's our ethical responsibility to express these reservations. For instance, if a physician orders a specific modality, but we suspect that the patient's skin integrity in that area is compromised and unlikely to tolerate it, we should seek clarification from the physician or suggest an alternative approach.

In all cases, the guiding principle must be the unwavering commitment to putting the patient's best interests first. Our paramount duty is to ensure our patients' highest level of care and safety, even if it means challenging or seeking clarification on medical decisions.

Involving Patients in Medical Decisions

Frequently, healthcare providers encounter situations where there is a conflict between the patient's preferences and the desires of their family, significant other, adult child, or parents. These conflicts can manifest in various ways, such as a patient refusing medication when their family insists they should take it or family members wanting to withhold information from the patient, thereby excluding them from their care plan. Other examples include patients refusing nutrition, treatment, and blood sugar control.  

Ethical Dilemma Example

Mr. Morris is in end-stage renal failure. Despite efforts to help manage the disease, including dialysis three times weekly, his condition has worsened. Mr. Morris's physician has noted the decline in his status and has informed the family that Mr. Morris may have only a few weeks to live. Mrs. Morris and their children are skeptical about telling Mr. Morris how bad his condition is, and the physician has made no effort to talk to the patient about it. After his family left for the evening, Mr. Morris called for the nurse and asked her to tell him what the doctor said, stating he felt like he was not getting the whole story.

This is a real ethical dilemma. It is not uncommon for family members or significant others to withhold information, often intending to protect their loved ones. Nevertheless, from an ethical perspective, this raises concerns related to paternalism, where someone else is presumed to know better than the patient. Ethical principles such as veracity, informed consent, and autonomy are paramount here.

Healthcare practitioners must uphold their duty to provide information in situations like this. Patients have the inherent right to be informed about their condition and prognosis. While it may not always fall on the physical therapy practitioner to deliver such information, knowing where to direct the patient to ensure they receive the information they are entitled to is crucial. Resolving such situations requires a collaborative approach, ensuring that the patient's rights and autonomy are respected while addressing the concerns of their family. This case highlights how various ethical principles intersect and must be carefully navigated to provide the best care.

End of Life Wishes

This issue frequently arises, particularly in acute care, hospitals, long-term care, and even home care. A survey of ethical challenges in end-of-life care often reveals two prevalent issues: a lack of resources and a breach of the patient's autonomy. In these circumstances, family members, healthcare staff, or others may exert pressure on the healthcare team to undertake actions that run counter to the wishes of the dying individual.

What becomes paramount in such cases is the necessity to be aware of the dying person's wishes. Is there an advanced directive or some form of documented guidance in place? Waiting until the last moment to address these critical matters is far from ideal. Ideally, well in advance, someone should have worked with the patient to articulate their true desires and what they wish to avoid in their end-of-life care.

The complex aspect emerges when family members express differing opinions from the patient. Some may assert, "We can't just let mom die," while others may believe, "Mom wouldn't have wanted to live like this." There is no conflict of interest when family members concur with the patient's wishes. However, it's common for conflicting statements to arise, complicating the situation. Healthcare providers, including therapists, can sometimes feel caught in the middle as they hear both the patient's and the family's perspectives.

In such situations, it can be beneficial to involve an ethics committee. The central principle to uphold is that of autonomy and self-determination. The patient's voice and choices should be respected and preserved whenever possible.

This underscores the fact that our primary duty and commitment always lie with the patients we treat. Patient advocacy remains paramount, but there may be scenarios where family interests come into play, as our second duty is to the family. 

Ethical Dilemma Example

Mrs. Douglas has metastatic lung cancer. Her physician has advised about treatment options that may prolong her life by six months to a year. However, to the dismay of her family, Mrs. Douglas has chosen comfort measures only. Mrs. Douglas has prepared an Advanced Directive, including signing a DNR. 

In cases like these, where the patient's wishes diverge from the family's, it is crucial to prioritize the patient's autonomy and documented preferences. The patient's wishes, as outlined in their Advanced Directive, should be respected and followed. This is a fundamental principle of medical ethics and legal practice.

Conversely, if a patient lacks an Advanced Directive and the healthcare facility is unsure of their preferences, it is imperative to initiate the appropriate discussions. While it may not fall upon us directly, if possible, someone within the care team should engage with the patient and their family to understand their preferences and document them. These critical conversations should explore the patient's values, goals, and treatment preferences, ensuring their decisions are at the forefront.

Lifestyle Choices

• Ethical questions can be raised about individual client responsibility and preferences about lifestyle choices.
  • Do we discuss choices about exercise, religious beliefs, or cognitive activities?  
  • Screen for depression, functional change, or cognition changes, or do we wait to do these screens until symptoms become problematic?
• Commonly voiced beliefs, biases, and stereotypes make health promotion harder to implement
• Health promotion is seen as easier to set aside than other healthcare
• Elderly have chronic conditions linked to lifestyle choices that do not include positive health promotion activities

The role of lifestyle and health promotion in our practice is critical but often overlooked. We must ask ourselves how frequently we discuss exercise and cognitive activities with our patients. Do we regularly screen for issues like depression, functional changes, and cognitive decline, or do we wait until these problems become severe? It's a common scenario where we only address these concerns when they reach a critical point.

To illustrate, a recent case came to my attention where an occupational therapist questioned the responsibility of addressing lifestyle choices with a patient, specifically regarding type 2 diabetes. The therapist observed the patient's diet and lifestyle choices and wondered about their obligation to initiate a conversation about healthier lifestyle choices, including nutrition. While we are not dietitians or nutritionists, this raises the question of our ethical obligation to promote healthier choices.

Unfortunately, we often encounter biases and stereotypes in our practice, such as the belief that people's choices are unchangeable or that older individuals can do as they please because they've reached a certain age. These preconceived notions can hinder our efforts in health promotion, prevention, and addressing lifestyle-related chronic conditions. We must revisit our professional code of ethics and remember that health promotion is a crucial part of our role, not to be set aside in favor of solely focusing on impairments. This applies across all age groups and emphasizes the importance of encouraging positive health promotion activities.

Issues Surrounding Dementia

In the realm of end-of-life care and the advanced stages of dementia, we often encounter complex scenarios where patients may refuse nutrition, fluids, or treatment. These behaviors can sometimes serve as a form of communication or be linked to the need for human contact. Additionally, in cases where two individuals with dementia are attracted to each other, it can be challenging when one of them is married. Family members may voice concerns, and the facility may prioritize the family's wishes over the desires and happiness of the individuals involved.

This situation underscores the complexity of balancing patient autonomy with the concerns of family members. It can be a difficult task to navigate, but it is essential to genuinely inquire about what each individual involved wants and what brings them contentment.

Engagement in meaningful activity is another critical aspect, and we often encounter situations where individuals are not actively participating in activities and are, as you described, "busy doing nothing." Encouraging proper hydration, a healthy diet, and physical activity is well within our professional scope. While we may not provide detailed dietary recommendations, we can certainly promote general principles of a healthy lifestyle.

Sexuality can be equally complex and sensitive, and the approach may vary depending on the specific care setting and policies in place. Having clear policies and procedures to address such issues is essential. When these situations arise, it's crucial to know who to consult and how to handle them appropriately, ensuring the rights and dignity of all involved are respected.

Accountability

Our primary accountability in healthcare is to the patient. The patient's well-being and best interests should always be at the forefront of our decisions and actions. Our families are second. However, there are situations where it might be necessary to consider the family's needs and welfare as well.

For example, I observed the following:

A well-intentioned daughter took her father into her home after discharge. The daughter had a family that included a husband and children. During the home care sessions, I witnessed the father making frequent and excessive demands on the family. While the daughter aimed to provide care, the unreasonable requests placed a major strain on the household.

An example illustrating when family interests may take precedence is when a patient's unreasonable demands, which they can handle themselves, begin to put undue stress and burden on their family members. In such cases, the distress and disruptions caused by the patient's behavior can lead to the potential breakdown of the entire family unit. When this occurs, healthcare professionals may advise the family to seek alternative care arrangements, prioritizing the family's well-being.

Nonetheless, these instances are exceptions and should be approached carefully considering the clinical situation, social dynamics, and the best interests of all parties involved. In most cases, our primary obligation remains with the patient. The concept of a "rejection of responsibility" is complex and should be assessed on a case-by-case basis, considering the patient's specific circumstances, their family dynamics, and the broader context.

This issue frequently arises when working with adults who have faced neglect or abuse early in life or when dealing with complex family histories, such as a caregiver with a history of alcoholism. In each case, it's essential to gather all relevant information to make a sound value judgment regarding whether a true rejection of responsibility is occurring and how to best address it while upholding the patient's rights and well-being. 

Ethical Dilemma Example

Mr. Simms was diagnosed with lung cancer three years ago. After chemotherapy, he experienced a brief remission but recently learned the cancer had recurred. Mr. Simms's doctor advised him and his family that treatment would likely be unsuccessful and, although it may offer a few more months of life, Mr. Simms's quality of life will rapidly deteriorate. The doctor recommends hospice with comfort measures only, including oxygen and opioid pain relievers. Despite symptoms of pain, such as grimacing and crying, Mr. Simms refuses pain medication, stating he does not want to experience the effects of feeling sleepy and missing precious time with his family. His wife is distraught and asks the nurse if there is a way to administer pain medication without her husband knowing.

The ethical dilemma presented in the case of Mr. Simms revolves around the tension between beneficence and autonomy. Beneficence dictates the healthcare provider's duty to act in the patient's best interests, ensuring their well-being and comfort. This scenario translates to providing pain relief to alleviate Mr. Simms's suffering.

On the other hand, autonomy grants patients the right to make decisions about their care, including refusing certain treatments or interventions. Mr. Simms, despite experiencing pain, exercises his autonomy by refusing pain medication, fearing that the side effects may deprive him of precious time with his family.

The wife's distress and her inquiry about administering pain medication without Mr. Simms's knowledge introduce a complex layer to the situation. It implies a level of paternalism, where she believes that she knows what is best for her husband's well-being.

This scenario is a poignant example of the ethical challenges healthcare professionals face when trying to balance the principles of beneficence and autonomy. It highlights the need for careful analysis, communication, and ethical decision-making to ensure that Mr. Simms's wishes are respected while addressing his pain and suffering in a way that aligns with his values and preferences.

Entering a Skilled Nursing Facility (SNF)

• Disparity between views (taking a medication or getting a specific type of treatment)
• Paternalism contradicts autonomy
• Must discuss decisions with the client in detail and make the decision best for the client and the family

Entering a skilled nursing facility highlights the common disparity between the views of healthcare professionals and patients or clients regarding certain treatment options or medications. This discrepancy often underscores the ethical conflict between paternalism and autonomy.

Paternalism suggests that healthcare providers may act in what they believe to be the patient's best interests, even if it means overriding the patient's autonomous decision. However, this approach contradicts the principle of autonomy, which grants patients the right to make informed decisions about their care.

Engaging in detailed discussions with the client or patient and providing comprehensive information to ensure informed consent are imperative. Open and honest communication, or veracity, is critical to ensure that the patient truly comprehends the options and is actively involved in decision-making. Ultimately, the decision should best serve the client's and family's well-being and preferences.

The scenario becomes even more complex when a person's legal competence is in question, particularly in the context of seniors. 

Legal Incompetence

There has to be legal incompetence. When the person is cognitively unable to decide, we look to the family. The actual decision rests with the legal guardian, who must weigh the implications of the family’s standpoint in relation to the patient’s interests. Consideration is given to the patient's needs, physical condition, personality, and whether continued home care is possible.

If the individual has not been deemed incompetent, they must be part of that decision. Ethics play a significant role when considering placement. It's crucial to assess whether the individual can genuinely be adequately cared for at home.

Healthcare Ethics & Common Related Offenses

Confidentiality

• Records management, storage, ownership, retention
• Information exchanged
• Disclosure/release of information
• Access to records
• Exchange of records between professionals

Example HIPAA Violations

Unencrypted Thumb Drives and Laptops

Recently, a Department of Health and Human Services Administrative Law Judge ruled in favor of the Office of Civil Rights (OCR) and required a Texas cancer center (MD Anderson) to pay $4.3 million in penalties for HIPAA violations for failure to mitigate known security risk vulnerabilities and the use of unencrypted thumb drives and laptops. 

OCR is serious about protecting health information privacy, and it will pursue litigation.

Dermatology Practice Penalized for HIPAA Violations

Private practices are the kind of covered entity most scrutinized by the Office of Civil Rights (OCR).

In one HIPAA violation case, a dermatology practice lost an unencrypted flash drive that contained protected health information.

The group was fined $150,000 and was required to install a corrective action plan.

Submitting Bills to Collections with Protected Information

This one was related to billing and sending past-due bills to a collections agency. Dr. Helfmann’s employees regularly forwarded past-due patient bills to a collections firm. The bills contained protected information like CPT codes, which can reveal patient diagnoses, and they didn't remove that information before sending them to the collection agency. Collections agencies do not need to know other information other than the amount that was owed. As a result, the State of New Jersey sought to suspend and revoke Helfmann’s license.

Hospital Worker Charged with HIPAA Violation

In 2014, Texas hospital employee Joshua Hippler received an 18-month jail term for wrongful disclosure of private patient medical information. He was arrested in Georgia and found to be in possession of medical records. Though the filing didn’t say how many records he had, he was charged with wrongful disclosure of private health information for personal gain.  

Case Against Walgreens Pharmacist Leads to $1.4 Million HIPAA Award

Also, in 2014, a Walgreen Co. pharmacist shared confidential medical information about a customer who once dated her husband. $1.4 million lawsuit, and the customer’s lawyer, Neal F. Eggeson Jr., said the case sets an example since it proves businesses can now be held liable for the actions of their employees.   

HIPAA Violation-OBGYN office

A similar situation I read recently was a woman went to her OBGYN, and when she got there, the person who worked the desk knew her mother, and she just said, hi, hello, how are you? The woman went in to see her OBGYN and discovered she was pregnant. She did not want to be pregnant, which was the key here. The patient left, and the person behind the desk, who was friends with Mom, looked at that person's record. She had no right to look at that record, and she phoned the patient's mom, who was her friend and said, oh, congratulations, your daughter is pregnant; this is wonderful. The patient didn't want her mom to know that she was pregnant. Again, there was a lawsuit there.

Criminal HIPAA Conviction for a Respiratory Therapist

Jamie Knapp, a respiratory therapist and employee of ProMedica Bay Park Hospital in Ohio, accessed 596 medical records in a 10-month period. 

Knapp was authorized to view records as part of her job, but only for the patients she was treating.  Allegedly, she viewed files for almost 600 unrelated patients.

Knapp was convicted of criminal HIPAA violations by a federal jury in Ohio, facing up to one year in prison.

$2.5 Million Settlement in Stolen Laptop HIPAA Case

A cardiac monitoring vendor got into HIPAA "hot water" when a laptop containing hundreds of patient medical records was stolen from a parked car. The OCR reached a $2.5 million settlement with the vendor, demonstrating that the federal government is extremely aggressive in prosecuting HIPAA cases involving third parties and portable digital media.

Facebook HIPAA Violation

In 2017, a HIPAA violation resulted in the firing of a medical employee after she posted about a patient on Facebook.  

The 24-year-old med tech commented on a post about a patient killed in a car crash, using the words, “Should have worn her seatbelt…”  While that seemed pretty innocent, believe it or not, it disclosed patient health or protected health information about that patient.

The person was fired, and there was an obviously HIPAA violation. Past that, I don't remember what happened, but at a bare minimum, they were fired.

Analyze Ethical Dilemmas-CELIBATE Model

CELIBATE stands for clinical ethics, and legal issues bait all therapists equally. 

The process for analyzing ethical dilemmas, as presented, is a comprehensive and multi-step approach that considers both legal and ethical considerations. This systematic multi-step process can guide healthcare professionals through complex ethical situations. Here are the key steps in this analytical method:

1. Identify the Problem: The first step is to clearly define and identify the problem or ethical dilemma at hand. This step sets the stage for the subsequent analysis.

2. Gather All the Facts: It's essential to gather all the relevant facts and details pertaining to the situation. This includes not just the surface-level information but a deep dive into the specifics of the case.

3. Identify Interested Parties: Determine all the individuals or groups who are interested in the situation. This can include the patient and healthcare professionals, colleagues, supervisors, rehab directors, administrators, family members, caregivers, payers, and more.

4. Understand the Nature of Their Interest: It's crucial for each interested party to understand why the issue is important to them. This may be related to professional, personal, business, economic, intellectual, societal, or other factors. This helps in assessing the motivations behind their perspectives.

5. Assess for Ethical Issues: Analyze whether there is a genuine ethical issue at play. Evaluate whether the situation violates your professional code of ethics, state practice act, or any other moral, social, religious, or cultural values. It's vital to compare the actions or decisions to the relevant ethical standards.

6. Consider Legal Aspects: Determine if there are any legal issues involved. This entails reviewing practice acts, licensure laws, and regulations to identify which sections, if any, are being violated.

Legal Issues 

Legal issues can be any of the following:

• Age Discrimination?
• Antitrust?
• Assault and/or battery?*
• Breach of contract?
• Child abuse?
• Copyright violation?
• Confidentiality of student records?
• Covenants not to compete?
• Disability Discrimination?
• Elder abuse?
• Embezzlement?
• Family Medical Leave Act?
• Fraud? (Insurance)*
• Gag clauses?
• Guardianship/conservatorship?
• Kickbacks?
• Malpractice?
• Medical fraud?
• Modalities without training?
• Negligence?
• Omnibus Budget Reconciliation Act (OBRA) violation-long-term care facilities would ascribe to?
• Patient confidentiality?
• Plagiarism?
• Sex discrimination?
• Sex with a patient?
• Sexual harassment?
• Spousal abuse?
• Theft?
• Trade secrets?
• Treatment without a prescription or referral?
• Violation of privacy laws?

Addressing ethical issues within your workplace is a complex matter that can lead to various outcomes and ramifications. It's essential to consider both your professional and personal perspectives when deciding how to handle these situations. Here are some key points to keep in mind:

Many ethical issues can be addressed internally within your workplace. Depending on the nature and severity of the issue, actions taken within the organization may include verbal warnings, written warnings, suspensions, or even termination. Your workplace policies and procedures will guide the internal resolution process.

The decision to involve licensing boards should be made on a case-by-case basis. There may be instances where a breach of ethics is severe enough to warrant reporting to the relevant licensing board. This is typically appropriate when the issue involves a violation of professional standards outlined in your state's practice act.

Deciding whether to report to the board is a personal choice. It depends on the specific circumstances, your level of involvement or responsibility, and your own ethical and professional standards. There is no one-size-fits-all answer, and it's essential to consider the potential consequences and the potential impact on your career.

Familiarize yourself with your state's practice act and any specific requirements related to reporting ethical violations. Your practice act provides guidance on when and how to report violations and the potential consequences.

Some ethical issues may have legal implications, leading to criminal or civil lawsuits. Depending on the nature of the issue, you may need to contact the relevant legal authorities or law enforcement agencies.

Ultimately, how you address ethical issues in your workplace should align with your professional and personal values and the specific circumstances of the situation. It's important to act in a way that upholds the integrity of your profession while also considering the best interests of all parties involved.

The remaining steps in this process:

7. Assess the Need for More Information: Determine if you require additional information to fully understand the ethical dilemma. Consider whether there are policies, procedures, laws, or regulations that you may not be aware of and need to research. Explore the existing evidence and literature related to the issue. Consult with experts, mentors, supervisors, or individuals who can provide guidance and expertise in the specific area of concern.

8. Brainstorm Possible Action Steps: Generate a list of potential actions or solutions to address the ethical dilemma. Brainstorming encourages creativity and exploring various options.

9. Analyze Action Steps: Evaluate the proposed action steps and eliminate those that are obviously inappropriate or unfeasible. For the remaining options, consider how they will impact the patient, involved parties, society, and yourself. Assess whether the choices align with your practice act, regulations, and code of ethics, as well as your personal moral, religious, and social beliefs and values.

10. Choose a Course of Action: Select the most appropriate course of action based on the analysis, considering all relevant factors. Evaluate your decision using criteria such as the Rotary Four-Way Test: Is it truthful, fair, goodwill-building, and beneficial to everyone concerned? You should strive for a win-win outcome, but that may not always be possible.  You may not feel great if you had to report somebody to the board or they lost their job, but you have to feel good about the fact that you made the best choice possible, considering the available information and ethical considerations.

This structured approach helps healthcare professionals navigate complex ethical dilemmas, ensuring that their decisions are well-informed, ethically sound, and aligned with their professional and personal values.

Let's Practice: Example  (Terri)

Terri is a student at the Sunnyside Nursing Home.  She has struggled throughout her student internship. Calling her performance marginal would be a compliment. As her supervisor and her CI, you have repeatedly given her very specific feedback, including instructing her in various ways that she can change her behavior. Unfortunately, Terri fails to heed your advice. At midterm, her performance merited a failing grade. She forgets to lock the brakes on wheelchairs. She shows a complete disregard for other patient safety precautions. Well, here you are now at her final evaluation, and after spending half an hour at a minimum struggling with this failing final evaluation, your boss, the rehab director, looking over your shoulder, says, "Well, whoa, you can't fail, Terri. She's done her best even though she has a learning disability." And she says, "Even though she really failed this clinical internship, it's just too much trouble to give her a failing grade." Your supervisor reminds you that your facility doesn't want to be sued for an Americans with Disabilities Act violation. And should Terri fail her clinical internship, that's what you would see. You had no previous knowledge of Terri's learning disability, only her failing performance.

Let's go through the steps.

What is the problem?   

• The boss wants the supervisor to pass a failing student intern whose performance doesn't warrant a passing grade. I hope that that would make most of us feel some level of conflict and discomfort.

What are the facts of the situation?  

• Terri is a student intern at Sunnyside Nursing Home
• Midterm performance was failing  
• Terri’s supervisor provided her with adequate supervision and ample specific feedback on how she could perform better and improve her performance in various areas.
• Terri failed to modify her behavior in response to your feedback
• Terri forgets to abide by patient safety precautions
• Terri’s is still failing at the end of the fieldwork
• The supervisor intends to fail her
• The rehab director tells the supervisor not to fail Terri
• The supervisor learns for the first time about the learning disability
• The learning disability was not considered  
• The facility does not want a lawsuit

We know that she is not abiding by safety precautions, specifically locking the brakes on wheelchairs during transfers and some other things. We also know that she still warrants a failing grade at the end of this clinical affiliation. The supervisor feels that Terri earned a failing grade and intends to fail her. The rehab director tells the supervisor, you are not to fail Terri. At the end of the internship, the rehab director informs the supervisor for the very first time that she has a learning disability. In assigning a failing grade, the supervisor did not consider any learning disability. The rehab director tells the supervisor that he/she cannot fail her because of the fear of an unwanted ADA lawsuit. 

Who are the interested parties?

• Terri
• Supervisor  
• Rehabilitation Director and Facility
• Terri’s future patients and employers  
• Academic program from which Terri came
• Other therapists/students at the facility
• Terri’s professional association/licensing board

What is the nature of their interests?

Many different stakeholders have an interest in Terri's situation as an intern struggling to pass her clinical internship. Analyzing the nature of these interests is complex but necessary to make an ethical decision.

Terri: Personally, she wants a job and needs to pass. She also has professional (she wants her license and desires to practice therapy) and economic interests in passing the clinical, obtaining licensure, and securing employment, as she spent a lot of time and money going to school.  

Supervisor - Professional interest in competent therapists and reputation; Personal desire to avoid failing students; Business interest as a supervisor need to balance management expectations and patient safety 

Facility - Economic/business interests 

Terri’s parents - Economic interest in her career success 

Terri’s future patients - Safety and quality care

Federal government - Societal interest- individuals with disabilities are not denied opportunities.

Academic program - Reputation and student outcomes

Other therapists - Professional standards  

Licensing board - Public protection

Considering these diverse perspectives helps illuminate the full scope of consequences in either reporting Terri or assisting her. An ethical resolution will account for all stakeholder needs.

Is there an ethical violation?

Yes. At the very least, passing a student who achieved a failing grade violates a code of ethics addressing justice, veracity, and maybe non-maleficence too, because this student could possibly harm someone in the future.

Is there a legal issue?

Again, we would need to look at the practice act there. We don't have much information there.

Are there other possible legal issues?

Although our information is limited, it's possible that an ADA violation occurred, such as filing a false report, contract breach, or confidentiality issue. Additionally, issues of negligent supervision could come into play.

ADA, filing a false report, practice act, contract breach, confidentiality, negligent supervision, and other legal issues. Do you need more information? Possibly, possibly. Other good information. Was this this person's first internship, or would maybe it be the last? If it was the first, maybe there's another opportunity. Maybe you fail her because she will have another opportunity. Maybe you need to familiarize yourself with ADA, the practice act, and maybe somebody else on the management team for advice. So, let's brainstorm. Remember, there are no right or wrong answers here. What can you do?

Do you need more information? 

It's conceivable that this may not have been Terri's first internship, and there might be more at stake than initially apparent. If it indeed was her first internship, other opportunities may be available. It would be prudent to familiarize yourself with the ADA and the practice act or seek advice from a colleague within the management team. Let's brainstorm. Remember, there's no definitive right or wrong answer in this situation. What options can you consider?

• Brainstorm possible courses of action.
  • Fail Terri
  • Pass Terri 
  • Call the coordinator at the university 
  • Research the ADA issue  
  • Complain to the rehabilitation director’s boss 
  • Call the police?  Terri’s parents? 
  • Contact the Justice Department 
  • Consult with an ADA lawyer 
  • Discuss the situation  
  • Quit your job rather than fail Terri

You might choose to fail Terri, or you could pass her. Another approach would be to contact the university's academic coordinator and request guidance. Another avenue is researching the ADA to determine if a failing grade is permissible. Discussing the matter with the rehab director's immediate supervisor is a possibility. Alternatively, you could reach out to the police or Terri's parents. If you're unsure, you could contact the Justice Department, responsible for enforcing the ADA, to inquire if failing Terri violates the law. Consulting with an ADA lawyer is also an option. You could discuss the situation with your spouse, significant other, or a religious or spiritual advisor. However, quitting your job rather than failing Terri is an extreme step.

Let's evaluate these options by first eliminating those that are clearly inappropriate. Calling the police is unnecessary as there is no criminal activity involved. Contacting Terri's parents, spouse, or clergy would breach confidentiality. Quitting your job is not a rational choice. Now, let's apply a moral and ethical litmus test to the remaining choices. Do they align with your personal code of ethics and professional standards? Finally, you can select the best course of action based on the contextual factors at hand.

In this case, it might be advisable to call the academic program to seek guidance and involve another supervisor at the facility to gather additional insights before making a final decision. Keep in mind that the goal is to achieve a win-win outcome, ensuring that your choice aligns with the situation's ethical considerations. There may not be a definitive answer, but this is how we could approach the analysis.

Analyze The Ethical Dilemmas-RIPS Model

The Realm-Individual Process-Situation Model (RIPS)is another way of analyzing ethical dilemmas.

Step 1: Recognize and Define the Ethical Issue 

• Realm
• Individual process
• Implications for action
• Type of ethical situation
• Barriers

Step one involves recognizing and defining the ethical issues at hand. This process is quite similar to our previous discussion. In this step, you need to determine the realm, the process, the implications for action, the nature of the ethical situation, and any barriers you might encounter. Let's delve into these aspects in greater detail:

Realm. Begin by identifying the ethical realm to which the issue belongs. There are three primary realms to consider:

• Individual Realm: This pertains to matters related to the patient's or client's well-being. It focuses on rights, duties, interpersonal relationships, and individual behaviors.

• Institutional or Organizational Realm: Here, the emphasis is on the organization's well-being. You should consider the structures and systems that contribute to its achievement of goals.

• Societal Realm: This realm is concerned with the common good of society as a whole. It involves ethical considerations that transcend individual or organizational interests and aim to benefit the broader community.

Individual Process. The second aspect of recognizing ethical issues involves assessing individual processes. These processes help you understand how the problem manifests in terms of moral decision-making. Consider whether the issue aligns with any of the following aspects:

• Moral Sensitivity: Recognizing, interpreting, and framing ethical situations. It involves being aware of the ethical dimensions of a situation and understanding the potential implications for all involved parties.
• Moral Judgment: In this step, you are tasked with deciding what is morally right or wrong. You evaluate the ethical principles and values at play and decide on the most appropriate course of action.
• Moral Motivation: Moral motivation concerns your ability to prioritize ethical values, principles, and considerations over personal financial gain or self-interest. It involves a willingness to act in accordance with one's ethical beliefs even when there may be external pressures to do otherwise.
• Moral Courage: This aspect is about implementing the chosen ethical action, even when doing so may lead to adversity or challenges. It requires the determination to follow through with the right course of action despite potential consequences or resistance.

Situation. How do you classify the ethical situation? To effectively analyze the ethical situation, you should classify it into one of the following categories:

• Problem or Issue: Determine whether the situation qualifies as a problem or issue, meaning whether important moral values are being challenged.
• Temptation: If the situation involves a choice between a right action and a wrong action, where the wrong action may offer personal benefits, it falls under the category of temptation. This often tests your moral integrity.
• Silence: When key parties recognize the existence of ethical issues but remain passive, not discussing or taking any action to address them, the situation can be classified as one of silence. This is a scenario where there is an unspoken agreement not to confront ethical challenges.
• Distress: If a structural barrier hinders you from doing what you believe to be the right thing, it falls under the distress category. There are two subcategories:
  • Type A Distress: In this case, the barrier is apparent, but it prevents you from doing what you know is right.
  • Type B Distress: Here, there is a barrier, but you are uncertain about the specific nature of the problem. Something feels ethically wrong, but you may be unable to pinpoint it.

Dilemma. There are two or more correct courses of action that cannot both be followed. You're doing something right and also doing something wrong, and most often, this involves ethical conduct. Ethical dilemmas typically involve the need to balance and make decisions between conflicting principles. Some common examples include:

• Honoring Autonomy vs. Preventing Harm: On one hand, you may be required to respect an individual's autonomy and their right to make decisions about their own life, even if it might lead to harm. On the other hand, there's an obligation to prevent harm, which may require intervention that infringes upon their autonomy.
• Conflicting Traits of Character: Ethical dilemmas can also involve conflicting character traits, such as honesty vs. compassion. For instance, you might need to decide between being completely honest and potentially hurting someone's feelings or showing compassion by withholding some information to protect them.

Step 2: Reflect

• Background
• Major stakeholders
• Consequences of action or inaction
• Laws broken?
• Professional guidance
• Right-versus wrong tests

The process is very similar to the ethical decision-making (CELIBATE) model we discussed earlier. When faced with an ethical dilemma, it's crucial to consider the following factors carefully:

• Relevant Facts and Contextual Information: Gather all the pertinent facts and contextual information about the situation. This provides the foundation for making an informed ethical decision.

• Major Stakeholders: Identify and understand the key parties involved in the situation, as their interests and perspectives can significantly influence the ethical implications.

• Consequences: Analyze both intended and unintended consequences of potential courses of action. This includes considering the impact on individuals, organizations, and the broader community.

• Relevant Laws, Duties, and Ethical Principles: Examine any applicable laws, regulations, professional duties, and ethical principles that are relevant to the situation. These provide a framework for ethical decision-making.

• Professional Guidance: Seek guidance from your profession's ethical guidelines or code of conduct. This guidance can help you align your decision with industry standards and values. Examine whether the situation aligns with the code of ethics, the guide to professional conduct, or any core values of your profession.

• Right vs. Wrong Tests: Evaluate the situation by asking if a course of action is morally right or wrong, considering your own values and principles. You may include: 

  • Legal Test: Determine if any actions the involved parties take are illegal, as this can impact the ethical assessment.

  • Stench Test: Assess whether the situation feels wrong or unethical, even if it may not be clearly defined as such by laws or regulations.

  • Publicity or Front Page Test: Consider how the situation would be perceived by the public or if it were to become widely known. This can shed light on potential reputational and ethical concerns.

  • Universality or Mom Test: Reflect on whether the decision is right, regardless of who is involved. Consider what your moral compass or what your "mom" would advise. 

Step 3: Decide the Right Thing to Do

You can do this in three different ways.

• Principle-Based Ethics (Deontological): This approach focuses on following universal rules or principles, regardless of consequences. You act based on what you believe everyone should do in a similar situation. For example, you should always tell the truth to patients, even if it might cause distress.
• Outcome-Based Ethics (Teleological): This method prioritizes actions that result in the best overall outcome for the majority. Decisions are made by weighing potential benefits against harms for all affected parties. For instance, allocating limited resources to treatments that will help the greatest number of patients.
• Care-Based Ethics (The Golden Rule): This perspective emphasizes empathy and treating others as you would want to be treated. It involves considering how you would feel in the patient's position and acting accordingly. For example, explaining procedures thoroughly because you would want the same if you were the patient.

Step 4 Implement, Evaluate, and Assess Needed Changes to Prevent Recurrence

We're considering implementation here. Did it meet our expectations? What were the challenges? How does it compare to other situations? Did it enhance our professionalism? Do we need to establish policies or procedures to prevent such occurrences in the future?

Example Using RIPS Model (Kate)

Kate graduated from State University last year and is working at County Hospital. Her PT school best friend, Sandy, works in a small rehab hospital across the state. They often compare experiences and ideas for interventions. The young colleagues, typical of their generation, primarily communicate via text messaging and Facebook. They rarely talk on the phone.  

On a Monday morning, Kate starts her workday by reviewing scheduled patient charts. Looking through the new admissions, she notices a familiar last name. She checks the face sheet and confirms that the patient is Ms. Edwards, one of her former professors at the state university. Kate is surprised to see that Ms. Edwards was admitted to rule out a brain tumor.

Kate walks down the hall to visit her former professor but doesn't find her in the room. Assuming she's undergoing tests, Kate plans to check back later. However, she doesn't get the chance to meet Ms. Edwards that day. Later in the evening, while on Facebook, Kate writes a message on her friend Sandy's wall about their former professor's hospital admission. The message quickly spreads through the Facebook news feed, and Kate discusses Ms. Edwards' condition with several former classmates and others.

That evening, Ms. Edwards' daughter discovers the news of her mother's hospitalization on the social networking site, which surprises her. She immediately calls her mother, who is upset by the news, and contacts Joanne, the County Hospital's Director of Physical Therapy. Joanne summons Kate to her office the following day, expressing irritation and asking for an explanation.

Kate is confused by the issue and attributes it to a generation gap between herself, Ms. Edwards, and Joanne, all of whom are baby boomers. She defends her actions, stating that sharing and communicating information in this manner is common among people her age. However, Joanne emphasizes that the problem isn't about technology or etiquette but about confidentiality. Kate is puzzled by Joanne's frustration.

This situation resembles the one I mentioned earlier, where someone who wasn't directly involved with the patient's treatment shared information about the location of an estranged mother with family and others.

Let's go through the RIPS model now. 

Step 1: Recognize and Define the Ethical Issue  

• Realm: While Kate is sure it is individual, Joanne considers it institutional.  
• Individual process: Kate doesn't have the moral sensitivity to recognize that her messages and decision to read the chart of a patient to whom she had no professional connection or obligation were breaches of confidentiality.
• Implications for action: Joanne must address Kate's obvious lack of understanding of confidentiality issues.
• Type of ethical situation: A problem: Kate's actions are inappropriate in that they are unclear to her.
• Barriers: Yes, there are barriers. Joanne has the authority to take action, but it's unclear if she fully understands the generational challenge she is confronted with.

Step 2: Reflect

• Background: We don't really know anything more than this. We know that Kate is not treating Ms. Edwards; she's just curious about her.
• Major stakeholders: Kate, Joanne, Ms. Edwards, and Kate's friend, Sandy, who is dragged into this because Kate was chatting with her.
• Consequences of action or inaction: Yes. Joanne is obligated to take action. As a new professional, Kate must understand that her professional responsibilities affect her personal life and values.
• Laws are broken: There is a HIPAA violation at a bare minimum.
• Professional guidance: Kate would do very well to reflect on the principles of the code of ethics regarding the rights and dignity of all individuals and the exercise of sound professional judgment. She needs to consider integrity and social responsibility.
• Right versus wrong tests. Is it illegal? The situation feels wrong for sure, if not to Kate. Would there be discomfort if this information became public? Probably. Would your parents take action in a similar situation? The answer is probably yes. Finally, is there a violation of the professional code of ethics? Again, the answer is yes.

Step 3: Decide the Right Thing to Do

So what do you do? For Kate, the barrier to behavior change is getting her to understand that her actions, while perhaps socially acceptable and expected among her peers, are inconsistent with the expectations of her profession and her patients.

Step 4: Implement, Evaluate, and Assess Needed Changes to Prevent Recurrence

So what do you do? This situation may result in a change in institutional behavior as Joanne examines her orientation program and recognizes that she has young staff with social norms that differ from hers. 

This whole situation looks at confidentiality and how we, as therapists, manage protected health information that we have at our disposal. Again, confidentiality is one of our biggest obligations. Changes in technology and communication are challenging how we view confidentiality. We need to look at it in light of the technology. Some levels of policy and procedures should be in place, reviewed regularly, and are part of orientation as well.

Second Example Using RIPS model (Mike and James)

James works in home care and enjoys independence and variety in his work. One of his current patients, Mike, an active 72-year-old retiree and widower who recently had a left total knee replacement, spent a week at a rehab center before he came home.

Mike has a great attitude and is eager to get back in the swing of things. Payment for his physical therapy is unaffected by outpatient guidelines as long as he remains at home. This makes James very happy because Mike is a hard worker and an ideal patient. He can't afford to pay for physical therapy beyond what Medicare and supplemental insurance will allow. James aims to ensure Mike's safety in the home environment and his ability to manage independently. His discharge goal is to be self-sufficient while possibly experiencing some residual pain and capable of transporting himself to physical therapy on an outpatient basis. The plan of care is estimated at three times a week for three weeks.

When the PT arrives for his third appointment in the first week, he notices that his patient's car is in the driveway rather than in the garage. Mike answers the door and goes into the kitchen, where he's putting away groceries. James knows there's no family in the area, and he asks Mike who did the driving and the shopping. Mike says, "Well, I did." James is surprised because Mike should be technically homebound to receive physical therapy at home. There are physical and clinical issues, but Mike's like, "Yeah, I get it, but there's gotta be a little wiggle room. What harm is there in me trying to do a little bit for myself?"

Mike's car is gone when James arrives for the next follow-up appointment. About five minutes later, Mike returns to his house in his car. Mike says he went to the hardware store for plumbing supplies to fix the leaky sink. Jamie notices Mike getting up the stairs, and he's getting back into the home safely, but obviously with some level of effort. 

James feels conflicted. Mike needs more physical therapy, but based on the fact that he's shown obvious progression, he's technically no longer homebound; what does he do? Does he continue home care, or does he discharge and send him to outpatient?

Step 1: Recognize and define the ethical issue

• Realm: Individual and societal
• Individual process: Moral sensitivity on James's part
• Implications for action: Mike will stop receiving PT that can benefit him
• Type of ethical situation: A dilemma
• Barriers: Concern for Mike's safety 

The realm between James and Mike is individual, but I think there's also a societal element here because of reimbursement. There's that moral sensitivity in the individual process, particularly for James.

Implications for action. So if James exercises moral courage, Mike will stop receiving home care that could benefit him, and we don't know if he could or could not go to outpatient at this point.

This is a dilemma. Mike is exercising his autonomy, but James is concerned for his safety. James is exhibiting non-maleficence in wanting to keep Mike on the home care schedule. James is also concerned about veracity. He believes in being truthful. He doesn't want to lie about his homebound status.

Are there barriers? Yes, one barrier is for Mike's safety if home health is discontinued.

Step 2: Reflect

• Major stakeholders: James and Mike
• Consequences of action or inaction: Mike will lose the additional PT he needs if James takes action.  Inaction means that he receives PT while not technically homebound.
• Laws broken? Medicare laws are very specific regarding homecare
• Professional guidance: Principle 7 of the Code of Ethics
• Right vs. Wrong: Illegal? Yes. The situation feels wrong. Discomfort if information becomes public? Yes. Are your parents likely to take action in similar circumstances? Yes. Violations of APTA's professional codes and documents? Yes. 

However, inaction means that he has a patient who is not homebound. Are there laws broken? Yeah, Medicare obviously has very specific laws regarding home care. What is the professional guidance? Regarding the state and the code of ethics, a physical therapist shall seek only such remuneration as is deserved and reasonable. There's a core integrity here as well. Right versus wrong tests. I think all of these, we could say it feels wrong. Your mom would take action in a similar situation. It doesn't pass the stench test.

Step 3: Decide the Right Thing to Do

• So what does James do? While James must consider discharge, he must also do all he can to ensure Mike's safety by ensuring his continued access to the outpatient services he needs.  

Step 4: Implement, Evaluate, and Assess Needed Changes to Prevent Recurrence

• It's unclear whether any institutional policy or culture change is warranted, but that possibility should be fully explored. I think what we're looking at here is, to some degree, pressure to provide patients with optimal care within the guidelines. There's always pressure to do the right thing in light of reimbursement. You can't let reimbursement drive practice. We have to make sure that the proper sequence is followed and that we do the right thing for our patients and for our practice as well.

Example-Jenna

Jenna has been working at Pond View for about six years. She is known for her wound care expertise. She's been the CI for the past four years and recently completed the CI credentialing course. She supervises at least three students yearly as they rotate through their clinical experience. She enjoys the interactions, particularly those related to wound care. This is the next to last clinical rotation for Brendon, a third-year DPT student at the local university who made a career change from the corporate world and is thus a little older than the students who generally rotate through. He is working with another PT, Mary, for the first part of his rotation, and then he will move on to Jenna's supervision about midway through.

One day, three weeks into the affiliation, Brendon stays late to finish up some paperwork. He ends up leaving the building at the same time as Jenna, who also worked late. They get into a long conversation while standing in the parking lot. Brendon's very interested in wound care and asks Jenna many questions about what he'll see when working with her in the next few weeks. They also exchanged a little small talk, during which Jenna mentioned that her birthday was next week. With the conversation ending after 20 minutes, Brendon asks Jenna if she would let him buy her a birthday drink at a nearby bar (within walking distance). She responds that she appreciates the offer, but it strikes her as inappropriate given that she'll be his supervisor in just a few weeks.

He responds that, having worked in the corporate environment, he's sensitive to these types of issues. "It's just one birthday drink, and anyway, you can think of it as a penny for your thoughts because I want to pick your brain about some cases that I've seen." She sees this as reasonable. Would having a single drink with Brendon while engaged in a professional dialogue be so wrong?

I would like you to take this one back with you and go through the steps I have laid out.  

Step 1: Recognize and define the ethical issue

• Realm: Into which realm or realms does this situation fall: individual, organizational/institutional, or societal? 
• Individual process: What does Jenna's situation require? Of Brendon? Which individual process is most appropriate: moral sensitivity, moral judgment, moral motivation, or moral courage?
• Implications for action: Are there implications for action on the parts of anyone besides Jenna and Brendon?
• What type of ethical situation is this: a problem, dilemma, distress, or temptation?
• Are there barriers to Jenna taking action?

Step 2: Reflect

• What do you know about the legal obligations Jenna may face?  
• Who are the major stakeholders?
• What are the potential consequences of action or inaction on Jenna's part?
• What ethical principle(s) may be involved?
• How does this scenario stack up against the “tests?”

Step 3: Decide the Right Thing to Do

• If it fails all of the “tests,” this step is superfluous
• If it passes the tests, then determine the right thing to do
  • Rule-based: Follow only the principle you want everyone else to follow
  • Ends-based: Do whatever produces the greatest good for the greatest number of people
  • Care-based: Do unto others as you would have them do unto you

Step 4: Implement, Evaluate, and Assess Needed Changes to Prevent Recurrence

• Having determined in your own mind the right thing to do and the best way to implement the decision, reflect on the course of action chosen and think about whether a change in the clinic's organizational policy or culture might prevent this scenario from recurring

Analyze Ethical Dilemmas-Rest’s 4-Component Model

This next model is a nursing model, but I believe it is appropriate. We will go through it quickly. It looks at four different areas.

• Moral Sensitivity  
• Moral Judgment  
• Moral Motivation  
• Moral Action

Moral Sensitivity

• Recognition that an ethical dilemma exists  
• Ability to empathize with others  
• Be aware of how one’s actions affect other people  
• Recognize the values, beliefs, understandings, and obligations of others  
• Appropriate emotional response  
• Impact of actions on others  
• Discern relevant aspects of the situation  
• Consider other aspects, such as care

Moral Judgment

• Judging which action is most ethically justifiable for a moral dilemma  
• Identify the morally relevant aspects of the situation  
• Weighs the significance of aspects  
• Identify potential actions and consequences  
• Clarifying factual, conceptual, and ethical issues

Moral Motivation

• Whether the practitioner is motivated to enact the moral decision made  
• Internal or external barriers can undermine motivation  
• Requires clarity, courage, support, skillful advocacy, and a willingness to subordinate other important commitments  
• Wisdom and virtue are essential elements

Moral Action 

• Executing and implementing a plan with perseverance and resoluteness  
• Consider the best way to implement the decision  
• Requires diplomacy, skilled communication, collaboration, and strategic planning  
• Create a trustworthy process with clear expectations, fair processes, and precise communication.  
• Attention to objections/resistance

Consequences Of Ethical Dilemmas

Ethical dilemmas can affect individuals, potentially leading to burnout and stress. For several reasons, it's essential to address these dilemmas promptly and effectively. Unaddressed ethical dilemmas can fester and grow, making them more challenging to resolve later. Addressing them early can prevent escalation. Swift resolution of ethical dilemmas can help reduce the stress and emotional burden that staff may experience. This, in turn, supports their well-being and mental health.

Some ethical dilemmas may have legal consequences, potentially resulting in actions such as loss of licensure, termination of employment, reprimand, or implementing an action plan to respond to the issue.

Ethics Committee

Hopefully, you have an ethics committee that you can go to regarding some of these issues. If you don't, it might be something that you consider in your place of employment, suggesting or, at a bare minimum, having a team there.

As mentioned, I practice in nursing homes and recently found a study. In this study, out of 40 ethics committees, a striking 29 of them did not include a single patient. This underscores the importance of having all relevant stakeholders, including the patients, actively participate in an ethics committee. Ethical discussions should encompass major ethical dilemmas and everyday ethical considerations that arise in our practice.

Avoiding Ethical Dilemmas

How do you avoid ethical dilemmas? You do it by Protecting Thy Patients and Thyself. It's a mnemonic.

• P: Put a copy of your licensure law on your desk and read it!
• R: Report ethical and legal violations
• O: Open your eyes
• T: Tell them you want it in writing or in an email. If it doesn't seem right, it probably isn't right. If somebody asks you something that doesn't make sense or you're questioning it (it doesn't pass your stench test), ask for it in writing. If it's illegal or unethical, they won't typically put it in writing.
• E: Encourage ethical behavior
• C: Complete, thorough documentation
• T: Think!! Don't fall into the trap of panicking first and thinking later.

• T: Take the patient’s interest above all
• H: Handle situations as they arise
• Y: Yearn to learn

• P: Plug into your professional associations
• A: Ask a lot of questions
• T: Train and supervise all subordinates properly
• I: Internet sources (but be cautious too-Clarify and make sure you have the correct information)  
• E: Establish a relationship with a mentor or peer
• N: Never fall behind
• T: Take a good look at the professional literature
• S: Surf the internet for regulatory changes   

• &

• T: Take the time to read your code of ethics
• H: Hand over patients to those with expertise
• Y: Yield to the dictates of payers  
• S: Save a copy of the correspondence
• E: Explore all alternatives
• L: Look at professional association/licensure homepages
• F: Fill out all forms accurately and truthfully

Resources to Help

• Core documents from APTA -- APTA Code of Ethics, APTA Guide for Professional Conduct, Standards of Ethical Conduct for the Physical Therapist Assistant
• Consensus Statement on Clinical Judgement in Health Care Settings
• Other resources from APTA
  • Coding and Billing
  • Compliance
  • Managed care contracting tool kit  
  • PT in Motion

Situational Examples

I'm going to go through these examples a little bit on the quick side. I would like you to bring these back to your clinics and maybe talk about them as a group as they relate to ethics.

When compiling documents for an additional request, you discover that the restorative nursing assistant documented that services were rendered when the resident was clearly out of the facility at the hospital. 

I've seen this in physical therapy and occupational therapy, where we continue to document, and the patient was discharged. It's clear the person was never seen or actually treated because we probably would not have that documentation. That is an ethical violation; you can brainstorm what you would do.

You, the therapist, have delegated the treatment of a client to the physical therapy assistant under your supervision.  The client complains of pain during the treatment session.  The PTA applies ultrasound to the patient during the session without consulting you and without a physician's script/order to do so.

We see this sometimes when the PTA has applied a modality that was not part of the plan of care, and they have changed the plan of care without consulting the physical therapist - of course, that is a huge "NO."

When reading the daily notes of the assistant you supervise, you discover that he is adding and changing goals for the client without consulting you. 

This is very similar to the prior example. It is also a no-no, as it is not in the PTA's scope of practice, and the therapist must be consulted on any change to the plan of care (treatments and goals).

You work in an outpatient clinic, primarily dealing with Medicare Part B as a payer. Your clinic has an aide. You ask the aide to complete the therapeutic exercise program with the client, and you bill for these services.

This example goes back to fraud and abuse. We cannot bill for services provided by individuals who are not legally allowed to provide that service in that setting.

As a PT, you have been told to continue treating your patient—just three more sessions—so the facility can continue to obtain skilled reimbursement and because the family is not quite ready at home for discharge.

Could you work on something? I suspect yes, but that might be wrong if it's just for that facility to get reimbursed. So I think you'd have to look at that one cautiously—if there truly is something clinically skilled that you could be doing, then by all means, but if there isn't, then we would probably want to continue with discharge.

A patient attended a follow-up appointment, which did not go as expected. There was bad news.  The patient wants to know the extent of the report, but the family wants to withhold the information to protect their emotions. 

We talked about this earlier. Again, maybe it's not up to us to give that information, but it is definitely up to somebody to share that information with the patient.

A 56-year-old man is referred to physical therapy for sciatica, degenerative disc disease, and degenerative joint disease. He is the sole caretaker for his disabled wife. Over the last month, he has lost his capacity to bend, lift, and carry during daily living and work activities. Medicaid will only provide for a PT evaluation.  No follow-up services are covered.  The PT recommends follow-up twice a week for four weeks.

I mean, this is a tough one. How do you proceed? Should the patient be asked to pay out of pocket? Should the patient be offered free or discounted services? No, because we don't do that. We need to look at alternatives to traditional duration and frequency, as well as models of care. Maybe there are some other options there. Maybe we need to advocate for the patient to the insurance provider to seek additional services. 

As a therapist, you suspect that a patient is concealing information that may impact his health, but you want to respect his privacy.

This situation is a tough one. If your patient doesn't share, they don't share. We develop that trusting relationship, and we hope they share it with us. We have to obviously always keep their confidentiality.

As the supervisor of your department, you see that Marie, one of the PTs, has been regularly receiving expensive gifts from the elderly woman's family. The woman was scheduled to be discharged from the program weeks ago, but Marie continues to delay the discharge, citing many reasons.

This is a problem. I think most of us work in a situation where we are not allowed to accept gifts, and it looks like we're getting some gift or kickback from this patient. That is a no-no. 

You are friends with Paula on Facebook, and you happen to notice that she is also friends with several of your patients and their family members. 

Is that terribly wrong? Not necessarily, but I think at a bare minimum, we would want a policy that addresses whether we can be friends with these individuals or not. Maybe we could be friends after treatment ceases, and maybe not during treatment. Again, that would be up to a policy and procedure there.

Lauren, a PT, is the only witness to a patient fall in the clinic gym. The patient has balance problems, and the PTA, Hal, who is working with her, was not guarding her. Lauren observed Hal placing a gait belt on the patient after the fall and before calling for assistance. Lauren is unsure what to do about this situation. 

That's another ethical situation. This person was not maintaining appropriate patient safety, which must be addressed.

Jim, a PT, works at a private practice with several regional clinics. It has a centralized management structure. One of the top managers calls Jim and asks him to call a previously scheduled new patient to reschedule an initial evaluation since a VIP/shareholder has been referred to the clinic and wants to be seen as soon as possible. Jim is uncomfortable with this request.

This goes against justice and fairness, really. What do you do here? It's an ethical consideration. I don't know that we have an exact answer, but I think it's something we need to talk through. Maybe there's room for both people to be treated. If there's not, we must put our patients first.

Sara works in a private practice with a profit-sharing plan. Her year-end bonus is directly related to maximizing return visits as they are the most cost-effective. Her boss has been heard to say to other staff members that they should treat patients to the maximum of their benefits; after all, you can always change the goals so there is more therapy to do – it just requires being a little creative. She has also been heard to encourage therapists to discontinue treatment early for those patients with poor reimbursement. Sara is uncomfortable with this situation but is counting on her year-end bonus.

Obviously, this needs to be addressed. This is a serious "no" that would be frowned upon by any state practice act, where we deliver treatment based not on that patient's needs but on something else.

Rob, a morbidly obese disabled veteran, arrived at an outpatient clinic requesting PT services. His doctor referred him to this clinic because of their great reputation. Mary, a PT, was working in the gym and saw Rob walking into the clinic. She called the front desk requesting they not assign her the patient. The patient was scheduled two days later for another PT. Ellen, a PTA who works with Mary, overheard the conversation requesting that the patient not be assigned to her. Ellen knows that Mary is a fitness fanatic and has heard her make derogatory comments about people who are overweight. Ellen feels very uncomfortable about this situation and wonders if she should do anything.

If there was a real reason for that person not to be on her caseload, that's one thing, but if it's because of bias or discrimination, that's another issue that would need to be addressed. 

Recent Research Roundup on Ethics

Recent literature from 2022 to the present has continued to explore ethical considerations in physical therapy, addressing challenges and proposing frameworks to enhance ethical practice. Below is an elaboration on key studies from this period:

Professional Identity and Moral Agency Post-Pandemic

In her 2022 Mary McMillan Lecture, Swisher (2022) examined the ethical challenges faced by the physical therapy profession in the aftermath of the COVID-19 pandemic. She emphasized the importance of viewing physical therapy as a moral community, highlighting the need for collective moral agency to address societal health disparities. Swisher advocated for proactive engagement in public health initiatives and policy advocacy to promote health equity. She also called for building ethical resilience through preparedness and support systems to navigate future challenges.

Ethics in the Clinical Relationship

García-Sánchez et al. (2023) conducted a qualitative study exploring physiotherapists' perspectives on ethical behavior in clinical practice. The study identified that therapists emphasized the importance of empathy, respect, and effective communication in building trust with patients. Participants highlighted the need for reflective practice and continuous learning to navigate complex ethical situations. Challenges reported included managing dual relationships, maintaining professional boundaries, and addressing cultural differences. The study concluded that there is a need for enhanced ethics education focusing on real-world applications and supporting therapists in developing practical strategies for ethical decision-making.

Ethical Challenges in Early Career Practice

Howard et al. (2022) examined encounters with ethical issues among occupational therapy practitioners during their first five years of practice. The study found that common ethical challenges included productivity and billing pressures, compromised care due to cost containment, and issues within therapeutic relationships. Practitioners with more than one year of experience or those working in adult or older adult settings reported a higher frequency of ethical issues. The study emphasized the need for effective ethics education and mentoring to prepare new practitioners for ethical decision-making in clinical practice.

Ethical Principles and Responsibilities

World Physiotherapy (2022) updated its policy statement on ethical principles and responsibilities for physiotherapists. The document outlines core ethical principles, including respect for individual rights, informed consent, confidentiality, and professional integrity. It emphasizes the physiotherapist's role in contributing to community health planning and addressing health inequities. The policy serves as a comprehensive guide for ethical conduct in physiotherapy practice.

These studies and policy updates underscore the evolving ethical landscape in physical therapy. They highlight the importance of continuous ethics education, reflective practice, and proactive engagement in addressing systemic challenges to uphold ethical standards in the profession.

Q&A

Q: "Working in home health, sometimes I'm assigned more patients than I can see. How can I ethically navigate which patients to see? I can't see them all, there's not enough staff. Some patients will have a missed visit."

A: So, you know, that's an interesting one. I think that's one you have to return to; there's no easy answer here. You must return to your supervisor and discuss staffing; what else can we do? Can we, you know, could some visits be shortened, some visits be longer? Could you look at frequency and duration, et cetera? Unfortunately, in some cases, I think do need to prioritize, and I know that's not the right answer, but, you know, this person we can put off today and maybe see tomorrow because they're doing very well. Maybe that person it's time for them to go to outpatient. Again, it's an ethical challenge, but at a bare minimum, you must return to your supervisor and discuss that.

Q: "If an aid or a rehab tech is guiding your patient to complete the rest of their exercises during a session, how do you bill for this?"

A: Well, you know, again, I'm gonna caution what I say. You must know the payer source and whether you can bill those services. I come from an area of Medicare Part B, where we can't bill for those services again. So, in that case, if the tech is overseeing that and you are not there, that is likely not a billable service. You have to go back to the payer, of course. The question then becomes, should this be turned over to an independent home exercise program? If the patient can do it without you physically present, is there a skill you are bringing to the table? And I think the answer to that would be no. 

Q: "If you're leaving a practice and you have patients who want to know where you'd be practicing next, would this be seen as recruitment to share that information with them?"

A: That is a wonderful question. Thank you for asking that. If the patient says, "Hey, where are you going next?" And you say, "Oh, I'm going to Happy Day Clinic down the street." That is one thing. Then, if that patient chooses to follow you to that new practice, that's a different story. I think what we discussed taking patients with you by saying, "Hey, I provide really, really good care. This place really doesn't. I'm moving down here, and you need to follow me." So, enticing or asking them is one thing. They are asking us, I think, a totally different story. 

References

American Physical Therapy Association. (1981). APTA guide for professional conduct (Issued by the Ethics and Judicial Committee). (Last amended: March 2019). Retrieved from https://www.apta.org/contentassets/7b03fbe1fa5440668a480d2921c5a0b6/apta-guide-for-conduct-pt.pdf

American Physical Therapy Association. (2020). Code of Ethics for the Physical Therapist. Retrieved from https://www.apta.org/siteassets/pdfs/policies/codeofethicshods06-20-2825.pdf

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