Looking back over the past year and reflecting on my own growth with respect to professional and ethical development, makes me realize how much I had to overcome and how much I had to grow. Being a professional and always using an ethical frameworks sometimes brought on many clinical dilemmas and resulted in great moral distress. In order to deal with these situations I needed to be equipped with the necessary skills and knowledge. Higgs, McAllister, and Whiteford (2009) highlights how important it is for students and professionals to develop the ability to make good judgements and decisions in uncertain and complex situations.
Professionalism in the health care system are seen as a complex and evolving concept. It has previously been based on knowledge and skills, and a code of ethical and professional conduct. Now it has evolved to include a strong focus on professional autonomy, reflective practice, communication, professional relationships, commitment to continuing professional development, and accountability to society and the profession (Grace & Trede, 2013). Other examples include Brehm et al. (2006), who highlight the importance of building appropriate relationships with clients and colleagues, and Fornari (2004) that focusses on honesty and integrity, responsibility and accountability, self-improvement, self-awareness and knowledge limits, collaboration, respect for others, compassion and empathy as characteristics of a professional.
One of my previous blog post also highlighted the characteristics of a health care professional. I mentioned how during clinical rotations we see the way the clinicians and supervisors handle themselves and we try to mimic that. However, not all clinicians act in a professional way, therefore how can we assure that we have the characteristics of a professional?
“Since you cannot always carry and display your diploma. Kindly act like you have one. That’s Professionalism.”
― Joshua De Vera Bautista
According to Schuck, Gordon, and Buchanan (2008), all health professionals including students, need to refer to a framework of ethical principles to inform their decisions and actions. This will help to ensure the continued integrity of their professions and to maintain the trust of their societies. Taking responsibility for one’s actions has also been associated with being a professional. It therefore means that one must make consistent professional decisions based on principal professional values, and not only automatically applying predetermined rules of conduct in every case simply as a matter of procedure. However, this is not always as easy, as you can see in this following clinical experience:
During my earlier clinical rotations, I had a patient who was a 45 year old lady. She was admitted to the hospital with a Neck of femur fracture and underwent a total hip replacement. During the initial session I would just go to her, follow the treatment protocol for total hip replacement and leave. During the third treatment session she asked a shocking question, which would forever change the way I conduct a treatment session. She asked: “why, for such a young men, are you so cross at the world”. She said, “I am the one in pain, but for some reason it looks like you have more pain than me”. Upon reflecting on this, I realized that I never even tried to build a professional relationship with the patient. I saw her only as another patient that, by law, needed to be treated and discharged. I never showed compassion and empathy, which is important characteristics for being a profession. This shows how one can just automatically apply rules and follow procedure instead of also include professional values.
Schuck, Gordon, and Buchanan (2008) also explain that the terms accountability and responsibility can be used to describe the actions of a profession in such a case. The relationship between these two terms can sometimes, however, be uneasy. Accountability requires from a professional to explain their actions according to rules and regulations. It can therefore free a practitioner from taking responsibility for their actions. However, ‘responsibility’ requires them to explain their actions, their professional reasoning and ethical principles. It is therefore important to have the characteristic of responsibility and include professional values in one’s sessions with patients.
Grace and Trede (2013) believed that these professional values ‘cannot simply be assimilated, but will mature with practice experiences accompanied by collective discussion and debate’. According to Stark et al. (2006) self-reflective learning is a practical and necessary method of learning professionalism, meaning that a majority of it is learned in ‘the world of work’ through active involvement and reflection on experiences. Trede (2009) explains that experience, lifelong learning, practical involvement, and reflection on professional practice experiences seems like the fundamental strategies in the process of becoming a professional (Trede 2009).
During my last clinical block while writing a reflective piece on a specific clinical experience about professionalism, I realized how all my patient actually started to like working with me. From that first experience where the lady asked me about why I am so cross at the world, I started to change my way of treating patients. I started seeing my patients not only as individuals that needed to be treated according to law, but as human beings that needs my professional help to get back to living life! I incorporated not only the rules of HPCSA into my treatment, but also included professional values. I even noticed how much better my professional conduct report was at the end of last block, compared to first clinical block.
While being all professional and improving on my way of treating patients, there was still something that I struggled with, which was getting informed consent from some patients. As mentioned in one of my other blog post, once during my clinical rotations, I had an old (80) male patient that suffered from cancer and had a big trochanteric pressure sore on the left. The patient refused treatment on initial contacts and was very rude to me. Only the next day after much struggle he said yes to treatment, but only because his nurse told him to oblige. After conducting a short subjective assessment, I realized that the patient might not even have the mental capacity to actually give consent, but because I was a student in my first clinical block, I did not really understand the principle of getting informed consent and because the patient eventually agreed I continued treating the patient.
Health care practitioners are required by law and medical ethics to obtain informed consent of their patients before treating them. Valid informed consent is based on the disclosure of appropriate information to a competent patient who is permitted to make a voluntary choice. When a patient lack the competence to make a decision about treatment, one must seek substitute decision makers (Appelbaum, 2007).
It is therefore important to determine whether a patient is competent or not. Although incompetence should, in principal, be determined by a court, turning to judicial review in every case where impairment of mental capacity is suspected would probably bring the legal and medical systems to a standstill. Therefore, in most cases it is good to continue the traditional practice of having physicians determining the patient’s capacity and decide when to seek substituted consent (Appelbaum, 2007).
I have therefore, over the last couple of months, done a bit of research to help improve in my knowledge of how to determine if a patient has the capacity for informed consent. According to Appelbaum (2007), the legal standards for determining the decision-making capacity for informed consent to treatment includes the ability to ‘communicate a choice, to understand the relevant information, to appreciate the medical consequences of the situation, and to reason about treatment choices.
Even though I now knew how to obtain informed consent from patients and how to evaluate the decision-making capacity for informed consent, there were still situations that caused me to experience moral distress. We as practitioners are not only guided by ethics but also by moral values, such as respect, dignity, honesty, and integrity, and as a result, when these values are threatened we experience moral distress! Carpenter (2010).
Carpenter (2010) define moral distress as “arising when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.’’
As a student physiotherapist, I form part of the interdisciplinary team. This in my opinion mean that all of the health care professionals discuss with each other how to help treat a patient, but what if no one talk to each other and each profession only did their part of the treatment?
I once had a patient who received a total hip replacement. She was in her early 40’s and needed the replacement due to a fracture at her right femur. She was referred for physiotherapy the day after her surgery, so I went to her on that day and started with my subjective assessment. During this assessment I noticed that the patient had drooping on the left side of her face and that she couldn’t speak well (dysarthria). I immediately asked her if her face was like that before and if she had a history of speech impairment on which she indicated that it started the day before. I then asked her to lift up her left arm and when she struggled lifting the arm, I immediately went to the sister in charge to ask about the patient’s condition and ask whether they knew about the paralysis on her left side.
I knew that these signs were very serious, and that it was probably indicative of a CVA. However, the nursing staff did not even notice the paralysis before and they didn’t seem to think it was an emergency. She just said that the doctor is not in the ward and he will still come and do his rounds. They clearly was not going to call the doctor. Due to the fact that I am only I student I didn’t know what else to do. So I suspended my assessment and returned an hour later. The doctor was still not there and neither have the nurses contacted him. Only after another two hours the doctor came and when I asked about the patient she just said that it looks like the patient suffered a major stroke. Test were only done an hour later. The next day the patient past away.
During this clinical event, I experienced a lot or moral distress. I knew what was the right thing to do, but due to hospital constrains I was unable to follow my own plan of action. Only a week after this incident something similar happened. I was now ready for this and was not going to let indolent people stand in the way of proper medical treatment. So I immediately bleeped the doctor myself, who then came to the ward in a few minutes to follow up on the patient.
Earlier I might have thought about professionalism as the way you looked. I thought that you had to be neat, uniform neatly pressed, hair short, clean and tidy, and don’t get me wrong, I still think that’s important. However, I now also know that professionalism is strengthened by your own beliefs, thoughts, and values and that it must be guided by an ethical code of conduct.
“Physiotherapists are rehabilitation experts who provide health services within health care dimensions of promotion, prevention, and intervention to people, communities and populations” (Delany, Edwards, Jensen, & Skinner, 2010).
Appelbaum, P. S. (2007). Assessment of patients’ competence to consent to treatment. New England Journal of Medicine, 357(18), 1834-1840.
Brehm, B., B. Brown, L. Long, R. Smith, A. Wall, and N. Warren. 2006. Instructional design and assessment: An interdisciplinary approach to introducing professionalism. American Journal of Pharmaceutical Education 70, no. 4: 1–5.
Carpenter, C. (2010). Moral distress in physical therapy practice. Physiotherapy theory and practice, 26(2), 69-78.
Delany, C. M., Edwards, I., Jensen, G. M., & Skinner, E. (2010). Closing the gap between ethics knowledge and practice through active engagement: an applied model of physical therapy ethics. Physical Therapy.
Fornari, A. 2004. Promoting professionalism through ethical behaviours in the academic setting. Journal of the American Dietetic Association 104, no. 3: 347–49.
Grace, S., & Trede, F. (2013). Developing professionalism in physiotherapy and dietetics students in professional entry courses. Studies in Higher Education, 38(6), 793-806.
Higgs, J., L. Mcallister, and G. Whiteford. 2009. The practice and praxis of professional decision-making. In Understanding and researching professional practice, ed. B. Green, 101–34. Rotterdam: Sense Publishers.
Schuck, S., S. Gordon, and J. Buchanan. 2008. What are we missing here? Problematising wisdoms on teaching quality and professionalism in higher education. Teaching in Higher Education 13, no. 5: 537–47.
Stark, P., C. Roberts, D. Newble, and N. Bax. 2006. Discovering professionalism through guided reflection. Medical Teacher 28, no. 1: 25–31.
Trede, F. 2009. Becoming professional in the 21st century. eJournal of Emergency Primary Health Care. 7, no. 4: 1–5.