Every positive change in your life begins with a clear, unequivocal decision that you are going to either do something or stop doing something. – Unknown
Let me first begin by sharing my thoughts on ethics as a third year student: what is ethics, can I eat it? As a third year physiotherapy student you got treated as a learner with some knowledge and a lot of learning ahead of yourself – true. Ethics was a distant principle that included concepts like autonomy, beneficence and maleficence. Did I really know what these mean and how to apply them? Definitely not. Never was I bothered with ethical dilemmas. I just avoided whatever was bothering me. Now, as a fourth and final year physiotherapy student, I am treated differently – assumingly because I have more knowledge and experience. The jump however was enormous. As a final year physiotherapy student I spent most of my days on clinical blocks, dealing with both patients and health professionals. How I interact with these individuals depended on the moral and ethical values I adopted over the time on clinical blocks that have passed. In a matter of about three months (the transition from third year to fourth year physiotherapy) it was expected that I am familiar with ethical concepts and am able to deal with dilemmas and challenges faced on clinical practice.
Trede (2012) states that professional development characterised by knowledge, skills, effective communication and clinical reasoning without emotional responses and personal values influencing the management of the patient. The ongoing process which improves an individual’s ability to provide a service is called personal development (Trede, 2012). Personal growth with regards to guidance and training and ultimately developing skills and acquiring knowledge leads to work competence (Trede, 2012). Ethics is defined by the Health Profession Council of South Africa (2016) as the moral principles that ensure that health professionals are managing patients within ethical standards to help ensure equality and fair treatment in the healthcare setting.
This video discusses ethics and professionalism specific to physiotherapy:
Professional is not a label you give yourself – it’s a description you hope others will apply to you.– David Maister
Looking back on the past year, I would definitely agree that I have developed and grown towards the professional I would like to be. I have kept many things to myself and had to learn when to speak up. I have learned where I, a student physiotherapist, fit into the multi-disciplinary team (MDT). Along the way I have stumbled, I have fallen and even sustained a few scratches. Ethical principles did not became part of my development by thinking about it abstractly, but by observing human behaviour (Branch, 2000), by observing the rest of the MDT. I have had a rough journey up until here – am I loyal to my patient or my clinician? This concept is also known as the “the dilemma of the double agent” (Bruckner, 1987) and was, still is, one of my biggest challenges.
The following video discusses professionalism:
Throughout the year I was faced with the ethical dilemma of being loyal to either or my patients or my clinicians. Managing the conflict that arose was somewhat difficult, especially if the conflict was with my clinicians. The latter I already noticed during my first clinical block and only became problematic in my fourth clinical block. My previous post called “Free pass to unprofessionalism“highlighted my subordinate position and my strategy to avoid conflict rather than addressing the issue at hand. I would console myself and point out that the officious attitude of my superior was the problem and not me. Following that blog post, I launched a case study in which I explored strategies/approaches to manage conflict. I started out using an avoidance approach – it is a non-confrontational approach. Parties that use this approach avoid the existence of the problem, and therefore no conflict resolution takes place (Thomas & Kilmann, 2001; Vivar, 2006). Following the case study, it became evident that I incorporated a collaboration strategy more – this approach has a win-win orientation and encourages the identification of areas of agreement/disagreement, and a selection of solutions equally approved by the parties (Thomas & Kilmann, 2001; Vivar, 2006). At the end of the day, I had to be the one to change my view of individuals and how I handle situations. I cannot sweep matters under the mat again and hope for the best, I have to work hard and approach conflict to a point where it can be resolved and everyone is satisfied with the outcome. For most of the year I would avoid the issues, be “loyal” to my clinicians due to the fear of receiving a bad block report from them. Now, with the little experience that I have, I realise that approaching individuals to resolve issues do not end up in bad block reports, the picture is bigger. Managing conflict as an adult and professional suggests more than what avoidance and possibly, bad block reports may suggest.
A video to continue the discussion on the importance of professionalism:
As a therapist, and actually every other health professional, we will always come across cases where some patient rights have been violated in some way or another. These rights were put in place to protect both the patient and the health professional, but when not paying attention to the finer details, these rights are violated too easily. We as health professionals are our patients’ caregivers and their advocates (Branch, 2000). And yet again, the therapist becomes a double agent: to whom do I stay loyal, my patient or my clinician (in the case of a student)? Staying loyal to my patient may put my work (measured with a block report) in danger, but staying loyal to my clinician my cause physical and/or psychological harm to my patient (Bruckner, 1987). It is a constant tug of war, a dilemma. The incidents mentioned in The harder right vs the easier wrong and …Silence is consent… are only two incidents, but numerous can be named. As a physiotherapist, and student physiotherapist, it can be assumed that in the clinical aspect of our jobs we are quite competent; however, ethical dilemmas may compromise the delivery of quality of care (Bruckner, 1987). Implementing the Batho Pele principles, it becomes evident how I struggled between delivering quality of care (patient loyalty) and quantity of care (clinician loyalty). Some of the principles so easily get neglected so that I can impress my clinicians with the amount of patients I am able to attend to. Taking a closer look at these principles and the Patients’ Rights Charter caused me to look closer at myself, the therapist. In the process of proving myself, I got lost and my patients received poor quality of therapy. The American Physical Therapy Association encourages the choice of patient loyalty above clinician loyalty (Bruckner, 1987). As a therapist, I have the ability to make independent decisions which are not influenced by any other health professional with the goal as maintaining and improving the well-being of my patient (Bruckner, 1987).
May we ever choose the harder right, instead of the easier wrong – Thomas S. Monson
At the end of the day it is not just about me that is potentially violating patients’ rights. What do I do when I know of someone else violating a patient right? Referring to …Silence is consent…, it is easy to stand back and wash my hands in innocence, defending myself by denying being part of any interventions done by other health professionals. But was I not supposed to speak up and report the incident, or even just confronting the relevant party involved? I also have the duty to report medical negligence and ensuring that patients are aware of their health status – it is part of patient education. As a student in the health sector, we often have more time to our availability to gain patient trust and listen to the patients (Branch, 2000). With this being said, it is often us as students that come across the finer, vital information and also need to inform the rest of the MDT when relevant. Being receptive of information from patients lay the foundation for care and taking responsibility for your patient’s care (Branch, 2000). Batho Pele is so much more than just informed consent and access to health care. It is there to ensure that the patient is comfortable with the knowledge of their health status and has access to the necessary resources to manage it. It is about having the peace of mind that they are allowed to ask questions and receive true and honest answers. As a student, I do not only adopt ethical principles from my lecturers and supervisors, but my clinicians and other members of the MDT assist in the formation of this core concept. In the past I would literally just avoid the fact that a patient is unaware and uninformed regarding their health status and procedures done. During this year, I actually went the extra mile and followed up on queries of patients and asked the relevant parties to attend to the patient as it is not in my scope of practice or my responsibility to inform the patient of certain details. It relates back to conflict and how I manage it. Do I avoid the issue at hand, or address it appropriately? Our clinicians and the rest of the MDT influence us as students more than they realise and more than what we would like to admit. The information we absorb, however, needs to be filtered and we must choose what to use and what not. I could have easily neglected patients due to their health and psychological status, but ethically, what will I be doing? Violating patient rights, that’s correct. During the journey to developing myself, I also came across numerous situations where clinicians would advise me to rather skip certain patients – well actually neglect their care – and spend more time with others.
Ethics must begin at the top of the organization. It is a leadership issue and the chief executive must set the example. – Edward Hennesy
As a health professional, one will always come across the issue of understanding patients, their choices and situations. Whether I want to admit it or not, I often find myself struggling to manage a patient due to personal conflict relating to the patient or my inability to understand their situation. Meyers and Herb (2013) mention that students in clinical practice develop skills through experiences to equip them to become competent. Incorporating the past experiences, knowledge and evidence from textbooks assist in making professional and ethical decisions in the clinical setting (Meyers & Herb, 2013). Using the example in my previous post, The BIG black dog…, I often also ignore the issue at hand because it is a matter close to home. I do not want to understand the phenomenon of depression because I know that depression is in my family and I am too scared that I might pick up that I am depressed. It is not just depression, it is the patient refusing treatment that just pushes me over the edge, or the family’s choice to push the patient more than what I know the patient can handle. Little big things. As a health professional, it is somewhat important to put aside your goals and your believes and your perception. Speak to your patient, research whatever it is that you are unsure of, ask for a second opinion. When I started out in clinical practice I would only do the necessary research because my clinician and supervisor expected it of me, not because it interested me. So in other words, I actually mostly managed patients with conditions that I had no to little knowledge of based on guess-treatment. THAT IS WRONG! It was only this year that I developed the confidence to research the conditions and make the time to understand it, that I managed my patients more holistically. I was now actually able to refer the patient once an issue needed to be addressed which was outside my scope of practice. It was only when I understood the condition and the patient’s reactions, that I was able to make better decisions regarding treatment and treatment environments. In this process, however, I must also be able to distance myself enough and not get personally involved.
Students need to be trained by being placed in different clinical situations to allow them to combine the theory and practical skills in order to improve personal, professional and ethical development (Meyers & Herb, 2013) and that is exactly what we get on clinical practice. McVeigh (2013) states that students in the medical field who receive positive feedback from other medical professionals will show greater confidence and will help improve their personal development. I can say from personal experience that a confidence boost really does assist in the development of you as an individual, both personally and professionally. By observing human behaviour, ethical behaviour can be pointed out and adopted (Branch, 2000), but as a student you also need to learn that some health professionals do not show professional and ethical characteristics (McVeigh, 2013).
As the past year has gone by, I learned that observation is not the only manner in which I can develop ethically and professionally, but reflection too. Reflecting on an experience provided me with the opportunity to analyse and reason my way through the dilemma while not being worked up on the spot. Discussions with my peers also assisted in my development, however, one only have a better insight when being faced with the dilemma personally. Bruckner (1987) states that clinical competency is important, but the ability to develop professionally is also imperative. According to McVeigh (2013) students need to be the change for future generations, we need to display professional and ethical characteristics when managing patients.
We need students who can learn how to learn, who can discover how to push themselves and are generous enough and honest enough to engage with the outside world to make those dreams happen. – Seth Godin
ABIM Foundation. (2010). Why Does Professionalism Matter? (Part I) [Video file]. Retrieved from https://www.youtube.com/watch?v=2PIplMOIINg&feature=youtu.be
ABIM Foundation. (2010). Why Does Professionalism Matter? (Part 2) [Video file]. Retrieved from https://www.youtube.com/watch?v=2PIplMOIINg&feature=youtu.be
Branch, W.T. (2000). The Ethics of Caring and Medical Education [Electronic Version]. Academic Medicine, 75(2), 127 – 132
Bruckner, J. (1987). Physical Therapists as Double Agents: Ethical Dilemmas of Divided Loyalties [Electronic version]. Journal of the American Physical Therapy Association, 67(3), 383-387.
Fielder, R. (2015). Responses to Healthcare Workplace Conflict[Video file]. Retrieved from https://www.youtube.com/watch?v=AkMvcAcaVu4
Health Profession Council of South Africa. (2016). Guidelines for Good Practice in the Health Care Professions. Retrieved November 05, 2016, from http://www.hpcsa.co.za/PBPhysiotherapy.
McVeigh, J. G. (2013). Professionalism and Patient-Centred Care [Electronic Version]. Physiotherapy Practice and Research, 34(1), 55-56.
Meyers, M., Herb, R. (2013). Ethical Dilemmas in Clerkship Rotations [Electronic Version]. Academic Medicine, 8(1), 88-100.
Thomas, K.W. & Kilmann, R.H. (2001) Thomas-Kilmann Conflict Mode Instrument [Electronic Version]. PsycTESTS Dataset. DOI: http://dx.doi.org/10.1037/t02326-000
Trede, F. (2012). The Role of Work-Integrated Learning in Developing Professionalism and Professional Identity [Electronic Version]. Asia-Pacific Journal of Cooperative Education, 13(3), 159–167.
Vivar, C. (2006). Putting conflict management into practice: a nursing case study [Electronic Version]. Journal of Nursing Management, 14(3), 201-206.