Professionalism_PPTs.profession presenetation

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1. DISCOVER . LEARN. EMPOWER
Professional values
INSTITUTE -UAIHS
DEPARTMENT OF PHYSIOTHERAPY
Professional ethics and PTT 301
By
Gulnaazkaur(BPT-MPT)
Assistant professor

2. 2
Professional
values
CO
Number
Title Level
CO1 Definecore values Remember
CO2 Accountability Understand
CO3 altruism Understand
CO4 Integrity Understand
CO5 Excellence Understand
Course Outcome
https://www.grupojuste.com/filosofia-
valores/?lang=en

3. professional values are the guiding beliefs and
principles that influence your work behaviour.
….your professional values are usually an
extension of your personal values such as
honesty, generosity and helpfulness.
….while these values may change over time and
around different life events, your core beliefs
should stay the same.
3
Professional
values
https://www.google.com/url?sa=i&url=https%3A%2F%2Fbabettetenhaken.com%2F2016%2
F02%2F08%2Fprofessional-
value%2F&psig=AOvVaw1lOrJPjKaLt6er3L2MhN0c&ust=1593431987557000&source=image
s&cd=vfe&ved=0CA0QjhxqFwoTCPi22oS7pOoCFQAAAAAdAAAAABAJ

4. Core values
•APTA has identified seven core values that define the critical elements
of professionalism in physical therapy. These core values are listed
below in alphabetical order with no preference or ranking given to
these values. The seven values identified were of sufficient breadth
and depth to incorporate the many values and attributes that are part
of physical therapist professionalism.
•For each core value listed, the list that follows explicates these values
by providing a core value definition and sample indicators (not
exhaustive) that describe what the physical therapist would be doing
in practice, education, and/or research if these core values were
present.
4

5. •Accountability
•Altruism
•Compassion/Caring
•Excellence
•Integrity
•Professional Duty
•Social Responsibility
5

6. Accountability
•Accountability is active acceptance of the responsibility for the diverse
roles, obligations, and actions of the physical therapist including self-
regulation and other behaviorsthat positively influence patient/client
outcomes, the profession and the health needs of society.
•Responding to patient's/client's goals and needs.
•Seeking and responding to feedback from multiple sources.
•Acknowledging and accepting consequences of his/her actions.
•Assuming responsibility for learning and change.
•Adhering to code of ethics, standards of practice, and policies/procedures
that govern the conduct of professional activities.
6

7. •Communicating accurately to others (payers, patients/clients, other
health care providers) about professional actions.
•Participating in the achievement of health goals of patients/clients
and society.
•Seeking continuous improvement in quality of care.
•Maintaining membership in APTA and other organizations.
•Educating students in a manner that facilitates the pursuit of learning.
7

8. Altruism
•Altruism is the primary regard for or devotion to the interest of
patients/clients, thus assuming the fiduciary responsibility of placing the
needs of the patient/client ahead of the physical therapist's self interest.
•Placing patient's/client’s needs above the physical therapists.
•Providing pro bono services.
•Providing physical therapy services to underserved and underrepresented
populations.
•Providing patient/client services that go beyond expected standards of
practice.
•Completing patient/client care and professional responsibility prior to
personal needs.
8

9. Compassion/Caring
•Compassion is the desire to identify with or sense something of
another's experience; a precursor of caring. Caring is the concern,
empathy, and consideration for the needs and values of others.
•Understanding the socio-cultural, psychological and economic
influences on the individual's life in their environment.
•Understanding an individual's perspective.
•Being an advocate for patient's/client’s needs.
•Communicating effectively, both verbally and non-verbally, with
others taking into consideration individual differences in learning
styles, language, and cognitive abilities, etc.
9

10. •Designing patient/client programs/interventions that are congruent with
patient/client needs.
•Empowering patients/clients to achieve the highest level of function possible and
to exercise self-determination in their care.
•Focusing on achieving the greatest well-being and the highest potential for a
patient/client.
•Recognizing and refraining from acting on one's social, cultural, gender, and
sexual biases.
•Embracing the patient's/client’s emotional and psychological aspects of care.
•Attending to the patient's/client’s personal needs and comforts.
•Demonstrating respect for others and considers others as unique and of value.
10

11. Excellence
•Excellence is physical therapy practice that consistently uses current
knowledge and theory while understanding personal limits, integrates
judgment and the patient/client perspective, embraces advancement,
challenges mediocrity, and works toward development of new knowledge.
•Demonstrating investment in the profession of physical therapy.
•Internalizing the importance of using multiple sources of evidence to
support professional practice and decisions.
•Participating in integrative and collaborative practice to promote high
quality health and educational outcomes.
•Conveying intellectual humility in professional and interpersonal situations.
•Demonstrating high levels of knowledge and skill in all aspects of the
profession.
11

12. •Using evidence consistently to support professional decisions.
•Demonstrating a tolerance for ambiguity.
•Pursuing new evidence to expand knowledge.
•Engaging in acquisition of new knowledge throughout one's
professional career.
•Sharing one's knowledge with others.
•Contributing to the development and shaping of excellence in all
professional roles.
12

13. Integrity
•Steadfast adherence to high ethical principles or professional standards;
truthfulness, fairness, doing what you say you will do, and "speaking forth"
about why you do what you do.
•Abiding by the rules, regulations, and laws applicable to the profession.
•Adhering to the highest standards of the profession (practice, ethics,
reimbursement, Institutional Review Board [IRB], honorcode, etc).
•Articulating and internalizing stated ideals and professional values.
•Using power (including avoidance of use of unearned privilege) judiciously.
•Resolving dilemmas with respect to a consistent set of core values.
13

14. •Being trustworthy.
•Taking responsibility to be an integral part in the continuing management
of patients/clients.
•Knowing one's limitations and acting accordingly.
•Confronting harassment and bias among ourselves and others.
•Recognizing the limits of one's expertise and making referrals
appropriately.
•Choosing employment situations that are congruent with practice values
and professional ethical standards.
•Acting on the basis of professional values even when the results of the
behaviormay place oneself at risk.
14

15. Professional Duty
•Professional duty is the commitment to meeting one's obligations to provide
effective physical therapy services to individual patients/clients, to serve the
profession, and to positively influence the health of society.
•Demonstrating beneficence by providing "optimal care."
•Facilitating each individual’s achievement of goals for function, health, and
wellness.
•Preserving the safety, security and confidentiality of individuals in all professional
contexts.
•Involved in professional activities beyond the practice setting.
•Promoting the profession of physical therapy.
•Mentoring others to realize their potential.
•Taking pride in one’s profession.
15

16. Social Responsibility
•Social responsibility is the promotion of a mutual trust between the profession
and the larger public that necessitates responding to societal needs for health
and wellness.
•Advocating for the health and wellness needs of society including access to
health care and physical therapy services.
•Promoting cultural competence within the profession and the larger public.
•Promoting social policy that effect function, health, and wellness needs of
patients/clients.
•Ensuring that existing social policy is in the best interest of the patient/client.
•Advocating for changes in laws, regulations, standards, and guidelines that affect
physical therapist service provision.
•Promoting community volunteerism.
16

17. •Participating in political activism.
•Participating in achievement of societal health goals.
•Understanding of current community wide, nationwide and
worldwide issues and how they impact society’s health and well-
being and the delivery of physical therapy.
•Providing leadership in the community.
•Participating in collaborative relationships with other health
practitioners and the public at large.
•Ensuring the blending of social justice and economic efficiency of
services.
17

18. Quick revision
•Accountability
•Altruism
•Compassion/Caring
•Excellence
•Integrity
•Professional Duty
•Social Responsibility
18

19. FAQ
•Define Accountability
•Define Altruism
•Define Compassion/Caring
•Define Excellence
•Define Integrity
•Define Professional Duty
•Define Social Responsibility
19

20. Assessment pattern
Q1. define integrity.
Q2. why core values are important.
20

21. Abbreviation
•nil
21

22. REFERENCES
•http://www.ptcas.org/Professionalism/
22

23. THANK YOU
For queries
Email: [email protected]

24.  
 
 
Last Updated: 9/20/19 
Contact: [email protected]  
 
CORE VALUES FOR THE PHYSICAL THERAPIST AND PHYSICAL THERAPIST ASSISTANT HOD P06‐19‐48‐55 
[Amended: HOD P06‐18‐25‐33; Initial HOD P05‐07‐19‐19;] [Previously Titled: Core Values: for the Physical 
Therapist] [Position] 
 
The core values guide the behaviors of physical therapists (PTs) and physical therapist assistants (PTAs) to 
provide the highest quality of physical therapist services. These values imbue the scope of PT and PTA activities. 
The core values retain the PT as the person ultimately responsible for providing safe, accessible, cost‐effective, 
and evidence‐based services; and the PTA as the only individual who assists the PT in practice, working under 
the direction and supervision of the PT. The core values are defined as follows:  
 
 Accountability 
Accountability is active acceptance of the responsibility for the diverse roles, obligations, and actions of the 
physical therapist and physical therapist assistant including self‐regulation and other behaviors that 
positively influence patient and client outcomes, the profession, and the health needs of society.  
 
 Altruism 
Altruism is the primary regard for or devotion to the interest of patients and clients, thus assuming the 
responsibility of placing the needs of patients and clients ahead of the physical therapist’s or physical 
therapist assistant’s self‐interest.  
 
 Collaboration 
Collaboration is working together with patients and clients, families, communities, and professionals in 
health and other fields to achieve shared goals. Collaboration within the physical therapist‐physical therapist 
assistant team is working together, within each partner’s respective role, to achieve optimal physical 
therapist services and outcomes for patients and clients. 
 
 Compassion and Caring 
Compassion is the desire to identify with or sense something of another’s experience; a precursor of caring.  
 
Caring is the concern, empathy, and consideration for the needs and values of others.  
 
 Duty 
Duty is the commitment to meeting one’s obligations to provide effective physical therapist services to 
patients and clients, to serve the profession, and to positively influence the health of society.  
 
 Excellence  
Excellence in the provision of physical therapist services occurs when the physical therapist and physical 
therapist assistant consistently use current knowledge and skills while understanding personal limits, 
integrate the patient or client perspective, embrace advancement, and challenge mediocrity.  
 
 Integrity 
Integrity is steadfast adherence to high ethical principles or standards, being truthful, ensuring fairness, 
following through on commitments, and verbalizing to others the rationale for actions.  

25. 2
 
 Social Responsibility 
Social responsibility is the promotion of a mutual trust between the profession and the larger public that 
necessitates responding to societal needs for health and wellness. 
 
Explanation of Reference Numbers: 
HOD P00‐00‐00‐00 stands for House of Delegates/month/year/page/vote in the House of Delegates minutes; 
the "P" indicates that it is a position (see below). For example, HOD P06‐17‐05‐04 means that this position can 
be found in the June 2017 House of Delegates minutes on Page 5 and that it was Vote 4. 
 
P: Position | S: Standard | G: Guideline | Y: Policy | R: Procedure 

26. DISCOVER . LEARN. EMPOWERPersonal values
INSTITUTE -UAIHS
DEPARTMENT OF PHYSIOTHERAPY
Professional ethics and PTT 301
By
Gulnaazkaur(BPT-MPT)
Assistant professor

27. 2
Personal values
CO
Number
Title Level
CO1 Personal values Remember
CO2 ethics Understand
CO3 morals Understand
Course Outcome

28. .
3
Personal values
https://www.scu.edu/mobi/resources--tools/blog-
posts/ethics-in-life-and-business/ethics-in-life-and-
business.html
Personal values are desirable to an
individual and represent what is important
to someone. The same value in different
people can elicit different behaviours, egif
someone values success one person may
work very hard to gain success in their
career whereas someone else may take
advantage of others to climb the career
ladder.

29. •The Code of Ethics reflects physiotherapists’ commitment to use their
knowledge and expertise to promote high quality, competent and
ethical care for patients and thereby instillin the public, confidence in
the profession.
The ethical values for physiotherapists in Ontario spell out the
acronym R.E.A.C.H. These values should be applied in all aspects of
professional practice, particularly in the patient-physiotherapist
relationship and when facing an ethical problem or dilemma.
4

30. •Making ethical decisions is not always easy and can be accompanied
by significant discomfort. While the Code of Ethics cannot alleviate
this discomfort, adopting the R.E.A.C.H. values and a standard process
to analyze a situation will allow physiotherapists to feel more secure
in their ability to make the best decision possible and that is also in
the best interest of their patients.
There are a variety of ethical decision making models available, and
although one version is presented here, physiotherapists should
choose a model that is most comfortable for them and meets their
professional needs.
5

31. •Physiotherapists should also understand that while a consistent
process can be followed each time an ethical decision is required, the
decision or outcome can vary and there can be differences of opinion.
It is not expected that there will always be complete agreement as
context is critical.
•The proposed actions to an ethical dilemma can include both those
who are in favour and those who are opposed to the decision.
Although there may not be complete agreement on one unique line
of action, some actions will be more defensible and others will be less
defensible.
6

32. Ethical Values
•Respect Physiotherapists are respectful of the differing needs of each
individual and honour the patient’s right to privacy, confidentiality,
dignity and treatment without discrimination.
•Excellence Physiotherapists are committed to excellence in
professional practice through continued development of knowledge,
skills, judgment and attitudes.
•Autonomy and Well BeingPhysiotherapistsare at all times guided by
a concern for the patient’s well-being. Patients have the right to self-
determination and are empowered to participate in decisions about
their health-related quality of life and physical functioning.
7

33. •Communication, Collaboration and Advocacy Physiotherapists value
the contribution of all individuals involved in the care of a patient.
Communication, collaboration and advocacy are essential to achieve
the best possible outcomes.
•Honesty and Integrity Each physiotherapist’s commitment to act with
honesty and integrity is fundamental to the delivery of high quality,
safe and professional services.
8

34. Steps to Ethical Decision Making
•Recognize that there is an ethical issue—i.e. something is making you
uncomfortable.
•Identify the problem and who is involved—What is making you
uncomfortable? Who else is involved?
•Consider the relevant facts, laws, principles and values—What laws or
standards might apply? What REACH value or ethical principle is
involved
•Establish and analyze potential options—Weigh possibilities and
outcomes. Use your moral imagination.
9

35. •Choose a course of action and implement it—Are there any barriers
to action? What information should be recorded?
•Evaluate the outcome and determine if further action is needed—
What did you learn? What can you do to prevent future occurrence?
10

36. Assessment pattern
FAQ
Q1. what are values.
Q2. explain ethics.
11

37. Abbreviation
•nil
12

38. REFERENCES
•https://www.collegept.org/rules-and-resources/ethics
13

39. THANK YOU
For queries
Email: [email protected]

40. HOME CONTACT US
Home | About | MOA | XV. Ethical Rules & Guidlines
XV. Ethical Rules & Guidlines
22/07/2012 22:05:00
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1. General Responsibilities
(a) Physiotherapists shall provide honest quality care, competent and accountable professional consultancy,
therapeutic and otherwise, as 1st contact practitioner to any person who may seek or may be in need of the same.
(b) The Physiotherapists shall administer only such treatment that is in the interest of the patient with the
responsibility for the exercise of sound judgment with diligence.
(c) The physiotherapists shall respect the dignity and basic rights of the patients and professional colleagues.
(d) The physiotherapists shall refer the patient to the appropriate specialists whenever the problems/symptoms of
the diseases of the patient so demand.
(e) The physiotherapists shall maintain secrecy of the patient’s disease and shall not divulge the same to any other
individual except to professional colleagues during scientific case discussions/meetings.
(f) The physiotherapists shall provide accurate information to the patient or to the next relative if required about the
problem and specific physiotherapy management of that individual’s problems if required.
(g) The physiotherapy management shall have the prior consent of the patient/relative if the procedure adopted
involves risk of any damage to the tissue, organ system or any side effects/complications after explaining the same
accurately.
(h) The physiotherapists shall comply with the laws governing the patient’s rights and cause.
(i) The physiotherapists shall not solicit patients through fee splitting. It shall be based upon their individual
competence and ability in accordance with the accepted scientific standards.
(j) The physiotherapists shall constantly strive to keep himself/herself abreast of the recent and latest scientific

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41. developments related to physiotherapy and add to the knowledge fund.
(k) The physiotherapists shall not indulge in or associate with any activity that goes against the dignity, honour and
development of the profession.
(l) The physiotherapists shall contribute to the planning and development of professional services which address the
health needs of the community.
(m) Maintain high standards of professional conduct.
(n) Follow ethical practices outlined in the Code of Ethics. Strive to follow the ethical practices outlined in the
Principles for Physiotherapy Education and practice norms.
(o) Balance the wants, needs, and requirements of program patients, institutional policies, laws, and sponsors.
Members’ ultimate concern must be the long-term well-being of Physiotherapy education and practice norms.
(p) Resist pressures (personal, social, organizational, financial, and political) to use their influence inappropriately
and refuse to allow self aggrandizement or personal gain to influence their professional judgments.
(q) Seek appropriate guidance and direction when faced with ethical dilemmas.
(r) Make every effort to ensure that their services are offered only to individuals and organizations with a legitimate
claim on these services.
2. In Their Professional Preparation and Development, Members Shall:
(a) Accurately represent their areas of competence, education, training, and experience.
(b) Recognize the limits of their expertise and confine themselves to performing duties for which they are properly
educated, trained, and qualified, making referrals when situations are outside their area of competence.
(c) Be informed of current developments in their fields, and ensure their continuing development and competence.
(d) Stay abreast of laws and regulations that affect their clients.
(e) Stay knowledgeable about world events that impact Physiotherapy education and practice program patients.
(f) Stay knowledgeable about differences in cultural and value orientations.
(g) Actively uphold IAP’s Ethical Rules &Guidelines when practices that contravene it become evident.
3. In Relationship with Students, Scholars, and Other Members Shall:
(a) Understand and protect the civil and human rights of all individuals.
(b) Not discriminate with regard to race, color, national origin, ethnicity, sex, religion, sexual orientation, marital
status, age, political opinion, immigration status, or disability.
(c) Recognize their own cultural and value orientations and be aware of how those orientations affect their
interactions with people from other cultures.
(d) Demonstrate awareness of, sensitivity to, and respect for other education and practice systems, values, beliefs,
and cultures.
(e) Not exploit, threaten, coerce, or sexually harass others.
(f) Not use one’s position to proselytize.
(g) Refrain from invoking governmental or institutional regulations in order to intimidate patients in matters not
related to their status.
(h) Maintain the confidentiality, integrity, and security of patients’ records and of all communications with treatment

42. program, Members shall secure permission of the individuals before sharing information with others inside or
outside the organization, unless disclosure is authorized by law or institutional policy or is mandated by previous
arrangement.
(i) Inform patients of their rights and responsibilities in the context of the institution and the community.
(j) Respond to inquiries fairly, equitably, and professionally.
(k) Provide accurate, complete, current, and unbiased information.
(l) Refrain from becoming involved in personal relationships with patients when such relationships might result in
either the appearance or the fact of undue influence being exercised on the making of professional judgments.
(m) Accept only gifts that are of nominal value and that do not seem intended to influence professional decisions,
while remaining sensitive to the varying significance and implications of gifts in different cultures.
(n) Identify and provide appropriate referrals for patients who experience unusual levels of emotional difficulty.
(o) Provide information, orientation, and support services needed to facilitate patient’s adaptation to a new
education and practice and cultural environment.
4. In Professional Relationships, Members Shall:
(a) Show respect for the diversity of viewpoints among colleagues, just as they show respect for the diversity of
viewpoints among their clients.
(b) Refrain from unjustified or unseemly criticism of fellow members, other programs and other organizations.
(c) Use their office, title, and professional associations only for the conduct of official business.
(d) Uphold agreements when participating in joint activities and give due credit to collaborators for their
contributions.
(e) Carry out, in a timely and professional manner, any IAP responsibilities they agree to accept.
5. In Administering Programs, Members Shall:
(a) Clearly and accurately represent the identity of the organization and the goals, capabilities, and costs of
programs.
(b) Recruit individuals, paid and unpaid, who are qualified to offer the instruction or services promised, train and
supervise them responsibly, and ensure by means of regular evaluation that they are performing acceptably and
that the overall program is meeting its professed goals.
(c) Encourage and support participation in professional development activities.
(d) Strive to establish standards, activities, instruction, and fee structures that are appropriate and responsive to
patient’s needs.
(e) Provide appropriate orientation, materials, and on-going guidance for patients.
(f) Provide appropriate opportunities for students to observe and to join in mutual inquiry into cultural differences.
(g) Take appropriate steps to enhance the safety and security of patients.
(h) Strive to ensure that the practices of those with whom one contracts do conform to IAP’s Code of Ethics and the
Principles for Physiotherapy Education and practice.
6. In Making Public Statements, Members Shall:
(a) Clearly distinguish, in both written and oral public statements, between their personal opinions and those

43. opinions representing IAP, their own institutions, or other organizations.
(b) Provide accurate, complete, current, and unbiased information.

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45. ____________________________________________________________________
Page 1 of 6
Copyright  2001 Paul Chippendale
eMail: [email protected] Web: www.minessence.net
A Values Inventory (AVI):
www.minessence.net/AValuesInventory/AboutTheAVI.aspx
On Values, Ethics, Morals &
Principles
By
Paul Chippendale

I am frequently asked, "What are the differences between values, ethics, morals and
principles?" My short answer to the question is usually, "Values motivate, morals
and ethics constrain." In other words values describe what is important in a person's
life, while ethics and morals prescribe what is or is not considered appropriate
behaviour in living one's life. Principles inform our choice of values, morals and
ethics.
"Generally speaking, value refers to the relative worth of a quality or object. Value is
what makes something desirable or undesirable" (Shockley-Zalabak 1999, p. 425).
Through applying our personal values (usually unconsciously) as benchmarks, we
continually make subjective judgments about a whole manner of things:
...we are more likely to make choices that support our value systems than
choices that will not. Let us say that financial security is a strong value for an
individual. When faced with a choice of jobs, chances are the individual will
carefully examine each organisation for potential financial and job security.
The job applicant who values financial security may well take a lower salary
offer with a well established company over a higher-paying offer from a new,
high risk venture. Another job seeker with different values, possibly adventure
and excitement, might choose the newer company simply for the potential
risk and uncertain future.
Values, therefore, become part of complex attitude sets that influence our behaviour
and the behaviour of all those with whom we interact. What we value guides not only
our personal choices but also our perceptions of the worth of others. We are more
likely, for example, to evaluate highly someone who holds the same hard-work value
we do than someone who finds work distasteful, with personal gratification a more
important value. We may also call the person lazy and worthless, a negative value
label. (Shockley-Zalabak 1999, pp. 425-426)
What then of ethics? Ethics are the standards by which behaviours are evaluated for
their morality - their rightness or wrongness. Imagine a person who has a strong value
of achievement and success. Knowing only that this value is important to them gives
us a general expectation of their behaviour, i.e. we would expect them to be goal
oriented, gaining the skills necessary to get what they want, etc. However, we cannot
know whether they will cheat to get what they want or "do an honest day's work each
day". The latter dimension is a matter of ethics and morality. Take another example, a
person has a high priority value or research/knowledge/insight. They have a career in

46. ____________________________________________________________________
Page 2 of 6
Copyright  2001 Paul Chippendale
eMail: [email protected] Web: www.minessence.net
A Values Inventory (AVI):
www.minessence.net/AValuesInventory/AboutTheAVI.aspx
medical research. In fact, knowing their value priority we would expect them to have
a career in some form of research, however, we do not know from their value priority
how they are likely to undergo their research. Will the person conduct experiments on
animals, or would they abhor such approaches? Again, the latter is a mater of ethical
stance and molality. Johannesen (cited Shockley-Zalabak 1999, p. 437) gives further
examples which help distinguish between values and ethics:
Concepts such as material success, individualism, efficiency, thrift, freedom,
courage, hard work, prudence, competition, patriotism, compromise, and
punctuality all are value standards that have varying degrees of potency in
contemporary American culture. But we probably would not view them
primarily as ethical standards of right and wrong. Ethical judgments focus
more precisely on degrees of rightness and wrongness in human behaviour.
In condemning someone for being inefficient, conformist, extravagant, lazy,
or late, we probably would not also claim they are unethical. However,
standards such as honesty, truthfulness, fairness, and humaneness usually
are used in making ethical judgments of rightness and wrongness in human
behaviour.
Clearly our values influence what we will determine as ethical; "however, values are
our measures of importance, where as ethics represent our judgments about right and
wrong" (Shockley-Zalabak 1999, p. 438). This close relationship between importance
and right and wrong is a powerful influence on our behaviour and how we evaluate
the behaviour of others.
Now let's move to another level. How does one go about choosing what ethics are
right? In the next section I describe the approach to answering this question I believe
best suited to today’s society.
The Principle Centric Approach to Behavioural
Choices
'Principle' is defined in Nuttall's Concise Standard Dictionary of the English
Language as, "n. the source or origin of anything;...a general truth or law
comprehending many subordinate ones;...tenet or doctrine; a settled law or rule of
action;... v.t. to impress with any tenet; to establish firmly in the mind".
In this Millennium, perhaps more than ever before, I firmly believe that we need to
reformulate a set of principles to guide us. There are two main benefits of taking a
principle centric approach to guide all human action: (1) knowing a set of principles
concerning 'the nature of things' enables us to make informed choices and judgments
as we would know, with a high degree of certainty, the likely outcomes of our actions,
(2) knowing even a few principles helps us avoid information overload. On the latter
point, Birch (1999, p. 44) says:

47. ____________________________________________________________________
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One way in which drowning in information is overcome is by the discovery of
principles and theories that tie up a lot of information previously untied. Prior
to Charles Darwin biology was a mass of unrelated facts about nature.
Darwin tied them together in a mere three principles of evolution: random
genetic variation, struggle for existence and natural selection. So we do not
need to teach every detail that was taught to nineteenth century students. A
mere sample is necessary to illustrate the universal principles.
Before you raise your voice in protest, "What do scientific principles have to do with
informing what constitutes ethical and moral human behaviour?" Stop for a moment
and ponder the what has been institutionalised into Western society all in the name
extolling the virtue of progress through unencumbered evolution - i.e. guided by the
principles made evident by Charles Darwin. We push for free trade; level playing
fields, argue that cloning interferes with natural selection, push for de-regulation so
that competition prevails and only the fit organisations should survive, etc., etc.
But what if we've got Darwin wrong? What if the principles instead were: survival of
those who cooperate for the greater good, selection guided by a moral sense, etc. We
would have a completely different society from that which we have today.
Understanding and internalising the principles that comprise 'the nature of things'
is perhaps the single most powerful determining factor in the shaping of the society
in which we live. It is vital that we maintain a continual dialogue around principles so
those we internalise and institutionalise are up-to-date and are our current best shot at
the truth.
Some readers may be surprised to discover that Darwin believed in the evolution of a
moral sense which provided both the core drive and structure for mind (Loye 2001,
pp. 127-128):
Go the next step then, and we see that beyond ourselves he is writing of the
moral impact of the evolving mind of humanity as a whole upon the shaping
of ourselves, and upon all else that constitutes the human world.
Alas, that this should be so difficult for us to see this! But having for so long
lost the language or the social encouragement to know ourselves and the
meaning of life this way, it is asking for mind to step out into the unknown.
But we must try for the future hangs on the effort.
Defining the Good and the Bad
The following extract from the work of David Loye (2001, pp. 128-130) is used to
illustrate the use of a principle centric approach to the formulation of a morality to
guide us into the 21st Century:
An increasingly critical problem that Darwin can help us with is defining what
good is not. It is clear, for example, that it is not the use of "morality" by
rightist and authoritarian religious and political interests as a club with which

48. ____________________________________________________________________
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to try to beat - and even in the extreme kill - all who might in any way
disagree with them.
Large buildings, even hundreds of people, are being blown up; people trying
to check a potentially disastrous population explosion globally and save rape
victims are being machine gunned; being poor is being relabelled evil; our
right to bear assault rifles is being defended as a holy cause; whole villages
are being slaughtered down to the last woman and child; and, via the
booming persuasion of the media in all its forms, political character
assignation and actual assignation is becoming an advanced art - all in the
name of Jesus, Allah, or some other supposedly unquestioned source of
"moral" law.
This is moralism, not morality. And how may the difference be defined? If we
examine closely what the Darwin in his own time and we in ours find
appalling, we see that moralism can be defined as a false, fake, or
hypocritical self-promotional 'morality.' generally designed to put down,
intimidate, or terrorise rather than be helpful to others. But what then is
morality?
...Darwin's central concept of the moral sense is what today we would call
moral sensitivity. As he makes evident in the warm wonder and all the ins
and outs of his tales of goodness at work in the so-called animal world, but
also more abstractly at our level, this is the ability to emphasise, to feel
sympathy for, to care for, to resonate to, to want to nurture, or heal, or help -
in short, to be morally sensitive to others. But what his exploration makes
clear is that he is writing about considerably more than moral sensitivity.
If we are morally sensitive to another we may resonate to their needs or
plight with mind and heart - or cognition and affection. This, however, doesn't
necessarily mean we are going to get up out of our easy chair with book or
watching television to do anything to help them. This depends on courage
and all the other components of what we call the will, or in psychological
terms, conation.
Throughout Darwin's explanation of how the moral sense developed and
operates both in animals and humans, we can see that what holds everything
together - advancing the individuals over its lifetime and the species over
aeons - is the more active involvement in the fate of one another. It is the
drive of moral agency.
An agent acts on behalf of another. Moral agency is then the force of action
on behalf of moral sensitivity and of another. A moral agent is then the
person who acts in such a way.
This is why Darwin's is actually a theory of moral agency rather than of the
moral sense, which carries only the more passive meaning that the old
philosophical term conveys.
And what is moral intelligence? Out of the grand sweep of the second and
third levels for his theory of the moral agent, the evolutionary picture Darwin
provides is of the drive of moral sensitivity. Through inspiration and
education, this drive is given the edge of moral agency. Then comes what
builds true wisdom for our species. Out of the thrust of moral agency comes

49. ____________________________________________________________________
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learning experience that builds within us the core to higher mind of moral
intelligence.
And what of morality? It is the codes, the programming, the human software
of whatever evolutionarily prevails at any point or place in time. It is the huge
inbuilt user's manual that provides the guidelines for human-to-human and
human-to-prehuman behaviour.
It is everything that, based on the experience of the past, we have collectively
agreed to be ruled by. It is the norms, the rules, the customs, the laws, the
commandments whereby out of the power of caring, the power of reflection,
the power of language, and the power of habit, we establish social
expectancies for moral sensitivity, moral intelligence, and moral agency.
Ethics is then all the sub-booklets in mind, the sub-routines or more finely-
tuned differentiations, of how these codes are to be applied in specific
situations.
The 'moral sense' for Darwin and more broadly considered is all this. But still
it is more. Yearning for comfort and reassurance, sensing a transcendent
reality and source of meaning, for the sake of a word that might bring this
concept to earth, for thousands of years most of us have called this 'more'
God, or earlier and again increasingly in our time Goddess.
For many of us - including at least four of the greatest Asian spiritual
visionaries, Gautama, Lao Tsu, Confucius, and Mencius, as well as Darwin
historically - this has posed difficulties. However, this may be, more important
than what now or in the future this Greater Force may be called, it is
something that is more felt than named, and seems to me undeniable - and
here, too, groping in this direction can be detected in Darwin.
Out of something that is timeless and larger than ourselves, embracing the
future as well as the present and the past, there works within us something
else that additional to our experience of the past also seems to speak to us in
the shaping of all moral codes. It is simply there. Out of the evolution of the
cosmic mystery that is both within ourselves and that surrounds us,
unknowable by that part of our self we think is our mind, yet at times most
surely felt within all our being, there seems to be this voice that quietly but
persistently urges everything emergent on this earth, including ourselves, to
be the best that is in us.
The old theory encourages us to just sit back and enjoy the medium. For
supposedly the message is settled. Having been scientifically worked out and
certified by people much smarter than we are, who are we to question what
we have been and will again and again be told? Oh, sure the message may
not be what we want to hear, but the old theory affirms that this is the grim
reality we must each - as best we can - adapt to.
The new theory tells us that the message is open-ended and eternal,
stretching out of the dim past into the mists of the future for our species. It
tells us we have a voice in the shaping of the message - but that this
message needs a great deal more nurturance, and understanding, and the
assignment of much more of the power of the media to its spreading. Above

50. ____________________________________________________________________
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Copyright  2001 Paul Chippendale
eMail: [email protected] Web: www.minessence.net
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all, it tells us we are not just what we more or less dutifully adapt to. Much
more importantly, we are what we refuse to adapt to.
Concluding Comments
Whether we are prepared to accept it or not, science has had a profound impact on our
world-view and our understanding of 'the nature of things'. Many of the principles
from science we unconsciously use to inform our morality and structure our society
today are in desperate need of revision. Our blind acceptance of the old interpretation
of Darwin, with its emphasis on competition and survival of the fittest is leading us
into troubled waters. Likewise the materialistic model of Newton is still powerfully
influencing us today - with its emphasis on forces and objects.
If our morality and the way we structure society today were to be informed by the
principles of today's science, what a different world we would live in. That society
would be based on: cooperative relationships rather than competition; a concept of
evolution which includes moral agency rather than blind adaptation to the
environment through random selection; emphasis on the subjective ahead of the
objective; fields and energy would be structured to enable flow in desired directions
rather than a focus on objects to be manipulated through the application of force.
References
Birch, C. 1999, Biology and the Riddle of Life, University of New South Wales press,
Sydney.
Loye, D. 2001, 'Rethinking Darwin: A Vision for the 21st Century', Journal of
Futures Studies, vol. 6, no. 1, pp. 121-136.
Shockley-Zalabak, P. 1999, Fundamentals of Organisational Communication:
Knowledge, Sensitivity, Skills, Values, Longman: New York.

51. DISCOVER . LEARN. EMPOWER
Attitude and behaviour
INSTITUTE -UAIHS
DEPARTMENT OF PHYSIOTHERAPY
Professional ethics and PTT301
By
Gulnaazkaur(BPT-MPT)
Assistant professor

52. 2
Attitude and behavior
CO
Number
Title Level
CO1 What is attitude Remember
CO2 Componentsof attitude Understand
CO3 behaviour Understand
Course Outcome

53. A professional is punctual (to class and laboratory meetings)
because he/she respects the valuable time of others; a
professional follows the supervisor’s instructions; a
professional in the field respects private and public property; a
professional arrives ready to work, appropriately dressed, with
his or her tools; a professional is observant and sees what
needs to be done; a professional is responsible and does what
should be done (carrying the instruments and tools, for
example). A professional helps maintain a safe workplace with
a civilized atmosphere. A professional is perceived as a
representative of his or her organization and always acts in a
manner that reflects favorablyon that organization. A
professional asks a question rather than risk making a serious
mistake with an unfamiliar scientific instrument.
3
Attitude and behavior
https://www.katieroberts.com.au/career-advice-
blog/12-professional-behaviour-tips/

54. Introduction
•What Are Attitudes?
•Anyone who has ever had a 2-year-old fully understands the terrible twos
and the attitude a 2-year-old can give you. While that person might be
pint-sized, his attitude during the terrible twos can be over ten feet tall and
bulletproof.
•Now, not all attitudes are as intense as our little 2-year-old, but they are
indeed present in every person, and they are part of who we are. Our
attitudes are shaped by our experiences, and as we experience more, our
attitudes can change. You see, attitudesare a way of thinking, and they
shape how we relate to the world both in work and outside of work. Taking
this a step further, attitudes have several different components, and those
are cognitive, affective and behavioral.
4

55. Components of Attitudes
•Before we can discuss how attitudes impact the workplace, we need to
understand the components of attitudes. Those components are:
•Cognitive: This represents our thoughts, beliefs and ideas about
something. Typically these come to light in generalities or stereotypes, such
as 'all teenagers are lazy,' or 'all babies are cute.'
•Affective: This component deals with feelings or emotions that are brought
to the surface about something, such as fear or hate. Using our above
example, someone might have the attitude that they hate teenagers
because they are lazy or that they love all babies because they are cute.
•Conative: This can also be called the behavioralcomponent and centerson
individuals acting a certain way towards something, such as 'we better
keep those lazy teenagers out of the library,' or 'I cannot wait to kiss that
baby.'
5

56. •Each one of these components is very different from the other, and
they can build upon one another to form our attitudes and, therefore,
affect how we relate to the world. For example, we can believe
teenagers are lazy (cognitive), we do not have to hate the teenagers
for being lazy (affective), but we could still try to keep them out of the
library because of that fact (conative). Or, we could indeed believe
they are all lazy (cognitive), hate them for it (affective) and that would
drive our behaviortowards them (conative).
6

57. To perform effectively you need to:
• prioritise and plan your work to meet objectives, managing
conflicting pressures and making best use of time and resources
• ensure the quality of your work always meets or exceeds agreed
requirements
• develop and maintain effective working relationships, being
supportive to colleagues where required
7

58. •actively develop your own skills and knowledge, acting on feedback
where appropriate
• demonstrate a professional attitude, appropriate to the culture of the
organisation in which you work.
8

59. Examples of relevant activities include
• actively evaluate your own performance and participate in your
organisation’s appraisal process
• identifying your own development needs and regularly review your
personal development plan
9

60. • working effectively and reliably to ensure that everything for which
you are personally responsible is completed to a high standard
• working effectively as part of a team, providing support for others
where appropriate
• working effectively on partnership/joint projects with workers in
other organisations.
10

61. Quick revision
•Cognitive: This represents our thoughts, beliefs and ideas about
something. Typically these come to light in generalities or stereotypes, such
as 'all teenagers are lazy,' or 'all babies are cute.'
•Affective: This component deals with feelings or emotions that are brought
to the surface about something, such as fear or hate. Using our above
example, someone might have the attitude that they hate teenagers
because they are lazy or that they love all babies because they are cute.
•Conative: This can also be called the behavioralcomponent and centerson
individuals acting a certain way towards something, such as 'we better
keep those lazy teenagers out of the library,' or 'I cannot wait to kiss that
baby.'
11

62. FAQ
Q1.How will you assess the attitude and behaviour?
Q2. define attitude?
Q3. write the components of attitude?
12

63. Assessment pattern
Q1. What are the basic ethical issues.
Q2. write some theory based on ethics .
13

64. Abbreviation
•nil
14

65. REFERENCES
•https://www.physio-pedia.com/Ethical_Issues_in_Private_Practice_Settings
15

66. THANK YOU
For queries
Email: [email protected]

67. The Identification of Ethical Issues in
Physical Therapy Practice
Background and Purpose. The purpose of this study was to identify
(1)
current ethical issues facing physical therapists and (2) ethical issues
that may be faced in the future by physical therapists.
Subjects and
Methods.
The Delphi technique was used as the research design for the
study. The panel of experts for the study were selected from lists
submitted by past and present members of the Judicial Committee of
the American Physical Therapy Association. A series of three question-
naires were sent to the members of the panel. Following the Delphi
technique, the first questionnaire contained broad questions designed
to elicit a wide range of responses. The second and third question-
naires were then developed from the information received in the
preceding questionnaire.
Results. The results of the first question of
the study identified
10 current ethical issues as consensus choices by
the panel and
3 issues as near-consensus. The panel responses to the
second question identified
4 future ethical issues. A combined list of
current and future contained 16 issues in physical therapy.
Conclusion
and Discussion.
The 16 issues addressed ethical considerations in
different areas of physical therapy practice: 6 issues involving patient
rights and welfare,
5 professional issues, and 5 issues relating to
business and economic factors. Thirteen of these issues have not been
discussed in previous physical therapy literature and would be sug-
gested topics for future study. [Triezenberg
HL. The identification of
ethical issues in physical therapy practice.
Phys Thm.
1996;76:1097-1106.1
Key Words: Delphi technique; Ethics; Physical therapy profession, professional issues.
Herman L Triezenberg
Physical Therapy . Volume 76 . Number 10 . October 1996
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68. dentification and examination of the ethical issues
facing a profession is an important activity1 and is
considered a mark of professionalism. During the
past 20 years, there has been an increased interest
in ethical issues. With this increase in interest, there has
been a concurrent increase in publications relating to
medical ethics. Much of this literature has related to
medicine and nur~ing.~ Only in the last few years have
other health professions begun to address the ethical
issues specific to their professions. The need for these
other health professions to address their unique ethical
issues has become more urgent as these professions have
expanded their scope of responsibilities, placing practi-
tioners into positions in which ethical decisions must
frequently be made.
In recent years, the profession of physical therapy has
increased its autonomy in decision making and has
expanded its role in patient care.3 These changes can be
seen by examining the changes that have been made in
the practice acts of nearly every state to give physical
therapists some degree of autonomy in practice. This
increase in autonomy has increased the ethical consid-
erations for physical therapists and has served to focus
more clearly the responsibility of physical therapists to
identify and discuss ethical questions that arise in the
practice of physical therapy.
An example of this change
can be observed by examining the increased role that
physical therapists now have in the supervision of
sup
port personnel. Physical therapists are required to super-
vise a larger number and a more diverse group of
assistants, aides, and related health care professionals.
With this increase in the supervisory role come addi-
tional questions of authority, professional autonomy,
responsibility, and quality of care. Other examples can
be seen in the variety of business opportunities available
to physical therapists. These business arrangements
introduce a number of questions relating to patient
autonomy, utilization of services, and equity in billing.
Any change in practice creates a new set of ethical
considerations.
In response to these recent changes in practice, there
has been an increased interest in ethical issues facing
physical therapists and in ethical decision making. Prior
to 1970, there were only a handful of articles that
broadly considered the responsibility of physical thera-
pists to the physician and the patient.4-8 The concepts of
ethics described in these articles were represented in
terms of appropriate professional behavior and etiquette
rather than considerations of ethical decisions or issues.
These articles defined good professional behavior for
that period in the history of physical therapy, but they
did not address how to approach ethical decision mak-
ing or what ethical issues are associated with the practice
of physical therapy. The first cod^ of Ethics for the
American Physical Therapy Association (APTA) was
developed in 1935.Y The establishment of a code as well
as subsequent articles in the 1940s and 1950~,-'-~ how-
ever, indicated that the profession believed ethical
behavior should be expected of its members. The
responsibility of physical therapists to behave in an
ethical manner was emphasized in subsequent litera-
t~re.~-]~ This more recent literature identified physical
therapists as professionals who were responsible for
making ethical decision^'^^.^^.^^.^^ and who needed to
understand the ethical principles involved in such deci-
sions.12 This perspective was presented by Guccione, in
1980, when he stated
The need to identify and clarify ethical issues within a
health profession increases as the profession assumes
responsibility for those areas of direct patient care in its
domain
.... The physical therapist today, in defining the
limits of his legal and professional autonomy, must examine
the practice of his profession from an ethical point of
vieW,17(p1264)
Purtilo, in 1979, also emphasized the changing role as
she stated
In short,
nonphysician health professionals are involved in
ethic decision-making processes and increasingly will b:
asked to participate in determining moral p~licv.'*(p~~~)
In 1980, Guccione17 reported on a survey of 450 APTA
members in New England in which he identified
7
primary and 11 secondary ethical issues in physical
therapy. Identification of issues facing physical therapists
helped to identify physical therapy as a profession with
issues particular to itself and placed additional respon-
sibility on the profession to address these issues.
Guc-
cione indicated in his conclusions that he wanted to
establish priorities for action by APTA and encourage
discussion, promote study, and direct education for
physical therapists. No follow-up articles were written on
HL Triezenberg, PhD, PT, is Associate Professor and Chair, Department of Health Promotion and Rehabilitation, Central Michigan University,
134 Pearce
Hall, Mt Pleasant,
M1 48059 (USA) ([email protected]).
This study was approved by the institutional review board at Michigan State University.
This article was submitted St=plembm 19, 1995, and was accepld May 21, 1996.
1
1098 . Triezenberg Physical Therapy . Volume 76 . Number 10 . October 1996
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69. any of the 7 primary issues identified by Guccione. These
issues were
1. Establishing priorities for patient treatment when
time or resources are limited.
2. Discontinuing treatment for noncompliant patients.
3. Continuing treatment with a terminally ill patient.
4. Continuing treatment to provide psychological sup-
port after physical therapy goals have been reached.
5. Determining professional responsibilities when a
patient's needs or goals conflict with the family's
needs or goals.
6. Deciding whether to represent certain necessary
patient services in a way that would meet third-party
payer limitations.
7.
Maintaining a patient's or family's confidence in
other health care professionals regardless of personal
opinions.
Two of the secondary issues were considered in subse-
quent Literature. The issues were (1) informing patients
about limits of treatment or informed consent and (2)
the duty of physical therapists to report misconduct by
colleagiles (ie, whistle blowing).
Articles that included discussion of ethical issues facing
physical therapy were published in the 1980s and 1990s.
The two issues that received the most attention were
informed consentla-'0 and patient ~ompliance.~~~~~~~~~~2
Other issues that have been examined include the right
to health carelH and the treatment of patients with
acquired immunodeficiency syndrome (AIDS) .23,24 Dur-
ing the 1980s and 1990s, however, there were still very
few articles that addressed ethical issues in physical
therapy.
This study was undertaken to assist in the process of
identify:ing ethical issues that are important in the prac-
tice of physical therapy. The identification of important
ethical issues facing physical therapists may provide a
stimulus for increased discussion of those issues.
Methodology
The Delphi technique was chosen as the research
method for this study. The Delphi technique is a
com-
moilly used method for determining consensus in social
science :research.'"30 The Delphi method was developed
in the early 1950s and was initially used in Future's
research.'s31 "Future's research" refers to research that
attempts to predict future trends and outcomes. This
technique consists of a series of questionnaires that are
completed by a selected panel of experts. The purpose is
to achieve consensus within a group of experts but to
avoid the psychological distractions of group interac-
ti~n.~"here are typically three or four rounds of
questionnaires, with the responses to each questionnaire
providing the material for the development of the
subsequent que~tionnaire.~The purpose of this process
is to reach agreement among the group of experts on
the specific statements.
The first questionnaire of the series is composed of
broad questions that are intended to elicit open
responses from the panel of experts. The composition of
the questions in the second round are based on the
responses of the panel members to the initial broad
questions of the first questionnaire. The second ques-
tionnaire is intended to provide the panel with a com-
pilation of the results of the initial questionnaire as well
as questions to clarify the specific issues identified by the
individual panel members. This questionnaire also pro-
vides the panel with a list of specific areas of consensus
and areas of disagreement. The third questionnaire
provides the panel with a compilation of the results of
the second questionnaire and additional data on the
opinions and comments of the other panel members.
This questionnaire describes areas of agreement
between the experts and also presents minority opin-
ions. The third questionnaire provides the panel with an
opportunity to make revisions and respond to the infor-
mation presented from the results of the second ques-
tionnaire. If consensus is not obtained following the
third questionnaire, then a fourth questionnaire would
need to be constructed. Three questionnaires are usually
considered sufficient, as little meaningful change us~ially
takes place between the third and fourth rounds.'"
The Delphi Panel of Experts
The choice of the panel of experts is an important step.
In my study, the panel of experts was composed of
6
members. These experts were
chose11 by polling mem-
bers of the Judicial Committee of APTA. Each member
who had served on the Judicial Committee during the
last 10 years was asked to identify five individuals who
they considered to be experts in ethical issues for
physical therapy. They were asked to write the names on
a form provided and return this form to the investigator.
Their responses remained anonymous. Of the 12 cur-
rent or former Judicial Committee members contacted,
nine responses (75%) were received.
An individual was
then selected for the panel of experts if he or she was
identified by more than one Judicial Committee mem-
ber as an expert. By use of this method,
6 individuals
were identified as experts and included on the panel. All
6 of the potential panel members consented to partici-
pate in the study.
Physical Therapy . Volume 76 . Number
10 . October 1996 Triezenberg . 1099
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70. The final composition of the panel was quite diverse,
with representation from the East, West, South, and
Midwest regions of the United States. There were four
male and two female panel members. This gender ratio
does not reflect the current composition of the physical
therapy profession. According to statistics provided by
APTA, the physical therapy profession is approximately
76% female and 24% male." Five of the panel members
were physical therapists with extensive backgrounds in
clinical practice. Four of these five physical therapists
possessed advanced academic degrees. Three of the six
panel members had academic appointments. All mem-
bers of the panel have had additional experience in
ethical issues relating to physical therapy as speakers,
instructors, authors, or as members of state or national
judicial committees.
The
Delphi Instrument
The initial questionnaire of the Delphi instrument used
in this st~ldy was composed of five questions. For the
purpose of this report,
I will focus on the first two of
these questions. The first two questions dealt with
present and future ethical issues facing physical thera-
pists. The questionnaires for the second and third
rounds of the Delphi instrument contained a compila-
tion of the data received in the preceding questionnaire
and requested that the panel consider their earlier
responses in light of the additional information.
The first
two questions of the initial questionnaire
consisted of the following broad statements:
1. List the ethical issues that you feel are currently most
important for physical therapists to address.
2. List any other ethical issues that you feel will become
important for physical therapists within the next 10
years.
Each question was designed to elicit an open response in
which the panel members could write as much or as little
as they felt necessary.
The initial statements were then compiled and divided
into groups of similar statements. The statements iden-
tified were supported by differing numbers of panel
members. Some statements were supported by all the
panel
members, and some statements were supported by
only one panel member.
The next step in the process was to determine the degree
of consensus within the panel on the statements made.
Questionnaire
B presented the panel members with the
statements of the other panel members and asked them
to respond to these statements. This questionnaire was
designed to allow for clarification of the specific issues
and to develop statements that accurately represent the
various issues. It was intended to give panel members
information on the views of the other members of the
panel to assist them in responding to further questions.
Consensus was sought on the issues listed. The purposes
of questionnaire
B, therefore, were
1. To obtain clarification on the issues.
2. To obtain agreement on the content of
he
statements.
3. To obtain consensus on the issues derived from the
first questionnaire.
4. To identify any issues that were omitted from the
results of the first questionnaire.
The first two questions of questionnaire
B reflected the
same two questions contained in questionnaire
A. For
question 1, each of the
23 statements of ethical issues
were listed as well as the statements made by the panel
members in each of these
23 topic areas. The panel
members were then asked to
1. Agree or disagree with the statement.
2. Suggest changes to clarify the statement.
3. Identify any panel statements that did not fit under
this topic area.
4. Rephrase the panel statements that did not fit to
clarify their distinctiveness from the ethical issues as
written.
The same procedure was followed for question
2, which
dealt with the eight future ethical issues.
Questionnaire
C was developed based on an analysis of
the information received in questionnaire
B. This ques-
tionnaire was designed to allow the panel to reach
consensus on which statements to include in a listing of
ethical issues facing physical therapy and of practice
issues that have ethical ramifications.
Question la of questionnaire
C listed the consensus
choices and asked the panel members to confirm their
choice or make changes as necessary. Question
lb listed
the statements that were chosen by the majority of the
panel members and provided the panel members with
the statements made by the panel members in question-
naire
B. The panel members were asked to accept or
reject these statements and to provide any comments
they felt necessary. The same procedure was followed in
question
lc with the issues that were rejected by the
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71. The inequity of the provision of health services within the current health care system
The determination of appropriate utilization and supervision of personnel other than physical therapists leg, physical therapist assistants,
physical therapy aides, certified athletic trainers) in the treatment of patients referred for physical therapy
The involvement of physical therapists in business relationships that limit professional autonomy or have the potential for financial abuse
The overutilization of physical therapy services
The qualification of physical therapists as the entry point into the health care system
The delineation of professional expertise and practice in relationship to other health care providers
The accountability of physical therapy education programs to develop in physical therapy students the skills needed as professionals
The identification of what constitutes informed consent for physical therapy evaluation and treatment
The protection of the patient's right to confidentiality in interactions with therapists, personnel under the supervision of therapists, and
physical therapy students
Justifiability of fees charged for services and reasonable rate of return
Defining the proper ethical limits of intervention: When doing everything possible may not be in the best interests of the patient
Truth in advertising
Fraud in billing
Sexual abuse by physical therapists
The trtratment or nantreatrnent of patients with acquired immunodeficiency syndrome by physical therapists
Maintaining of clinical competency by physical therapists
Compliance of physical therapists with the need for supportive documentation for services and charges rendered
Resolving the conflicts that sometimes occur between what is permitted by law and what is not permitted by the Code of Ethics
The la'ck of research evidence to support clinical practice techniques
The lack of cultural diversity within the physical therapy profession
Adhering to the ethical guidelines for the use of human subiects in clinical research
The enldorsement of equipment or products in which the physical therapist has a financial interest
The use of ethics and the disciplinary process to achieve personal gain
Figure 1.
Initial list of current ethical issues from questionnaire A, question 1.
majority of the panel members in questionnaire B. This
process was also followed in question Id with new
questions that were introduced by the panel members in
questionnaire
B.
Question 2 of questionnaire
C dealt with future ethical
issues. The same procedure was followed for question
2
as was outlined for question 1 of questionnaire C.
Results
The participation of the six chosen panel members in
the three rounds of the study was good throughout the
study. In the first round, all six panel members com-
pleted the questionnaire and responded to all questions.
This provided the investigator with a large variety of
responses from which to develop the second round of
questions. The second questionnaire was the longest of
the three questionnaires given to the panel, and it
required the panel members to consider the responses
of the other panel members in determining their
answers to the questions. Five of the six panel members
completed the second questionnaire. The third ques-
tionnaire was less complex than the second question-
naire. This questionnaire asked the panel members to
either agree or disagree with the statement of issues
presented in rounds
1 and 2. Five of the six panel
members responded to the third questionnaire. The
results of the study presented in this article provided
information in the two topic areas of current ethical
issues in physical therapy and future ethical issues in
physical therapy.
Current Ethical Issues
The first portion of this study identified current ethical
issues in physical therapy. The panel members were
given the broad directive in question 1 of "List the
ethical issues that you feel are currently most important
for physical therapists to address." This open-ended
question allowed the panel members to identify a wide
variety of ethical issues.
The question resulted in a total of 41 responses by the
panel members. The number of issues indicated by the
individual panel members varied from four to nine
issues. Some issues were included by all panel members,
and some issues were only listed by one member. From
the list of 41 statements of ethical issues,
23 unique issues
were identified. The
23 statements of current ethical
issues are listed in Figure
1.
The 23 ethical issues that were identified in the initial
round of the study were the starting point for
determin-
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72. ing a list of consensus ethical issues facing physical
therapy. In the next hvo rounds of the Delphi study, the
panel members were asked to consider this list of ethical
issues while also considering the statements of the other
panel members. They were asked to modify the state-
ments if they felt it would clarify the issue. They were also
instructed to add additional statements if they felt a new
statement was needed. At the completion of three
rounds of the study, a positive consensus was achieved on
10 of the original 23 statements. Three of the statements
were also considered near-consensus items.
An item was
considered a near-consensus
itern if only one panel
member dissented. There was also negative or near-
negative consensus on 6 of the 23 statements. Of the
remaining
4 statements, there was a majority vote to
accept 2 statements and a majority vote to reject 2
statements.
The results obtained after three rounds of question-
naires had identified 10 statements as consensus choices
and 3 statements as near-consensus choices. These 13
statements are listed in Figure 2. A fourth round for this
question was not considered necessary because 19 of the
23 statements were at or near consensus and the final
4
statements did not show substantial change between the
second and third questionnaires.
Future Ethical
Issues
The second goal of this study was the identification of
ethical issues that are likely to face physical therapists in
the future. In questionnaire
A, the panel was asked to list
additional ethical issues that could become important
issues for physical therapists within the next 10 years.
The panel members identified 12 statements as future
ethical issues. Eight specific issues were identified from
the 12 statements of ethical issues. Three of the six panel
members also stated that all of the issues identified as
current issues would be likely to remain in the future.
One panel member stated,
"I don't expect the issue to
change substantially in the next 10 years, and I doubt
that many of the current issues will be totally resolved in
the next 10 years, either." The 8 original statements of
the future ethical issues are listed in Figure
3.
The results of the second round of the study achieved
consensus on four of the statements of future ethical
issues. The third round of the Delphi study did not
provide any change in the results obtained from the
second round. The three rounds of questionnaires iden-
tified the four consensus future ethical issues, which are
listed in Figure
4. A fourth round was not considered
necessary as the responses of the panel did not show any
changes
bctlveen the second and third questionnaires.
The responses of the panel members to the first two
questions of this study, relating to current ethical issues
and future ethical issues, resulted in the 16 distinct
ethical issues that are listed in Figure
5. These
I6 ethical
issues have been included in a list as important iswec
facing physical therapists and constitute the final results
of this study. I have combined both current and future
ethical issues in the final list because a majorih. of the
panel members felt that current ethical issues will
remain in the future and future issues must be dealt with
today. The distinction between future ethical issues and
current ethical issues was not clear, and it seemed
appropriate to combine all of the ethical issues into one
composite list.
Discussion
The 16 issues identified in this study dealt with a wide
variety of topics relating to different aspects of physical
therapy practice. Further examination of these issues
suggested three classifications of issues. For the purpose
of discussion, the 16 issues have been divided into the
following groups: (1) issues that relate to patient rights
and welfare, (2) issues associated with professional
responsibility and role. and (3) issues involving business
relationships and economic considerations.
Dividing the issues into specific categories helps to focus
the discussion on areas of general concern and to
understand the relationships between various issues.
There is necessarily some overlap of categories, as an
issue in one category may also affect another category of
issues.
An
example of this overlapping of categories is
that a professional issue may also have an impact on
patient welfare. The issues have been assigned to their
specific category based on my determination as to what
constituted the primary focus of that issue. This classifi-
cation has been done for the purpose of discussion and
with the understanding that there could be other group-
ings of these issues that are equally as valid.
Patients'
Rights and Welfare
Issues were included in this categor) of issues if the
primary focus of the concern related directly to the
therapist interaction with the patient and involved the
individual rights of the patient. Six issues were identified
as belonging to this classification (Fig. 6). These issues
focus on personal interaction and human rights and
deal with informed consent, confidentiality, sexual and
physical abuse, social characteristics, and personal rela-
tionships. Of the ethical issues identified in this section,
the issue of the patient's right to informed consent has
been most frequently discussed in physical therapy liter-
at~re.l9,2~,ss,s-l The ethical implications of this issue were
examined by Coylg and Purtilo," and the issue was
discussed from a legal perspective by Banja and WolP1
and S~ott.?~ Guccione also identified the issue of
informed consent as a secondary issue in his 1980
study." The only other issue from this category that has
been discussed in the physical therapy literature is the
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73. Consensus Choices
The determination of the ap ropriate level of training, utilization, and supervision of supportive personnel other than physical therapists
who assist in the delivery o?physical therapy treatments
The overutilization of physical therapy services
The identification of the factors that constitute informed consent
The protection of the patient's right to confidentiality in interactions with therapists, personnel under the supervision of therapists, and
physical therapy students
The i~~stification of appropriate fees charged for the services rendered by physical therapists
The maintenance of truth in advertising
The identification and prevention of sexual misconduct (abuse) with patients by physical therapists
The maintenance of clinical competence by physical therapists
The adherence to ethical guidelines for the use of human subiects in clinical research
The endorsement of equipment or products in which the physical therapist has a financial interest
Near-consensus choices
The involvement of physical therapists in business relalionships that have the potential for patient exploitation
The identification and elimination of fraud in billing for physical therapy services
1 The responsibility of physical therapists to provide adequate physical therapy services to all patients according to their need for care
without regard to the patients' personal or social characterist~cs
Figure 2.
Final list of ethical issues identified by panel of experts in questionnaire C, question 1.
The response of physical therapists to environmental issues of pollutants and health hazards associated with specific treatment modalities
I Discriminating in employment opportunities within physical therapy private practices
The duty of physical therapists to report misconduct in colleagues
Defining the limits of personal relationships within the professional setting
How t3 address the issue of encroachment of other disciplines into the practice of physical therapy
I The utilization of treatment techniques without research to verify the degree of effectiveness
The use of advertising in physical therapy practice
The sexual and physical abuse of patients by physical therapists or those supervised by physical therapists
Figure 3.
Initial list of future ethical issues identified by panel members in questionnaire A, question 2.
issue of providing services without consideration of a
patient's social characteristics. This issue was discussed
by Sim and Purtilo2+ relative to the treatment of patients
with AIDS. The remaining issues in this category have
not yet been considered in the physical therapy litera-
ture. This omission includes the important issues of
physical and sexual abuse, confidentiality, and the limits
on personal relationships. The implications of these
issues on the welfare and rights of patients are great and
suggest
a need for immediate discussion and study.
Professional
Issues
The second category of issues was designated as profes-
sional issues. The issues in this category dealt primarily
with policies that affect the delivery of physical therapy
services .and with physical therapists' interactions with
other health professionals. The five issues identified as
belonging to this classification are overutilization of
services, maintaining clinical competence, supervision of
personnel, the environment, and reporting misconduct
of others (Fig.
7). The only issue of this group that has
been discussed in the physical
therapy literature is the
reporting of misconduct by colleagues, which was
addressed by Banjalo in 1985. In that article, Banja
presented a clear description of the ethical principles
and issues associated with whistle blowing.
Guccione,I7 in his 1980 study, identified as secondary
issues three of the five issues that were classified as
professional issues in the current study. The ethical
issues identified in both Guccione's study and the cur-
rent study related to (1) the use of support personnel,
(2) the reporting of misconduct by colleagues, and (3)
the responsibility of therapists to maintain clinical com-
petence. Professional issues that have not been discussed
include overutilization of services, utilization of support
services, and maintenance of competence and standards.
These are important issues that have a major impact on
our relations with other organizations and professions.
The recent examination of the health care industry has
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74. The responsibility of physical therapists to respond to the environmental issues of pollutants and health hazards associated with physical
therapy treatment
The dulty of physical therapists to report misconduct in colleagues
The need for therapists to define the limits of personal relationships within the professional setting
The se.uual and physical abuse of patients by physical therapists or those supervised by physical therapists
Figure 4.
Final list of future ethical issues identified by panel of experts in questionnaire C, question 2.
The overutilization of physical therapy services
The identification of the factors that constitute informed consent
The protection of the patient's right to confidentiality in interactions with therapists, personnel under the supervision of therapists, and
physical therapy students
The justification of appropriate fees charged for the services rendered by physical therapists
The maintenance of truth in advertising
The identification and prevention of sexual and physical abuse of patients by physical therapists or those supervised by physical therapists
The maintenance of clinical competence by physical therapists
The adherence to ethical guidelines for the use of human subjects in clinical research
The endorsement of equipment or products in which the physical therapist has a financial interest
The determination of the ap ropriate level of training, utilization, and supervision of supportive personnel other than physical therapists
who assist in the delivery orphysical therapy treatments
The involvement of physical therapists in business relationships thot have the potential for patient exploitation
The ideintification and elimination of fraud in billing for physical therapy services
The responsibility of physical therapists to provide adequate physical therapy services to all patients according to their need for care
without regard to the patients' personal or social characteristics
The responsibility of physical therapists to respond to the environmental issues of pollutants and health hazards associated with physical
therapy treatment
The duty of physical therapists to report misconduct in colleagues
The need for therapists to define the limits of personal relationships within the professional setting
Figure 5.
Final list of current and future ethical issues identified by panel of experts.
brouglit Illany of these issues into policy discussions and
decisions. It is important that physical therapists engage
themselves in those discussions and consider the policy
changes from an ethical as well as an economic point of
view. To assist in determining the appropriate ethical
position for the p~ofession of physical therapy through
these changing times, we need further study and discus-
sion of the ethical implications of the policies being
considered.
Business and Economics
The third category of issues related to business relation-
ships and economic factors. For an issue to be included
in this category, its primary focus had to be related to
financial considerations. The five issues in this category
dealt with appropriate fees, advertising, en do^ sement of
equipment, exploitive business relationships, and fraud
in billing (Fig.
8).
rhese are all issues that determine
how phjsical therapists conduct themselves in relation to
the business aspects of the profession. The fair and
appropriate use of resources is an important considel-
ation for all health care providers. The current discus-
sions at the national level on the cont~inment of health
care costs emphasized the importance of the exaniina-
tion of these issues by individual health professions. In
this examination, it is again important to identifv and
discuss the ethical considerations as well as the financial
issues.
None of the issues identified in this category have been
discussed from an ethical perspective in the physical
therapy literature. Guc~ione'~ did not identify an) of the
issues listed in this category as either primary or second-
ary issues. There has been an absence of formal discus-
sion on the important ethical issiies relating to business
interaction. This appears to be an area that has great
potential and need for exploration and study.
Limitations
My study was designed to stimulate and help
clariQ the
discussion of ethics within the profession of pl~ysical
therapy. The results of this study should be viewed in the
context of the study's limitations. The first limitation was
the small size of the panel of experts and whether they
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75. The identification of the factors that constitute informed consent
The protection of the patient's right to confidentiality in interactions with therapists, personnel under the supervision of therapists, and
physical therapy students
The identification and prevention of sexual and physical abuse of patients by physical therapists or those supervised by physical therapists
The adherence to ethical guidelines for the use of human subjects in clinical research
The responsibility of physical therapists to provide adequate physical therapy services to all patients according to their need for care
withol~t regard to the patients' personal or social characteristics
The need for therapists to define the limits of personal relationships within the professional setting
Figure 6.
Issues relating to patients' rights and welfare.
The overutilization of physical therapy services
The niaintenance of clinical competence by physical therapists
The determination of the ap ropriate level of training, utilization, and supervision of supportive personnel other than physical therapists
who assist in the delivery orphysical therapy treatments
The responsibility of physical therapists to respond to the environmental issues of pollutants and health hazards associated with physical
therapy treatment
The duty of physical therapists to report misconduct in colleagues
Figure 7.
Issues of professional role and responsibility
were representative of all experts. To choose a panel, it
was necessary to outline specific procedures prior to the
study. These procedures were then followed throughout
the study. This process identified a panel of six experts.
This is
a relatively small panel size but not necessarily a
problen~ for a Delphi study. The primary problem
associated with a small panel is that the number of issues
that are identified would be limited to the experiences of
the small number of panel members. This could lead to
some important issues being overlooked. The panel
should represent a broad constituency and diverse
opinions.
The six-person panel used in this study appeared to
represent a large portion of the physical therapy com-
munity, but it is still likely that some issues may have
been overlooked due to the small size of the panel. As
described earlier, the panel consisted of four men and
2
women. This gender ratio does not accurately reflect the
population of physical therapists in the United States,
which is
76% female and 24%
male.3' This discrepancy
could result in a bias toward issues of concern to male
therapists and less emphasis on issues that have greater
impact on female therapists. It would therefore be
prudent not to consider this study as all-inclusive or to
limit the discussions of ethical issues in physical therapy
to only the ethical issues identified in this study. Impor-
tant eth~ical issues could have been overlooked by the
panel OF experts participating in the study.
Another limitation was the focus on the developrrlent of
general statements about ethical issues. These represen-
tations rernoved the contextual information from the
issues in an attempt to create more generic statements
that reflect many specific instances. Because ethical
action takes place in specific situations in which the
particular context defines the ethical issue, this removal
of context creates the risk of making these statements of
issues too generic to be useful or meaningful. To address
that limitation, the purpose of the study needs to be
considered. The purposes of this study were to identift
ethical issues that warrant further analysis and to stimu-
late discussion. The initial step in this process needed to
be a broad one that could initiate additional study. The
broad statements of the ethical issues identified in this
study need to be understood as representing constella-
tions of similar specific issues, which then need to be
separated by further studies. This study was useful in
identifying these broad issues but did not address spe-
cific cases. The results of the study also suggest the need
for a series of more focused studies on the particular
broad issues that could then identify the specific forms
the issue may take. That type of study would provide a
way to examine the particular cases and stories associ-
ated with the issue. The process for coming to an
understanding about the ethical components of our
practice requires many steps, and this study should be
viewed as only one of the steps toward that
understanding.
Recommendations and Conclusion
Within each of the three categories, I believe that there
is an identified need for further study. Areas of inquiry
that could provide important additional information
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76. The justification of appropriate fees charged far the services rendered by physical therapists
The maintenance of truth in advertising
The endorsement of equipment or products in which the physical therapist has a financial interest
'the involvement of physical therapists in business relationships that have potential for patient exploitation
The identification and elimination of fraud in billing for physical therapy services
Figure 8.
Issues involving business relationships and economic factors
include (1) a comprehensive examination of the broad
issues identified in the study to identify the specific
instances and problems,
(2) a broad study of clinicians
to identify additional ethical issues that may have been
omitted in this study and to identify the importance of
these issues in practice, and
(3) a study to examine the
methods and substance of the current teaching of ethics
within physical therapy curricula, and
(4) a series of
studies to examine the effects of various teaching meth-
ods on the moral development of physical therapy
students. Each of these areas of future study has great
potential for adding to the understanding of ethical
thought and action in physical therapy practice.
In order to broaden the discussion of ethics within
physical therapy, a comprehensive study was needed to
identify the ethical issues that are important to the
the issues relating to the practice of physical therapy.
Increased dialogue among physical therapists and fur-
ther study will help us chart the best moral course
through the many changes facing our profession.
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Researrh Rriejir~gs. 1995;2(1).
33 Banja JD, Wolf SL. Malpractice litigation fnr ~~~~infbrmed consellt to
patient care: legal and ethical considerations for physical therapy. Plrss
Thtr. I987:67:1226-1229.
34 Scott RW. lnforrned consent. Clinzral .~Ia~~ugrn~tt~t.
1991;11(3):12-14.
Triezenberg's study is a fine example of "descriptive
ethics." Descriptive ethics uses the methods of empirical
research to identify the perceived ethical issues facing
practitioners or others in a given health professions
group. 'The goal of descriptive ethics is to describe the
factual basis of practice to better evaluate what ought to
be encouraged in the profession. In that regard descrip-
tive ethics is very much a part of the endeavor to create
a more ethical environment for all involved
in health
care. The term "descriptive
ethics" may be misleading to
some, only insofar as
most people think that ethics must
concentrate directly on the right- or wrong-making
characteristics of acts or the virtue of professionals. A
more accurate distinction is to call the latter "normative
ethics."
As
Triezenberg notes correctly, the profession of physi-
cal therapy has been slow to generate data by which to
judge the focus for ethicists, physical therapy practitio-
ners, and policymakers in their efforts to help create
ethical practices and policies relevant to the actual
situations facing physical therapy.
Triezenberg's study makes a signal contribution in sev-
eral specific ways. First, it further legitimizes physical
therapy as a profession. As he notes in the article, one of
the descriptors of a profession is that the group has
ethical issues and they are taken seriously. Second, his
study provides an opportunity for considered and
informed discourse with other health care disciplines. In
an era when strong winds are creating sometimes stormy
seas in the health professions world, the necessity of
identifying common values, issues, and ethical chal-
lenges takes on greater importance than when there are
few waves of change. Data such as this study provides are
resources for survival as well as the ability to thrive in an
unsettled moment.
A third contribution is that his and other such studies by
physical therapists provide public statements about the
ethical concerns physical therapists themselves are iden-
tifying as a focus for their reflection and action. This, in
turn, allows for others to evaluate and correct the
profession's self-perceptions. For instance, it is interest-
ing that Triezenberg's panel of experts identified
informed consent as a key issue for physical therapists. At
the same time, some writers are questioning whether
informed consent is an ideal method of enablement and
comn~unication for complex processes such as rehabili-
tation. At the very least, the fact that the physical therapy
profession is aware of this mechanism and has named
the issue for discussion signals that we are willing to be
on the frollt lines of rethinking informed consent, if
necessary.
There are also some caveats in this type of study. One
caveat is embedded in the 19th century philosopher
George
E Moore's adage: "Is does not imply ought." In
other words, simply identifying what
is (perceived to be
an ethics issue) does not
necessam'ly lead to direct guid-
ance about what (the ethical standards) ought to be. Put
another way, although Triezenberg succeeds in delineat-
ing the group's key areas of ethical concern, the consen-
sus of the group could be faulty, short-sighted, or
otherwise unhelpful in determining how physical thera-
pists can become more ethical in their practice. The
worst outcome would be that readers will not allow room
for error in the panel of experts' perceptions about what
the most important ethical issues are or to limit further
identification of new issues as they arise. A time-honored
method of testing the accuracy of a small group's
perception of the moral life is to measure their judg-
Physical Therapy . Volume 76 . Number 10 . October 1996 Purtilo . 1 107
Downloaded from https://academic.oup.com/ptj/article-abstract/76/10/1097/2632960 by guest on 27 June 2020

78. DISCOVER . LEARN. EMPOWERCode of conduct
INSTITUTE -UAIHS
DEPARTMENT OF PHYSIOTHERAPY
Professional ethics and PTT 301
By
Gulnaazkaur(BPT-MPT)
Assistant professor

79. 2
Code of conduct
CO
Number
Title Level
CO1 Code of conduct Remember
CO2 Rules and regulations Understand
CO3 Generalresponsibilities Understand
CO4 Professional Preparation and Development, Understand
CO5 Professional Relationships Understand
Course Outcome

80. Rules and regulations are important for the
all the profession as it provides safe
environment to practice your skills.
3
Code of conduct
https://www.scu.edu/mobi/resources--tools/blog-
posts/ethics-in-life-and-business/ethics-in-life-and-
business.html

81. General responsibilities
•(a) Physiotherapists shall provide honest quality care, competent and
accountable professional consultancy, therapeutic and otherwise, as 1st
contact practitioner to any person who may seek or may be in need of the
same.
•(b) The Physiotherapists shall administer only such treatment that is in the
interest of the patient with the
•responsibility for the exercise of sound judgment with diligence.
•(c) The physiotherapists shall respect the dignity and basic rights of the
patients and professional colleagues.
•(d) The physiotherapists shall refer the patient to the appropriate
specialists whenever the problems/symptoms ofthediseases of the patient
so demand.
4

82. •(e) The physiotherapists shall maintain secrecy of the patient’s disease and
shall not divulge the same to any other
•individual except to professional colleagues during scientific case
discussions/meetings.
•(f) The physiotherapists shall provide accurate information to the patient or
to the next relative if required about the
•problem and specific physiotherapy management of that individual’s
problems if required.
•(g) The physiotherapy management shall have the prior consent of the
patient/relative if the procedure adopted involves risk of any damage to
the tissue, organ system or any side effects/complications after explaining
the same accurately.
5

83. •(h) The physiotherapists shall comply with the laws governing the patient’s rights and cause.
•(i) The physiotherapists shall not solicit patients through fee splitting. It shall be based upon their
individual
•competence and ability in accordance with the accepted scientific standards.
•(j) The physiotherapists shall constantly strive to keep himself/herself abreast of the recent and
latest scientific
•-Navigation -
•developments related to physiotherapy and add to the knowledge fund.
•(k) The physiotherapists shall not indulge in or associate with any activity that goes against the
dignity, honour and
•development of the profession.
•(l) The physiotherapists shall contribute to the planning and development of professional services
which address the health needs of the community.
6

84. •(m) Maintain high standards of professional conduct.
•(n) Follow ethical practices outlined in the Code of Ethics. Strive to follow the
ethical practices outlined in the Principles for Physiotherapy Education and
practice norms.
•(o) Balance the wants, needs, and requirements of program patients, institutional
policies, laws, and sponsors. Members’ ultimate concern must be the long-term
well-being of Physiotherapy education and practice norms.
•(p) Resist pressures (personal, social, organizational, financial, and political) to
use their influence inappropriately and refuse to allow self aggrandizement or
personal gain to influence their professional judgments.
•(q) Seek appropriate guidance and direction when faced with ethical dilemmas.
•(r) Make every effort to ensure that their services are offered only to individuals
and organizations with a legitimate claim on these services.
7

85. In Their Professional Preparation and
Development, Members Shall:
•(a) Accurately represent their areas of competence, education, training, and experience.
•(b) Recognize the limits of their expertise and confine themselves to performing duties
for which they are properly
•educated, trained, and qualified, making referrals when situations are outside their area
of competence.
•(c) Be informed of current developments in their fields, and ensure their continuing
development and competence.
•(d) Stay abreast of laws and regulations that affect their clients.
•(e) Stay knowledgeable about world events that impact Physiotherapy education and
practice program patients.
•(f) Stay knowledgeable about differences in cultural and value orientations.
•(g) Actively uphold IAP’s Ethical Rules &Guidelines when practices that contravene it
become evident.
8

86. In Relationship with Students, Scholars, and
Other Members Shall:
•(a) Understand and protect the civil and human rights of all
individuals.
•(b) Not discriminate with regard to race, color, national origin,
ethnicity, sex, religion, sexual orientation, marital status, age, political
opinion, immigration status, or disability.
•(c) Recognize their own cultural and value orientations and be aware
of how those orientations affect their interactions with people from
other cultures.
•(d) Demonstrate awareness of, sensitivity to, and respect for other
education and practice systems, values, beliefs, and cultures.
9

87. •e) Not exploit, threaten, coerce, or sexually harass others.
•(f) Not use one’s position to proselytize.
•(g) Refrain from invoking governmental or institutional regulations in
order to intimidate patients in matters not related to their status.
•(h) Maintain the confidentiality, integrity, and security of patients’
records and of all communications with treatment program, Members
shall secure permission of the individuals before sharing information
with others inside or outside the organization, unless disclosure is
authorized by law or institutional policy or is mandated by previous
arrangement.
10

88. •(i) Inform patients of their rights and responsibilities in the context of the
institution and the community.
•(j) Respond to inquiries fairly, equitably, and professionally.
•(k) Provide accurate, complete, current, and unbiased information.
•(l) Refrain from becoming involved in personal relationships with patients
when such relationships might result in either the appearance or the fact
of undue influence being exercised on the making of professional
judgments.
•(m) Accept only gifts that are of nominal value and that do not seem
intended to influence professional decisions, while remaining sensitive to
the varying significance and implications of gifts in different cultures.
11

89. •n) Identify and provide appropriate referrals for patients who
experience unusual levels of emotional difficulty.
•(o) Provide information, orientation, and support services needed to
facilitate patient’s adaptation to a new education and practice and
cultural environment.
12

90. 4. In Professional Relationships, Members
Shall:
•(a) Show respect for the diversity of viewpoints among colleagues, just as
they show respect for the diversity of viewpoints among their clients.
•(b) Refrain from unjustified or unseemly criticism of fellow members, other
programs and other organizations.
•(c) Use their office, title, and professional associations only for the conduct
of official business.
•(d) Uphold agreements when participating in joint activities and give due
credit to collaborators for their contributions.
•(e) Carry out, in a timely and professional manner, any IAP responsibilities
they agree to accept.
13

91. 5. In Administering Programs, Members Shall:
•a) Clearly and accurately represent the identity of the organization and the
goals, capabilities, and costs of programs.
•(b) Recruit individuals, paid and unpaid, who are qualified to offer the
instruction or services promised, train and
•supervise them responsibly, and ensure by means of regular evaluation
that they are performing acceptably and that the overall program is
meeting its professed goals.
•(c) Encourage and support participation in professional development
activities.
•(d) Strive to establish standards, activities, instruction, and fee structures
that are appropriate and responsive to patient’s needs.
14

92. •(e) Provide appropriate orientation, materials, and on-going guidance
for patients.
•(f) Provide appropriate opportunities for students to observe and to
join in mutual inquiry into cultural differences.
•(g) Take appropriate steps to enhance the safety and security of
patients.
•(h) Strive to ensure that the practices of those with whom one
contracts do conform to IAP’s Code of Ethics and the Principles for
Physiotherapy Education and practice.
15

93. 6. In Making Public Statements, Members
Shall:
•(a) Clearly distinguish, in both written and oral public statements,
between their personal opinions and those
•opinions representing IAP, their own institutions, or other
organizations.
•(b) Provide accurate, complete, current, and unbiased information.
16

94. Quick revision
•General responsibilities
•Relationships
•Public statements
17

95. FAQ
•What is role of physiotherapy
•General reponsibilities
18

96. Assessment pattern
Q1. list the general responsibilities of physiotherapist.
Q2. explain the professional relationship.
19

97. Abbreviation
•nil
20

98. REFERENCES (size:44)
•http://www.rfhha.org/index.php?option=com_content&view=article&id=1&Itemid=67#Laws%20governing%20the%20qu
alifications
•https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjo0vGx8KHqAhV2H7cAHRiUAgsQFj
AAegQIBBAB&url=https%3A%2F%2Fnimsuniversity.org%2Fwp-content%2Fuploads%2F2018%2F05%2FCode-
Physitherapy.pdf&usg=AOvVaw0-oCoyX4v3Ljfhk6i33KZ3
21

99. THANK YOU
For queries
Email: [email protected]

100. HOME CONTACT US
Home | About | MOA | XV. Ethical Rules & Guidlines
XV. Ethical Rules & Guidlines
22/07/2012 22:05:00
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1. General Responsibilities
(a) Physiotherapists shall provide honest quality care, competent and accountable professional consultancy,
therapeutic and otherwise, as 1st contact practitioner to any person who may seek or may be in need of the same.
(b) The Physiotherapists shall administer only such treatment that is in the interest of the patient with the
responsibility for the exercise of sound judgment with diligence.
(c) The physiotherapists shall respect the dignity and basic rights of the patients and professional colleagues.
(d) The physiotherapists shall refer the patient to the appropriate specialists whenever the problems/symptoms of
the diseases of the patient so demand.
(e) The physiotherapists shall maintain secrecy of the patient’s disease and shall not divulge the same to any other
individual except to professional colleagues during scientific case discussions/meetings.
(f) The physiotherapists shall provide accurate information to the patient or to the next relative if required about the
problem and specific physiotherapy management of that individual’s problems if required.
(g) The physiotherapy management shall have the prior consent of the patient/relative if the procedure adopted
involves risk of any damage to the tissue, organ system or any side effects/complications after explaining the same
accurately.
(h) The physiotherapists shall comply with the laws governing the patient’s rights and cause.
(i) The physiotherapists shall not solicit patients through fee splitting. It shall be based upon their individual
competence and ability in accordance with the accepted scientific standards.
(j) The physiotherapists shall constantly strive to keep himself/herself abreast of the recent and latest scientific

- Navigation -

101. developments related to physiotherapy and add to the knowledge fund.
(k) The physiotherapists shall not indulge in or associate with any activity that goes against the dignity, honour and
development of the profession.
(l) The physiotherapists shall contribute to the planning and development of professional services which address the
health needs of the community.
(m) Maintain high standards of professional conduct.
(n) Follow ethical practices outlined in the Code of Ethics. Strive to follow the ethical practices outlined in the
Principles for Physiotherapy Education and practice norms.
(o) Balance the wants, needs, and requirements of program patients, institutional policies, laws, and sponsors.
Members’ ultimate concern must be the long-term well-being of Physiotherapy education and practice norms.
(p) Resist pressures (personal, social, organizational, financial, and political) to use their influence inappropriately
and refuse to allow self aggrandizement or personal gain to influence their professional judgments.
(q) Seek appropriate guidance and direction when faced with ethical dilemmas.
(r) Make every effort to ensure that their services are offered only to individuals and organizations with a legitimate
claim on these services.
2. In Their Professional Preparation and Development, Members Shall:
(a) Accurately represent their areas of competence, education, training, and experience.
(b) Recognize the limits of their expertise and confine themselves to performing duties for which they are properly
educated, trained, and qualified, making referrals when situations are outside their area of competence.
(c) Be informed of current developments in their fields, and ensure their continuing development and competence.
(d) Stay abreast of laws and regulations that affect their clients.
(e) Stay knowledgeable about world events that impact Physiotherapy education and practice program patients.
(f) Stay knowledgeable about differences in cultural and value orientations.
(g) Actively uphold IAP’s Ethical Rules &Guidelines when practices that contravene it become evident.
3. In Relationship with Students, Scholars, and Other Members Shall:
(a) Understand and protect the civil and human rights of all individuals.
(b) Not discriminate with regard to race, color, national origin, ethnicity, sex, religion, sexual orientation, marital
status, age, political opinion, immigration status, or disability.
(c) Recognize their own cultural and value orientations and be aware of how those orientations affect their
interactions with people from other cultures.
(d) Demonstrate awareness of, sensitivity to, and respect for other education and practice systems, values, beliefs,
and cultures.
(e) Not exploit, threaten, coerce, or sexually harass others.
(f) Not use one’s position to proselytize.
(g) Refrain from invoking governmental or institutional regulations in order to intimidate patients in matters not
related to their status.
(h) Maintain the confidentiality, integrity, and security of patients’ records and of all communications with treatment

102. program, Members shall secure permission of the individuals before sharing information with others inside or
outside the organization, unless disclosure is authorized by law or institutional policy or is mandated by previous
arrangement.
(i) Inform patients of their rights and responsibilities in the context of the institution and the community.
(j) Respond to inquiries fairly, equitably, and professionally.
(k) Provide accurate, complete, current, and unbiased information.
(l) Refrain from becoming involved in personal relationships with patients when such relationships might result in
either the appearance or the fact of undue influence being exercised on the making of professional judgments.
(m) Accept only gifts that are of nominal value and that do not seem intended to influence professional decisions,
while remaining sensitive to the varying significance and implications of gifts in different cultures.
(n) Identify and provide appropriate referrals for patients who experience unusual levels of emotional difficulty.
(o) Provide information, orientation, and support services needed to facilitate patient’s adaptation to a new
education and practice and cultural environment.
4. In Professional Relationships, Members Shall:
(a) Show respect for the diversity of viewpoints among colleagues, just as they show respect for the diversity of
viewpoints among their clients.
(b) Refrain from unjustified or unseemly criticism of fellow members, other programs and other organizations.
(c) Use their office, title, and professional associations only for the conduct of official business.
(d) Uphold agreements when participating in joint activities and give due credit to collaborators for their
contributions.
(e) Carry out, in a timely and professional manner, any IAP responsibilities they agree to accept.
5. In Administering Programs, Members Shall:
(a) Clearly and accurately represent the identity of the organization and the goals, capabilities, and costs of
programs.
(b) Recruit individuals, paid and unpaid, who are qualified to offer the instruction or services promised, train and
supervise them responsibly, and ensure by means of regular evaluation that they are performing acceptably and
that the overall program is meeting its professed goals.
(c) Encourage and support participation in professional development activities.
(d) Strive to establish standards, activities, instruction, and fee structures that are appropriate and responsive to
patient’s needs.
(e) Provide appropriate orientation, materials, and on-going guidance for patients.
(f) Provide appropriate opportunities for students to observe and to join in mutual inquiry into cultural differences.
(g) Take appropriate steps to enhance the safety and security of patients.
(h) Strive to ensure that the practices of those with whom one contracts do conform to IAP’s Code of Ethics and the
Principles for Physiotherapy Education and practice.
6. In Making Public Statements, Members Shall:
(a) Clearly distinguish, in both written and oral public statements, between their personal opinions and those

103. opinions representing IAP, their own institutions, or other organizations.
(b) Provide accurate, complete, current, and unbiased information.

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105. DISCOVER . LEARN. EMPOWERTypes of profession
INSTITUTE -UAIHS
DEPARTMENT OF PHYSIOTHERAPY
Professional ethics and PTT 301
By
Gulnaazkaur(BPT-MPT)
Assistant professor

106. 2
Code of conduct
CO
Number
Title Level
CO1 What is profession Remember
CO2 Typesof profession Understand
CO3 Characteristics of profession Understand
CO4 Minimum standards of profession Understand
CO5 Improvement in profession Understand
Course Outcome

107. The term professional refers to anyone who
earns their living from performing an activity
that requires a certain level of education,
skill, or training. There is typically a required
standard of competency, knowledge, or
education that must be demonstrated (often
in the form of an exam or credential), as well
as adhering to codes of conduct and ethical
standards.
3
What is a Professional?
https://www.scu.edu/mobi/resources--tools/blog-
posts/ethics-in-life-and-business/ethics-in-life-and-
business.html

108. Types of Professionals
•There are many different types of
professionals. Whether they are athletes
or business people, there are many
categories and groups, which are listed
below.
•Types of professionals include:
•Accountant
•Teacher
•Technician
•Laborer
•Physical
•Commercial Banker
•Engineer
•Lawyer
•Psychologist
•Pharmacist
•Dietitian
•Research Analyst
•Midwife
•Mechanic
•Dentist
•Electrician
•Consultant
•Investment Banker
•Programmer
4

109. Professional Standards
•Professional standards are a set of practices, ethics, and behaviors
that members of a particular professional group must adhere to.
These sets of standards are frequently agreed to by a governing body
that represents the interests of the group.
•Examples of professional standards include:
•Accountability –takes responsibility for their actions
•Confidentiality –keeps all sensitive information private and away
from those who shouldn’t have access to it
•Fiduciary duty –places the needs of clients before their own
5

110. •Honesty –always being truthful
•Integrity –having strong moral principles
•Law-abiding –follows all governing laws in the jurisdictions they
perform activities
•Loyalty –remain committed to their profession
•Objectivity –not swayed or influenced by biases
•Transparency –revealing all relevant information and not concealing
anything
6

111. Characteristics of a Profession
•In a profession, autonomy and self-regulation still hold true or are
even desirable in the modem corporate and bureaucratic world.
•A profession's right to exist, along with the power and privileges its
members enjoy, rests upon the professions upholding of public values
through the development, transmission and application of a body of
knowledge.
7

112. •The creation of this body of knowledge and its concentration in the
hands of a few creates a knowledge gap between the professional
and client. That gap gives the profession power. Such power is
reinforced by differential access to other resources -technological,
physical and organizational. For example, it is not just medical
knowledge but access to medical technology that gives the medical
profession its capacity to heal. It is the institutional links to courts
that make barristers so effective.
8

113. •The knowledge differential is deliberately created and increased to further
the power of the profession. However, once power differentials are created
for whatever reason, there is a reluctance to give them up and there
remains a temptation to use them for personal gain, either at the expense
of the client or in some cases to the mutual enrichment of professional and
client at the expense of the wider public.
•Controlling the use and abuse of that power is one of the principle
concerns of the community and one of the principle purposes for
professional ethics.
•The fundamental question concerning any profession receiving public
support and privileges is how can that support, and its continuation, be
justified.
9

114. •That justification cannot be in terms of the benefits the profession
confers on its members but the benefits the profession confers on the
general public. The argument is that an educated group of specialists
developing, transmitting and applying a specialist body of knowledge
will use that knowledge to benefit the broader community.
•This argument builds upon the ideal that the establishment and
sustenance of a profession involves a social compact with society,
granting privileges such as autonomy, self-regulation, monopolistic
rights and public funding of professional education in return for the
provision of desirable social goods.
10

115. •The provision is that the profession places 'the public interest
foremost, even if serving the public interest may at times be at the
professionals' own expense'. Crucially, different public values and
interests will apply to different professions and should be seen as
embodied in the very definition of these professions.
•For example, the medical profession and its privileges are justified by
the values of preserving life and health. The legal profession and its
privileges are justified by the values of upholding justice, the rule of
law and the rights of the individual. It is easy to be cynical about such
claims but there is little doubt that most professionals believe them
and, for the most part try to act upon them.
11

116. Professional Minimum Standards
•At each stage of the behavioural continuum it is necessary to look at
the means by which values are articulated, enforced and reinforced. It
is emphasized the latter because praise and rewards are the most
important means of promoting and realizing values.
•It should also be necessary to identify temptations, conflicts and
dilemmas specific to the type of profession, the type of practice and
the individual standing within the behavioural continuum.
12

117. •It is important to highlight the fact that different levels of the continuum
require different levels of specificity, different sanctions (positive and/or
negative) and different institutional interpretation and enforcement:
•At the lowest levels of the behavioural continuum, the sanctions are
greatest -including fines, imprisonment and public opprobrium. The
criminal law is designed as a means for indicating the opprobrium of
society for certain kinds of actions and the attachment of that opprobrium
to those who are proven to have performed them.
•To be effective and just, formal sanction and social opprobrium require
clear and prior statements of the maximum possible precision, endorsed by
the highest authority (which is, in a democracy, at the very least the
representative parliament and sometimes an elected president as well).
13

118. •The authoritative interpretation and enforcement of these rules must be by a
justice system on which the highest standards of procedural fairness are imposed.
•The profession will set minimum standards for membership of the profession and
procedures for detecting breaches. These minimal values are those of the
profession so that the profession is, in general, the appropriate body to define,
interpret and enforce them.
•These minimal professional standards will obviously be higher than those
required to escape criminal sanction.
•The requirements of precise (and prior) definition, social endorsement and
procedural fairness do not apply so rigidly to the policing of minimal professional
standards. However, in recognition of the costs both financial and to reputation
of being expelled from a profession, there needs to be procedural fairness,
independence and precision in the definition and application of those norms
whose breach can lead to expulsion or suspension.
14

119. •It is not necessary for the court to actually enforce these norms although it
may act in its supervisory capacity to ensure that the profession
procedures reach appropriate standards of fairness and legality.
•Moving up the scale of professional behaviour to the 'standard aspiration'
of good practice, the profession should retain an important role in setting
such standards, particularly those that improve service to clients and
realize the values that justify the profession existence.
•Although it is not the role of the profession to punish an individual for
failing to meet these higher standards, the profession should be involved in
encouraging all its members to aspire to these ideals. Institutions that can
play a vital role in this regard include all the places in which professional
work, including the agency, firm, practice, company and hospital.
15

120. •As institutions they will generally be concerned to ensure that 'best
practice' is, as far as possible, promoted and achieved.
•They have a clear financial and legal interest in monitoring both overall
performance and the work of individual professionals as employees.
•In pursuing these objectives, how much attention should the institution
give to the goal of furthering values of the profession?
•The answer is that if the profession is to move up the normative and
behavioural continuum from 'just good enough to avoid prosecution or
disbarment' towards the inspirational standards of good practice, the firm
must pay much more attention to furthering the values of professions.
16

121. •It is at this level that there is a great deal of criticism of professions. For example, the
structure of legal institutions, especially law firms, is a major impediment to individual
reflection and the realization in daily practice of the higher values of the profession.
•The modern catch-cry that 'law is big business' encapsulates the potential for conflict
between professional values and business interests/maximization of profits.
•The rise of the American practice of monitoring and judging the performance of
employee solicitors (and later partners) on the basis of the number of 'billable hours'
rightly raises concerns about the temptation to overcharge or otherwise engage in sharp
practice.
•The problem is strikingly simple. Whatever the firm public position on professional
values, if it judges and promotes its own employees on the basis of their money-raising
ability, then it is very obviously pursuing profit maximization at the expense of
professional values. We would argue that such a firm should forfeit the right to be seen
as an organization of professionals and to enjoy the associated regulatory privileges.
17

122. Improving Professional or Institutional Behaviour
•Improving professional or institutional behaviour (and avoiding
misbehaviour) requires a coordinated approach based on a 'trinity' of
ethical standard setting, legal regulation and institutional reform.
•Such an approach recognizes that professional behaviour falls into a
normative continuum from the highest professional standards, through
good work, sub-par work, misconduct and criminality. It also recognizes
that there is a professional practice range from solo to large group settings
and that there are many distinctions among professionals important for
ethical issues.
•The goal of the 'trinity' is to raise individual professionals as far up the
normative continuum as possible, using means appropriate to the
particular profession and work setting.
18

123. •A individual self-assessment as the basis for determining continuing
competence is a good example of a focus on continually lifting standards
within a profession. Such a strategy is far more likely to be successful than
a policy of deterrence based on punitive sanctions.
•Not only is it obviously better to avoid the opportunity for ethical failings
than to deal with their consequences, there is some evidence that
punishment can in fact be counterproductive. Imposing criminal sanctions,
society should not primarily emphasize community disgust at the
behaviour condemned.
•Rather society should emphasize the positive values of the profession (and
society) that have been betrayed. This is the reason why the individual has
received a higher level of punishment than others who were not
professionally committed to those values.
19

124. •The majority of individuals (the 'virtuous actors'), an appeal to reason
(persuasion) will be sufficient. The assumption is that the threat of deterrence in
its various forms will be sufficient for the 'rational actor'.
•What is vital is the co-ordination of the various approaches to improving
behaviour to shift as much behaviour as high up the behavioural scale as
possible. Ethical standards should set out the inspirational goals at the highest
levels of the behavioural continuum; disciplinary codes and criminal sanctions
should be addressed to the lowest levels of the behavioural field.
•Even for those who do not reach the highest ideals of the profession, other
means should underpin and reward higher standards at all levels. The more
successful a co-ordinate approach based on ethical standard -setting, legal
regulation and institutional reform, the higher the overall standards of the
profession and the fewer professionals at the lower levels committing crimes and
ethical breaches.
20

125. •Thus, in a well-ordered profession, the aspirations of most practitioners will
be to strive for the highest standards of the profession and this focus will
keep individuals so far from the sanction minimum that there will be very
few breaches, even by those who fall below the average.
•Criminal behaviour will also be rarer if the occurrence of institutional
temptations or dilemmas is reduced. The more effective is ethical standard
setting and ethical education, the lesser the opportunity to resort to the
excuse of ignorance.
•And the more effective is institutional reform, the less likely the profession
acceptance of the excuse that the individual faced an ethical dilemma,
alone and unsupported.
21

126. Quick revision
•Types of profession
•Characteristics of a Profession
•Professional Minimum Standards
•Improving Professional or Institutional Behaviour
22

127. FAQ
•What do you mean by profession?
•Why profession is imoportant?
23

128. Assessment pattern
Q1. list the characteristics of profession.
Q2. explain the professional relationship.
24

129. Abbreviation
•nil
25

130. REFERENCES (size:44)
•https://www.academia.edu/37103491/Characteristics_of_a_Profession
26

131. THANK YOU
For queries
Email: [email protected]

132. Characteristics of a Profession
Artur Victoria
Forewords
In Québec, 54 professions are governed by the Professional Code and supervised by 46
professional orders. As stipulated in article 25 of the Professional Code, several aspects
must be considered to determine whether a profession should be regulated and supervised
by a professional order. The factors taken into account are mainly related to the nature of
the professional activities in question and the characteristics of the individuals who practise
them:
- The knowledge required in order to engage in the activities
- The degree of independence enjoyed by the persons practising the activities and the
difficulty which persons not having the same training and qualifications would have in
assessing those activities
- The personal nature of the relationships between such persons and those having recourse
to their services, by reason of the special trust which the latter must place in them
- The gravity of the prejudice which might be sustained by those who have recourse to the
services of such persons, because their competence was not supervised by an order
- The confidential nature of the information to which such persons are made privy in the
course of practising their profession - Québec Inter professional Council definition.

Characteristics of a Profession
In a profession, autonomy and self-regulation still hold true or are even desirable in the
modem corporate and bureaucratic world.
A profession's right to exist, along with the power and privileges its members enjoy, rests
upon the professions upholding of public values through the development, transmission and
application of a body of knowledge.
The creation of this body of knowledge and its concentration in the hands of a few creates a
knowledge gap between the professional and client. That gap gives the profession power.
Such power is reinforced by differential access to other resources -technological, physical
and organizational. For example, it is not just medical knowledge but access to medical
technology that gives the medical profession its capacity to heal. It is the institutional links
to courts that make barristers so effective.

133. The knowledge differential is deliberately created and increased to further the power of the
profession. However, once power differentials are created for whatever reason, there is a
reluctance to give them up and there remains a temptation to use them for personal gain,
either at the expense of the client or in some cases to the mutual enrichment of
professional and client at the expense of the wider public.
Controlling the use and abuse of that power is one of the principle concerns of the
community and one of the principle purposes for professional ethics.
The fundamental question concerning any profession receiving public support and privileges
is how can that support, and its continuation, be justified.
That justification cannot be in terms of the benefits the profession confers on its members
but the benefits the profession confers on the general public. The argument is that an
educated group of specialists developing, transmitting and applying a specialist body of
knowledge will use that knowledge to benefit the broader community.
This argument builds upon the ideal that the establishment and sustenance of a profession
involves a social compact with society, granting privileges such as autonomy, self-regulation,
monopolistic rights and public funding of professional education in return for the provision
of desirable social goods.
The provision is that the profession places 'the public interest foremost, even if serving the
public interest may at times be at the professionals' own expense'. Crucially, different public
values and interests will apply to different professions and should be seen as embodied in
the very definition of these professions.
For example, the medical profession and its privileges are justified by the values of
preserving life and health. The legal profession and its privileges are justified by the values
of upholding justice, the rule of law and the rights of the individual. It is easy to be cynical
about such claims but there is little doubt that most professionals believe them and, for the
most part try to act upon them.

Professional Minimum Standards
At each stage of the behavioural continuum it is necessary to look at the means by which
values are articulated, enforced and reinforced. It is emphasized the latter because praise
and rewards are the most important means of promoting and realizing values.
It should also be necessary to identify temptations, conflicts and dilemmas specific to the
type of profession, the type of practice and the individual standing within the behavioural
continuum.

134. It is important to highlight the fact that different levels of the continuum require different
levels of specificity, different sanctions (positive and/or negative) and different institutional
interpretation and enforcement:
At the lowest levels of the behavioural continuum, the sanctions are greatest - including
fines, imprisonment and public opprobrium. The criminal law is designed as a means for
indicating the opprobrium of society for certain kinds of actions and the attachment of that
opprobrium to those who are proven to have performed them.
To be effective and just, formal sanction and social opprobrium require clear and prior
statements of the maximum possible precision, endorsed by the highest authority (which is,
in a democracy, at the very least the representative parliament and sometimes an elected
president as well).
The authoritative interpretation and enforcement of these rules must be by a justice system
on which the highest standards of procedural fairness are imposed.
The profession will set minimum standards for membership of the profession and
procedures for detecting breaches. These minimal values are those of the profession so that
the profession is, in general, the appropriate body to define, interpret and enforce them.
These minimal professional standards will obviously be higher than those required to escape
criminal sanction.
The requirements of precise (and prior) definition, social endorsement and procedural
fairness do not apply so rigidly to the policing of minimal professional standards. However,
in recognition of the costs both financial and to reputation of being expelled from a
profession, there needs to be procedural fairness, independence and precision in the
definition and application of those norms whose breach can lead to expulsion or
suspension.
It is not necessary for the court to actually enforce these norms although it may act in its
supervisory capacity to ensure that the profession procedures reach appropriate standards
of fairness and legality.
Moving up the scale of professional behaviour to the 'standard aspiration' of good practice,
the profession should retain an important role in setting such standards, particularly those
that improve service to clients and realize the values that justify the profession existence.
Although it is not the role of the profession to punish an individual for failing to meet these
higher standards, the profession should be involved in encouraging all its members to aspire
to these ideals. Institutions that can play a vital role in this regard include all the places in
which professional work, including the agency, firm, practice, company and hospital.

135. As institutions they will generally be concerned to ensure that 'best practice' is, as far as
possible, promoted and achieved.
They have a clear financial and legal interest in monitoring both overall performance and
the work of individual professionals as employees.
In pursuing these objectives, how much attention should the institution give to the goal of
furthering values of the profession?
The answer is that if the profession is to move up the normative and behavioural continuum
from 'just good enough to avoid prosecution or disbarment' towards the inspirational
standards of good practice, the firm must pay much more attention to furthering the values
of professions.
It is at this level that there is a great deal of criticism of professions. For example, the
structure of legal institutions, especially law firms, is a major impediment to individual
reflection and the realization in daily practice of the higher values of the profession.
The modern catch-cry that 'law is big business' encapsulates the potential for conflict
between professional values and business interests/maximization of profits.
The rise of the American practice of monitoring and judging the performance of employee
solicitors (and later partners) on the basis of the number of 'billable hours' rightly raises
concerns about the temptation to overcharge or otherwise engage in sharp practice.
The problem is strikingly simple. Whatever the firm public position on professional values, if
it judges and promotes its own employees on the basis of their money-raising ability, then it
is very obviously pursuing profit maximization at the expense of professional values. We
would argue that such a firm should forfeit the right to be seen as an organization of
professionals and to enjoy the associated regulatory privileges.

Improving Professional or Institutional Behaviour
Improving professional or institutional behaviour (and avoiding misbehaviour) requires a
coordinated approach based on a 'trinity' of ethical standard setting, legal regulation and
institutional reform.
Such an approach recognizes that professional behaviour falls into a normative continuum
from the highest professional standards, through good work, sub-par work, misconduct and
criminality. It also recognizes that there is a professional practice range from solo to large
group settings and that there are many distinctions among professionals important for
ethical issues.

136. The goal of the 'trinity' is to raise individual professionals as far up the normative continuum
as possible, using means appropriate to the particular profession and work setting.
A individual self-assessment as the basis for determining continuing competence is a good
example of a focus on continually lifting standards within a profession. Such a strategy is far
more likely to be successful than a policy of deterrence based on punitive sanctions.
Not only is it obviously better to avoid the opportunity for ethical failings than to deal with
their consequences, there is some evidence that punishment can in fact be
counterproductive. Imposing criminal sanctions, society should not primarily emphasize
community disgust at the behaviour condemned.
Rather society should emphasize the positive values of the profession (and society) that
have been betrayed. This is the reason why the individual has received a higher level of
punishment than others who were not professionally committed to those values.
The majority of individuals (the 'virtuous actors'), an appeal to reason (persuasion) will be
sufficient. The assumption is that the threat of deterrence in its various forms will be
sufficient for the 'rational actor'.
What is vital is the co-ordination of the various approaches to improving behaviour to shift
as much behaviour as high up the behavioural scale as possible. Ethical standards should set
out the inspirational goals at the highest levels of the behavioural continuum; disciplinary
codes and criminal sanctions should be addressed to the lowest levels of the behavioural
field.
Even for those who do not reach the highest ideals of the profession, other means should
underpin and reward higher standards at all levels. The more successful a co-ordinate
approach based on ethical standard - setting, legal regulation and institutional reform, the
higher the overall standards of the profession and the fewer professionals at the lower
levels committing crimes and ethical breaches.
Thus, in a well-ordered profession, the aspirations of most practitioners will be to strive for
the highest standards of the profession and this focus will keep individuals so far from the
sanction minimum that there will be very few breaches, even by those who fall below the
average.
Criminal behaviour will also be rarer if the occurrence of institutional temptations or
dilemmas is reduced. The more effective is ethical standard setting and ethical education,
the lesser the opportunity to resort to the excuse of ignorance.
And the more effective is institutional reform, the less likely the profession acceptance of
the excuse that the individual faced an ethical dilemma, alone and unsupported.

137. DISCOVER . LEARN. EMPOWERCultural issues
INSTITUTE -UAIHS
DEPARTMENT OF PHYSIOTHERAPY
Professional ethics and PTT301
By
Gulnaazkaur(BPT-MPT)
Assistant professor

138. 2
Cultural issues
CO
Number
Title Level
CO1 What is culture Remember
CO2 Impact of culture Understand
CO3 Food habitts Understand
Course Outcome
https://study.com/academy/lesson/what
-is-cultural-sensitivity-definition-
examples-importance.html

139. Culture is the characteristics and knowledge of a particular
group of people, encompassing language, religion, cuisine,
social habits, music and arts.
The Centerfor Advance Research on Language Acquisitiongoes
a step further, defining culture as shared patterns of behaviors
and interactions, cognitive constructs and understanding that
are learned by socialization. Thus, it can be seen as the growth
of a group identity fostered by social patterns unique to the
group.
"Culture encompasses religion, food, what we wear, how we
wear it, our language, marriage, music, what we believe is right
or wrong, how we sit at the table, how we greet visitors, how
we behave with loved ones, and a million other things," Cristina
De Rossi, an anthropologist at Barnet and Southgate College in
London, told Live Science.
3
Culture
https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.pinterest.com%
2Fpin%2F67413325657321045%2F&psig=AOvVaw2TcBdecOJYHBtYGKd3frAc&u
st=1593499428077000&source=images&cd=vfe&ved=0CA0QjhxqFwoTCLDGj42
2puoCFQAAAAAdAAAAABAO

140. WHAT IS CULTURE
•Learned behaviour which has been socially acquired.
•Product of human societies, and man is largely a product of his cultural
environment.
•Lays down norms of behaviorand provides mechanisms which secure an
individual in his personal and social survival.
•Culture stands for the customs, beliefs, laws, religion and moral percept, arts
& other capabilities, skills acquired by man as a member of society.
4

141. •Every culture has its own customs, which influences diseases. Eg. lung
carcinoma & liver cirrhosis in west due to smoking & alcohol intake
and oral Ca in India due to tobacco intake.
•Involved in matters of personal hygiene, nutrition, immunization,
seeking early medical care, family planning -in short, the whole way
of life.
•Not all customs and beliefs are bad. Some are based on centuries of
trial and error and have positive values, while others may be useless
or positively harmful.
5

142. IMPACT OF CULTURE
•1. Concept of etiologyand cure
•2. Environmental Sanitation
•3. Food Habits
•4. Mother and child health
•5. Personal hygiene
•6. Marriage & sexuality:
6

143. CONCEPT OF ETIOLOGY ANDCURE
•2 groups –(a) supernatural (b) physical.
•A. SUPERNATURAL CAUSES:
(1) Wrath of god: E.g. Smallpox and chickenpox.
Administration of drug is considered harmful. Cases are not notified
and pujasare made to please the gods.
(2) Breach of taboo : Venereal diseases are believed by some to be
due to illicit sexual intercourse with a woman of low caste, or a
woman during menstruation.
7

144. •SUPERNATURAL CAUSES (CONTD…)
•(3) Past sins: Leprosy and tuberculosis.
•(4) Evil eye: Children are considered to be most prone to the effect of
evil eyes. Charms and amulets are prescribed and incantations recited
by the exorcist.
•(5) Spirit or ghost intrusion: Hysteria and epilepsy are regarded due to
spirit or ghost intrusion into the body. The services of an exorcist are
sought to drive away the evil spirit or ghost.
8

145. •B. PHYSICAL CAUSES :
•(1) Effects of Weather : For heat stroke, application of oil and ghee on
the soles of feet and administration of mango-phoolwith a pinch of
salt.
•(2) Water : Impure water is associated with disease.
•(3) Impure blood : Skin diseases (scabies, acne, boil) are considered to
be due to impure blood. Eating neemleaves and flowers is considered
to purify blood.
9

146. ENVIORNMENT SANITATION
•A. DISPOSAL OF HUMAN EXCRETA:
•Open field defecation.
•No idea of latrines among villagers.
•Latrines are meant for city dwellers, where there are no fields for
defecation.
•Faeces are infectious, pollutes water and soil and promotes fly
breeding. Problem of excreta disposal is bound up with numerous
beliefs and habits based on ignorance.
10

147. •B. DISPOSAL OF WASTES:
•Not aware that mosquitoes breed in collections of waste water.
•The solid waste is invariably thrown in front of the houses where it is
permitted to accumulate and decompose. Periodically it is removed
to the fields and used as fertilizer.
•The animal dung (cow dung) is allowed to accumulate. It is used
sometimes as manure and often times pressed into cakes, sun-dried
and used as fuel.
11

148. •C. WATER SUPPLY : Ponds & Tanks → Common use for washing,
bathing, drinking Some rivers are considered "holy". Epidemics of
cholera, gastroenteritis have occurred due to these cultural practices.
12

149. •. D. HOUSING: Rural houses are same all over the country. Usually
kucchaand damp, ill-lighted and ill-ventilated. For reasons of
security, no windows are provided, and if at all one is provided, it is
merely a small hole. Absence of a separate kitchen, latrine,
bathroom and drainage are characteristic features of an average rural
house. Animal keeping is very common in villages. Infrequently,
human beings and animals live under one roof.
13

150. FOOD HABBITS
•Influenced by local conditions (e.g. soil, climate), religious customs
and beliefs.
•Vegetarianism is given a place of honour in Hindu society. Food
taboos: beef, pork
•Foods such as meat, fish, eggs, and jaggeryare considered to
generate heat in the body;
•Foods such as curd, milk, vegetables and lemon are considered to
cool the body.
•Adulteration of milk is a common practice.
14

151. •FASTING-
•ladies→ married, old, pregnant, widow (drinking water only, fruits
alone, salt/spice restricted diet, single meal/day)
•Muslims observe fasts during Ramzanand Hindus on several
occasions
15

152. •Alcoholic drinks are tabooed by Muslims and high caste Hindus.
•Ganja, bhang and charasare frequently consumed by sadhus; these
habits are now spreading into the general population, especially the
younger generation.
•Eating and drinking from common utensils is considered as a sign of
brotherhood among Muslims.
•In some societies, men eat first and women last and poorly.
•Some people do not eat unless they have taken a bath.
16

153. MOTHER AND CHILD HEALTH
•Marriage is universal in Indian society
•Family is incomplete without a male child!
•Good:
•Prolonged breastfeeding,
•Oil bath, massage and exposure to sun.
17

154. •. Bad:
•Some foods (e.g., eggs, meat, fish , milk, leafy vegetables) are
forbidden during pregnancy in some parts.
•Deliveries are conducted by the traditional untrained daior birth
attendant.
•No breast feed during the first 3 days of birth because of the belief
that colostrummight be harmful; instead the child is put on water,
and sugar solution
18

155. •Unimportant: -Piercing ear/ nose -Topical application of oil on head
Uncertain: -Application of surma/ kajal→!Trachoma
19

156. •Indians have an immense sense of personal cleanliness.
•(1) Oral Hygiene:
•Many people use twigs of neemtree; ashes; charcoal.
•Eating pan leaves with lime with or without tobacco.
•(2) Bathing:
•Bathing naked is a taboo.
•Villagers: no use of soap, use of common cloth to wipe body → cross
infection
•Women after menstruation must have a
20

157. •purifying bath;
•After childbirth, there may be 2-3 ceremonial baths, the time for
which is fixed upon the advice of the priest.
•(3) Shaving:
•Done by the traditional barber (nai).
•No sterilization of the instruments used;
•No idea of micro-organisms.
21

158. •(4) Smoking:
•Can spread tuberculosis.
•Burning end of the cigar in mouth-common custom among villagers
in Andhra Pradesh, is associated with oral cancer.
•Among patients with peptic ulcer, smokers have a higher death rate.
•A mother's smoking during pregnancy may retard the growth of the
foetus.
22

159. (5) Purdah:
• High incidence of tuberculosis.
• Deprives the beneficial effect of the sunrays.
(6) Sleep:
• Sleep on the ground for reasons of poverty
• Exposed to insect bites.
23

160. •(7) Wearing Shoes:
•• Walking barefoot → insect bite & parasite infestation (ANAEMIA-
MALNUTRITION)
•(8) Circumcision:
•• Prevalent custom among Muslims, which has a religious sanction.
24

161. •Sexual customs vary among different social, religious and ethnic
groups.
•Among the Irish, there are taboos against digital exploration of the
vagina.
•During menstruation women are forbidden to pray.
•Orthodox Jews are forbidden to have intercourse for seven days
after the menstruation ceases.
25

162. •Marriage is a sacred institution.
•It is the usual social custom in India to perform marriages early, at
about the age of puberty.
•Late marriages may create many problems.
•Because of the universality of marriage in India there are no
problems such as unmarried mothers and of illegitimate births, as in
the western countries.
•Child marriages are fortunately disappearing.
26

163. •In India mean age of marriage for boys-24yr & for girls-19yr.
Monogamy is the most universal form of marriage.
•Polygamy (marriage of one man with several woman) prevails in
certain communities.
•Polyandry (marriage of several men with one woman) is found
among the Todasof Nilgirihills, the inhabitants of JaunsarBawarin
Uttar Pradesh and the Nayarsin Malabar coast.
27

164. •Cultural factors are highly involved in matters of personal hygiene,
nutrition, immunization, seeking early medical care, family planning,
disposal of refuse, excreta etc…… In short THE WHOLE WAY OF LIFE
28

165. Quick revision
•MOTHER AND CHILD HEALTH
•SANITATION
•FOOD HABITS
29

166. FAQ
•HOW DOES CULTURE EFFECT IN INDIA
•SANITATION
•POPULATION
30

167. Assessment pattern
FAQ
Q1. how culture affects health in india.
31

168. Abbreviation
•nil
32

169. REFERENCES
•https://www.wcpt.org/
33

170. THANK YOU
For queries
Email: [email protected]

171. See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/228546479
Cultural Health Attributions, Beliefs, and Practices: Effects on Healthcare and
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172. 64 The Open Medical Education Journal, 2009, 2, 64-74

1876-519X/09 2009 Bentham Open

Open Access
Cultural Health Attributions, Beliefs, and Practices: Effects on Healthcare
and Medical Education
Lisa M. Vaughn*
,1
, Farrah Jacquez
2
and Raymond C. Baker
3

1
University of Cincinnati College of Medicine (UCCOM), Department of Pediatrics, Divisions of General and Commu-
nity Pediatrics and Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
2
University of Cincinnati College of Arts and Sciences, Department of Psychology, Cincinnati, Ohio, USA
3
UCCOM, Department of Pediatrics, Division of General and Community Pediatrics, Cincinnati Children’s Hospital
Medical Center, Cincinnati, Ohio, USA
Abstract: Health attributions influence health beliefs and subsequent health behaviors. Health attributions are partly
shaped by culture. In turn, cultural health attributions affect beliefs about disease, treatment, and health practices. Like-
wise, culture influences health and healing practices. Certain cultures have culture-bound syndromes about which medical
practitioners should be trained. Other sociocultural factors such as immigration, acculturation, and social support play sig-
nificant roles in health attributions and medical adherence. Culturally diverse patient populations require that medical
educators learn new methods of cultural assessment and treatment in order to be effective. Medical educators also need
teaching and learning approaches and philosophies that consider health attributions, beliefs, and practices of patients.
Keywords: Cultural health attributions, health beliefs, cultural diversity, culture and medical education, culture and healthcare.
INTRODUCTION
Medical educators have wide ranging responsibilities in
the education of physicians and other healthcare providers.
Keeping current in the rapidly growing body of scientific
knowledge in medicine is one of these responsibilities that
requires extensive self-directed learning and continuing
medical education activities. These activities provide the
core medical knowledge that is required to accomplish the
task of educating and training the next generation of
healthcare providers. Of equal importance in this education
is teaching the interpersonal interaction which must occur
between physicians and patients and is critical to diagnosis
and treatment of the diseases and conditions that initiated the
encounter. This interaction requires communication and in-
terpersonal skills which will build a trust between physicians
and patients that will encourage them to accept and follow
the medical advice (medical adherence) that will restore or
maintain wellness.
This interaction in the medical setting is complex and
requires shared knowledge about each other. This shared
knowledge requires active give-and-take communication,
empathy, and time to develop so that each party is comfort-
able with the other so the physician can provide the most
appropriate advice and care. Shared knowledge is the key to
establishing trust, which research shows to be an important
factor in medical adherence. When there are significant dif-
ferences between physician and patient, this process takes
more work and more understanding. Differences in culture in
its broadest sense (e.g. race, ethnicity, country of origin,


*Address correspondence to this author at the Cincinnati Children’s Hospi-
tal Medical Center, ML 2008, 3333 Burnet Avenue, Cincinnati, Ohio
45229-3039, USA; E-mail: [email protected]
socioeconomic status, gender) are present in virtually all
interactions and these differences must be acknowledged and
considered as healthcare decisions are made. This process is
a learned process and a key role for the medical educator to
teach.
In order to effectively address these issues, medical edu-
cators must have knowledge about cultural differences and
how those differences affect treatment decisions and they
must know how to obtain this information from patients.
This article will address several aspects of how culture af-
fects the health and well-being of patients, which will arm
medical educators with the information needed to effectively
teach this critical aspect of medicine. We will discuss several
specific cultures, but it is not within the scope of this article
to be inclusive. Healthcare providers who provide medical
care to patients or groups of patients with cultural back-
grounds unique to their practice need to learn from the pa-
tients the details of those cultures and how those culture’s
indigenous medical beliefs and practices might affect health
outcomes and interactions with the services provided in the
medical care setting.
Topics that will be covered in this article include 1)
health attributions and the effects of different cultures on
those health attributions; 2) models of common cultural
health beliefs; 3) cultural practices of health and healing; 4)
culture-bound syndromes (conditions found only in certain
cultures; 5) effects of immigration and other sociocultural
factors on health; 6) assessment of cultural background via
treatment and therapy approaches; and 7) cultural considera-
tions in medical education (relative to theories of adult learn-
ing).

173. Cultural Health Attributions, Beliefs and Practices The Open Medical Education Journal, 2009, Volume 2 65
ATTRIBUTIONS AND HEALTH
Like any behavior, the heart of health behavior is attribu-
tions - the causal explanation process used to understand the
world. Attributions have long been a focus for social psy-
chologists, who have determined that attributions play an
important role in both deciding to act and in decision-making
among alternative courses of action [1, 2]. Individuals tend
to have a consistent attributional style, but research shows
that attributional styles differ cross-culturally (e.g., [3-6]).
One example of cultural differences in attribution-making is
found in one of the most well-documented facets of attribu-
tional theory, the self-serving bias, or the tendency to make
dispositional attributions for successes and situational attri-
butions for failures (in other words, we take responsibility
for the good and deny the bad [7, 8]. Although the tendency
to look into the mirror with rose-colored glasses exists across
cultures, the self-serving bias is more pervasive in the West
than in more collectivist cultures
1
[9]. Research from West-
ern cultures has shown that having self-biases has been
linked to improved health practices, better coping strategies,
greater achievement, better health overall, and improved
mental outlook [10, 11].
People of diverse cultural backgrounds often make dif-
ferent attributions of illness, health, disease, symptoms and
treatment. Cultural differences in health attributions have
major implications for medical professionals because over
time, attributions play an essential role in the formation of
beliefs concerning health and illness (e.g., [12-14]). This
relationship in turn becomes reciprocal and health beliefs
form a cognitive schema that influences the way that people
make attributions. For instance, with regard to health beliefs
in the U.S., African Americans may be likely to attribute
illness externally to destiny or the will of God (equity attri-
butions) and believe in the healing power of prayer [15, 16].
As compared to ethnic minorities in the U.S., Anglo Ameri-
cans are likely to hold more traditional Western health be-
liefs such as individual responsibility for health and illness
[17, 18] and more “empirical” explanations of illness [12].
Because of the emphasis on micro-level and natural causes
of illness, many White Americans believe that illness can be
treated without reference to family, community or deities
[17].
Although very diverse, Latino populations as a whole are
likely to believe in attributional equity as the cause of illness
(e.g., God is punishing me for bad behavior and making me
ill) and utilize ethnomedical approaches to healthcare such as
santeros (practitioners/priests of Santería who combine in-
digenous rituals with the saints of the Catholic church),
herbalista (herbalists), and folk remedies [19]. Among the
U.S. Latino populations, Murguía and colleagues found that
U.S. acculturated Latino adults were less likely to make eq-
uity attributions about illness, and those Latinos who made
equity attributions were more likely to delay seeking
healthcare when sick [19]. Flores reported that Latino par-
ents sometimes have false beliefs about the cause of certain
illnesses and therefore are more likely to delay vaccinations
in children and use home remedies [20].


1
Collectivist cultures are those in which people tend to think of themselves as members
of groups such as families, work teams, tribes, and nations. People in collectivist cul-
tures are likely to put greater emphasis on the needs of the group rather than the needs
of individuals. Most Asian cultures are collectivist.
In comparison to Western populations, African patients
may be more likely to attribute illness to a spiritual or social
cause rather than a physiological or scientific cause [21]. As
such, medical practitioners in many African countries em-
phasize the whole person-body, mind and soul [21]. African
patients are more likely to expect health practitioners to pro-
vide an experiential and a spiritual reason why they have
been afflicted with illness. For example, one study found that
Ethiopians were more likely to attribute mental illness to
cosmic or supernatural causes, including curses or spirit pos-
session [22]. In order to effectively treat these illnesses,
remedies must be both material (e.g. herbal remedy) and
spiritual (e.g., amulets) explanations and techniques. Chip-
fakacha [23] notes that most black Africans attribute illness
to superstitious causes and therefore believe that disease is
due to 1) magic and evil spirits; 2) conditions for which
causes have been empirically determined; and 3) psychologi-
cal phenomena. For many Africans, the cause of disease re-
lates to conflict and tension between good/evil and har-
mony/disharmony [23].
MODELS OF CULTURAL HEALTH BELIEFS
Different cultural groups have diverse belief systems
with regard to health and healing in comparison to the West-
ern biomedical model of medicine. These belief systems may
include different disease models, wellness/illness paradigms
(e.g., Chinese medicine, magico-religious thinking), various
culturally-specific diseases and disorders, feelings about
healthcare providers and seeking Westernized healthcare,
and the use of traditional and indigenous healthcare practices
and approaches. Helman suggests that people attribute
causes of illness to: 1) factors within individuals themselves
(e.g., bad habits or negative emotional states); 2) factors
within the natural environment (e.g., pollution and germs);
3) factors associated with others or the social world (e.g.,
interpersonal stress, medical facilities, and actions of others);
and 4) supernatural factors including God, destiny, and in-
digenous beliefs such as witchcraft or voodoo [24]. Western-
ers tend to attribute the cause of illness to the individual or
the natural world whereas individuals from non-
industrialized nations are more likely to explain illness as a
result of social and supernatural causes [12]. In a study com-
paring African Americans, Latinos and Pacific Islanders with
White Americans on causal attributions of illness, the ethnic
minority groups rated supernatural beliefs as significantly
more important than White Americans [25]. There was no
difference between the groups about illness causation due to
interpersonal stress, lifestyle, environment and chance.
Stainton Rogers describes eight “theories” that people
use as a basis in thinking about health and illness: body as
machine, body under siege, inequality of access, cultural
critique, health promotion, robust individualism, God’s
power, and willpower [26]. In a study of British lay percep-
tions on health and recovery from illness, Furnham found
that strength of religious beliefs tend to predict fatalistic or
supernatural health-related beliefs; older people and those
with left wing political beliefs were more likely to empha-
size external causes and cures for illness; and people who
believed in alternative medicine were more likely to endorse
controllable or internal causes of health, illness and recovery
and less likely to believe in fatalistic or external causes [27].
Overall, the British participants emphasized psychological

174. 66 The Open Medical Education Journal, 2009, Volume 2 Vaughn et al.
and behavioral determinants of health and illness. Furnham
also examined health beliefs across the three cultures of
Britain, Uganda and South Africa and found that the African
participants were more likely to attribute illness to “evil oth-
ers” but all of the groups rated interpersonal stress as a po-
tential source of illness [12]. The British participants rated
fatalistic factors as extremely unimportant while both Afri-
can groups rated them as a marginally important contributor
to illness [12].
More recently, Jobanputra and Furnham [28] tested Hel-
man’s model of health beliefs [24] in British Caucasians and
British Gujarati Indian immigrants and found general sup-
port for the four domains with the Gujarati Indian immi-
grants being more likely to endorse supernatural explana-
tions of ill health as compared to the British Caucasians.
There was no significant difference in the two groups in
terms of attributions made to psychological factors, social
factors, and the external environment.
CULTURAL PRACTICES OF HEALTH AND HEAL-
ING
All cultures have disease theory systems which include
attributional concepts to explain illness causality. Three
commonly held paradigms of disease across cultures are
naturalistic, personalistic and emotionalistic [29-31]. Natu-
ralistic disease theories explain disease in objective, scien-
tific terms and have the core concept that illness occurs when
the body is out of balance. For instance, the Western bio-
medical model views disease as originating inside the body
due to a specific, identifiable “medical” cause or pathogen
(viral, bacterial, etc.). In the traditional biomedical model,
the pathogens need to be eradicated so that the person is
without disease and only then are they considered healthy.
The humoral system is another naturalistic disease theory
originating from Greek and Roman philosophers and popu-
larized by Hippocrates. According to Hippocrates, the body
contains four elements (humors): blood, phlegm, yellow bile
and black bile and health comes from an equal balance of the
four humors. In this theory, healing occurs by restoring the
proper balance of humors through removal (bleeding, starva-
tion) or replacing (special diets, medicine) the deficiency
[24].
Personalistic disease theory attributes illness to interven-
tion by an agent such as another human, witch, sorcerer,
non-human, or supernatural force. Emotionalistic disease
theories explain illness as caused by strong emotional states
(e.g., intense anger, jealousy, shame, grief or fright). The
personalistic and emotionalistic disease theories are easily
applied to patients of non-Western cultural backgrounds who
are familiar with and have faith in the medical beliefs and
practices from their own cultures [29, 30]. These health at-
tributions and beliefs, however, are significantly different
from those of Western medicine. Some Asian cultures be-
lieve in the yin and yang principle in which there is a balance
between opposite forces (e.g. positive and negative, light and
dark, hot and cold) that reflect the difference between health
and illness. Others believe that illnesses are caused by spirits
or ghosts [32].
In order to more effectively treat naturalistic, personalis-
tic, and emotionalistic aspects of illness, there has been an
increasing interest and training in osteopathic medicine and
complementary and alternative medicine in North America
and Europe (see for example, the article by Grossoehme et
al. in this supplement). Two well known cultural systems of
medicine and healing considered to be alternative by West-
ern standards of medicine are Chinese Medicine and
Ayurvedic Medicine. Traditional Chinese Medicine (TCM)
is based on the concept that the human body has intercon-
nected systems/channels (meridians) that need to stay bal-
anced in order to maintain health. TCM healing practices
include herbal medicine, acupuncture, dietary therapy, and
Shiatsu massage. Qigong (breathing and meditation practice)
is also closely associated with TCM [33]. Ayurvedic Medi-
cine is native to India. The Ayurvedic system is based on the
idea that every human contains a unique combination of
Doshas (the three substances of wind/spirit/air, bile, and
phlegm) that must be balanced for health. In addition,
healthy metabolism, digestion, and excretion are thought to
be vital functions of the body. Similar to TCM, Ayurvedic
Medicine also uses herbs, massage, meditation and Yoga as
healing practices [34].
The Western world has become more interested in alter-
native healing practices such as acupuncture, homeopathy,
herbal medicines, and spiritual healing [35]. Depending on
the model of health and cultural health beliefs, there are a
variety of possibilities for the treatment approach.
CULTURE-BOUND SYNDROMES
There are some physical and mental illnesses that are
unique to particular cultures and are influenced directly by
cultural belief systems and other cultural factors. In 1994,
the DSM (Diagnostic and Statistical Manual of the American
Psychiatric Association) added culture-bound syndromes
(i.e., troubling patterns of behavior/ experience that may not
fall into one of the traditional Western DSM diagnostic cate-
gories). Culture-bound syndromes are considered within the
specific culture to be illnesses or at a minimum afflictions
and the majority have local names. For example, dhat is a
disorder affecting Indian males that involves an intense fear
that losing semen will result in the depletion of vital energy.
Dhat is thought to occur through intoxicants, eating heated
foods, having a fiery constitution, and sexual excesses which
can cause fatigue, weakness, body aches, depression to the
point of suicidal feelings, anxiety, and loss of appetite [36].
Susto (magical fright) and mal de ojo (evil eye) are common
afflictions in Latin America. Susto is a disorder occurring
when the soul leaves the body after a frightful episode.
Symptoms include sleep disturbance, easy startling, palpita-
tions, anxiety, involuntary muscle tics, and other depressive
symptoms. Mal de ojo is an affliction caused by an admiring
glance from a more powerful/stronger person and usually
affects children. The symptoms of evil eye are fussiness,
refusal to eat or sleep, fever, and seizures. Prevention in-
cludes wearing special amulets and shielding babies from
direct eye contact. Treatment for evil eye can include physi-
cal contact from the perpetrator on head or prayer and ritual
with egg [37].
Eating disorders span both physical and mental bounda-
ries of cultural health. Eating disorders especially in highly
industrialized societies continue to rise [36]. Although in
some cultures, being stout and plump is associated with good
health and prosperity, and certain historical time periods

175. Cultural Health Attributions, Beliefs and Practices The Open Medical Education Journal, 2009, Volume 2 67
have celebrated more voluptuous women (consider the
Rubenesque woman) being thin and fit as a cultural ideal for
women has increased in popularity [36, 38, 39]. In the West-
ern world, especially with young women, the cultural notion
of the thin ideal makes it is clear that culture has a definite
influence on attitudes toward body size, body shape, and
eating behaviors [38, 40].
Somatization, or physical ailments due to stress or emo-
tional distress, is common especially in collectivistic socie-
ties perhaps because people avoid expressing psychological
complaints to families and friends [36]. In other words, a
person suffering from depression or anxiety might use soma-
tization as a culturally sanctioned way to signal distress [41].
Recognizing that there are culture-bound syndromes and that
the expression and formation differs culturally paves the way
for practicing culturally sensitive medicine and psychother-
apy. Otherwise, misdiagnosis can occur when ethnic and
cultural differences are not taken into account.
OTHER SOCIO-CULTURAL FACTORS RELATED
TO HEALTH ATTRIBUTIONS, BELIEFS, AND
PRACTICES
Cultural influences on health attributions and beliefs and
practices are well recognized. Shifts have occurred both in
the goals and approach of health and the definition of health
itself. Rather than curing being the end-goal of health, now
there is more emphasis on prevention of disease and promo-
tion of health internationally (e.g., appropriate diet and exer-
cise). Also increasing in importance has been the inclusion
of social and behavioral sciences to understand health prob-
lems and supplement the biological and medical technology
emphases [42]. This has underscored the importance of con-
text via community-based approaches [43] and the important
role that sociocultural, behavioral and environmental factors
play in health such as poverty, social support, medical ad-
herence/compliance with treatment regimen, resilience, ac-
culturation, immigration, and shared water sources. The
definition of health has been extended to include other as-
pects of well-being—“state of complete physical, mental,
and social well being, and not merely the absence of disease
or infirmity” [44]. This extension of the definition of health
encompasses well-being including quality of life, positive
mental health, and the consideration of culturally sensitive
approaches to healthcare as well as indigenous and alterna-
tive forms of healing as legitimate forms of treatment.
Immigration can have a significant effect on cultural
health beliefs and practices. Immigrants may have certain
infectious diseases which are endemic to the patient’s coun-
try of origin. Immigration itself can cause illness and disease
due to disrupted family and social networks, financial hard-
ship, and discrimination that prevent the maintenance of a
healthy lifestyle. Immigrants leave their countries for a vari-
ety of reasons including violence, economic hardships, or
natural disasters all of which cause extreme stress and even
physical injury [32]. Immigrants frequently work in low-
paying jobs, face poverty, lack health insurance, have limited
access to healthcare and social services, and have communi-
cation difficulties due to language differences [32].
Immigrant families may have trouble accessing
healthcare services for a variety of reasons. Language and
cultural barriers (including lack of cultural competent
healthcare providers), distance to care, cost of treatments,
lack of transportation, perceptions of lack of respect, dis-
crimination or racism, and a complex Western healthcare
system can all contribute to reduced access to healthcare
[45]. Immigrant families from collectivist countries in which
kinship is a strong value may view the role of caregiver as an
expected way of showing gratitude and love when a family
member is ill [46]—this may cause families to delay seeking
professional healthcare. Mir and Tovey note that some im-
migrant families may not seek healthcare because they lack
awareness of the healthcare services offered or they may find
the services culturally inappropriate or insensitive [47].
Compared to the U.S. born population, foreign born immi-
grants are twice as likely to lack health insurance [48]. Re-
cent immigrants to the U.S. have less contact in general and
less timely contact with the healthcare system [49] and are
more likely to have infectious diseases, especially tuberculo-
sis, Hepatitis B, and parasitic infections, as compared to U.S.
natives [50-53].
Immigrant children can have infectious diseases that
Western pediatricians are not used to diagnosing and treat-
ing, and immigrant children often lack adequate immuniza-
tion. The psychosocial factors of immigration may impose
additional stressors on immigrant children (e.g., disparities in
social, economic, and professional status from family’s
country of origin). Immigrant children may experience ongo-
ing mental health issues due to relocation and potential
atrocities experienced in home country and because of adap-
tation issues with school and peer groups. Like their parents,
immigrant children may lack of a larger social support net-
work of family and friends which was present in their coun-
try of origin [54]. As compared to U.S. born children, immi-
grant children may experience more dental problems and be
more at risk for nutrition problems which result in growth
deficiencies [54].
Much of the health-related information about immigrants
paints a bleak picture. However, immigrants in the U.S. are
generally better off on measures of health risk factors,
chronic conditions, and mortality as compared to U.S. na-
tives [55]. Recent immigrants to Westernized countries such
as the U.S. seem to have a health advantage in certain areas
which is known as the “healthy migrant” phenomenon. In-
terestingly, this health advantage, however, disappears dra-
matically and moves to health disparity. Length of time in
the U.S. is positively correlated with increases in low birth
weight infants, adolescent risk behaviors, cancer, anxiety and
depression, and general mortality [55]. Such a phenomenon
may be due to the loss of healthy resources from the country
of origin including social networks, cultural practices and
appropriate level of employment commiserate with educa-
tion [56]. Social support offers people a mechanism to cope
with stressful life events. Social support networks act as a
buffer mitigating the adverse health effects of physical and
mental stress [57]. Few studies have considered cultural dif-
ferences when it comes to the role of social support and pat-
terns of social relationships. One article by Kim and col-
leagues examines social support of Asians and Asian Ameri-
cans [58]. In this study, Asians and Asian Americans, as
compared to European Americans, were more reluctant to
ask for support from close others (extended family, friends,
etc.). This finding along with other similar findings suggests
that social support is culturally mediated and must be viewed

176. 68 The Open Medical Education Journal, 2009, Volume 2 Vaughn et al.
within the context of cultural beliefs about social relation-
ships. Social support has been shown to reduce psychologi-
cal distress during difficult times and has a variety of health
benefits including resilience to life threatening diseases. So-
cial support can act to prevent illness, speed recovery from
illness, and reduce the risk of death from serious disease
[58]. If social support is defined as the “explicit seeking and
receiving of support,” it appears that people from collectivis-
tic cultures are less likely to utilize social support than peo-
ple from individualistic cultures [58, p. 522].
While trying to adjust to a new culture, most immigrants
undergo a shared experience dealing with “unexpected ob-
stacles of poverty, discrimination, language, ambiguous im-
migration or legal status” [59, p. 282]. In most situations,
immigrants have been parted from family, friends, and are
estranged from the inherent security one attains with being a
member of a community [60]. Immigrants may also feel bur-
dened by the necessity of learning and/or enhancing non-
primary language skills and overcoming bias when seeking
employment, living arrangements, and schools. This process
is often hampered by an overwhelming sense of ineptness in
a new and different social environment. These cultural hur-
dles add to the “confusion and conflict, anomie, personal
disorganization, and a variety of other problems related to
social marginality….” [61, p. 78].
Immigrants and other non-dominant individuals can be
affected by acculturation. Smart and Smart define accultura-
tive stress as “the psychological impact of adaptation to a
new culture” with potential effects on physical health and
self-esteem [62, p. 25]. Acculturative stress occurs as immi-
grants lose touch with self-identifying constants, values and
social institutions of their former homeland. Theorists have
suggested that this process of acculturation may lead to
higher rates of mental disorders especially depression, ad-
justment, and general psychosocial dysfunction [42] all of
which result from “the processes of adaptation, accommoda-
tion, and acculturation which involve dynamic and synergis-
tic changes in the immigrants’ intrapsychic character, their
interpersonal relationships, and their social roles and
statuses” [61, p. 78]. Uncertainty about the future along with
heightened levels of anxiety may contribute to family dys-
function which can manifest as strict and authoritarian chil-
drearing practices including harsh disciplinary methods
(spanking) and possible severe, physical abuse [60]. Addi-
tionally, households in which both parents work means chil-
dren may be left unsupervised or neglected, and in some
cases, parents have left children behind in their native coun-
try. Both of these circumstances can increase conflicts sur-
rounding relationships, gender roles, and respect issues [60].
According to Berry, individuals and/or groups develop
one of four strategies toward acculturation [63, 64]. He de-
lineates these strategies on two dimensions: 1) maintenance
of heritage, culture and identity and 2) relationships sought
among groups, including both dominant and non-dominant
groups. Berry postulated that the four strategies of ethnocul-
tural groups include integration (maintain one’s original cul-
ture and have regular interactions with dominant culture),
separation (maintain cultural identity and avoid interactions
with dominant culture), assimilation (seek out interaction
with dominant culture and do not maintain cultural identity),
and marginalization (do not maintain cultural identity and
exhibit little interest in interactions with dominant culture).
The acculturation strategies chosen by individuals or groups
depend on the socio-cultural context of the larger society.
For instance, the integration strategy will only work in socie-
ties that value cultural diversity and have relatively low lev-
els of prejudice [42]. The dominant group and larger society
play an essential role in how acculturation occurs. Assimila-
tion when desired by the dominant culture is termed “melt-
ing pot” indicating a blending into the dominant group.
When separation is demanded by the dominant group, it is
“segregation”. Integration occurs when the dominant society
endorses mutual accommodation now widely called “multi-
culturalism”. In several studies, Berry’s acculturation strate-
gies have been examined in non-dominant acculturating
groups. Across these studies, the strategy of integration is
generally preferred over the three other strategies and mar-
ginalization is the least preferred. However, exceptions do
occur such as some Turks in Germany and Canada [42] who
prefer separation over integration.
Managing psychological acculturation is challenging
given the complexity of situational and personal factors that
contribute to the process [42]. First, there is the society of
origin and the society of settlement both of which have
unique cultural factors. The cultural characteristics of the
individual (developed from the society of origin) and the
cultural characteristics present in the society of settlement
(including political, economic, and demographic conditions)
must be understood in order to estimate cultural distance
between the two societies. The “migration motivation” of the
individual needs should be considered in order to understand
the individual’s degree of reactive (negative, constraining)
versus proactive (positive, enabling) factors toward the mi-
gration experience [42]. The presence or absence of a multi-
cultural ideology in the society of settlement gives important
information about openness to cultural pluralism and thus
acceptance of new members. Societies that support cultural
pluralism generally provide a better context for immigrants
due to the presence of multicultural institutions and corre-
sponding resources (i.e., culturally sensitive healthcare and
multicultural education curricula and services) and because
of less pressure to assimilate or be excluded [42].
Although the process of acculturation is fraught with
variability due to moderating factors that occur before or
during the process, Berry has outlined five primary features
that affect the process of psychological acculturation [63].
First, there is the stress or demand of dealing with and par-
ticipating in two different cultures. Second, individuals
evaluate the meaning of dealing with the two cultures and
depending on the appraisal, the changes that follow will ei-
ther be relatively easy or more challenging and problematic.
Third are the coping skills and strategies used by individuals
if the situation is deemed problematic. The fourth feature of
acculturation is the physiological and emotional reactions to
the situation. The fifth and last feature is the long term adap-
tation that may or may not be achieved depending on how
the other aspects of acculturation have been addressed.
Other factors related to cultural health attributions, be-
liefs, and practices include poverty and medical adherence.
Poverty remains pervasive and is a causal factor affecting
health and health disparities of vulnerable populations across
the globe. In 2005, The World Bank estimated that one

177. Cultural Health Attributions, Beliefs and Practices The Open Medical Education Journal, 2009, Volume 2 69
fourth of the population of the developing world lived below
the international poverty line of $1.25/day considering 2005
prices [65]. Because of the generational aspects and relation
to other cultural categories (i.e. race, ethnicity), some view
socioeconomic status and poverty as the key disadvantages
in society trumping other cultural categories such as gender
and race/ethnicity alone [66]. According to the World Health
Organization and other international groups, there is an ex-
tremely high rate of malnutrition of children under the age of
five in developing countries, and this is intimately tied to
socioeconomic status [67]. Socioeconomic status and pov-
erty have profound effects on children’s development. The
effects of poverty contribute to deficiencies in cognitive out-
comes, school achievement, emotional or behavioral out-
comes, and other areas like teenage pregnancy, increased
child abuse and neglect, increased violent crimes, and fear of
neighborhoods [68]. Poverty can seriously play a significant
role in health risks and barriers to care. One consequence of
poverty is substandard housing which can be a factor causing
stress and illness and may be even worse for immigrants
because of language barriers, large family sizes, and lack of
awareness about housing rights.
Patients’ health attributions and beliefs are also consid-
ered to be a major factor in medical adherence [69]. Depres-
sion, social support, and disease severity all play a signifi-
cant role in predicting adherence. This suggests that ap-
proaches to medical care need to effectively understand, as-
sess, and manage “language, culture, ethnicity and social
class to enhance patient adherence” [69]. Medical adherence
is second only to gaining access to appropriate healthcare in
directly affecting health outcomes of children and adults.
CULTURAL CONSIDERATIONS IN TREATMENT
AND THERAPY
One aspect of healthcare is how a culture organizes the
health system in terms of public or private access to care. In
some countries, access to healthcare is mediated by
socioeconomic factors, and only the wealthy receive quality
care. In other countries, healthcare is widely accessible by all
regardless of income level or insurance status. Many aspects
of culture can affect successful and effective treatment
approaches including religion and spirituality, social support
networks, beliefs and attitudes about causes and treatments,
socioeconomic status, and language barriers [40]. There is no
one perfect program that is culturally relevant for all
involved, however, approaching treatment and healing from
a culturally competent perspective should be paramount.
There is an undeniable need for culturally competent
healthcare services in order to address the health needs of an
increasingly diverse pluralistic world, eliminate existing
health disparities for minorities, mend a fragmented system
of care where some receive better services than others, and
meet the required cultural competency standards of accredi-
tation bodies within medical training. Within medicine, the
notion of cultural competency originated from medical an-
thropology with emphasis on the universality/relativity of
distress and disease. Kleinman described medicine as a cul-
tural system which requires careful cultural analysis to de-
termine disease and illness (e.g., what is considered illness in
one culture may be considered idiosyncratic or even divine
in another) [70]. Historically, most Western healthcare initia-
tives in cultural sensitivity have emphasized immigrants and
refugees with limited dominant language proficiency and
“buy-in” to Western norms. This approach became some-
what problematic because stereotyping was common and
therefore the unique experiences and perspectives of the
various immigrant and refugee groups were not recognized.
Cultural issues have increasingly become incorporated
into medical care as there has been greater recognition of the
intimate tie between cultural beliefs and health beliefs. Per-
ceptions of good and bad health and the causes of illness are
formed in a cultural context—what is acceptable in one cul-
ture is not in another. For example being overweight is
viewed as acceptable in some cultures—it may even be seen
as a sign of health and wealth. Many healthcare institutions
and community sites have incorporated linguistic compe-
tence into their services and have employed skilled interpret-
ers to manage linguistic diversity in their patients. However,
being linguistically competent is not the same as being cul-
turally competent. For example, although a site may have
interpreters available for patients, the site may still impose a
Western values-based healthcare and environment (e.g., cer-
tain feeding practices and dietary mandates, lack of religious
accommodation such as non-denominational spaces for
prayer, particular grieving expectations, non-recognition of
extended family members or “tribal” connections as imme-
diate family, etc.).
In medical education, the most commonly cited ap-
proaches to cultural competence are a combination of culture
specific information with enhancements to communication
and assessment skills. Some of the more popular models
include the L-E-A-R-N model [71], Kleinman’s questions
[70], cultural assessments [72, 73] and the ETHNIC frame-
work [74]. Green, Betancourt, and Carillo recommend a so-
cial context review of systems to examine the factors of so-
cial stressors, support networks, changes in environment, life
control, and literacy to understand cultural differences from a
deeper perspective [75]. Coming from international business
and sojourner work, Brislin uses critical incidents in order to
provoke thinking as participants reason through different
responses [76]. Many of the techniques/strategies share simi-
larities but concentrate on different aspects/dimensions of
cultural competence. Given the array of models and ap-
proaches, four main categories of culturally competent ap-
proaches to health and healing are suggested: 1) Collabora-
tive Approaches; 2) Personality Approaches; 3) Assessment
Techniques; and 4) Partnership/ Empowerment Strategies.
This classification is discussed in detail elsewhere [77].
The “life domains” approach is a nontraditional model
for healthcare that incorporates cultural health attributions,
beliefs and practices [78]. Life domains include language,
social affiliation, daily living habits, media, education, work,
intimate relations, childrearing, celebrations and events,
identity, values, religion/ spirituality, and health practices.
By examining life domains, healthcare providers can better
understand a family’s acculturation level and their world-
view which will assist in future healthcare provision.
Because physicians often lack time to do a thorough cul-
tural assessment or go to the depth that may be necessary
with some families or patients, other intermediaries such as
cultural brokers and lay health workersshould be considered.
Cultural brokers in the healthcare context are patient

178. 70 The Open Medical Education Journal, 2009, Volume 2 Vaughn et al.
advocates who act as liaisons, bridging, linking, or mediating
between the healthcare provider and the patient whose
cultural backgrounds differ in order to negotiate and
facilitate a successful health outcome [79]. “A cultural bro-
ker program has the potential to enhance the capacity of in-
dividuals and organizations to deliver healthcare services to
culturally and linguistically diverse populations, specifically
those that are underserved, living in poverty, and vulnerable”
[79, p. 6].
Lay health workers (LHW) or promoters, sometimes
referred to as Promotores when working with Latinos, and
by many other names
2
, provide public health services to
those who have typically been denied equitable and adequate
healthcare in many different cultures and countries. LHW
typically come from the communities in which they work.
They do health promotion, education and service delivery
within a limited scope of practice. “Lay health workers are
effective because they use their cultural knowledge and so-
cial networks to create change” [81, p. 516]. There is good
evidence that these type of models work because they are
culturally appropriate and integrated into communities [82].
As globalization continues to increase, other international
approaches to therapy should be considered especially ones
which consider trauma and violence at a cultural level. One
developmental approach to therapy is the HEARTS Model
[83]. The HEARTS model is not linear and should be ad-
justed according to client’s needs. The steps include:
H (Listening to H
istory) - providing the opportunity for
client to safely communicate their story; compassion-
ate connection necessary keeping in mind the honor
of a survivor’s willingness to relay their story to you
E (Focus on E
motions and Reactions) - focusing on the
emotions experienced throughout their experience; al-
lowing survivor to put words to his/her feelings about
what took place; increasing “feeling vocabulary”
A (A
sking Questions about Symptoms) - discussing
behaviors and physical symptoms
R (Explaining the Reasons for Symptoms) - helping
survivor make sense of symptoms; discussing physi-
cal and psychological symptoms as related to experi-
ence of trauma; normalizing; helping establish sense
of control; symptoms as method employed by body
for protection
T (T
eaching Relaxation and Coping Strategies) - in-
creasing sense of mastery and reducing symptoms; imagery and focused breathing; identifying coping
skills used during times of trauma, stress
S (Helping with S
elf-Change) - identify ways in which
survivor is the same and different after trauma; posi-
tive changes; river example


2
“Lay Health Promoters have gone by many names including: Village Health Workers,
Primary Healthcare Workers, Indigenous Healthcare Workers, Community Health
Workers, Community Health Assistants, Community Health Representatives, Medical
Auxiliaries, Rural Health Assistants, Community Health Aides, Brigadistas, Promo-
tores y Promotoras de Salud, Indigenous Health Aides, Lay Health Advisors, Auxiliary
Health Workers, Front Line Health Workers, Barefoot Doctors, Feldsher, Community
Health Promoters, Kaders, Prokesa. These terms are not necessarily interchangeable,
since each has its own practical, historical and political significance” [80] Nuestra
Comunidad Sana. Lay health promoters. [cited 2008 November 21]; Available from:
http://community.gorge.net/ncs/background/promoters.htm.
Folklore therapy or the use of Spanish dichos/refranes
(sayings or folklore) may be helpful to mental health practi-
tioners working with Spanish-speaking clients. Di-
chos/refranes are proverbs and sayings that use folk wisdom
to convey helpful information [84]. Dichos therapy groups
and individual therapies have been used successfully by
some psychotherapists [85]. Dichos often draw clients in
whereas other efforts fail because the sayings are relevant to
cultures and families, are associated with positive imagery,
and offer flexibility in the approach [85].
Ubuntu therapy [86] comes from the South African Zulu
Ubuntu philosophy which contains three dimensions: 1) psy-
chotheological; 2) intrapsychic; and 3) interpersonal and
“humanness”—(e.g., Zulu saying “umuntu ngu muntu nga
bantu” which means I am because we are). The psycho-
thelogical dimension views god as creator who breathed life
into all people. The intrapsychic dimension signifies the hu-
man essence enabling a person to become abantu (human-
ized being). The interpersonal dimension emphasizes rela-
tionships with others (kindness, good character, generosity,
hard work, discipline, honor, respect, ability to live in har-
mony with others). The overall goal of Ubuntu therapy is to
address conflicts within these three dimensions as related to
ubuntu values. The therapeutic process consists of hearing
the client’s story and determining at what level their conflict
exists and at what level to address the problem. Therapeutic
techniques and approaches include “burning platform,”
eclectic approaches and art.
Such alternative models to health and healing bring a
fresh perspective to cultural awareness and challenges. They
do not rely on traditional methods which tend to focus either
on improving the cultural competence of the provider, such
as through training, or improving the patient, such as through
culturally relevant informational materials. Making either
party to the healthcare transaction more competent is
laudable but addresses only the individual competency of
persons and does not address the interaction between family
and provider or the systemic competency of the organization.
More creative and comprehensive approaches are required
that do not rely on the traditional approaches of changing the
persons involved but instead focusing on the system as a
whole.
CULTURAL CONSIDERATIONS IN MEDICAL EDU-
CATION
A culturally diverse patient population requires that
medical educators modify their teaching and learning ap-
proaches and philosophies in order to take into account cul-
tural health attributions, beliefs, and practices of patients
who medical learners will encounter. This diversity man-
dates medical educators to teach medical learners how to
approach and manage illness in patients with different back-
grounds from their own. In order to emphasize the impor-
tance of the role that cultural attributions, values, beliefs and
practices play in health and healing, medical education pro-
grams need a teaching philosophy and curriculum in order to
incorporate approaches, interventions and models which take
such factors into account. Training in medical education
must incorporate the changing demographics, globalization,
and technology as sociocultural conditions that shape the
learning needs in today’s world [87]. Although changes and

179. Cultural Health Attributions, Beliefs and Practices The Open Medical Education Journal, 2009, Volume 2 71
diversity bring new possibilities for global interaction and
expanding learning modalities, they also may have a “splin-
tering” and “fragmenting” effect on society in which minori-
ties and marginalized people may have less access to educa-
tional resources and may experience oppression from the
dominant groups [87]. Critical theory and social change edu-
cation offer important insights for medical education and
learning concerning the political realm including socio-
cultural issues, globalization, oppression, and power within
society.
Critical theory originated from the Frankfurt School, an
informal name given to members of the Institute for Social
Research (Institut für Sozialforschung) at the University of
Frankfurt in Germany. The designees of the Frankfurt
School were considered neo-Marxist and therefore ardently
anti-capitalist. The School emphasized social theory, socio-
cultural research, and philosophy and became known for
critical theory, which focused on radical social change, and
was the antithesis of “traditional theory” in the positivistic
and scientific ideologies . The emphasis of critical theory in
general is the analysis and critique of power and oppression
in society. At its root, critical theory aims for human eman-
cipation from any circumstances that cause enslavement.
Critical theory emerged as a critique of capitalism and the
social inequalities (that result from capitalism), the
dominance of a single ideology, and the potential impact of
critical thought in the world [88].
There are many “critical theories” that have been
developed as a result of various social movements all of
which attempt to eradicate domination and oppression. All
critical theories share the emphasis on decreasing hegemony
and increasing human freedom with “utopian hopes for new
social responses in an alienated world” [89, p. 135]. As such,
approaches like feminism, critical race theory, post-colonial
theory, and queer theory can all be considered critical
theories. Social change education, an educational application
of critical theory, concerns itself with challenging injustices
across social, economic, and political realms [90]. Much of
the theoretical basis of critical theory and social change
education comes from Jürgen Habermas and Paulo Freire.
German philosopher and sociologist, Jürgen Habermas
was a later student of the Frankfurt school and is said to be
one of the more activist members from that school. Drawing
heavily on the ideas of Marx and yet rejecting some of
Marx’s work, Habermas’s approach is described as a creative
blend of systems theory, pragmatism, and analytic philoso-
phy all with the intent of application to society [89]. Haber-
mas was interested in a more equitable society and he be-
lieved that this could be achieved by empowering the mem-
bers of society to action through self-reflection and dialogue.
His writings promoted the idea that that we lack freedom in
society and that powerful “systems” (government, corpora-
tions, media, etc.) are manipulating individuals and therefore
not meeting our needs. He believed that communication has
become a controlling tool primarily used to satisfy the selfish
interests of the communicator regardless of the recipient’s
needs or interests [91]. Habermas advocated that we should
engage in “communicative action” (a coming together to
engage in dialogue for the purpose of common action) in
order to become empowered against the hegemonic system.
This theory of communicative action includes everyday
communication practices and proposes that reason comes out
of mutual understanding within ordinary human communica-
tion.
Welton and others have brought Habermas’s version of
critical theory to adult education and have pointed to the
applicability of his ideas like reflective discourse and learn-
ing communities [87]. The ideal conditions that Habermas
proposes for authentic reflective discourse (dialogue, discus-
sions) to occur are comprehensibility, sincerity, truth, and
legitimacy. A key element of his notion of discourse is that it
should involve an honest attempt to put aside bias and be
open to all sides of an argument in order to come to consen-
sus [87]. In terms of learning communities, Habermas advo-
cates determining whether institutions and adult educators
are enabling us to reach our full potential by not being too
concerned with planning classes or arranging classrooms and
failing to consider more “political” issues like accessibility
of education [87].
Paulo Freire was a Brazilian educator and activist who
proposed a social emancipatory view of learning. This is
sometimes called popular education, liberating education,
social change education, or critical pedagogy. He follows in
the footsteps of Habermas because the basis of his approach
is “critical” in nature and critiques the oppressive systems of
society. Freire rose in distinction during the 1960s and 70s
when anti-colonialism was strong in the Third World. He
examined education in terms of its emancipatory potential
which appealed to the oppressed masses in Third World
countries. His theory emphasized that “knowledge” came
from those in power, so people need to deconstruct that
knowledge and create new knowledge that is liberatory in
nature. Freire found traditional educational practices con-
straining and non-liberating because he believed the op-
pressed have been conditioned to identify with the oppressor
and view them idealistically [92]. He reasoned that if the
oppressed wanted freedom they had to use critical con-
sciousness to examine things as they truly exist in society.
Freire is well known for his participatory model of liter-
acy described in his well-known book, Pedagogy of the Op-
pressed, first published in 1970. Overall, Freire critiques the
dominant “banking model” of education and says that educa-
tion in general is suffering from “narration sickness” [93, p.
71]. He says that traditional education is one-way with the
teacher narrating the content to the students who are passive
recipients of content who are required to memorize and re-
peat it back to the teachers. The “banking” metaphor derives
from the teachers who “deposit” ideas into the students who
become “depositories” and “automatons” waiting to be filled
with the knowledge and wisdom of the all-powerful teachers.
Freire views this as an inherently oppressive model and in-
sists that such a banking model goes directly against the idea
of dialogue and gets in the way of a critical orientation to the
world [93]. Students are controlled, knowledge is static, the
teacher is the authority, and the realities of life are trivialized
which results in a dehumanized and paternalistic model that
reinforces the inequalities and injustices of society.
Instead Freire calls for a “problem-posing” (authentic or
liberating) education where “men and women develop their
power to perceive critically the way they exist in the world
with which and in which they find themselves; they come to
see the world not as a static reality but as a reality in the

180. 72 The Open Medical Education Journal, 2009, Volume 2 Vaughn et al.
process of transformation” [93, p. 83]. Problem-posing edu-
cation starts with a transformation of the teacher-student
relationship whereby teachers become both teachers and
learners and vice versa. Dialogue is an essential process
within this model and the relationship between teachers and
students is “horizontal” rather than hierarchical. In this
model, the educational situation is marked by posing prob-
lems that relate to the real world which encourages critical
reflection about these problems resulting in a continual creat-
ing and recreating of knowledge by both teachers and stu-
dents. According to Freire, problematizing is a three-phased
process that involves asking questions with no predeter-
mined answers. Phase one is a naming phase where the prob-
lem is identified. Phase two is the reflection phase to dis-
cover why or how the situation can be explained. The third
phase is an action phase marked by questions about changing
the situation or considering options.
Prabhu summarizes the primary differences of the bank-
ing model and the problem-posing model in terms of world,
teacher, student, teacher/student relation, style of communi-
cation, social function of education, and application to extra
classroom situations [92]. He indicates that problem-posing
education is dynamic and malleable. The teacher is a co-
learner; the student is actively engaged in the process of
learning; the teacher/student relationship is equalized; com-
munication is dialogical and democratic; the social function
of education is questioning for the purpose of transforming
social reality; and learning is seen as lifelong and complex.
Ultimately such a model, according to Freire, is a “revo-
lutionary futurity” because teachers and students learn that
dominant ideas can be challenged and oppressive systems
transformed which helps them move forward and transcend
the past [93, p. 84]. Although some scholars have mistakenly
labeled Freire’s educational ideas as too laissez-faire, he
asserts that problem-posing education is purposeful and rig-
orous. The teacher still gives structure and helps to facilitate
the direction of learning through constructive feedback and
goal setting.
Although critical theory and social change education cer-
tainly have their critics, the approaches bring more to the
table compared to other theories that address diversity and
the socio-cultural-political issues within education and learn-
ing. The intent of critical theory and social change education
is “to extend democratic socialist values and processes, to
create a world in which a commitment to the common good
is the foundation of individual well-being and adult devel-
opment” [94, p. 21]. The strength of such approaches is that
they challenge the existing hegemony in hopes of transform-
ing society for the better for all people even the disenfran-
chised or marginalized. The main weaknesses seem to be
that such approaches are not always pragmatic. Although
they call for change, they do not always offer specific strate-
gies to effect change [87].
CONCLUSION
Given the increasing diversity of cultural health
attributions, beliefs and practices, it is crucial that the field of
medicine prioritizes such factors in healthcare and medical
education. The following aspects of culture suggest ways to
contribute to successful and meaningful interactions with
culturally different individuals and groups at both the pa-
tient/provider and the medical education levels:
• Culture is multi-faceted, complex and pervasive. Cul-
ture encompasses more than nationality, race or eth-
nicity and is intimately related to beliefs and prac-
tices.
• Many external factors impact culture. These include
immigration, acculturation, discrimination, economic
status, and social support/networks.
• Many cultural factors impact health. These include
health attributes, culture-specific health and healing
practices, and access to culturally competent
healthcare.
• Bi-lingual does not mean bi-cultural and multilingual
does not mean multicultural. Language is one aspect
of culture, but for many people it is not the most im-
portant. Do not make assumptions about an individ-
ual’s cultural experience based on the language they
speak on initial presentation.
• Be humble, humanistic and hopeful. We are all more
similar than we are different especially when it comes
to basic human needs and rights. Admit to what you
do not know and be open to learning from those of
different backgrounds than your own. (e.g., patients,
students, parents, local leaders).
• Collaborate WITH people rather than ON them! Pro-
grams, interventions and healthcare are more success-
ful if members of the target population are involved
from the beginning and contribute to program devel-
opment.
• Cultural competency is a lifelong endeavor. Because
culture is fluid and constantly developing, it is impos-
sible for even the most dedicated medical profes-
sional to know everything about every culture for
every person.
• Seek information to help your understanding of tradi-
tional health beliefs and practices including religious
practices that impact health and well being.
• Relationships, relationships, relationships. Building
relationships based on mutual trust will enable cul-
tural information sharing.
• If you have questions about someone’s cultural back-
ground and beliefs, ASK. Most people welcome the
opportunity to talk about themselves and their back-
ground and appreciate your interest.
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Received: February 10, 2009 Revised: May 21, 2009 Accepted: May 30, 2009

© Vaughn et al.; Licensee Bentham Open

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(http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the
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183. Standards of Physical Therapy Practice
The World Confederation for Physical Therapy (WCPT) aims to improve the quality of global
healthcare by encouraging high standards of physical therapy education and practice. WCPT
recognises the absolute importance of the development and documentation of agreed
standards for the practice of physical therapy in support of this.

The Standards of Physical Therapy Practice are WCPT’s statement of performance and
conditions that they expect physical therapists to aspire to in order to provide high quality
physical therapy professional services to society. They provide the foundation for the
assessment of physical therapy practice. They represent the physical therapy profession’s
commitment to society to promote optimal health and function in individuals and populations by
pursuing excellence in practice. These standards provide the basis for physical therapy
practice in all settings, including but not limited to, clinics, hospitals, schools, and commercial
premises.
Detail is provided on standards covering: administration and practice management, communication, community responsibility, cultural competence, documentation, education,
ethical behaviour, informed consent, legal, patient/client management, personal/professional
development, quality assurance, research and support personnel.
The standards have been developed with input from and specific reference to the Member
Organisations (MOs) of WCPT. However, the standards may also be used by physical
therapists in countries where a WCPT member organisation does not currently exist.
These standards are considered to be achievable Standards of Practice. They are presented
as ideal standards to which all physical therapists should aspire as part of their professional responsibility. At the same time, it is recognised that some interpretation will be required based
on the setting, resources and support systems available. It is acknowledged that individual
MOs of WCPT may have their own more detailed Standards of Practice and these are not
intended to replace them.

184. Page 2 of 16

These standards apply to all physical therapists, whether newly qualified or highly specialist, in
direct or indirect contact with patients/clients, carers, and other professional colleagues.
Physical therapy practice is more than direct patient/client contact;
1
it includes how services are
structured, managed and delivered. These standards reflect this. As highlighted in section 1.2,
collaboration is essential to delivering high quality physical therapy services. Some of these
standards cannot be achieved without collaboration with appropriate colleagues from other
professions and health service managers.
The Standards of Practice document is a tool that may be used by physical therapists,
patients/clients, members of the public, managers, and others who have an interest in providing
or receiving high quality physical therapy services.
2
1. ADMINISTRATION AND PRACTICE MANAGEMENT
1.1 Administration
1.1.1 A physical therapist is responsible for the direction of the physical therapy
service.
1.1.2 The physical therapist who is responsible for the direction of the physical
therapy service shall:
1.1.2.1 Ensure compliance with statutory (e.g., local, state, regional, federal,
provincial, institutional and national) requirements
1.1.2.2 Ensure compliance with current professional documents, including
Standards of Practice for Physical Therapy and Code of Ethics
1.1.2.3 Ensure that services are consistent with the mission, purposes, and
goals of the physical therapy service
1.1.2.4 Review and updates policies and procedures and ensures that
services are provided in accordance with them
1.1.2.5 Provide for training of physical therapy support personnel that
ensures continued competence for their job description
1.1.2.6 Provide for continuous in-service training on safety issues and for
periodic safety inspection of equipment by qualified individuals
1.1.2.7 Undertake an evaluation of clinical practice, ensuring that:

1
The term patient/client is used in this document as a generic term to refer to individuals and groups of
individuals who can benefit from physical therapy interventions/treatments.
2
Physical Therapy and Physiotherapy: The professional title and term used to describe the profession’s
practise vary and depend largely on the historical roots of the profession in the country of the WCPT
Member Organisation. The most generally used titles and terms are ‘physical therapist’ or
‘physiotherapist’ and ‘physical therapy’ or ‘physiotherapy’. Physical therapist and physical therapy are
used in this document but may be replaced by WCPT Member Organisations in favour of those terms
officially used by them and their members without any change in the meaning of the document.

185. Page 3 of 16
1.1.2.7.1 Confidentiality is maintained throughout evaluation and
audit activities
1.1.2.7.2 Clinical documentation is audited regularly
1.1.2.7.3 Clinical audit tools are used to evaluate clinical practice
1.1.2.7.4 Where it is undertaken, physical therapists participate in
multiprofessional audit
1.1.2.7.5 Recommendations following audit are documented
1.1.3 The physical therapy manager ensures the provision of the following, as
appropriate:
1.1.3.1 A job description for each staff member and a formal appraisal
system
1.1.3.2 Regular staff meetings
1.1.3.3 Annual report
1.1.3.4 Objectives of the organisation and an organisation chart
1.1.3.5 All policies and procedures are available to staff
1.2 Collaboration
1.2.1 The physical therapy service collaborates with all professionals as
appropriate.
1.2.2 The physical therapist shall be aware of the qualifications and roles of other
professionals involved in comprehensive patient/client care/management and
practices in collaboration with them to provide quality patient/client services.
1.2.3 The collaboration when appropriate:
1.2.3.1 Uses a team approach to the care of patients/clients
1.2.3.2 Provides instruction of patients/clients and families
1.2.3.3 Ensures professional development and continuing education
1.2.4 When physical therapists are members of a multiprofessional team providing
services for the patient/client, they will ensure that:
1.2.4.1 Relevant information is sought and communicated promptly and
clearly within the team
1.2.4.2 A system is in place for written communication with other members of
the team
1.2.4.3 Operational policies exist for cross referral to other professionals in
the team, discharge, and transfer of patients/clients

186. Page 4 of 16
1.2.4.4 Evidence exists of participation in case conferences, rounds,
individual patient/client programme meetings, discharge planning,
and collaborative patient/client records
1.2.4.5 The physical therapy goals comply with the team goals
1.3 Communication
1.3.1 Communication links exist between staff, the director/manager of the service,
and the organisation to optimize the quality of the patient/client services
provided.
1.3.2 The physical therapy director/manager ensures the appropriate
communication and availability of service specific and organisational policies, procedures and documents including:
1.3.2.1 A job/position description for each staff member and a formal
appraisal system
1.3.2.2 Annual report
1.3.2.3 Objectives of the organisation and an organisation chart
1.4 Fiscal Management
1.4.1 The director/manger of the physical therapy service, in consultation with
physical therapy staff and appropriate administrative personnel participates in
planning for, and allocation of, resources. Fiscal planning and management of
the service is based on sound accounting principles.
1.4.2 The fiscal management plan:
1.4.2.1 Includes a budget that provides for optimal use of resources
1.4.2.2 Ensures accurate recording and reporting of financial information
1.4.2.3 Ensures compliance with legal requirements
1.4.2.4 Allows for cost-effective utilization of resources
1.4.2.5 Uses a fee schedule that is consistent with the cost of physical
therapy services and that is within customary norms of fairness and
reasonableness
1.4.2.6 Considers option of providing pro bono services
1.5 Mission, Purposes, and Goals
1.5.1 The physical therapy service has a statement of mission, purposes, and goals
that reflects the needs and interests of the patients/clients served, the physical
therapy personnel affiliated with the service, and the community.
1.5.2 The statement of mission, purposes, and goals:

187. Page 5 of 16
1.5.2.1 Defines the scope and limitations of the physical therapy service
1.5.2.2 Identifies the goals and objectives of the service
1.5.2.3 Is reviewed annually
1.6 Organisational Plan
1.6.1 The physical therapy service has a written organisational plan that:
1.6.1.1 Describes relationships among components within the physical
therapy service and, where the service is part of a larger
organisation, between the service and the other components of that
organisation
1.6.1.2 Ensures that the service is directed by a physical therapist
1.6.1.3 Defines supervisory structures within the service
1.6.1.4 Reflects current personnel functions
1.7 Physical Setting
1.7.1 The physical setting is designed to provide a safe and accessible environment
that facilitates fulfilment of the mission, purposes, and goals of the physical
therapy service. The equipment is safe and sufficient to achieve the purposes and goals of physical therapy
1.7.2 The physical setting is planned, constructed, and equipped to provide
adequate space and the proper environment to meet the professional, educational, and administrative needs of the service with safety and efficiency
1.7.3 The physical setting shall:
1.7.3.1 Meet all applicable legal requirements for health and safety
1.7.3.2 Have fire exits that are clearly marked and kept free of obstruction
1.7.3.3 Meet space needs appropriate for the number and type of
patients/clients served
1.7.3.4 Provide reception and waiting facilities with consideration to people
with disabilities
1.7.3.5 Provide treatment areas that offer privacy, security, and comfort
1.8 Equipment
1.8.1 The equipment meets all applicable legal requirements for health and safety
and accessibility.
1.8.2 The equipment is inspected and maintained routinely.

188. Page 6 of 16
1.9 Policies and Procedures
1.9.1 The physical therapy service has written policies and procedures that reflect
the mission, purposes, and goals of the service, and are consistent with the
WCPT Member Organisation’s standards, policies, positions, guidelines, and
Code of Ethics.
1.9.2 The written policies and procedures:
1.9.2.1 Are reviewed regularly and revised as necessary
1.9.2.2 Meet the legal requirements
1.9.2.3 Apply to, but are not limited to:
ΠCare of patients/clients, including guidelines
ΠClinical education
ΠClinical research
ΠCollaboration
ΠCompetency assessment
ΠContinuing education/professional development
ΠCriteria for access to care
ΠCriteria for initiation and continuation of care
ΠCriteria for referral to other appropriate health care providers
ΠCriteria for termination of care
ΠDisaster plan
ΠDocumentation
ΠEmergency plans (to include patient/client and facility)
ΠEquipment maintenance, including urgent repair and replacement
ΠFiscal management
ΠImprovement of quality of care and performance of services
ΠInfection control
ΠJob/position descriptions
ΠPatient and environmental safety and health issues
ΠPersonnel
ΠRights of patients/clients
ΠStaff orientation
ΠTransfer of patients

189. Page 7 of 16
1.10 Referral
1.10.1 A referral system is in place to ensure that patients/clients can access a
physical therapist either by direct access or from an appropriate referral
source.
1.11 Staff
1.11.1 The physical therapy personnel affiliated with the physical therapy service
have demonstrated competence and are sufficient in number to achieve the
mission, purposes, and goals of the service.
1.11.2 The physical therapy service has staff that:
1.11.2.1 Meet all legal requirements regarding licensure, registration and
certification of appropriate personnel
1.11.2.2 Ensure that the level of expertise within the service is appropriate to
the needs of the patients/clients served
1.11.3 Staff members are aware of their responsibilities as employees under any
appropriate Health and Safety Acts and attend training sessions as necessary.
1.11.4 Staff participate in the quality assurance programme, and information from
quality assurance activities is accessible to all staff.
1.12 Staff Development
1.12.1 The physical therapy service has a written plan that provides for appropriate
and ongoing staff development.
1.12.2 The staff development plan:
1.12.2.1 Includes self-assessment, individual goal setting, and organisational
needs in directing continuing education and learning activities
1.12.2.2 Includes strategies for lifelong learning and professional and career
development
1.12.2.3 Includes mechanisms to foster mentorship activities
2 COMMUNICATION
2.1 The physical therapist knows that communication is an integral element of every
patient/client and professional encounter and facilitates the provision of effective and appropriate physical therapy services.
2.2 The physical therapist communicates and coordinates all aspects of patient/client management including the results of the initial examination/assessment and
evaluation, diagnosis, prognosis, plan of care/intervention/treatment, response to
interventions/treatment, changes in patient/client status relative to the

190. Page 8 of 16
interventions/treatments, re-examination, and discharge/discontinuation of
intervention/treatment and other patient/client management activities.
2.3 The physical therapist provides the patient/client or parents, guardians, carers, or
others designed to act on the behalf of the patient/client who is not competent, with
relevant clear, concise written and verbal information ensuring that:
2.3.1 The role of the physical therapist is explained during the initial contact
2.3.2 The discretion of the physical therapist is used in the discussion of the
diagnosis with the patient/client
2.3.3 Treatment plans, goals, and predicted outcomes are agreed upon between the
patient/client and the physical therapist and any changes in previously agreed
intervention/treatment plans are discussed and agreed upon with the
patient/client
2.4 The physical therapist, when communicating with appropriate carers, respects the wishes of both the patient/client and carer.
2.5 The physical therapist communicates with other physical therapists to ensure
continuity of effective patient/client services and facilitates the use of available clinical
expertise.
2.6 The physical therapist, when communicating with members of a multiprofessional
team providing services for the patient/client, ensures that information is both sought
and communicated promptly and clearly within the team, and a system exists for
written communication with other members of the team.
3 COMMUNITY RESPONSIBILITY
3.1 The physical therapist takes an active part and demonstrates community responsibility by, for example, participating in community and community agency
activities, educating the public, formulating public policy, providing consultative
services for the MO’s public health infrastructure, or providing pro bono physical
therapy services.
4 CULTURAL COMPETENCE
4.1 The physical therapist acquires skills to better understand people from differing
cultures in order to achieve the best possible health outcomes.
4.2 Physical therapists show respect and sensitivity to people and communities, taking into account their spiritual, emotional, social and physical needs.
4.3 Physical therapy is planned and delivered in a way that respects cultural values,
requirements and variations.
4.4 Physical therapists should identify their own cultural realities, knowledge and
limitations.

191. Page 9 of 16
4.5 The cultural values of the physical therapist are acknowledged and respected.
5 DOCUMENTATION
5.1 The physical therapist clearly documents all aspects of patient/client
care/management including the results of the initial examination/assessment and
evaluation, diagnosis, prognosis, plan of care/intervention/treatment,
interventions/treatment, response to interventions/treatment, changes in patient/client
status relative to the interventions/treatment, re-examination, and
discharge/discontinuation of intervention and other patient/client management
activities.
5.2 Physical therapists ensure that the content of documentation:
5.2.1 Is accurate, complete, legible and finalised in a timely manner
5.2.2 Is dated and appropriately authenticated by the physical therapist
5.2.3 Records equipment loaned and/or issued to the patient/client
5.2.4 Includes, when a patient/client is discharged prior to achievement of goals and
outcomes, the status of the patient/client and the rationale for discontinuation
5.2.5 Includes reference to appropriate outcome measures, where possible
5.3 Physical therapists make sure that documentation is used properly by ensuring
it is:
5.3.1 Stored securely at all times in accordance with legal requirements for privacy
and confidentiality of personal health information
5.3.2 Only released, when appropriate, with the patient’s/client’s permission
5.3.3 Consistent with reporting requirements
5.3.4 Consistent with international and national data standards where possible
6 EDUCATION
6.1 The physical therapist contributes to the education of health professionals.
6.1.1 The physical therapist participates in the education of students by supervision.
6.1.2 The physical therapist educates and provides consultation to other health
professionals regarding the purposes and benefits of physical therapy.
6.2 The physical therapist contributes to the education of the public.
6.2.1 The physical therapist educates and provides consultation to consumers, the
general public, community organisations, clubs, and associations regarding
the purposes and benefits of physical therapy, and the roles of the physical
therapist and other support personnel.

192. Page 10 of 16
7 ETHICAL BEHAVIOUR
7.1 The physical therapist practices according to a Code of Ethics that is consistent with
WCPT’s Ethical Principles.
8 INFORMED CONSENT
8.1 The physical therapist shall inform the patient/client verbally, and where required in
writing, of the nature, expected duration, and cost of intervention/treatment prior to
the performance of such activities.
8.2 The physical therapist shall document in the clinical notes when consent is received,
implied, or expressed. Once consent has been received, the intervention/treatment
plan may be instituted
8.3 Patients/clients, wherever possible, are given information as to the physical therapy
interventions/treatments proposed, so that the patient/client is:
8.3.1 Aware of the findings of the examination/assessment
8.3.2 Given an opportunity to ask questions and discuss the preferred
interventions/treatments, including any significant side effects, with the
physical therapist
8.3.3 Given the opportunity to decline particular modalities in the plan of
intervention/treatment
8.3.4 Given the opportunity to discontinue intervention/treatment
8.3.5 Encouraged to be involved in the examination/assessment process and to
volunteer information that may have a bearing on the physical therapy
programme
8.4 For patients/clients who are determined not competent to give informed consent (e.g.,
children, individuals who are unconscious, have mental health problems, or are
elderly and confused), consent is obtained wherever possible from parents,
guardians, carers, or others designed to act on their behalf. In each case, the physical therapist shall:
8.4.1 Ascertain which agency or person is acting on the patient’s/client’s behalf
8.4.2 Provide the patient’s/client’s agent with all relevant information, and give the
agent the opportunity to decline the physical therapy intervention
8.4.3 Provide information to patients in such a way as to allow for nonverbal
responses
8.5 The physical therapist obtains the consent of the patient/client prior to touching the
patient/client in any part of the patient/client management process.
8.6 The physical therapist obtains written consent of the patient/client for participation in
teaching of physical therapy and in physical therapy research.

193. Page 11 of 16
8.7 The procedure for informed consent must comply with local legislation.
9 LEGAL
9.1 The physical therapist complies with all the laws and legal requirements of the
jurisdiction in which they practice and the body which regulates the practice of
physical therapy.
9.2 The physical therapist possesses a license to practice that is granted for the
legislative jurisdiction in which the physical therapist practices.
9.3 The physical therapist shall not release patient information to a third party without
consent of the patient/client or legal authorisation.
9.4 The physical therapist with first-hand knowledge shall report violations by physical
therapy personnel of laws and legal requirements of the jurisdiction.
10 PATIENT/CLIENT MANAGEMENT/CARE
10.1 Initial Examination/Assessment, Evaluation, Diagnosis, and Prognosis
10.1.1 The physical therapist performs an initial examination/assessment and
evaluation to establish a diagnosis and prognosis prior to intervention/treatment.
10.1.2 The physical therapist examination:
10.1.2.1 Is documented, dated, and appropriately authenticated by the
physical therapist who performed it
10.1.2.2 Identifies the physical therapy needs of the patient/client
10.1.2.3 Incorporates appropriate tests and measures to facilitate outcome
measurement
10.1.2.4 Produces data that are sufficient to allow evaluation, diagnosis,
prognosis, and the establishment of a plan of care/interventions/treatment
10.1.2.5 May result in recommendations for additional services to meet the
needs of the patient/client
10.1.2.6 Provides written evidence of the reasons why no further management
has been given to the patient/client and, when appropriate, to the
carer
10.2 Plan of Care/Interventions/Treatments
10.2.1 The physical therapist establishes a plan of care/interventions/treatments and
manages the needs of the patient/client based on the examination, evaluation,
diagnosis, prognosis, goals, and outcomes of the planned interventions/treatments for identified disabilities (impairments, activity

194. Page 12 of 16
limitations and participation restrictions) and/or for prevention, health
promotion, fitness, and wellness.
10.2.2 The physical therapist collaboratively involves the patient/client and others as
appropriate in the planning, implementation, and assessment of the plan of
care/intervention/treatment.
10.2.3 The physical therapist, in consultation with appropriate disciplines, plans for
discharge of the patient/client taking into consideration achievement of
anticipated goals and expected outcomes, and provides for appropriate follow-
up or referral.
10.2.4 The plan of care/intervention/treatment:
10.2.4.1 Is based on the examination, evaluation, diagnosis, and prognosis
and informed by current evidence
10.2.4.2 Identifies goals and outcomes
10.2.4.3 Describes the proposed intervention/treatment, including frequency
and duration
10.2.4.4 Includes documentation that is dated and appropriately authenticated
by the physical therapist who established the plan
10.3 Interventions/Treatment
10.3.1 The physical therapist provides, or directs and supervises, the physical
therapy intervention/treatment consistent with the results of the examination,
evaluation, diagnosis, prognosis, and plan of care/intervention/treatment.
10.3.2 The intervention/treatment:
10.3.2.1 Is based on the examination, evaluation, diagnosis, prognosis, plan
of care/intervention/treatment and informed by current evidence
10.3.2.2 Is provided by or under the ongoing direction and supervision of the
physical therapist
10.3.2.3 Is provided in such a way that directed and supervised
responsibilities are commensurate with the qualifications and the legal limitations of support personnel
10.3.2.4 Is altered in accordance with changes in response or status
10.3.2.5 Is provided at a level that is consistent with current physical therapy
practice
10.3.2.6 Is interprofessional when necessary to meet the needs of the
patient/client

195. Page 13 of 16
10.3.2.7 Documentation of the intervention is consistent with established
guidelines
10.3.2.8 Is dated and appropriately authenticated by the physical therapist
10.4 Re-examination
10.4.1 The physical therapist re-examines the patient/client as necessary during an
episode to evaluate progress or change in patient/client status and modifies
the plan accordingly or discontinues physical therapy services.
10.4.2 The physical therapist re-examination:
10.4.2.1 Is documented, dated, and appropriately authenticated by the
physical therapist who performs it
10.4.2.2 Includes modifications to the plan of care/intervention/treatment
10.5 Discharge/Discontinuation of Intervention/Treatment
10.5.1 The physical therapist discharges the patient/client from physical therapy
services when the anticipated goals or expected outcomes for the
patient/client have been achieved.
10.5.2 The physical therapist discontinues intervention/treatment when the
patient/client is unable to continue to progress toward goals or when the physical therapist determines that the patient/client will no longer benefit from
physical therapy.
10.5.3 The physical therapist recognises that the patient/client has a right to
discontinue treatment/intervention at any time.
10.6 Patient/Client Collaboration
10.6.1 Within the patient/client management process, the physical therapist and the
patient/client establish and maintain an ongoing collaborative process of
decision-making that exists throughout the provision of services.
10.7 Referral
10.7.1 Where the examination, diagnostic process, or any change in status reveals
findings outside the scope of knowledge, experience, and/or expertise of the
physical therapist, the patient/client shall so be informed and referred to the
appropriate practitioner/professional.
10.7.2 A referral system should be in place to other clinical specialists.
10.7.3 A procedure should be in place for the transfer of patients/clients.

196. Page 14 of 16
11 PERSONAL/PROFESSIONAL DEVELOPMENT
11.1 The physical therapist is responsible for individual professional development and
must maintain a high level of professional competence by continued participation in
varied learning experiences.
11.2 The physical therapist identifies their learning needs with support from appropriate
peers/managers taking account of: development needs related to the enhancement of
the individual’s scope of practice, feedback from performance data, mandatory
requirements, new innovations in practice, the needs of their organisation and career
aspirations.
11.3 The physical therapist continues to update and extend their knowledge and skills
through a variety of learning opportunities and keeps up to date with developments in research and evidence based practice.
11.4 The physical therapist is an active participant of an appropriate peer review appraisal system in their workplace.
11.5 The physical therapist complies with regulatory requirements in their country, where
they exist.
12 QUALITY ASSURANCE
12.1 The physical therapy service has a written plan for continuous improvement of quality
of care and performance of services.
12.2 The physical therapist shall demonstrate commitment to quality assurance by peer
review and self-assessment.
12.3 The improvement plan:
12.3.1 Provides evidence of ongoing review and evaluation of the physical therapy
service
12.3.2 Provides a mechanism for documenting improvement in quality of
care/services and performance
12.3.3 Is consistent with requirements of external agencies, as applicable
12.3.4 Includes specification of contracts with purchasers
12.3.5 Quality assurance activities focus on service user satisfaction by ensuring that:
12.3.5.1 A system is in place for monitoring service user satisfaction
12.3.5.2 Service users are invited to make suggestions about services
provided
12.3.5.3 A complaints procedure exists including a system for response

197. Page 15 of 16

13 RESEARCH
13.1 The physical therapist applies research findings to practice and encourages,
participates in, and promotes activities that establish the outcomes of patient/client
management provided by the physical therapist.
13.2 The physical therapist shall advance the science of physical therapy by conducting and/or supporting research activities or by assisting those engaged in research.
13.3 The physical therapist:
13.3.1 Ensures that their knowledge of research literature related to practice is
current
13.3.2 Ensures that the rights of research subjects are protected, and the integrity of
research is maintained
13.3.3 Participates in the research process as appropriate to individual education,
experience, and expertise
13.3.4 Educates physical therapists, students, other health professionals, and the
general public about the outcomes of physical therapist practice
13.4 The physical therapist recognises research as an integral part in the continuing growth and development of the profession.
13.5 The physical therapist conducting a research project has sufficient knowledge of
research principles and methodology and adheres to international standards for
performing research on human subjects.
14 SUPPORT PERSONNEL (where applicable)
3

14.1 Support personnel must be clearly identified as ‘support personnel’ so that the
patient/client is never in doubt that the employee is not a physical therapist.
14.2 Support personnel must at all times be under the direction and supervision of the
physical therapist when implementing direct interventions/treatment. This should reflect WCPT’s position statement on support personnel.
14.3 The physical therapist should not delegate any activity that requires the unique skill,
knowledge, and judgment of the physical therapist.

RESOURCE DOCUMENTS
American Physical Therapy Association (2003) Standards of Practice for Physical
Therapy APTA, Alexandria, USA.

3
The term support personnel is used in a generic sense to encompass a range of employment
classifications such as assistant, aide, technician or helper.

198. Page 16 of 16
European Region of WCPT (2002) European Core Standards of Physiotherapy Practice. ER-
WCPT, Brussels, Belgium.
New Zealand Society of Physiotherapists (2006) Standards of Physiotherapy Practice. New
Zealand Society of Physiotherapists, Wellington, New Zealand.

[A list of relevant documents available from WCPT’s Member Organisations will be compiled
and made available on the WCPT website.]



Date adopted: Adopted at the 16
th
WCPT General Meeting June 2007.
Date for review: 2011
Related WCPT
Policies:
Declaration of Principle: Quality Services
Declaration of Principle: Standards of Practice
Declaration of Principle: Relationship with other Health Professionals
Position Statement: Support Personnel for Physical Therapy Practice
Position Statement: Description of Physical Therapy

Copyright © World Confederation for Physical Therapy 2007

199. lecture no. 1

Evaluation and diagnosis

Introduction

The concept of classification and diagnosis of diseases originated in ancient times when physicians began
categorizing and labeling clusters of signs and symptoms. Diagnosis is the identification of the nature and
cause of a certain phenomenon, an experience to determine “cause and effect.” It is a brief conclusion
about the pathological condition, existing disease, injuries, or the cause of death of a person under
investigation. It forms the most important part of any consultation along with treatment.
Diagnosis being a process is not an exclusive domain of any single profession.[3] Diagnosis and
classification in Physical Therapy are complementary to the diagnosis made by other healthcare
practitioners. It does not intend to infringe on the practice of the others or attempt to assume roles that are
beyond the scope of education and training. This article highlights the diagnostic concept as pertinent to
physical therapy using the framework of International Classification of Functioning.
Physical therapy diagnosis

200. Need
The role of a practitioner of Physical Therapy has changed from a mere technician following prescriptive
orders to an independent health-care professional with sound scientific knowledge and evidence-based
practice. Vision 2020, adopted by the American Association of Physical Therapy (APTA), identified key
areas such as professionalism, direct access, evidence-base, and first contact practice to make physical
therapy a more autonomous profession. Direct access and first contact practice mandates the development
of diagnostic categories that would clarify what can be diagnosed by the virtue of their education. Physical
Therapist are able to independently evaluate, diagnose, and treat patients within the scope of physiotherapy
during clinical practice. They do not provide a medical diagnosis but are well- prepared to identify signs
and symptoms outside the scope of physiotherapy practice and refer to a physician or specialist as
appropriate.

Purpose

The aim of Physical Therapy Diagnosis (PTD) or Functional Diagnosis (FD) is to diagnose movement
system impairments to guide intervention for health optimization such that the disability can be minimized.
The objective is clearly focused in the expertise of identifying clusters of movement system dysfunction
and classifying them rather than diseases. Treatment effectiveness and prognosis are further mapped for a
particular classification of movement system impairment using function as an outcome. This not only
increases effectiveness of practice but also contributes to health care and research.
The key diagnostic questions addressed are:
(1) what are the impairments, their nature and source?
(2) Which impairments are related to patients functional limitation?
(3) Which among these can be remedied by intervention?
(4) What is the influence of the contextual (environment and personal) factor of a person in his function?
(5) Can the contextual factors be changed or remedied to maximize performance?
(6) What is the diagnostic label?

Differentiating from medical diagnosis

The major difference between the two diagnostic patterns lies in the purpose and phenomena that are being
classified. Physicians primarily classify the causes of disease, disorders, and injury, whereas physical
therapists primarily classify the consequences that result from them. These are the movement system
impairments, functional limitations, or disabilities. Given the expertise in movement science, the therapist
identifies key factors that underlie movement and movement dysfunction, which are most often separate
from the medical condition.

201. The focus of physical therapist is differential evaluation and the treatment of dysfunction rather than
differential diagnosis and treatment of disease as in the case of physician.
The medical diagnosis relates to the specific anatomical tissues that are considered to be the source of
symptoms. This known information of the patho-anatomical source of symptoms is required to guide the
physiotherapist to hypothesize the expected impairments and plan assessment with due precautions or
contraindications for diagnosing movement dysfunction. For example, movement of spinal flexion is done
with care with a medical diagnosis of a prolapsed intervertebral disc (PID). However, if the patient is
referred with a symptom-based diagnosis of “low back pain” where a patho-anatomical structure is not
known, extra caution is required to plan physical examination. A thorough evaluation of contextual factors
is also essential to guide physiotherapy interventions.
Where a medical diagnosis is important for defining the cause and prognostication, a physical therapy
diagnosis is important to identify the limitations of function and quality of life within the given context of
the individual to guide physiotherapy interventions.
These interventions may be directed toward symptom alleviation and remediation of impairments or
activity limitations or modify the contextual (environmental) factors for enhanced societal participation of
the person. For example, the medical diagnosis of “osteoarthritis knee” for a person A and person B
implies degenerative arthritis. However, the inability to walk or squat because of functional impairments of
pain, joint irritability, and loss of range at the knee in person A, which may not be present in person B,
necessitates a different approach of therapeutic intervention in both A and B. A diagnosis of
cerebrovascular accident would provide gross information about disease but a diagnosis of balance or
movement control impairment would assist the therapist in directing treatment. Medical diagnosis alone
cannot guide Physical Therapy interventions.

Process

PTD is the result of a process of clinical reasoning using a problem-oriented hypothetico-deductive model.
Potential impairments present primarily or secondarily as a consequence of tissue pathology are identified
along with the need for health restoration and prevention. A detailed patient interview that includes
information about the limitation of function in activities of daily living leads to the pattern recognition of
movement dysfunction and generation of hypothesis stating which body structures and functions may be
impaired. A brief examination that includes review of systems, communication ability, coping style,
language, learning style, and “red flags” is conducted. From the above, the therapist concludes the need to
carry out specific tests and measures to investigate the generated diagnostic hypothesis or refer to another
practitioner. The link between impairments, activity limitation, and participation restriction is identified.
The relationship between the individual's health condition and contextual factors influencing the individual
is explored to find the cause of the resultant disability. The data thus obtained would guide for intervention
strategies, plan of care, prognosis, and scope of practice.
For example, the inability to comb hair is the activity limitation commonly reported in adhesive capsulitis
(PA), as well as in impingement syndrome of the shoulder complex. Movement impairments associated
with both these medical diagnoses are abduction and external rotation. Specific assessments based on
biomechanical and neurophysiological principles are carried out to find the source of movement restriction
of abduction and external rotation.
The primary source in PA is the capsule of the glenohumeral mechanism; the treatment intervention would
be to improve extensibility of the capsule, whereas in case of impingement, the source lies in the scapula-
thoracic mechanism altering the scapular mechanics. Here, the focus of treatment would be to retrain
motor control of scapular muscles. Hence, though the movement impairment is same for a particular
activity, limitation management strategies are different.

202. Assessment tools

Physical therapist identifies clusters of signs, symptoms, and other relevant information from subjective
and objective examination of the patient, which can be labeled as classifications or diagnoses.
Body charts reveal extent of distress associated with pain. Structured interviews are used to assess:
(i) physical environment at workplace, home settings, school or college, and workplace;
(ii) level of anxiety, fear, depressed mood, perceived workplace problems (job satisfaction/stress, work
satisfaction), and family support. Fear avoidance, self-efficacy, and coping strategies are evaluated using
questionnaires. Functional assessment scales are used to assess components of function. For instance,
functional independent measures assess the level of dependency in activities of daily living, and the
disease-specific and generic quality of life scale measures the individual at physical, emotional, and social
levels.

Using the ICF framework

The World Health Organization (WHO) has defined “Health as a state of complete physical, social and
emotional wellbeing and not merely absence of disease or infirmity” (constitution of the world health
organization, WHO 1948). The WHO Family of International Classifications includes International
classification of Disease (ICD) and International classification of Functioning, Disability and Health (ICF).
These are commonly used to define and measure the components of health and complement each other.
ICD is the foundation for the identification of health trends and statistics in the world based on etiological
framework. It defines diseases, signs and symptoms, abnormal findings, complaints, and external causes of
injury; however, it lacks information on functional status and quality of life.
WHO-ICF is a framework for organizing and documenting information on functioning and disability
(WHO 2001). It conceptualizes functioning as a “dynamic interaction between a person's health condition,
environment factors and personal factors,” thus giving a holistic understanding of health. ICF integrates
both a medical model and a social model as “bio-psycho-social synthesis” and does not focus on one's
disease, illness, or disability alone.
Information within ICF is organized in two parts, one dealing with “Functioning and Disability” and other
with “Contextual factors”. This assists the physiotherapist to assess and understand each person's
experience of functioning and disablement in relation to their living conditions. A complex, dynamic, and
unpredictable relationship of various domains of ICF exists, which is bidirectional. The framework assists
in goal setting, evaluation of outcomes, and communication among colleagues or people using a common
language. Patient management for a health condition can be planned more effectively when one
understands how functioning is affected due to health condition (ICD) of the individual in context
(situation) to which he or she functions (ICF).
The construct of “Body structures and body functions” and “Activity and Participation” allows the
evaluation of a primary or secondary structural or functional impairment, diagnosing movement
dysfunction and providing remedies. For example, primary impairments of rigidity and bradykinesia in
Parkinson's disease can lead to secondary impairment of altered chest expansion and breathing capacity.

203. The identification of secondary impairments as a consequence of primary helps in planning of preventing
strategies. In circumstances where direct physical therapy treatment cannot remediate impairments, the
framework allows to plan modification in functions.
The degree of functional limitation is assessed on the basis of ability to execute a task or action (activity)
and capacity to fulfill socially defined roles (participation). These roles are expected of an individual in
terms of work, family, peers, etc. within a sociocultural and physical environment. Hence, the framework
concentrates not only on the individual but also the immediate and distant factors that may affect
functioning positively or negatively.
The domain of “environment and personal factors” evaluates the bio-behavioral constructs that may
facilitate or hinder overall functioning with respect to physical, social, and attitudinal world. Setting at
work, home, or school, motivation level of the individual, degree of family support, and factors related to
perceived problems within the environment (psycho social) are evaluated to plan ergonomic modification,
prescription of assistive devices, and therapy to improve performance in the given situation. For example,
lack of accessibility to wheelchair may prevent a wheelchair-bound individual from using public transport
and, hence, visit a rehabilitation center, or addition of grab bars in toilet to improve the ability to squat for
toilet activities.
Personal factors are the particular background of an individual's life and comprise features of an individual
that are not part of a health condition or health states but have an effect on disability and functioning.
Factors most relevant to physiotherapist are gender, age, lifestyle, fitness, habits, profession, coping styles,
culture, beliefs and ideologies, and attitudes such as pain experience, fear avoidance, and self-efficacy.
WHO-ICF model provides an effective framework for PTD as it encompasses health and health-related
states associated with all the health conditions across life span. The framework not only addresses the key
diagnostic questions but also identifies the roles of other health-care professionals such as social workers,
occupational therapist, psychologist, nutritionist, physician, and surgeons in restoring function.

Benefits of physical therapy diagnosis using ICF

Physical therapy diagnosis using ICF serves as a common language between all disciplines. The
parameters of measurement in diagnosis by the physical therapist are outcome-based assessments that
measure function.
It has a patient-centric approach, which can be easily understood and compared by patient as well as
physician in all health conditions; for example, improved ability to climb stairs or travel using public
transport after treatment intervention (total knee replacement or physiotherapy) to relieve pain and restore
movement.
The change can be measured easily over different time frame in different settings with consistency, for
example, improved functional capacity in terms of 6-min walk distance pre-and post-pulmonary
rehabilitation or pharmacotherapy in a patient with chronic respiratory disease. The awareness of impact of
contextual factors can lead to creating reforms and changing policies and laws.
The identification of similar clusters of movement dysfunction creates a diagnostic label. It generates data
across comparable settings, identifies predominant problems, adds to experience, and creates evidence-
based practice. It gives an opportunity for inter-professional education and collaboration to link and
integrate information across the health-care profession.

204. Lecture no. 2

Clinical reasoning is a multidimensional process that involves a wide range of cognitive skills physical
therapists
use to process information, reach decisions, and determine actions. Reasoning can be viewed as an internal
dialogue that therapists continuously employ while meeting the challenges of clinical practice. Clinical
decisions are the outcomes of the clinical reasoning process and form the basis of patient/client
management. A number of factors influence decision making, including the clinician’s goals, values and
beliefs, psycho social skills, knowledge base and expertise, problem-solving strategies, and procedural
skills. Many of these factors are the focus of discussion in later chapters in this text. Decision making is
also influenced by patient/client characteristics (goals, values and beliefs, and physical, psycho social,
educational, and cultural factors) as well as environmental factors (clinical practice environment, overall
resources, time, level of financial support, level of social support).

Decision making frameworks, such as algorithms, have been developed by experienced practitioners to
guide clinicians in their reasoning processes. For example, Rothstein and Echternach developed the
Hypothesis- Oriented Algorithm for Clinicians II (HOAC).1 An algorithm is a graphically represented
step-by-step guide designed to assist clinicians in problem solving by considering several possible
solutions. It is based on specific clinical problems and identifies the decision steps and possible choices for
remediation of a problem. A series of questions are posed, typically in yes/no format, addressing whether
the measurements met testing criteria, the hypotheses generated were viable, goals were met, strategies
were appropriate, and tactics were implemented correctly.

Hypotheses are defined as the underlying reasons for the patient’s problems, representing the therapist’s
conjecture as to the cause. Problems are defined in terms of activity limitations. A “no” response to any of
the questions posed in an algorithm is an indication for reevaluation of the viability of the hypotheses
generated and reconsideration of the decisions made. In using HOAC II as a model for clinical decision
making, the therapist also distinguishes between existing problems and anticipated problems, defined as
deficits that are likely to occur if an intervention is not used for prevention. The value of an algorithm is
that it guides the therapist’s decisions and provides an outline of the decisions made. , for examples of
problem centered algorithms. Physical therapists today practice in complex environments and are called
upon to reach increasingly complex decisions under significant practice constraints. For example, a
therapist may be required to determine a POC for the complicated patient with multiple co-morbidities
within 72 hours of admission to a rehabilitation facility. Reduced levels of treatment authorization with
shorter and shorter stays in rehabilitation also complicate the decision making process. Novice
practitioners can easily become overwhelmed.

Terminology: Functioning, Disability, and Health
Health condition is an umbrella term for disease, disorder, injury, or trauma and may also include other
circumstances,
such as aging, stress, congenital anomaly, or genetic predisposition. It may also include information about
pathogeneses and/or etiology.
Body functions are physiological functions of body systems (including psychological functions).

205. Body structures are anatomical parts of the body such as organs, limbs, and their components.
Impairments are problems in body function or structure such as a significant deviation or loss.
Activity is the execution of a task or action by an individual.
Activity limitations are difficulties an individual may have in executing activities.
Participation is involvement in a life situation.
Participation restrictions are problems an individual may experience in involvement in life situations.
Contextual factors represent the entire background of an individual’s life and living situation.
• Environmental factors make up the physical, social, and attitudinal environment in which people live and
conduct their
lives, including social attitudes, architectural characteristics, and legal and social structures.
• Personal factors are the particular background of an individual’s life, including gender, age, coping
styles, social background,
education, profession, past and current experience, overall behavior pattern, character, and other factors
that
influence how disability is experienced by an individual.
Performance qualiier describes what an individual does in his or her current environment. (The current
environment includes
assistive devices or personal assistance, whenever the individual uses them to perform actions or tasks.)
Capacity qualiier describes an individual’s ability to execute a task or an action (highest probable level of
functioning in
a given domain at a given moment).


Clinical Decision Making and Examination
General Demographics
• Age
• Sex
• Race/ethnicity
• Primary language
• Education

206. Medical/Surgical History
• Cardiovascular
• Endocrine/metabolic
• Gastrointestinal
• Genitourinary
• Gynecological
• Integumentary
• Musculoskeletal
• Neuromuscular
• Obstetrical
• Prior hospitalizations, surgeries, and
preexisting medical and other health
related conditions
• Psychological
• Pulmonary
Current Condtion(s)/
Chief Complaint(s)
• Concerns that led the patient/client to
seek the services of a physical
therapist
• Concerns or needs of patient/client
who requires the services of a physical
therapist
• Current therapeutic interventions
• Mechanisms of injury or disease,
including date of onset and course of
events

207. • Onset and patterns of symptoms
• Patient/client, family, significant other,
and caregiver expectations and goals
for the therapeutic intervention
• Previous occurrence of chief
complaint(s)
• Prior therapeutic interventions
Functional Status and Activity Level
• Current and prior functional status in
self-care and home management,
including activities of daily living (ADL)
and instrumental activities of daily
living (IADL)
• Current and prior functional status in
work (job/school/play), community, and
leisure actions, tasks, or activities
Medications
• Medications for current condition
• Medications previously taken for
current condition
• Medications for other conditions
Other Clinical Tests
• Laboratory and diagnostic tests
• Review of available records (eg.,
medical, education, surgical)
• Review of other clinical findings (eg.,
nutrition and hydration)

208. Social History
• Cultural beliefs and behaviors
• Family and caregiver resources
• Social interactions, social activities,
and support system
Employment/Work
(Job/School/Play)
• Current and prior work
(job/school/play), community, and
leisure actions, tasks, or activities
Growth and Development
• Developmental history
• Hand dominance
Living Environment
• Devices and equipment (eg., assistive,
adaptive, orthotic, protective,
supportive, prosthetic)
• Living environment and community
characteristics
• Projected discharge destinations
General Health Status
(Self-Report, Family Report,
Caregiver Report)
• General health perception
• Physical function (eg., mobility, sleep
patterns, restricted bed days)
• Psychological function (eg., memory,

209. reasoning ability, depression, anxiety)
• Role function (eg., community, leisure,
social, work)
• Social function (eg., social activity,
social interaction, social support)
Social/Health Habits
(Past and Current)
• General health perception
• Physical function (eg., mobility, sleep
patterns, restricted bed days)
• Psychological function (eg., memory,
reasoning ability, depression, anxiety)
• Role function (eg., community, leisure,
social, work)
• Social function (eg., social activity,
social interaction, social support)
Family History
• Familial health risks

210. lecture no. 3

Prognosis
The term prognosis refers to “the predicted optimal level of improvement in function and amount of time
needed
to reach that level.”4, p. 46 An accurate prognosis may be determined at the onset of treatment for some
patients.
For other patients with more complicated conditions such as severe traumatic brain injury (TBI)
accompanied by extensive disability and multisystem involvement, a prognosis or prediction of level of
improvement can be determined only at various increments during the course of rehabilitation. Knowledge
of recovery patterns (stage of disorder) is sometimes useful to guide decision making. he amount of time
needed to reach optimal recovery is an important determination, one that is required by Medicare and
many other insurance providers. Predicting optimal levels of recovery and time frames can be a
challenging process for the novice therapist. Use of experienced, expert staff as resources and mentors can
facilitate this step in the decision making process. For each preferred practice pattern, the Guide to
Physical herapist Practice includes a broad range of expected number of visits per episode of care.
Plan of Care
he plan of care (POC) outlines anticipated patient management. he therapist evaluates and integrates data
obtained from the patient/client history, the systems review, and tests and measures within the context of
other factors, including the patient’s overall health, availability of social support systems, living
environment, and potential discharge destination. Multisystem involvement, severe impairment and
functional loss, extended time of involvement (chronicity), multiple co-morbid conditions, and medical
stability of the patient are important parameters that increase the complexity of the decision making
process.

A major focus of the POC is producing meaningful changes at the personal/social level by reducing
activity
limitations and participation restrictions. Achieving independence in locomotion or activities of daily
living
(ADL), return to work, or participation in recreational activities is important to the patient/client in terms
of
improving quality of life (QOL).7 QOL is defined as the sense of total well-being that encompasses both
physical and psycho social aspects of the patient/client’s life. Finally, not all impairments can be
remediated by physical therapy. Some impairments are permanent or progressive, the direct result of
unrelenting pathology such as amyotrophic lateral sclerosis (ALS). In this example, a primary emphasis on
reducing the number
and severity of indirect impairments and activity limitations is appropriate. Essential components of the
POC include
(1) anticipated goals and expected outcomes;
(2) the predicted level of optimal improvement;

211. (3) the specific interventions to be used, including type, duration, and frequency; and
(4) criteria for discharge.
Goals and Expected Outcomes
An important first step in the development of the POC is the determination of anticipated goals and
expected outcomes, the intended results of patient/client management. Goal and outcome statements
address patient-identified priorities and predicted changes in impairments, activity limitations, and
participation restrictions. hey also address predicted changes in overall health, risk reduction and
prevention, wellness and fitness, and optimization of patient/client satisfaction. he difference is in terms of
time frame. Outcomes define the patient’s expected level at the conclusion of the episode of care or
rehabilitation stay, whereas goals define the interim steps that are necessary to achieve expected
outcomes.4 Goal and outcome statements should be realistic, objective, measurable, and time limited. here
are four
essential elements:
Individual: Who will perform the specific behavior or activity required or aspect of care? Goals and
outcomes
are focused on the patient/client. his includes individuals who receive direct care physical therapy
services and/or individuals who benefit from consultation and advice, or services focused on promoting,
health, wellness, and fitness. Goals can also be focused on family members or caregivers, for example,
the parent of a child with a developmental disability.

• Behavior/Activity: What is the specific behavior or activity the patient/client will demonstrate? Goals
and outcomes include changes in impairments (e.g., ROM, strength, balance) and changes in activity
limitations (e.g., transfers, ambulation, ADL) or participation restrictions (e.g., community mobility,
return to school or work).

• Condition: What are the conditions under which the patient/client’s behavior is measured? he goal or
outcome statement specifies the specific conditions or measures required for successful achievement, for
example, distance achieved, required time to perform the activity, the specific number of successful
attempts out of a specific number of trials. Statements focused on functional changes should include a
description of the conditions required for acceptable performance. For example, the functional levels of
performance in the Functional Independence Measure (FIM) are used in the majority of rehabilitation
centers in the United States. This instrument grades levels from No Helper/Independence (grade 7) to No
Helper/Modified Independence (grade 6; device), to Helper/Modified Dependence (grades 5, 4, and 3;
supervision, minimal, moderate, assistance), to Helper/Complete Dependence (grades 2 and 1; maximal,
total assistance) The type of environment required for a successful outcome of the behavior should also be
specified: clinic environment (e.g., quiet room, level floor surface, physical therapy gym), home (e.g., one
flight of eight stairs, carpeted surfaces), and community (e.g., uneven grassy surfaces, curbs, ramps).

212. • Time: How long will it take to achieve the stated goal or outcome? Goals can be expressed as shortterm
(generally considered to be 2 to 3 weeks and long-term (longer than 3 weeks). Outcomes describe the
expected level of functional performance attained at the end of the episode of care or rehabilitation stay. In
instances of severe disability and incomplete recovery, for example, the patient with traumatic brain injury,
the therapist, and team members may have difficulty determining the expected outcomes at the beginning
of rehabilitation. Long-term goals can be used that focus on the expectations for a specific stage of
recovery (e.g., minimally conscious states, confusional states). Goals and outcomes can also be modified
following a significant change in patient status. Each POC has multiple goals and outcomes. Goals may be
linked to the successful attainment of more than one outcome. For example, attaining ROM in dorsiflexion
is critical to the functional outcomes of independence in transfers and locomotion. The successful
attainment of an outcome is also dependent on achieving a number of different goals. For example,
independent locomotion (the outcome) is dependent on increasing strength, ROM, and balance skills. In
formulating a POC, the therapist accurately identifies the relationship between and among goals and
sequencesthem appropriately. In rehabilitation settings, the POC also includes a statement


Examples of Outcome and Goal Statements
• The following are examples of expected outcomes, all to be achieved within the anticipated rehab
stay:
• The patient will be independent and safe in ambulation using an ankle-foot orthosis and a quad
cane on level surfaces for
• unlimited community distances and for all daily activities within 8 weeks.
• The patient will demonstrate modified dependence with close supervision in wheelchair
propulsion for limited household
• distances (up to 50 feet) within 8 weeks.
• The patient will demonstrate modified dependence with minimum assistance of one person for all
transfer activities in
• the home environment within 6 weeks.
• The patient will demonstrate independence in basic activities of daily living (BADL) with
minimal setup and equipment
• (use of a reacher) within 6 weeks.
• The patient and family will demonstrate enhanced decision making skills regarding the health of
the patient and use of
• health care resources within 6 weeks.
• The following are examples of anticipated goals with variable time frames:
Short-Term Goals
• The patient will increase strength in shoulder depressor muscles and elbow extensor muscles in
both upper extremities
• from good to normal within 3 weeks.
• The patient will increase ROM 10 degrees in knee extension bilaterally to within normal limits
within 3 weeks.
• The patient will be independent in the application of lower extremity orthoses within 1 week.
• The patient and family will recognize personal and environmental factors associated with falls
during ambulation within
• 2 weeks.
• The patient will attend to task for 5 min out of a 30-min treatment session within 3 weeks.
Long-Term Goals
• The patient will independently perform transfers from wheelchair to car within 4 weeks.
• The patient will ambulate with bilateral knee-ankle-foot orthoses (KAFOs) and crutches using a
swing-through gait and
• close supervision for 50 feet within 5 weeks.

213. • The patient will maintain static balance in sitting with centered, symmetrical weight-bearing and
no upper extremity support or loss of balance for up to 5 minutes within 4 weeks.
• The patient will sequence a three- to five-step routine task with minimum assistance within 5
weeks.


Lecture no. 4

Discharge Planning
Discharge planning is initiated early in the rehabilitation process during the data collection phase and
intensifies as goals and expected outcomes are close to being reached. Discharge planning may also be
initiated if the patient refuses further treatment or becomes medically or psychologically unstable. If the
patient is discharged before outcomes are reached, the reasons for discontinuation of services must be
carefully documented. The therapist should also include the discharge prognosis, typically a one-word
response such as excellent, good, fair, or poor. It reflects the therapist’s judgment of the patient’s ability to
maintain the level of function achieved at the end of rehabilitation without continued skilled intervention.

Elements of the Discharge Plan

Patient, family, or caregiver education: instruction
includes information regarding the following:
• Current condition (pathology), impairments, activity
limitations, and participation restrictions
• Ways to reduce risk factors for recurrence of condition
and developing complications, indirect impairments,
activity limitations, and participation restrictions
• Ways to maintain/enhance performance and functional
independence
• Ways to foster healthy habits, wellness, and prevention
• Ways to assist in transition to a new setting (e.g., home,
skilled nursing facility)
• Ways to assist in transition to new roles

214. Plans for follow-up care or referral to another agency:
patient/caregiver is provided with the following:
• Information regarding follow-up visit to rehabilitation
center or referral to another agency (e.g., home care
agency, outpatient facility) as needed
• Information regarding community support group and
community fitness center as appropriate
Instruction in a home exercise plan (HEP): patient/
caregiver instruction regarding the following:
• Home exercises, activity training, ADL training
• Use of adaptive equipment (e.g., assistive devices,
orthoses, wheelchairs)
Evaluation/modiication of the home environment:
• Planning regarding the home environment and modifications
needed to assist the patient in the home (e.g.,
installation of ramps and rails, bathroom equipment
such as tub seats, raised toilet seats, bathroom rails,
furniture rearrangement or removal to ease functional
mobility)
• All essential equipment and renovations should be in place before discharge

Outcomes

An outcome measure is a tool used to assess a patient’s current status. Outcome measures
may provide a score, an interpretation of results and at times a risk categorization of the
patient. Prior to providing any intervention, an outcome measure provides baseline data. The
initial results may help determine the course of treatment intervention. Once treatment has
commenced, the same tool may be used in serial assessments to determine whether the
patient has demonstrated change. With the move towards Evidence Based Practice (EBP) in

215. health care, outcome measures provide credible and reliable justification for treatment on an
individual patient level. The results from outcome measures may also be grouped for
aggregated analysis focused on determining quality of care. When outcome measures are
used in an aggregated data situation to compare results, a risk adjustment process is required
to fairly compare results.


Classification


Patient Reported Outcome Measure
Outcome measures that we use in clinical practice are divided into four categories:

1. Self-report measures
2. Performance-based measures
3. Observer-reported measures
4. Clinician-reported measures

Self-report measures are typically captured in the form of a questionnaire. The questionnaires
are scored by applying a predetermined point system to the patient's responses. Although
self-report measures seem subjective in nature, self-report measures objectify a patient's
perception. Historically, the questionnaires required that either a therapist interviewed the
patient or the patient independently completed the questionnaire. Self-report outcome
measures that use paper and pencil for completion are considered a fixed-form questionnaire.
Computer based or electronic self-report measures are available. Electronic measures may be
fixed-form or adaptive. Computerized adaptive testing is a method of testing that determines
the questions for a response based on the patient's previous responses.[4] The questionnaires
where the patient reports on health or physical function are known as patient-reported
outcomes (PRO).[5] PROs can be categorized as disease specific or generic. PROs have been
defined as "any report of the status of a patient's health condition that comes directly from the
patient, without interpretation of the patient's response by a clinician or anyone else."[6]

Performance-based measures require the patient to perform a set of movements or tasks.
Scores for performance-based measures can be based on either an objective measurement
(e.g., time to complete a task) or a qualitative assessment that is assigned a score (e.g., normal
or abnormal mechanics for a given task).

216. Performance-based measures and patient reported measures both capture a current status.
These measures do not typically equate with each other. Performance-based measures tend to
bring to light physiologic factors. Patient reported outcome measures may capture a patient's
perception, beliefs, social factors and/or health factors.

Observer-reported measures are measurements completed by a parent, caregiver or someone
who regularly observes the patient on a daily basis.

Clinician-reported measures are measurements that are completed by a health care
professional. The professional uses clinical judgement and reports on patient behaviors or
signs that are observed by the professional.

Statistical Analysis
Important features of an outcome measure that need to be taken into account when using an
outcome measure are its psychometric properties. Psychometric properties are the intrinsic
properties of an outcome measure. Ideally, the psychometric properties of an outcome
measure used in practice should have been developed and tested through a series of research
studies. These properties include validity, inter-rater reliability, intra-rater reliability,
responsiveness, ceiling effects, floor effects and minimal clinically important difference.
Validity refers to the how accurately the test actually measures what it is supposed to
measure. High validity means the measure is consistently stable in its ability to measure its
intended focus. Inter-rater reliability takes into consideration the consistency of the results of
the measure when two different people are evaluating the results of a common subject. With
performance-based measures, if two physiotherapists scored the performance, high inter-rater
reliability would mean that both determined similar scores on the performance evaluated. For
patient reported outcome measures, a high intra-rater reliability indicates that the patient
consistently responds to attain the same results. (This would be more relevant with serial
testing and no intervention or change in status. Intra-rater reliability falls under test-retest
reliability.) Responsiveness refers to the ability for the measure to be able to capture change
in status. Ceiling effect occurs when the majority of patients are able to complete the measure
and score within the highest range of the measurement. (The test is too easy and is not
capturing their full capability.) Floor effect occurs when the majority of the patients score
within the lowest range of the measurement. (The test is too hard and does not have enough
easier items to distinguish varying levels of status.) When determining if change is relevant,
the p-value has no value. For outcome measures, the clinician needs to know the minimal
important difference. Minimal important difference refers to the amount of change that is
relevant from the patient's perspective. (clinical meaningfulness).sed Practice (EBP) in health
care, outcome measures provide credible and reliable justification for treatment on an
individual patient level. The results from outcome measures may also be grouped for
aggregated analysis focused on determining quality of care. When outcome measures are

217. used in an aggregated data situation to compare results, a risk adjustment process is required
to fairly compare results.

Referral relationships


lecture no. 6
Physiotherapist Consultation

What the Role Entails
Consultant Physiotherapists go beyond the boundaries of the profession, providing leadership and strategic
vision through four main domains. expert and clinical practice, education and clinical development,
professional leadership and consultancy, and research evaluation of practice and service development.
These areas were envisaged as being fundamental in the development of an all-round professional,
providing post-holders with opportunities to develop their career pathways, impacting clinical protocols
and service provision. It was viewed that these consultants could operate as primary practitioners, shifting
care from hospitals into the primary care setting helping to cut waiting times.


Definitive information about consultants is generally difficult to obtain, perhaps because consultants are by
nature entrepreneurial, and the business is competitive. Even so, consultants long have been a mainstay of
traditional businesses, helping their clients to solve work-related problems and assisting in decision

218. making. More recently, consultants have emerged outside this primary arena, and the title now is applied to
a wide range of service providers, from wedding planners to personal trainers.
Consultation has assumed this broader perspective because of the modern information explosion and a
fluctuating marketplace, circumstances that have led more organizations and individuals to seek
consultants for guidance, answers to questions, second opinions, and training. Consultants are also hired to
serve as sounding boards for new ideas and strategies and to provide expert advice for specific purposes.
The term consultant has become widely used in a variety of settings. The purposes of this chapter are to
provide a clear picture of consultation in physical therapy, identify opportunities for physical therapy
consultation, and consider the qualities of consultants. Consultation is the practice of providing advice for
a fee. This is a two-way interaction, a process in which a person or an organization seeks help, which the
consultant provides. The ultimate outcome of the process is a change in the way the person functions or an
organization operates. The person or organization seeking help is the client, who may also be known as the
customer, patient, or advisee. Regardless of the label applied to the interaction (advising, coaching,
counseling, consulting), this helping process is a key function of all professionals, including physical
therapists.
Given the nature of their work, most physical therapists (PTs) are familiar with the process of consultation.
The patient/client management role of the PT is a form of consultation, because patient care is a process of
giving and receiving help. By developing and implementing plans of care, PTs learn how to establish
helping relationships with patients and ways to offer advice. These helping skills can easily be transferred
to other consultation opportunities. The power of the advice given depends on two factors:
(1) how much the consultant helps clients use their own knowledge, experience, and expertise to arrive at a
decision or solve a problem, and
(2) how much the client participates in the proposed course of action. In some consultation arrangements,
the consultant provides an expert opinion that the client is expected to follow; in others the consultant
draws upon the client’s knowledge and expertise to help make the decision.

More often, the consultation relationship falls somewhere in between. For instance, a faculty advisor often
provides expert opinion while guiding students in making their own decisions about their careers. In the
same way, PTs make every effort to move away from the paternalistic model of “doing for the patient”;
instead, they try to use the active participation model, involving patients in decisions about their
rehabilitation. Maister, Green, and Galford6 proposed four levels of consultation that define the
consultant/client relationship. Box 5-1 presents examples of ways PTs might engage in consultation at each
level. Fuller suggested another framework that consultants could use to clarify their responsibilities. This
model identifies types of consultation in terms of client
demands for the following continuum of services:
● Specialized services
● Administrative skills
● Problem solving
● Investigative studies
● Assessments
● Advice

219. Because some blurring of roles occurs in a consulting continuum between consultants at the specialized
service-provider end and others at the advice-giving end, Fuller defined the consultant/client relationship
as a blend of service and advice, with some specialized information added.7 Often the precise boundary
between the advising and the service-providing processes is vague, especially if the individual who gave
the advice is then asked by the client to implement it. This is often the case in physical therapy. For
example, physical therapy consultants may help a business determine the physical therapy services it
should have, and the PTs may then provide the services identified as the answer to the client’s needs.
Physical therapy consultants are hired to meet a range of client needs. McGonagle and Vella8 and Cohen9
have identified broad categories of client needs that can be applied to physical therapy consultation.
Clearly, opportunities abound for PTs who seek helping relationships beyond patient/client
management.
Consulting PTs must also decide the type of clients with whom they want to work—physical therapy peers,
others, or both. Few professionals set out to become consultants, and the transition to consultation as a sole
source of income is often subtle and gradual.10 A typical starting point for PTs would be the service-
providing end of consultation, with perhaps some problem-solving work included. A physical therapy
consultant’s first clients often are other PTs because both consultant and client are comfortable with the
jargon, and they have a professional camaraderie. The initial consultation efforts often are opportunities
PTs take in addition to their full-time employment. Eventually PTs may realize that their primary source of
income has become consultation, at which point they disengage from fulltime employment and identify
themselves more as consultants than PTs. As the full-time consulting business grows, the level of
consultation often changes; also, the PT consultant’s client base may broaden to include other health care
professionals or different types of health care and community organizations. Some PT consultants develop
skills in organizational process, team building, or other consulting skills that do not require physical
therapy expertise. Generalist physical therapy consultants address a broad range of problems in physical
therapy, but many consultants narrow their spectrum of expertise, for example, serving as physical therapy
education consultants, physical therapy private practice development consultants, or physical therapy
sports medicine consultants.

220. lecture no .7
Building a consultant business

BUILDING A CONSULTING BUSINESS

Consulting Fees

Consultants must be prepared to pay themselves and have money left for developing and managing the
business. Although the value of the consultation ultimately is determined by the client, fees are determined
by many factors. On the client’s side, these factors include the type of business or industry, its size and
location, the demand for consultants by such businesses, and the client’s history of consultant use. On the
consultant’s side, factors include the individual’s level of expertise, degree of experience, and professional
standing. This supply-and-demand situation creates a wide price range for consultation. Competition also
drives fees. For example, consultants who are moonlighting may accept projects for much lower fees
because they have other income. Large organizations in metropolitan cities, which have more consultants
from which to choose, may encourage bidding for projects.

The real question is how to determine how much clients should be charged. A billable daily fee can be
arrived at in two ways. First, the consultant can determine a fee with an income goal in mind. With this
method, the consultant calculates the amount needed to cover living and business expenses for 1 year,
determines the number of billable days in a year, and uses this information to arrive at a per-hour fee. The
second method is to match the fees charged by other physical therapy consultants.

Obtaining this information may be difficult because other professionals, wanting to keep a competitive
edge, may be reluctant to share their fee schedules. Consultants often do their best to guess the amount
they believe the client is willing to pay, present this as the fee, and hope the client agrees. In reality,
consultants use both of these fee determination methods. If clients think that the consultant’s offer meets
their needs, they most likely will pay the fee without questioning it. Starting high, therefore, is easier than
increasing fees at a later time.

Method 1
1. Calculate the amount you need to cover living and business expenses for 1 year.
2. Calculate the number of billable days in a year:
● With 2 weeks of vacation, holidays, and weekends, a year has about 245 billable days.
● Subtract 2 or 3 days per week for marketing activities, networking, handling the
administrative aspects of the business, writing proposals, and engaging in professional

221. development.
● Typically 120 days per year are available for billable work (this number is affected by the
scheduling of available days when clients are available; for example, a client may find it
difficult to engage a consultant around the holidays in December. Consider the following
example of estimated expenses and income for 1 year:
Salary
$50,000
Taxes
$20,000
Retirement
$7,500
Insurance
$6,000
Overhead business expenses $25,200
Profit
$10,000
Total
$118,700
3. For this example, if you plan 80 billable days per year, your daily consulting fee would be about
$1,500 a day.
Method 2
1. Determine the fee potential clients are willing to pay (e.g., find out the fee paid to other consultants in
the area).
2. Determine your living and business expenses.
3. Calculate the number of consulting days per year you need to break even. For example, let’s
say the current daily fee for PT consultants in your area is $750, and your annual income goal
is $118,700:

222. $118,700 ÷ 750 = 158.26
You will need to work about 159 billable days per year to meet your income goal. Many organizations and
government agencies insist on a fixed price for projects, which often is determined through a request for
proposal (RFP) process. The organization announces an RFP with a particular goal or product in mind.
Several consultants submit proposals, including a fixed bid, and the organization selects the best proposal
for the best price. This approach to setting a fee is riskier than the billable day approach, which allows
consultants to renegotiate for more time as a project progresses or is modified. With a fixed-price project,
the consultant assumes the risk of the total cost of the project, including the risk of actual costs exceeding
the negotiated price.

At the service-providing end of the consultation spectrum, percentage fee arrangements may be used when
the financial outcome of the project is clearly measurable and the consultant agrees to a percentage of
profits.12 For instance, a physical therapy consultant hired to reduce denials of reimbursement claims may
base the fee on the percentage increase in dollars paid for claims submitted over the next 3 years.
Regardless of the method used, the consultant must determine a consistent pricing structure that applies to
all clients for the same work. Prices may vary if some aspect of the work is different (e.g., on-site versus
home-based consultation) or if the client is a nonprofit organization and the consultant chooses to give a
discount. If the fee structure changes, the consultant, to avoid a tarnished image, must be clear about the
reason for the change.

223. lecture no. 8

The Consulting Process, The Skills of a Good Consultant

The Consulting Process

Parallels can be drawn between the patient/client management process in physical therapy and the true
consulting process as described by Lippitt and Lippitt. Like PTs, consultants identify problems, consider
alternatives, select and implement the best solution, and evaluate the solution’s effectiveness. As
entrepreneurs, consultants must market their services and seek out potential clients. As with any
entrepreneurial business, as the consultant’s reputation grows, potential clients may self-refer, or former
clients may recommend new ones. The consultant/client relationship begins with acceptance of a proposal,
which may be developed in response to an RFP or as a result of a preliminary meeting with a potential
client. A strong consulting proposal hinges on a thorough knowledge of the client and the client’s needs.
The proposal should include the following sections, which are based on an outline by Hoyt:

1. Purpose of the proposal [or an objective]: A brief statement, couched in general terms, of what the client
wants.

2. Solution or action steps: Presented perhaps as a bulleted list or a table, this section specifies the
sequential actions to be taken, including dates for submission of periodic progress reports. The steps may
include information and data gathering, design, content to be included, materials needed, and the
implementation strategy

3. Anticipated benefits: The improvements the client can expect as a result of the consultation.

4. Evaluation: A plan for measuring the effectiveness of the consultation. At any level of consultation,
consultants must do their homework to develop proposals that are attractive to clients. The consultant must
learn everything possible about a client and about the factors that influence the client’s decision making
and goals so as to identify clearly problems and possible solutions.

The Skills of a Good Consultant

Consultation demands skills beyond good advice, technical capabilities, and entrepreneurial talent. Other
required skills include the ability to get along well with others, the ability to diagnose problems and find
solutions, the ability to communicate, and the ability to work under pressure. Some personal qualities and
attitudes are also critical. Consultants must be adventuresome, willing to accept risk, and determined to
find answers to problems.13 PTs develop many of these skills in patient care and others as managers of

224. patient care services and can transfer these capabilities to the consultant’s role. As in any other career
choice, PTs who decide to pursue consulting should take the time to reflect on their strengths and
weaknesses and prepare accordingly. Figure 5-3 presents a list of questions that can be helpful to PTs
considering this decision. Even when all the appropriate skills are in place, the key to success as a
consultant is the ability to build a trusting relationship with the client.

Respond to each item using a 1−4 scale.

1 = definitely true; 2 = possibly true; 3 = unlikely; 4 = definitely false
1. I am willing to work sixty to eighty hours a week to achieve success. 1 2 3 4
2. I love risk; I thrive on risk. 1 2 3 4
3. I have a thick skin. 1 2 3 4
4. I am good at understanding and interpreting the big picture. 1 2 3 4
5. I pay attention to details. 1 2 3 4
6. I am an excellent communicator. 1 2 3 4
7. I am a good writer. 1 2 3 4
8. I like to sell myself. 1 2 3 4
9. I can balance logic with intuition and the big picture with details. 1 2 3 4
10. I know my limitations. 1 2 3 4
11. I can say “no” easily. 1 2 3 4
12. I am compulsively self-disciplined. 1 2 3 4
13. I am comfortable speaking with people in all disciplines 1 2 3 4
and at all levels of an organization.

Respond to each item using a 1−4 scale.
1 = definitely true; 2 = possibly true; 3 = unlikely; 4 = definitely false
1. I am willing to work sixty to eighty hours a week to achieve success. 1 2 3 4
2. I love risk; I thrive on risk. 1 2 3 4
3. I have a thick skin. 1 2 3 4

225. 4. I am good at understanding and interpreting the big picture. 1 2 3 4
5. I pay attention to details. 1 2 3 4
6. I am an excellent communicator. 1 2 3 4
7. I am a good writer. 1 2 3 4
8. I like to sell myself. 1 2 3 4
9. I can balance logic with intuition and the big picture with details. 1 2 3 4
10. I know my limitations. 1 2 3 4
11. I can say “no” easily. 1 2 3 4
12. I am compulsively self-disciplined. 1 2 3 4
13. I am comfortable speaking with people in all disciplines 1 2 3 4
and at all levels of an organization.

226. lecture no. 9
Trust in the Consultant/Client Relationship

Trust in the Consultant/Client Relationship

Consultants must be able to give their clients objective, independent advice that is unaffected by the
client’s own biases, fears, and blind spots. However, consultants must also be alert to their own biases,
fears, and self-interests and take steps to guard against them. They can guard against these personal foibles
by attending to their obligations to their clients: loyalty and care. As in patient/client management,
consultants must place clients’ interests above their own and look after those interests carefully.

Clients often have mixed feelings about consultants that affect the consultant client interaction. On one
hand, clients may respect consultants for their unique skills or ability to resolve problems. On the other
hand, clients may view consultants with skepticism because of the perception that they profit from the
weaknesses of others. The presence of a consultant may suggest that the client has weaknesses and is
unprepared to deal independently with the issues at hand. A client’s employees may see the hiring of a
consultant as a red flag, signaling impending changes that may be unwelcome.

Establishing trust is critical to overcoming these hurdles. A consultant who puts the client’s interests first
and is sensitive and careful in interactions with the client and others affected greatly improve the chances
of success. Trust is earned through direct experience in a highly personal, emotional, and dynamic two-
way relationship that involves risk on both sides.

Because the client must feel free to accept or reject the consultant’s advice, the consultant is responsible
for organizing and directing the consultation process toward the desired end of solving a problem. Trusting
and being trusted are critical to the delicate balance that must be achieved if a consultant is to bring the
client to decisions that are in the client’s best interests without appearing to be righteous or self-serving. To
begin establishing trust, the consultant must honestly determine whether the consultation will contribute a
worthwhile component in an effective manner to the problem or objective.

A consultant must be sensitive to the position of clients, who put themselves on the line when retaining
consultants. Clients’ reputations are at stake, because they will be evaluated on the results of the
consultation. Clients need to feel confident that the consultant will do a thorough, professional job. In the
end, consulting is primarily a relationship business. Without that relationship, the consultant’s specialized
knowledge and experience are of no value. Also, the consultant’s success depends heavily on the quality of
the relationship that develops as the process moves toward the desired goal. The legal and ethical
ramifications of this trust relationship are paramount.

227. lecture no. 10

Ethical and legal issues in consultation

• ETHICAL AND LEGAL ISSUES IN CONSULTATION

The consultant role of the PT raises a number of legal and ethical issues, many of them related to
the type and setting of the consultation. This section addresses the legal status of employment;
relevant portions of the Code of Ethics and the Guide for Professional Conduct, both published by
the American Physical Therapy Association (APTA); institutional review boards for the protection
of the rights of research subjects; and the differences between patients and research subjects.

Legal Status of Employment

Consultants act with a system rather than as an integral part of it. However, the substance of the
relationship, rather than the label it is given, determines the consultant’s legal employment status.
No legal status exists for a consultant per se. Labor laws distinguish between employees and self-
employed contractors. Box 5-3 presents a comparison of the two groups of workers.2 The
consultant is an independent contractor more than an employee. In an independent contractor
agreement, a client hires an expert to perform a certain task, relinquishes control over the way the
task is accomplished, and is relieved of certain legal responsibilities of employers.8 However, the
farther the consultant’s task is from the center of the service–advice continuum, the less the
consultant is like an independent contractor. For example, at the advice end, the specific task or
service to be delivered may be less clear; at the service end, the client may have significant control
over patient assignments or scheduling.

If the answer to each of the following six questions is “yes,” the individual’s
employment status is likely to be that of consultant8:
1. Are you generally free to seek out many business opportunities and to work
for more than one client at a time?
2. Are you paid a flat, negotiated fee for your work?
3. Do you provide your own resources to get the job done?
4. Are you at risk for suffering a loss if your estimated expenses are exceeded?
5. Is there no expectation that the work will continue indefinitely?
6. Is the work you are doing not considered a routine part of the organization?

228. COMPARISON OF EMPLOYEE AND SELF -EMPLOYED CONTRACTOR STATUS



• Contract Law
Because the legal definition of consulting is unclear, a consulting agreement or con tract must
clearly delineate the factors that establish, maintain, and terminate the consultant-client
relationship. Ambiguity in the consulting agreement may seem attractive because it offers
flexibility in expectations and in addressing needs as they are identified during the consultation
process; however, it also poses certain risks. Lack of a clear agreement may feed distrust and
provoke suspicion, particularly if the actions of the consultant appear self-serving. Box 5-4 lists
suggested components of a consultant agreement.8 Those new to consulting may want to seek
legal advice in developing a template contract for their business.
Codes of Ethics have devised a code of ethics for consultants based on 11 principles:
o Responsibility
o Competence
o Moral and legal standards
o Avoidance of misrepresentation
o Confidentiality

229. o Client welfare
o Announcement of services
o Intraprofessional and interprofessional relations
o Remuneration
o Responsibility toward client organization
o Promotional activities


COMPONENTS OF A CONSULTING AGREEMENT
● The nature and scope of the services to be performed
● A statement specifying the consultant’s employment status and ownership of any final work
product
● The details of payment of compensation and costs
● The duration of the agreement
● In what ways, when, and by whom the agreement can be terminated
● In what ways the work to be performed can be changed and by whom
● Special requirements (covenants) to protect the client, such as the handling of confidential
information
● The manner in which any disputes will be handled
● The remedies available (and to whom) for default or failure to perform, as well as remedies that
are not available
● The manner in which formal notice is to be given, and how changes in the scope of the
assignment are to be recorded

230. lecture no. 11

History of Critical Inquirer

From the beginning, the profession of physical therapy has recognized the crucial roles of scientific
investigation and critical inquiry. The constitution of the American Women’s Physical Therapeutic
Association, published in 1921, stated that “the purpose of the Association shall be to establish and
maintain a professional and scientific standard for those engaged in the profession of Physical
Therapeutics.”2 Also in 1921, P.T. Review, the first physical therapy journal, began publication. The aims
of the journal were to provide a means by which physicians and reconstruction aides could more easily
keep up with each others’ work and to preserve the standards and advance the science of the profession.2

Mary McMillan acknowledged the importance of this aspect of physical therapy in the preface to the third
edition of her textbook, Therapeutic Exercise and Massage, published in 1932. She noted that “since the
second edition of this book was published there has been a great deal of research in various pathological
conditions that are treated by physiotherapeutic measures,” and explained that several chapters had been
revised so that “the student may be brought in touch with this important phase of physiotherapy work.”

This early awareness of the importance of science in the profession has never been lost. However, it has
only recently come to the forefront. In the 1975 McMillan Lecture, Helen Hislop lamented that the science
of physical therapy was just entering its infancy, even though the profession was over 50 years old. She
attributed the difficulty in developing the clinical science of physical therapy to the perception that
physical therapy practice was incompatible with the generalizations demanded of science because physical
therapists (PTs) treat individual persons.4 Also, in the early years of the profession, physicians were
entrusted with the task of conducting studies related to rehabilitation. In the 1993 McMillan Lecture, Gary
Soder berg again addressed the need for development of the science of physical therapy. He urged
academic experts and clinicians to collaborate in contributing to the clinical science of physical therapy
and called for an emphasis on clinical research, rather than basic scientific research, to advance the
profession.5 About the same time, Robertson6 expressed concern that the profession had failed to
accumulate a knowledge base that defined the uniqueness of physical therapy and its scientific merit. In a
review of articles in the professional journal Physical Therapy, she noted a lack of evidence and coherence
among the articles in three topic areas—knee, back, and electrical stimulation—as well as heavy reliance
on sources outside the field of physical therapy.
She concluded that the profession faces a number of issues in developing its unique knowledge base:
● Lack of agreement on what physical therapy is and what PTs do, as well as on the core knowledge PTs
should have
● Lack of understanding of why physical therapy is necessary
● Lack of agreement on terms and concepts
● Lack of clinical literature in the discipline
● Lack of development of relevant theory

231. ● Reliance on medicine and behavioral sciences for a physical therapy knowledge base
● Reliance on informal communication (e.g., personal contacts and oral conference presentations) rather
than formal, peer-reviewed information in the practice of physical therapy In 2003, using the Hedges
Project Criteria, Miller, McKibbon, and Haynes7 conducted a quantitative analysis of articles published in
Physical Therapy, the Australian Journal of Physiotherapy, Physiotherapy, and Physiotherapy Canada in
2000 and 2001.

On the basis of the criteria that assist in the classification of published research and quality ranking, they
concluded that 56% of the 179 articles reviewed were original research and the rest were general
discussion or miscellaneous articles. Although the volume of original research appears strong, only 11% of
the articles met the Hedges criteria for high-quality evidence suitable for direct application to patient care.
This low percentage may be the result of the way quality is defined by the Hedges project, which supports
an evidence-based approach to the literature; however, none of the articles addressed etiology, prognosis,
or diagnosis or dealt with economics. Miller and colleagues7 concluded that their findings, although not
reflective of all research done by PTs, raised a question: How valuable is some of the research reported in
journals to the actual clinical practice of the more than 125,000 PTs who receive at least one professional
publication?
More recently, pressures outside the profession have advanced the need to establish the scientific basis of
physical therapy clinical practice. Economic decisions based on well-founded scientific information are the
trend in health care policy. For example, the demand for outcomes data has been driven by institutional
accreditation demands for quality care, which has also increased the demand for scientific support for the
health care people receive. As the demand for health care continues to overwhelm available resources,
decisions about what to pay for are driven, appropriately or not, by evidence indicating the most effective
course for the money spent (see following section and Chapter 4). Just as with other health care
professionals, PTs cannot expect patients and third-party payers to accept on blind faith that PTs do good
things and people get better.

Yet, even as the science is emphasized, the impact of the patient-therapist interaction in helping patients
achieve their therapeutic goals cannot be underestimated. Because physical therapy remains a “high touch”
profession, care must be taken to include research on the human interaction inherent in its practice. As
Wolf 8 asks, “Do our patients improve because of the physical interventions we provide, thus affecting
their state of well-being, or do our caring and interaction favorably affect patient behaviors, which
subsequently motivates them to improve physically?”

Over the past 30 years, the American Physical Therapy Association (APTA) has taken major steps to
advance the science of the profession, including formation of the Foundation for Physical Therapy,
publication of a clinical research agenda, creation of a clinical research network, and the Hooked on
Evidence grass-roots initiative to develop a database for evidence in physical therapy (Boxes 6-1 through
6-4). These efforts contribute to the formation of the physical therapy knowledge base through funding of
research, clarification of the primary research questions to be addressed, collaboration among researchers,
and collection of evidence to support physical therapy interventions. The need for evidence in physical
therapy is an extension of the evidence-based movement in medicine.

232. lecture no. 12


Evidence based practice

According to Sackett et al.,9 evidence-based medicine (EBM) (or evidence-based practice
[EBP] as it applies to other health care professionals) is the integration of the best research
evidence with clinical expertise and patient values. Sackett and colleagues define best
research evidence as clinically relevant research from the basic sciences and patient-centered
clinical research that leads to accurate and precise diagnosis and prognostic markers, as well
as therapeutic, rehabilitative, and preventive regimens that replace traditional methods with
more powerful, accurate, efficacious, and safe practice.

Clinical expertise is the ability to use clinical skills and past experiences to identify each
patient’s unique health state and diagnosis, as well as the risks and benefits of potential
interventions in the context of the patient’s personal values and expectations.
These values are defined as the unique preferences, concerns, and expectations of each
patient that must be integrated into the professional’s decision making.9 The popularity of
EBP has emerged from clinicians’ realization of the following:
● They need new information on a daily basis.
● They lack the time to find and assimilate new information.
● Traditional information resources often are out of date, wrong, and overwhelming in
volume.
● A disparity exists between clinical judgment, which increases with experience, and
“current, relevant” information, which decreases with experience.
These problems have diminished with improvements in the means to assess the validity of
data, the creation of systematical reviews of health care, the development of evidence-based
journals, the creation of electronic systems for electronic retrieval of information, and
strategies for lifelong learning.

outcomes research

Outcomes research is a term applied to different types of health care research.9 One kind of
outcomes research is conducted by analyzing large administrative databases (e.g., Medicare)
to explore such issues as utilization, costs, morbidity, and mortality related to certain

233. conditions or interventions. The results of these studies often are used as a complement to
evidence-based information. For instance, data on all Medicare patients admitted to hospitals
for surgery as a result of osteoarthritis of the hip could be analyzed for differences in length
of stay, common secondary conditions that affect discharge disposition, and mortality.

The term outcomes research also is used for studies that focus on the end result of health care
in terms of health status, disability, and survival. Effectiveness studies address how well
routine clinical practices work in everyday practice, whereas efficacy studies, which are
typically conducted as randomized clinical trials in specialty centers with discrete sampling
of subjects, address whether clinical practices can work in ideal situations. A comparison of
effectiveness and efficacy studies of individuals with arthritis. Broad population-based
outcome studies may be conducted by using surveys to gather information from patients on
general health and quality of life. Questionnaires that address specific diseases, such as the
Arthritis Impact Measurement Scale (AIMS), can also be used.11 An excellent resource for
identifying the wide range of generic and disease-specific instruments is the Quality of Life
Instruments Database (QOLID), a web-based database of outcome instruments.

WHOSE RESPONSIBILITY IS RESEARCH?

The subject of who shoulders responsibility for the creation and dissemination of physical
therapy knowledge remains a matter of controversy. Certainly physical therapy faculties
assume a great deal of responsibility for new knowledge through the academic triad—
teaching, scholarship, and service. Doctoral students also meet this need through the
traditional dissertation requirement (see Chapter 8). However, the situation of academic
researchers functioning independently in academic centers raises concerns about the
construction of a profession-wide knowledge base. These individual research agendas are
more often driven by personal interest and available funding than by the needs of the
profession. As yet, no widespread efforts have been made to engage faculty members to
collaborate with clinicians in formulating clinical research projects that could answer both
efficacy and effectiveness questions. The Foundation for Physical Therapy’s work to create
clinical research networks is the first concerted effort to address this issue .

The critical inquiry expectations for entry-level PTs pose another educational issue. The
criteria for critical inquiry established by the Commission on Accreditation in Physical
Therapy Education (CAPTE) are presented in Box 6-8. Several factors influence the way
programs actually meet these criteria. The faculty resources available, particularly the time
required to supervise formal research studies by individual students, are an important
consideration. Some programs emphasize the need to experience the investigative process
through a formal thesis process, and require students to conduct formal research studies. The
belief is that this requirement teaches students to value research and stimulates interest in
advanced studies. Graduate schools also establish expectations. For instance, some colleges
require every graduate student to produce a thesis or dissertation to graduate. Despite such

234. emphasis, attitudes about research appear to change after graduation, particularly the
individual PT’s desire to be involved in research and the priority placed on research in
clinical practice.

At a minimum, most physical therapy students are required to demonstrate the ability to use
research and to critique new information. The experiences of physical therapy students in
critical inquiry, as well as their skill and interest in it, may vary widely. This variation in
educational experience may be one factor in the varying quality and quantity of clinical
research conducted by physical therapists with patients as subjects.

235. lecture no. 13

• ROLES OF THE STAFF PHYSICAL THERAPIST IN CRITICAL INQUIRY

The critical inquiry role of the PT may not be as valued or as evident as other roles. For example,
in the work of the PT, administrative and education responsibilities become routine, but evidence-
based practice and participation in clinical research do not. In 1996, 93.4% of PTs surveyed
reported no work-related research activity,14 and in 2001 PTs reported spending an average of 1%
of their time each week on research or critical inquiry.
Critical inquiry and administrative activities may overlap to some degree. For example, of the
activities listed, the development of clinical guidelines (and perhaps critical pathways unique to
particular institutions) and the evaluation of outcomes data may be considered administrative
functions. Because clinical decision making is a foundation of patient/client management, which
in turn closely resembles the consultation process, it also has an administrative aspect.

The following sections explore five remaining aspects of critical inquiry that do not overlap with
the PTs’ other roles: the PT as
(1) a user of research,
(2) a publisher of case reports,
(3) a collaborator in clinical research studies,
(4) an assessor of new concepts and technology, and
(5) a research subject.

Application and Critique of Research
PTs can use research in two ways. One approach, evidence-based practice, has been discussed
previously. Increasingly, PTs’ education gives them the skills to practice evidence-based physical
therapy. However, only a small percentage of the practice of physical therapy is supported by
evidence; therefore the traditional method, independent critiquing of the literature, continues to be
the primary means of updating the specific information needed for clinical practice.

Critique of the literature also is done in journal clubs, which are small groups of practitioners who
meet regularly to explore research on a selected topic.9 These clubs follow one of two models. In
one model, which is more conducive to an EBP approach to review of the literature, participants
first reach consensus on clinical questions the group has identified. A member is assigned to
search the evidence and supply the group with abstracts of reviews or articles that answer the
question. The rest of the club members critically appraise the evidence provided, using skills
needed in the EBM or information master model (Figure 6-1).

236. In the more traditional journal club model, participants take turns summarizing assigned journal
articles and leading group discussions to critique the studies. Box 6-9 provides guidelines for
critiquing a single research report, and Figure 6-2 shows Garrard’s matrix method of comparing
several research studies on the same topic.16 These guidelines require some modification for
review of qualitative research, and the column titles in the matrix can be modified to address
particular types of research. The guidelines and matrix can be used for individual critiques of the
literature and as guidelines for journal club discussions. The skills for traditional and evidence-
based strategies for critiquing the literature typically are developed in physical therapy school.
• GUIDELINES FOR CRITIQUING RESEARCH REPORTS
To critique means to criticize, which means to make judgments, to analyze qualities, and to
evaluate the comparative worth of something. A critique must go beyond reporting what the
researcher did; it must discuss the value of a study to the researcher and to the profession. That is,
the researcher must explain why the study does or does not have value. The following questions
can serve as a guide to physical therapists in critiquing research reports. Not all questions apply to
all studies, and some studies may evoke additional questions.
● What is the purpose of the study?
● What is the question being investigated?
● What type of study is it?
● Who were the subjects? Can the results be applied to the general population of patients?
● What are the merits or limitations of the measurement tools?
● Have all variables been considered? How were extraneous variables controlled?
● What factors could affect the study’s reliability and validity? How were they controlled?
● Can the study be duplicated?
● Based on the results, was the question answered?
● Were the statistical tests performed appropriate for the type of data analyzed?
● How do the findings relate to those of other studies?
● Did the researchers discuss the results? What were their conclusions?
● Are methodology limitations addressed?
● Are some conclusions not supported by the study?
● Have suggestions been made for further study? What are yours?
● What is the relevance of the study?
● How will the study affect your practice of physical therapy?

237. ● What is the relevance of the study to the profession?
● How do the results contribute to or test a theory?
● Can you follow the sequence of events in the study?
● Was anything overlooked?
● What would you do next?
● What would you have done differently?
● Is the study report well written?

238. Lecture no. 1

The Physical Therapist as Educator

• In 1917 the U.S. Army began to plan for the physical rehabilitation of the legions of
injured soldiers returning home from World War I. In 1918 Mary McMillan was
granted a leave of absence from the Army to develop one of seven emergency training
programs for reconstruction aides, the forerunners of today’s physical therapists
(PTs), at Reed College in Portland, Oregon. In 1919 McMillan became head of the
reconstruction aide training program at Walter Reed General Hospital, and in 1921
she wrote Massage and Therapeutic Exercise, the first textbook on physical therapy.
Figure 7-1 presents an excerpt from the third edition of the text, published in 1932.

• McMillan left the Army in 1920 to take a position in Boston. While there, she and Dr.
Frank Granger, a physician with whom she had worked in the reconstruction aide
project, developed graduate programs for PTs through the Harvard Graduate Medical
School.

• Meanwhile, as the need for rehabilitative services in the military dwindled, many of
the reconstruction aide projects were discontinued, and a jumble of programs
appeared to prepare physiotherapists to meet the needs of the civilian population.
Some of these programs were based in universities whereas others were based in
hospitals.

It became clear that the educational requirements for physiotherapists needed to be
standardized, and in 1929 the American Physiotherapy Association suggested a
curriculum to be used as a minimum standard for schools of physiotherapy (Box 7-
1).3 Given the prolonged struggle of the profession at the end of the century to
implement educational requirements beyond the baccalaureate level, it is striking that
these 1929 standards suggested a post baccalaureate curriculum with strong ties to
medicine that could be completed in 9 months. In 1930, 11 schools met or exceeded
these standards, as determined by the Council on Medical Education and Hospitals of
the American Medical Association (AMA).

From 1957 to 1976, the American Physical Therapy Association (APTA) collaborated
with the AMA to approve physical therapy education programs. In 1977 the APTA’S
Commission on Accreditation in Physical Therapy Education (CAPTE) became the

239. recognized accrediting body for physical therapy educational programs. By January,
2003, the list of CAPTE-accredited programs included 204 PT and 459 physical
therapist assistant (PTA) programs.

The criteria for accreditation were modified in 1996 to incorporate language and
concepts from the APTA’s Guide to Physical Therapist Practice1 and the Normative
Model of Physical Therapist Professional Education. 6 In theory, accreditation is a
voluntary process, the purpose of which is quality improvement. In reality, however,
the link between accreditation and licensure means that participation in the
accreditation process becomes mandatory. To be eligible for licensure as a PT or
PTA, a person must be a graduate of a CAPTE-accredited physical therapy program.

Because the profession emerged from a variety of settings, a persistent challenge in
physical therapy education has been the development of programs at various
educational levels. Before the term allied health was popularized during the
congressional deliberations that led to passage of the Allied Health Professions
Personnel Training Act of 1967, physical therapy education was based in hospitals or
universities. Passage of the Personnel Training Act produced the new concept of
unifying the various allied health disciplines into academic units with a single
administration.

The federal funding made available by the law allowed many freestanding physical
therapy schools to become part of the new colleges of allied health, which typically
awarded the baccalaureate degree.

Classification of physical therapy as an allied health profession remains the trend
today. Some have suggested that this is detrimental to the development of the
profession, because the allied health disciplines include a diverse group of degree
programs. Also, this designation perpetuates the concept of physical therapy as a
subsidiary of medicine rather than an autonomous profession. Consequently, the
movement away from affiliation with the AMA for program accreditation had been
set back, resulting in some loss of autonomy.

However, current accreditation policies reflect the effort to continue the move toward
autonomous practice. In January, 2002, CAPTE began accrediting only programs that
awarded post baccalaureate degrees. With many programs making the transition to the
post baccalaureate level, the APTA issued this new vision statement: “By 2020,
physical therapy will be provided by physical therapists who are doctors of physical
therapy.”7 Meanwhile, the awarding of multiple degrees for entry-level practice
continues. This situation arose after World War II, when PTs held degrees at the

240. baccalaureate, master’s, and certificate levels; currently, most practicing PTs hold
bachelor of science (B.S.) degrees, but new graduates hold the master’s or doctor of
physical therapy (DPT) degree.

241. lecture no. 2
Contemporary educational roles of the physiotherapist

PTs serve as educators at a variety of levels, from patient instruction to teaching as
tenured professors. Co-workers, physical therapy students, and PTA students in both
the classroom and clinical practice, as well as other groups of professional and lay
people, are potential audiences. Teaching opportunities, therefore, can take a number
of forms:

● Informal, short classes
● In-service courses for other staff members to update information or provide training
for specific skills
● Continuing education courses
● Clinical instruction (e.g., clinical instructor or center coordinator of clinical
education)
● Academic programs (e.g., adjunct faculty member, academic coordinator of clinical
education, or full-time tenure track faculty member)

Instruction of Patients

Patient instruction is a primary component of every physical therapy intervention. It is
the process of informing, teaching, or training patients (or families and caregivers) in
techniques that promote and optimize physical therapy services. This instruction may
cover a number of topics, such as the patient’s current condition and the related
impairments, functional limitations, and disabilities; plans of care; the need for
enhanced motor performance; a transition to a different treatment setting; risk factors;
or the need for health, wellness, and fitness programs.1 Patient instruction may be
integrated into a treatment session or provided as a separate, formal intervention (Box
7-3). For example, during an exercise program, PTs may instruct the patient in the
principles of exercise, as well as the importance of exercise to overall health, or
devote an entire treatment session to training a caregiver in home exercises and
transfer techniques or answering questions about a patient’s condition. One-on-one
instruction is a patient care skill expected of all PTs, and it lays the foundation for
goal setting and instructional strategies in other teaching venues.

242. Teaching Roles Beyond Patient Care

Many PTs are assigned or volunteer to make presentations as part of their job
responsibilities. Such a teaching assignment may be a one-time only session, or it
might be a component of a continuing training program. Examples of such
presentations include
● In-service classes for physical therapy or other staff members to present new
information or update skills (e.g., updating interventions for the hemiplegic shoulder
or reviewing current procedural terminology [CPT] coding skills)
● Job training programs (e.g., instructing nurses’ aides in body mechanics and in
assisting patients with ambulation regimens).
● Educational programs for groups of patients with common needs (e.g., making a
presentation on skin protection to the local diabetes association support group, or
teaching spouses of stroke survivors strategies for increasing their loved one’s activity
level).
● Public service presentations (e.g., making presentations in public schools or to
service-based organizations about the physical therapy profession or movement
disorders)
These educational presentations involve the same degree of preparation as other types
of instruction.

243. lecture no. 3
Teaching Opportunities in Clinical Education

Clinical faculty members, who train and supervise students at clinical education sites,
typically work one-on-one with a PT or PTA student. In physical therapy education,
the two kinds of clinical faculty members are the clinical instructor (CI) and the center
coordinator of clinical education (CCCE).6 CIs instruct and supervise students
directly during clinical education. They are responsible for providing a sound clinical
education and for assessing students’ performance based on entry-level practice
expectations.
After at least one year of work experience, a PT may volunteer to be or may be
recruited as a CI. The PT may prepare for this teaching role
(1) informally under the guidance of a CCCE,
(2) through self-study.
(3) through a series of more formal training sessions in the clinical center or affiliated
physical therapy programs, or
(4) through certification programs offered by the APTA and many of the regional
consortiums of physical therapy educational programs.
CIs face the challenge of maintaining the quality of patient care and meeting
productivity goals while providing learning experiences for students assigned to part-
time or full-time extended internships. PTs seek the additional work and responsibility
of a CI for a number of reasons: to “give back” to the profession out of gratitude to
the CIs who taught them, share their expertise, remain current or to refresh skills and
knowledge by teaching others, or modify their daily routines. CAPTE has established
criteria for clinical faculty members.

In each center with a physical therapy clinical education program, one person is
assigned the role of CCCE; this individual administers, manages, and coordinates the
assignment of CIs and the clinical learning activities of students. The CCCE
determines the readiness of PTs to serve as CIs and supervises their clinical teaching,
discusses students’ clinical performance with academic faculty members, and
provides information about the center’s clinical education programs to PT and PTA
programs. Depending on the size of the center and the number of CIs, the CCCE’s
patient care and CI responsibilities may be reduced to allow time for CCCE duties;
the position is considered supervisory or administrative. In smaller centers, the CI and
CCCE may be the same person and the only one engaged in clinical education.

244. CRITERIA FOR CLINICAL PHYSICAL THERAPY FACULTY
The clinical education faculty demonstrates clinical expertise in their area of practice
and the capacity to perform as effective clinical teachers. The clinical education
faculty are those clinicians who have the responsibility for education and supervision
of students at clinical education sites. Members of the clinical education faculty serve
as role models for students in scholarly and professional activities. Judgment about
clinical education faculty competence is based on appropriate past and current
involvement in in-service or continuing education courses; advanced degree courses;
clinical experience; research experience; and teaching experience (e.g., classroom,
clinical, in-service and/or continuing education). Clinical education faculty must have
a minimum of 1 year of professional experience (2 years of clinical experience are
preferred). Their continued ability to perform as clinical education faculty is assessed
based on the individual’s prior performance as a clinical educator and on other criteria
established by the program.

The CCCE is responsible for the quality of the clinical education program and for
keeping current on issues such as billing for services provided by students, evaluation
of student performance, and scheduling of students, who often are from several
different PT and PTA programs. The CCCE plays an important role in integrating a
clinical education program into the goals of a physical therapy organization. In an
informal arrangement, a PT is asked to volunteer to serve as CI, which is perceived as
extra duty, and student placement is unpredictable. When clinical education is tightly
integrated into an organization’s structure, students become part of the culture of the
organization, and clinical instruction is an expected part of the job for every qualified
PT.

One of the CCCE’s responsibilities is overseeing reimbursement for student services
under Medicare Part B10 (Box 7-6). The rules governing such services reflect
Medicare’s concern that reimbursement be provided only for skilled physical therapy
services; a PT, therefore, must be directly involved in the patient care for which
Medicare is billed. State laws governing the practice of physical therapy also typically
require that students be directly supervised. Such regulations pose a challenge to CIs,
who must directly supervise students while gradually improving their ability to
perform tasks independently.

The Clinical Performance Instrument (CPI), which was developed by the APTA as a
means of evaluating student performance in clinical education, defines a student
capable of entry-level practice as “a student who consistently and efficiently provides
quality care with simple or complex patients and in a variety of clinical environments.
The student usually needs no guidance or supervision except when addressing new or
complex situations.”11 As the student progresses through the clinical education
program under appropriate supervision and guidance, “the degree of monitoring or

245. cueing needed is expected to progress from full-time monitoring or cueing for
assistance to independent performance with consultation.”

246. lecture no. 4
Teaching Opportunities in Continuing Education

PTs are deluged with announcements of continuing education (nonacademic) courses,
which traditionally are offered in seminars or during professional conferences and
regional meetings. However, with the emergence of the computer and the Internet as
educational tools, continuing education courses now can be offered as interactive
web-based courses or home-based independent study programs that use texts or
computer-delivered content.

Qualified PTs may take the initiative in sharing their expertise by offering a
continuing education program, or they may be asked to volunteer to make
presentations, particularly at regional professional programs. PTs may also choose to
affiliate with a company in the continuing education business. In such cases the PT is
paid to teach the course but is not responsible for the development, credentialing, or
marketing aspects. Such arrangements can be lucrative for both parties, but
restrictions may be imposed on presenters in terms of the content, frequency, and
format of the courses.

An entrepreneurial PT can create a continuing education program, although this
requires skills beyond professional expertise. For each course offered, the following
components must be addressed:
● Target audience and marketing plan
● Clearly defined rationale and learning objectives
● Learning outcomes
● Instructional strategies
● Presentation format (seminar, distance learning, home study)
● Audiovisual or other technological expertise required to present content
● Length of course
● Determination of continuing education units to be awarded
● Approval of the course by the appropriate credentialing organization
● Plan for documentation of attendance and filing of permanent records

247. ● Fee for the course based on expenses and profit
● Course evaluation method

Continuing education is a market-driven industry that presents entrepreneurial
opportunities as well as sources of revenue for professional associations. National
criteria have been established for colleges, associations, and companies that wish to
be credentialed to award continuing education units (CEUs), the standard time
increments for measuring the value of continuing education courses.13 Approval of a
course by one of these organizations gives some assurance that the instructors are
qualified to present the course and that the learning objectives are reasonable.

Although the credentialing process is a step in the right direction, concern still exists
about the quality of course content and the evidence supporting the content. For
example, those assigned to review courses for CEUs may not be content experts.
Also, the information presented may be based on personal experience rather than
scientific evidence; this perpetuates the lack of evidence-based physical therapy tests
and interventions, particularly if the course involves the presentation of new treatment
strategies. These issues cloud the CEU requirement for licensure renewal. Whether
accumulation of a required number of CEUs truly reflects a PT’s efforts to maintain
or improve clinical competence is unclear, and the professions must depend on the
market to determine the popularity and acceptance of continuing education programs.

RESPONSIBILITIES OF THE ACADEMIC COORDINATOR OF CLINICAL
EDUCATION (ACCE) OR DIRECTOR OF CLINICAL EDUCATION (DCE)

The ACCE/DCE holds a faculty (academic or clinical) appointment and has
administrative, academic, service, and scholarship responsibilities consistent with the
mission and philosophy of the academic program. In addition, the ACCE/DCE has
primary responsibility for the following activities:
● Developing, monitoring, and refining the clinical education component of the
curriculum
● Facilitating quality learning experiences for students during clinical education
● Evaluating students’ performance, in cooperation with other faculty members, to
determine the students’ ability to integrate didactic and clinical learning experiences
and to progress in the curriculum
● Educating students and clinical and academic faculty members about clinical
education

248. ● Selecting clinical learning environments that demonstrate the characteristics of
sound patient/client management, ethical and professional behavior, and current
physical therapy practice
● Maximizing available resources for the clinical education program
● Keeping records and providing assessments of the clinical education component
(e.g., clinical education sites and clinical educators)
● Engaging core faculty members in clinical education planning, implementation, and
assessment

249. lecture no. 5
Academic Teaching Opportunities

PTs may maintain their clinical practice and serve as guest lecturers in physical
therapy and PTA programs. Some type of honorarium may be offered, but more often
these are unpaid teaching opportunities rewarded with letters of appreciation.
However, serving as guest lecturers allows PTs to explore their interest and skills in
classroom teaching. Also, guest lecturers may be treated less formally than full-time
academic instructors; they may not have to submit detailed credentials or allow
evaluative review of assignments by administrators. Faculty members assigned to
courses identify those in the community with expertise that complements or
supplements the course content and invite them to take part in classroom instruction.
The guest lecturer may participate in a single course or may present the same topic
each time the course is offered.

The most formal teaching opportunity for PTs is a position as a full-time or part-time
(adjunct) faculty member in a PT or PTA curriculum. Faculty positions are based on
the academic triad of teaching, research, and service. The distribution of the faculty’s
efforts among these three elements, as well as the performance expectations for
faculty members, vary according to the type of institution (e.g., private or public,
research or liberal arts) and the availability of tenure. For example, in community
colleges, the emphasis is on teaching, with very little expectation of faculty research.
In large universities, the expectations for research (production and dissemination of
new knowledge) and for obtaining external funding to support the research tend to
overshadow efforts in the other areas. In smaller colleges, the focus may be more on
teaching responsibilities and publication of new information. Cutting across these
institutional differences, CAPTE14 has clarified the scholarship expectations for each
faculty member in a physical therapy program, which are based on Boyer’s categories
of scholarship—discovery, integration, application, and teaching.
● Scholarship of discovery focuses on the development or creation of new knowledge
by traditional research that is disseminated through previewed publications and
through professional presentation of grants awarded for research or theory
development, recognition of scholarship, and outcome studies.
● Scholarship of integration involves critical analysis and review of knowledge within
disciplines and creative insights derived from different disciplines or fields of study.
Such work may involve publication of literature reviews, meta-analyses, and synthesis
of the literature from other disciplines accompanied by discussion of its significance
for physical therapy. This form of scholarship also includes the publication of books
and book chapters, reports on service projects, and policy presentations designed to
influence the positions of professional organizations and government agencies.
● Scholarship of application is the use of knowledge to solve real problems in the
professions, industry, government, and the community. The findings obtained through

250. scholarship of discovery and scholarship of integration are applied to clinical practice
or teaching and learning. This process may result in consultation reports, products,
licenses, copyrights, and grants supporting innovations in practice.
● Scholarship of teaching involves critical reflection on and dissemination of
knowledge about teaching and learning. It includes classroom assessment and
evidence gathering, the use of contemporary teaching theories applicable to the
particular profession, peer collaboration and review, and inquiry into issues related to
student learning. Scholarship of teaching is not synonymous simply with excellent
teaching; it also requires the individual to produce published, peer-reviewed articles
devoted to pedagogy, to devise teaching innovations, to merit recognition as a master
teacher, to write textbooks on teaching, and to obtain grants and make presentations
related to issues in teaching and learning.

CAPTE differentiates service responsibilities as internal service (e.g., serving on
departmental and college committees) and external service (e.g., holding elected
office in professional organizations or serving on boards of community
organizations).

To meet the institutional and CAPTE criteria for a faculty appointment, the PT must
pursue or have completed graduate study (the doctoral degree is heavily preferred in
physical therapy education) and must be comfortable to some degree with moving
away from direct patient care. The transition to faculty member from clinical practice
may be difficult, because the responsibilities are quite different and often surprising.
The transition may startle even individuals who have had peripheral contact with the
academic world as guest lecturers, because faculty members’ responsibilities extend
far beyond preparation of a lecture or course and the duties of the teaching-research-
service triad. Faculty members also develop curricula and courses, prepare syllabi,
choose instructional strategies, evaluate student performance, and contribute to the
student admission process. This involvement of the entire faculty in collegial decision
making to meet the needs of professional education is very different from clinical
working relationships.

251. lecture no. 6
THEORIES OF TEACHIN G AND LEARNING IN PROFESSIONAL
EDUCATION

Regardless of the audience, the effectiveness of teaching is determined to some
degree by how well the teacher understands the ways in which people learn.

A teacher’s philosophy of learning directs instructional strategy. Purists contend that
effectiveness may be compromised if learning theories are mixed; others strongly
believe that an eclectic approach is critical when a wide range of information and
skills must be learned. For example, knowledge acquisition can be achieved in a
variety of ways. Initial knowledge acquisition is perhaps best served by the classical
instruction method, with predetermined learning outcomes, sequenced instructional
interaction, and criterion-referenced evaluation. Patient problem solving and
integration of information, on the other hand, may be better taught from an
andragogic perspective.

An important tool from the behaviorist approach that is useful for all instruction is a
taxonomy of educational objectives, based on the early work of Benjamin Bloom
(Box 7-8). Learning behaviors are classified into three domains: the cognitive domain
(recall and use of information), the psychomotor domain (physical and manipulative
skills), and the affective domain (interest, attitudes, and values). In each domain,
learning is organized into a hierarchy of complexity. In the cognitive domain, for
example, analysis of information is a much higher learning objective than recall of
knowledge. This taxonomy is helpful for determining the level of learning expected,
and it provides the verbs for writing objectives.

In devising a teaching plan, whether for a group, an in-service presentation, or a
graduate course, the instructor should begin with the purpose or expected outcome (or
outcomes) of the learning unit. The outcomes should be classified according to the
taxonomy described previously so that objectives in specific terminal behaviors, or
the outcomes of the learning that the student must demonstrate, can be developed.
Examples of terminal behaviors are found in Box 7-9 in the “B” part of each learning
objective. The instructional method and the evaluation tool most appropriate for each
domain can then be identified. For example, if psychomotor goals are sought,
laboratory practice is indicated, and a practical examination would be the test of
choice. With affective goals, discussion groups and a report may be indicated.

252. lecture no. 7
ETHICAL AND LEGAL ISSUES IN PHYSICAL THERAPY
EDUCATION

Teachers are also responsible for understanding ethical and legal issues. A sample of
education legislation is presented in Table 7-2 to reflect the complexity of the higher
education process. Discrimination, privacy, dismissal policies, and academic freedom
are among the issues.

APTA Code of Ethics and Guide for Professional Conduct Principle 6 of the APTA
Code of Ethics obligates physical therapists to “maintain and promote high standards
for physical therapy practice, education, and research.”16 The association’s Guide for
Profession Conduct17 (GPC) elaborates on this principle, linking it to continual self-
assessment to determine compliance with professional standards (GPC 6.1),
professional competence and quality improvement (GPC 6.2), support for high-
quality professional education (GPC 6.3), continuing education (GPC 6.4), and
support for research (GPC 6.5). The ethical obligations of PTs involved in teaching or
continuing education are specifically addressed. PTs providing continuing education
courses should be competent in the content (GPC 6.4A) and should give accurate
information about the course in course materials (GPC 6.4B).17 Those attending
continuing education courses are obligated to evaluate the quality of the information
before putting it to use: “A physical therapist shall evaluate the efficacy and
effectiveness of information and techniques presented in continuing education
programs before integrating them into his/her practice” (GPC 6.4C).

Continuing Competence

The quality of continuing education and its contribution to continuing competence are
issues of particular concern to state practice boards, which are charged with protecting
the public from professional incompetence. By granting a license, the licensing board
signifies that it has determined the PT is competent to practice. As stated by the
APTA Code of Ethics and Guide for Professional Conduct, maintaining competence
requires commitment to a lifelong process of education and skill development to meet
the ever-changing needs of health care. Mandatory continuing education has been the
tool most commonly used to ensure that licensed PTs maintain competence, although
it is universally acknowledged that attendance at courses does not necessarily
translate into competence. The Federation of State Boards of Physical Therapy has
established standards of continuing competence for physical therapy and has
committed itself to developing measurement tools for assessing competence.

253. Academic Integrity

Programs that educate future professionals seemingly would be free of cheating and
violations of academic integrity; however, educational journals indicate that this is not
the case. Technology has created additional challenges to academic integrity by
making materials easier to copy. Also, students have been caught sending messages
by cell phone during practical examinations. As with any type of cheating, sanctions
for such actions must balance the ultimate good of the student against the
responsibilities of the educational and gatekeeping roles. Because self-regulation is
expected of professionals, serious violations of academic integrity may be considered
an indication that a student lacks the required moral qualities and decision-making
capability.

Vulnerability of Students

Just as patients are vulnerable to the PT’s knowledge and status, students are
vulnerable to the status and power of faculty members. Students may be subjected to
unfair grading, sexual harassment, or discrimination. Clinical faculty members have
particular power over students because the faculty members may make judgments that
are somewhat subjective without direct input from academic faculty members. A
study of covert bias among 83 physical therapists found that the PTs gave black
students lower ratings on a presentation than they did white and Asian students, even
though the presentations were identical in content.19 The results of the study are
disturbing in light of the small number of minorities in physical therapy. Furthermore,
academic educators may be reluctant to challenge clinical faculty members for fear of
losing scarce clinical placement sites.

254. lecture no. 8
THE HISTORY OF PHYSICAL THERAPY ADMINISTRATION

Physical therapists (PTs) have been administrators from the very beginning of the
profession. As chief aides, PTs supervised other reconstruction aides in the treatment
of wounded soldiers returning from World War I, and they subsequently worked with
orthopedists as equal partners to provide rehabilitation services for civilian patients.
After World War II, physical medicine and rehabilitation emerged as a medical
specialty. Physician specialists in this field, called physiatrists, were responsible for
the overall management of rehabilitation units in hospitals, and in the military
tradition, each discipline of the rehabilitation department had a “chief” (e.g., chief PT,
chief occupational therapist).

Because a high percentage of PTs were employed by hospitals, a typical career pattern
for a staff PT involved promotion to a supervisory position; this typically meant the
PT assumed responsibility for training and assigning the duties of support personnel
and perhaps some responsibility for scheduling staff and patients for a particular
subunit, such as outpatient services. The next step up the career ladder was the
administrative “chief” position, which involved hiring, evaluating, and firing staff
members; purchasing supplies and equipment; and collaborating with other members
of the rehabilitation and health care teams. However, PTs had very little opportunity
for advancement to such administrative positions in this physician-dominated,
hospital-based, bureaucratic model, which also characterized community-based
organizations such as the Easter Seal Society and other groups that provided services
to children and adults with chronic conditions.

As an employment alternative, PTs could work directly with a physician (typically an
orthopedist or a physiatrist), providing services in the physician’s office. These
positions also involved some administrative functions, depending on the number of
people providing physical therapy services and the extent to which the physician
delegated management of the practice to the PT.

Just as the health care system has changed over the past decades, so has the
management of physical therapy services. Beginning in the 1960s, physicians were
increasingly replaced as managers of hospital rehabilitation services by professional
health care managers, who were academically prepared to deal with the increasing
complexity of health care delivery. Some of these new, midlevel managers were PTs
and other health care professionals who had acquired management skills through
graduate studies or work experience. Others, who were not health care professionals,
had business degrees that focused on health care. This insertion of business practices
and overseers who are not health professionals into the management of health care

255. may be either a cause or a result (or perhaps both) of health care becoming an industry
rather than a service.

In the late 1960s, more entrepreneurial PTs began developing independent private
practices, and for-profit corporations were formed to provide outpatient rehabilitation
services in numerous centers, often nationwide. Freestanding private physical therapy
practices became commonplace. The provision of skilled services in nursing homes
offered new opportunities for these PTs as Medicare reimbursement for rehabilitation
services in skilled nursing homes became lucrative. In addition to providing direct
patient care services in freestanding clinics, PTs created companies through which
they contracted their services to health care organizations.

For health care organizations, outsourcing physical therapy services to rehabilitation
companies has several advantages, including the following:
● Reducing direct costs and providing flexibility in coping with periods of change
● Freeing up more time for focusing on organizational tasks rather than supervision of
staff
● Allowing access to a critical mass of expertise not available in-house

For PTs, outsourcing may be a means of enhancing professional autonomy in a
variety of work settings, increasing flexibility in the amount and scheduling of work,
and benefiting from the ability to focus on a particular specialty for career
development.

These incentives are more attractive to independent contractors than to PTs who work
for physical therapy contracting organizations, essentially as employees. However,
PTs in the latter situation at least work for other PTs, who are more likely to have
significant insight into important professional and clinical issues.

Outsourcing has two important disadvantages, which have the greatest impact when
the need for physical therapy services is unpredictable. First, PTs run the risk of
income loss for uncertain periods of time. Second, PTs may be unavailable when,
from the manager’s perspective, they are most needed by the health care organization.

256. PTs also practice in public school systems. The school system may employ the PTs
directly, or it may contract out physical therapy services to individual PTs or other
organizations. PTs in school systems often provide services at several schools and
work closely with teachers and other therapists to establish goals for each student’s
individualized education plan.

Another model of practice recently has emerged. A corporation provides an umbrella
for outpatient physical therapy centers which provide support for PTs who
independently manage their own practices. This arrangement has the potential to
provide the best of both worlds for a PT: the PT enjoys a great deal of autonomy in
the day-to-day management of a practice but has the business support needed for
developing the practice, marketing, billing, and other financial responsibilities.

In health care systems, the recent trend has been to move away from discipline
specific departments toward program, or product-line management. For example,
instead of the traditional physical therapy, occupational therapy, speech and language
pathology, and nursing departments, a hospital or medical center now may be
organized into patient-centered programs or units, such as the orthopedic service, the
stroke center, or the head trauma unit. This model has several advantages: the team of
professionals assigned to the program develops an expertise with patients who have a
particular diagnosis, and teamwork becomes easier, resulting in greater efficiency in
communication and treatment. The managers of these units typically come from one
of the participating disciplines,

so a PT may be managed by a nurse or occupational therapist or may supervise
professionals from a variety of disciplines. Despite these advantages, the program
model raises concerns about professional identity and autonomy that are similar to
those that arise when the manager of the service is a professional manager with no
credentials in a health care discipline or when physicians manage rehabilitation
services.

All employment situations pose the threat of loss of professional autonomy. Mark2
suggests that employed PTs may have less professional accountability and a
diminished guarantee of maintaining professional expertise because they must rely on
managers who are not physical therapy professionals for access to training and
development. Also, employed PTs may have less professional interaction with other
PTs and much less flexibility to provide or receive cover from PTs working in
competing areas of the organization.

257. lecture no. 9
CONTEMPORARY PHYSICAL THERAPY ADMINISTRATION
Physical therapists now have many more opportunities to assume managerial
responsibility in a wider range of organizational structures at different levels of
management. The development of skills for managerial roles is more important than
ever, and even without an administrative or a managerial title, PTs arguably call upon
many of these skills in providing direct patient care.
Because no theory of administration exists per se and because the terms
administration and management often are used interchangeably, the role of first-level
manager, often considered an administrative position, is best understood from the
broad base of management theory. (The term manager is used interchangeably with
administrator for this purpose.)

Management is the process by which an organization meets its goals. Managers are
responsible for selecting the procedures to be used and for evaluating the
effectiveness and efficiency of these procedures in meeting the stated goals. The
arrangement of the management system depends on the size and complexity of the
organization and the number of management levels.

Management theories, which originated in the early 20th century and have evolved
since then, are closely related to organizational and leadership theories (Table 8-1).
Organizations reflect a wide range and mix of these theories. Some remain strongly
bureaucratic, with a definite chain of command. Others have amore flexible structure
and management style that allow them to respond more easily to changes in missions
and goals and permits greater employee participation at all levels in decisions about
the organization.

As a professional trade organization that represents PTs and physical therapist
assistants (PTAs), the American Physical Therapy Association (APTA) represents one
type of organizational structure (Figure 8-1). The business of the membership is
conducted through an elected body of representatives, the House of Delegates.3 The
executive committee of the board of directors oversees the headquarters’ staff (Figure
8-2), which accomplishes the work of the association.

The APTA appears to be very much a traditional, bureaucratic, hierarchical
organization with a clear chain of command and very little connection among its five
divisions (i.e., communication, education, finance and administration,
governance/components/meetings, and practice/research). Even the designations used
(e.g., headquarters and divisions) are military terms that suggest the underlying

258. organizational and managerial model. In this type of organization, each division is
responsible for a portion of the work “pie,” and the work would be divided up into
particular tasks. Each division head has the opportunity to meet regularly with all
other division heads, probably in meetings chaired by the chief executive officer
(CEO), but little day-to-day interaction occurs among the divisions to accomplish the
goals of the organization. (See Case Scenario 1 for an opportunity to change the
organizational structure of the APTA.)

Given the wide range of perspectives and to avoid bias toward any particular theory,
physical therapy management is considered in this discussion on the basis of the
responsibilities managers hold in four broad areas: finances, human resources,
operations, and information (Table 8-2). Selected responsibilities that represent
contemporary professional issues also are presented.

Another perspective on the division of managerial responsibilities focuses on the
control an individual has at each management level over
(1) work to be performed immediately,
(2) future work,
(3) the work of others,
(4) the organization’s goals, and
(5) interaction with others at the same organizational level.

Although managers at every level of a physical therapy organization have the same
types of responsibility, the actual responsibilities vary. For discussion purposes,
responsibilities are presented as exclusive to each management level; however,
depending on the organization’s structure and management style, some variation or
overlap of responsibilities and titles may exist at adjacent levels. For example, a first-
line manager may also have a full caseload of patients, or a staff PT may be assigned
quality assurance duties.

259. lecture no. 10
PATIENT/CLIENT MANAGEMENT
The management of patients is the common level of management or administration
for all PTs. In day-to-day patient/client management, PTs take charge of resources,
plan the care of patients, direct support personnel, and organize time and work.
Through these duties, the PT becomes a manager of the assigned work, responsible
for ensuring that the outcomes of the care provided contribute to the organization’s
overall goals. Professional issues at this level of management include billing,
documentation, and delegation and supervision of support personnel.
Billing for Physical Therapy Services

The primary financial responsibilities at the patient/client management level of
administration is billing for physical therapy services provided. All medical billing is
based on the Current Procedural Terminology (CPT), which is published by the
American Medical Association (AMA).5 The CPT, first published in 1966, is a list of
descriptive terms and identifying codes used to report medical services and
procedures. Because it provides a uniform language for describing all medical,
surgical, and diagnostic services, the CPT serves as a nationwide means of
communication among physicians, patients, and third-party payers. In the 1980s the
Health Care Financing Administration (currently the Center for Medicare and
Medicaid Services) adopted the CPT for Medicare and Medicaid programs, and it is
the preferred coding system of other insurers.

The CPT is not a static text. For example, the fourth edition, published in 1977,
included significant updates in medical technology, and periodic updating was
initiated to keep pace with the rapidly changing medical environment. This updating
continues today.5 An AMA editorial panel is responsible for revising, updating, and
modifying the CPT. The panel, which is composed of 16 multidisciplinary members
and an insurance representative, includes a PT, who represents the nonmedical
professions. Just because a service has a CPT code does not mean the PT will be
reimbursed for it. In surors’ payment policies determine the language of benefits
packages, which are driven by cost containment. PTs, therefore, must remain up-to-
date on third-party payer decisions on covered services so that therapists can correlate
billing codes accurately with the services provided in each treatment session and also
so that they know which services are billable to which insurance companies. Recent
issues related to CPT coding for PTs include the following:
● Definition of one-on-one and group therapy
● Use of codes for evaluation and reevaluation
● Billing for interventions and evaluations on the same day

260. ● Denial of reimbursement for physical agents which have been determined to be
unskilled Health professionals may use any CPT code that is within their scope of
practice. PTs most often use the 97000 category (i.e., physical medicine and
rehabilitation) to bill for their services (Box 8-1). Other professionals, such as
physicians, occupational therapists, and chiropractors, also may bill for interventions
in this category, and PTs may use codes in other applicable categories.
In addition to specific procedures, the 97000 category includes services measured in
time spent with the patient (e.g., 97530, therapeutic activities with direct patient
contact, each 15 minutes). The number of units billed under the 97530 code depends
on how long the PT was in direct contact with the patient engaged in therapeutic
activities. However, code 97110—exercises for strength/ endurance/range of motion
(ROM)/flexibility—would be billed as 1 unit regardless of how long the patient
exercised.
Payers use a variety of methods to determine the value of each CPT code, such as
contracted rates (a discount rate negotiated by the payer and a provider, such as a
managed care organization) or capitated rates (a fixed amount per patient accepted
periodically by a provider for services to patients covered by the insurer). More
commonly, reimbursement rates are determined by fee schedules. The most frequently
used fee schedule is the Resource-Based Relative Value Scale (RBRVS), which
isused by Medicare. In this system the value of a procedure identified by a CPT code
is determined by the following:
● The value of the provider’s work, evaluated on the basis of time, technical skill,
physical effort, mental effort, and judgment, as well as the psychological stress that
may result when the work has a high risk to cause harm to the patient
● Practice expense related to performance of the procedure
● Malpractice costs
● A geographic price cost index (GPCI), which is applied to each of the preceding
components to account for economic variations across the United States
● An annual conversion factor, which is used to calculate the amount the provider
will be paid for each procedure and is determined annually by Congress and the
Centers for Medicare and Medicaid Services (CMS).6
Other payers may use the RBRVS to establish a fee schedule, but they often establish
conversion factors different from those Medicare uses.

Documentation

The APTA’s Interactive Guide to Physical Therapist Practice with Catalog of Tests
and Measures1 (commonly known simply as the Guide), defines documentation as

261. “any entry into the patient/client record, such as consultation reports, initial
examination reports, progress notes, flowsheets, checklists, reexamination reports, or
summations of care, that identifies the care or services provided.”1 PTs are
responsible for all documentation of the services provided to each patient, even when
support personnel actually make the entries and provide the care. This responsibility
includes reconciling documentation entries with fees claimed for services provided.

Reimbursement for physical therapy may be prospective; that is, the number of
sessions and interventions are agreed on prior to initiation of services. In such cases,
documentation to justify physical therapy charges may be less important; however, a
PT who might want authorization to continue services would be wise to keep records
that reflect the three traditional demands of Medicare; specifically, the documentation
should show that the services provided were skilled, medically necessary, and related
to improvement of function quality of care. The principles of documentation (Box 8-
2) apply, regardless of the practice setting or documentation system.
Many health care systems have incorporated centralized information systems, which
allow providers to make their documentation entries through a computer. The entries
are transmitted to the medical record, which can be accessed by all providers involved
with the patient’s care. These systems have alleviated some of the problems
associated with the traditional manual-entry method. Computer-based documentation
has the potential to do the following:
● Reduce the time spent on documentation and thereby maximize the provision of
direct patient care
● Eliminate duplication and reduce entry errors
● Limit entries to specific required information
● Improve the timeliness of the information shared
● Provide prompts for required entries
However, computer-based documentation also presents new challenges in terms of
patient privacy, confidentiality of information, and security of records. The APTA has
established guidelines for documentation and recommended documentation forms that
are consistent with the terminology, patient/client management model, and practice
patterns of the Guide.
Persuading all PTs to use the same documentation forms is a challenge because use of
the APTA forms is voluntary and requires some familiarity with the Guide. Also, the
documentation submitted for Medicare billing is not consistent with the APTA’s
recommended terminology, and PTs are not likely to adopt two formats that would
result in duplication of effort.
Despite these obstacles, standard terminology and documentation formats are
important for communication, not only between PTs themselves but also among PTs

262. and other health care providers, third-party payers, attorneys, and accrediting
agencies. From a research standpoint, standardized terminology and documentation
formats would be a major advantage in building a knowledge base from clinical data.

263. lecture no.11
FIRST-LINE MANAGEMENT
First-line managers in physical therapy may be assigned direct patient care tasks in
addition to financial, operations, human resource, and information responsibilities.
Their duties include budgeting; hiring, firing, and evaluating staff members; and
ensuring that the organization meets accreditation, certification, and other legal
requirements.

Budget Responsibilities
Budgeting is the process of making decisions about revenue and expenses to ensure
that funds are available to meet the goals of the organization. A first-line manager
may be asked to contribute to this decision-making process, which may occur
annually, biannually, or even at 5-year intervals. More important, first-line managers
are held accountable for implementing the components of an organization’s budget
that apply to physical therapy services. A first-line manager may report on revenue
and expenses to a midlevel manager as often as weekly. More typically, budget
projections are formally reviewed monthly with the midlevel manager, who may
oversee coordination of the budget among several departments.
First-line managers are responsible for ensuring that projected revenue is met and that
projected expenses are not exceeded. The major source of revenue, reimbursement for
services provided, is analyzed in terms of the projected payer mix (i.e., which payer
accounts for what percentage of revenue) and the fee schedules for each payer or
contract (Figure 8-3). The typical categories of expenses are salaries and benefits,
Federal Insurance Contributions Act (Social Security) payments, recruitment,
equipment, and supplies. A freestanding facility or practice also has budget provisions
for professional services, rent or lease, utilities, telephone service, maintenance,
depreciation, and insurance. In large organizations some of these expenses may be
prorated to departments on the basis of square footage, the number of employees, or
some other formula by which expenses are shared across the board.

Operations Responsibilities
First-level managers are responsible for capital equipment decisions. Allocation of
these funds is part of the budgeting process, although it is considered separately.
Typically, equipment is considered a capital investment at some predetermined cost
(e.g., over $1000). Because funds for capital investment frequently are limited,
managers often must submit a cost/benefit analysis to determine the potential gain in
meeting the organization’s goals (see Case Scenario 4). Other operations
responsibilities may include assigning staff members to particular units or patients,
determining the ratio of PTs to support staff (i.e., the skill mix), and establishing
productivity goals (Table 8-6). These decisions are closely tied to budget
determinations because salaries and benefits are always the greatest expenses. First-

264. line managers are responsible for striking a balance between use of the least
expensive (and least skilled) individuals able to provide care and maintenance of the
quality of care.

Human Resource Responsibilities
The human resource responsibilities of first-line managers include the hiring, firing,
and evaluation of staff members, decisions that are affected by a number of federal
employment laws. In large organizations human resource experts assist in the
management of many of these employment factors. However, the first-line manager
may have some control over salary negotiations and a great deal of responsibility for
assignment and scheduling of staff members, payroll reporting, and evaluation of
performance, which usually is linked to salary increases. Fairness and consistency in
these matters are not only legally important, but they are also vital to staff morale

Information Responsibilities
A major responsibility of the first-line manager is training staff members in correct
documentation and supervising all record keeping. Often this task is integrated into
other quality assurance processes. As part of the Health Insurance Portability and
Accountability Act (HIPAA), recent federal legislation has tightened the rules
protecting the confidentiality and security of patient information (Box 8-4). Another
major information responsibility of the first-line manager is preparation of regular
reports (typically quarterly) to mid-level managers that provide information on issues
such as productivity, budget status, ongoing projects, and progress toward meeting
departmental goals. Depending on the type of organization, first line managers are
also responsible for contributing to the preparation of materials required for
accreditation and licensure of organizations and compliance with the numerous health
care regulations. The APTA standards of practice are an important source of
information on these issues for first-line physical therapy managers.19 First-line
managers face many challenges. Their jobs are difficult because they answer to a
number of work initiators who are higher or lower in rank. Guy10 described this
difficulty as the conflict-ridden position of the person in the middle. At this
management level, more discord is seen among managers themselves

265. lecture no. 12
MIDLEVEL MANAGERS AND CHIEF EXECUTIVE OFFICER S
The responsibilities of the midlevel manager and chief executive officer have little to
do with day-to-day patient care and management of services; at these higher levels of
management, decisions must be made about the organization as a whole and its
interaction with other organizations. Individuals at this level of management are
concerned with the following:

● Negotiating contracts with third-party payers and subcontractors
● Establishing goals for the organization
● Identifying partners, collaborators, and stakeholders who affect those goals
● Ensuring the organization’s compliance with accreditation, licensure, and other
regulations
● Communicating with boards of trustees and shareholders
● Marketing the organization
● Safeguarding the organization’s financial solvency

PTs who hold these higher level management positions often have graduate degrees in
health care or business administration or have been trained through corporate staff
development programs. They may find themselves far removed from the practice of
physical therapy. The exception is the PT who establishes a private practice and
thereby assumes responsibility for all levels of management, including patient/client
management. Exciting, independent practice opportunities abound for entrepreneurial
PTs who have strong patient care and managerial skills.
• LEADERSHIP
As can be seen in Table 8-1, leadership theories have evolved because of the wide
range of perspectives from which leaders can be viewed. Leaders have not really
changed; groups of people still need leadership, and every group has a leader. Our
understanding of leadership depends on the perspective, be it the characteristics of
leaders, the roles of leaders, or the process of becoming a leader. An underlying
premise is that the organizational structure, management style, and leadership style all
must mesh if an organization is to meet its goals efficiently and effectively. For
example, a great man (or great woman) leadership style in an organization supported
by work teams in a participative management model would result in confusion about
who is in charge, how decisions are made, and who is accountable for the outcomes of
the organization’s work. Transitions from one organizational model to another are

266. made with great difficulty and are determined by the organization’s leadership. Strong
leadership also explains why traditional organizations remain successful; leaders can
motivate and control to achieve goals.
• ETHICAL AND LEGAL ISSUES
The APTA’s Code of Ethics rarely refers to the administrative role of the physical
therapist. For example, Principle 6 of the code states that “[a] physical therapist shall
maintain and promote high standards for physical therapy practice, education, and
research” but does not refer to the administrative or consultant roles.10 The principles
of the code that most directly relate to the role of the administrator are 3 (compliance
with laws and regulations), 4 (exercise of sound judgment), 7 (reasonable and
deserved remuneration), 8 (accurate and relevant information), and 9 (protecting the
public). Principle 3 states, “A physical therapist shall comply with laws and
regulations governing physical therapy and shall strive to effect changes that benefit
patients/clients.”11 In the APTA’s Guide for Professional Conduct (GPC), Section
4.2 explicitly addresses direction and supervision, stating that the supervising PT “has
primary responsibility for the physical therapy services rendered” (GPC 4.2A).11 This
section also prohibits a PT from delegating “to a less qualified person any activity that
requires the professional skill, knowledge, and judgment of the physical therapist”
(GPC 4.2B).12 The GPC elaborates on Principle 7 of the Code of Ethics regarding
business arrangements, making it quite clear that PTs must concern themselves with
the ethical stance of the organization: “A physical therapist’s business/employment
practices shall be consistent with the ethical principles of the association” (GPC 7.1A)
and “a physical therapist shall never place his/her own financial interest above the
welfare of individuals under his/her care”12 (GPC 7.1B). The GPC lists unacceptable
business practices as underutilizing services (GPC 7.1C), overutilizing services (GPC
7.1D), participating in unearned fees (GPC 7.1F), and receiving unearned commission
or gratuities (GPC 7.1G). The GPC also states that PTs may ethically participate in
the pooling of fees and money (GPC 7.1H), may enter into organizational agreements
(GPC 7.1I), may endorse products (GPC 7.2 A-C), and accept payment for
endorsements (GPC 7.2 B).

Organizational Ethics

A particularly difficult ethical situation arises for PTs when the ethical standards of
their workplace conflict with their professional ethics and values. The GPC states
clearly that PTs have an obligation to attempt to resolve conflicts between
organizational and professional ethics: “A physical therapist shall advise his/her
employer(s) of any employer practice that causes a physical therapist to be in conflict
with the ethical principles of the association. A physical therapist shall seek to
eliminate aspects of his/her employment that are in conflict with the ethical principles
of the association” (GPC 4.3B).10 The health care organizations in which PTs work
affect physical therapy directly through policies and procedures. Although this direct
influence is considerable, organizations may exert even greater influence by creating
an organizational culture. Organizational culture refers to the shared beliefs, values,

267. ideas, and expected behaviors within a group entity. As indicated by recent
accounting scandals, the organizational culture shapes the ethical decisions and
behavior of managers and employees. Because most PTs are salaried employees, they
may feel they have no control over business practices or the organizational culture.
Some PTs may not even know the fees charged by the organization for their services,
and they may be unfamiliar with billing procedures.

A fundamental reason for the frequent conflicts between professional ethics and the
ethics of health care institutions is the differing paradigms of medicine and business.
The premise of managed care and the current health care system is that health care
should be run more efficiently and more cost effectively; that is, more like a business.
Although most agree that health care costs must be controlled, business and medicine
unquestionably have competing values. As Mariner13 points out, business and
medicine make different assumptions about relationships with patients, goals, ethical
principles, the nature of health care, and the obligations of providers. Business
operates on a contractual basis with a “buyer beware” philosophy, and its goal is
efficiency and maximization of profit. The guiding ethical principle in business is fair
competition in delivering the commodity of health care. In the business model,
providers are accountable to stockholders for making the organization profitable.13 In
contrast, relationships in medicine (and physical therapy) are based on trust rather
than contracts. The ethical principles of autonomy (self-determination), beneficence
(promoting good), non maleficence (preventing harm), and justice guide decision
making in medicine, and health is viewed as either a service or a right. In the medical
model, the providers’ primary obligation is to the patient rather than the organization
or stockholders.13,14 Given the radically different assumptions of the two models,
which coexist in the current health care system, conflict between organizational and
professional values is not surprising.


The Administrator’s Role and Conflict of Interest
Managed care fosters conflict of interest and divided loyalty by creating incentives for
cost containment. In addition to the conflicts of interests created by reimbursement
incentives, administrators may create conflicts for staff PTs through personnel
policies. For example, unrealistic productivity standards or bonuses may force staff
PTs to choose between the provision of quality care and their financial self-interests.
The first-line manager faces the same challenges for the staff as a whole, which may
result in policing rather than leading and developing the staff. Similarly, organizations
in financial trouble may adopt policies that are not in the best interest of patients, such
as setting limits on the number of visits per patient or directing staff PTs to come up
with the most billable units possible for each patient.
More than other employees, first-line managers, caught between the high-level
managers making such policies and the staff PTs who provide direct patient care, may
feel their loyalty divided between their employers and their professional values.

268. Through their supervision of staff members, first-line managers influence the
professional values of many others by example and direction. At the same time, they
are responsible on a daily basis for meeting the goals of the organization in terms of
productivity, target charges, and other factors. These competing loyalties may be a
reason some organizations prefer managers who are not health care professionals.

Whistleblowing

All PTs, whether staff members or managers, may become aware of acts of
incompetence, unethical behavior, or illegal activity. Although most people find such
actions difficult to report, professionals have an obligation to help regulate colleagues
and protect the public. Reporting unethical or illegal behavior is especially difficult
when a PT’s workplace is involved because employees are expected to be loyal to the
organization. In addition, whistleblowers may face negative consequences within the
organization. Although a number of state and local laws protect or even encourage
whistleblowing, those who report illegal or unethical behavior may be ostracized or
denied future opportunities for professional advancement. Coyne15 recommends the
following five steps in approaching this dilemma:
● Self-analysis
● Discussion with the person engaging in unethical behavior
● Approaching a supervisor
● Taking the matter up the managerial ladder
● Filing a complaint These steps make it clear that other attempts should be made to
resolve the issue before the
PT resorts to actual whistleblowing. Perhaps because it is difficult to confront
colleagues, licensing boards and ethics committees report that too few PTs report
unethical or illegal behavior. This unfortunate reality would seem to be an abdication
of the professional responsibility to self-regulate and protect the public.


The Administrator’s Role in the Ethics Literature

Only a few peer-reviewed ethics articles published between 1970 and 2000 addressed
the PT’s role as administrator (see Figure 4-5). Although few publications focused

269. specifically on the ethical issues faced by administrators, several articles that
addressed multiple roles included the administrative level.