occupational therapists - 174- Minoo Kalantari
Journal of Medical Ethics and History of Medicine
Original Article
Perception of professional ethics by Iranian occupational therapists
working with children
Minoo Kalantari1, Mohammad Kamali2*, Soodabeh Joolaee3, Mehdi Rassafiani4, Narges
Shafarodi5
1 PhD Candidate in Occupational Therapy, Department of Occupational Therapy, School of Rehabilitation Sciences, Iran
University of Medical Sciences, Tehran, Iran;
2 Associate Professor, Department of Rehabilitation Management, School of Rehabilitation Sciences, Iran University of Medical
Sciences, Tehran, Iran;
3 Associate Professor, Center for Nursing Care Research, School of Nursing & Midwifery, Iran University of Medical Sciences,
and Iranian Academy of Medical Sciences, Tehran, Iran;
4 Associate Professor, Pediatric Neuro-rehabilitation Research Center, Department of Occupational Therapy, University of
Social Welfare and Rehabilitation Sciences, Tehran, Iran;
5 Assistant Professor, School of Rehabilitation Sciences, Department of Occupational Therapy, Iran University of Medical
Sciences, Tehran, Iran.
Corresponding Author:
Mohammad Kamali
Address: Mirdamad Blvd, Madar Sq, Shahnazari St., Nezam St., School of Rehabilitation Sciences, Tehran, Iran.
Email: kamali.mo@iums.ac.ir
Tel: 98 21 22221577
Fax: 98 21 22220946
Received: 01 Sep 2014
Accepted: 19 May 2015
Published: 23 May 2015
J Med Ethics Hist Med, 2015, 8:8
© 2015 Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences. All rights reserved.
Abstract
Ethics are related to the structure and culture of the society. In addition to specialized ethics for every profession, individuals
also hold their own personal beliefs and values. This study aimed to investigate Iranian occupational therapists’ perception of
ethical practice when working with children. For this purpose, qualitative content analysis was used and semi-structured
interviews were conducted with ten occupational therapists in their convenient place and time. Each interview was transcribed
and double-checked by the research team. Units of meaning were extracted from each transcription and then coded and
categorized accordingly.
The main categories of ethical practice when working with children included personal attributes, responsibility toward clients,
and professional responsibility. Personal attributes included four subcategories: veracity, altruism, empathy, and competence.
Responsibility toward clients consisted of six subcategories: equality, autonomy, respect for clients, confidentiality,
beneficence, and non-maleficence. Professional responsibility included three subcategories: fidelity, development of
professional knowledge, and promotion and growth of the profession. Findings of this study indicated that in Iran, occupational
therapists’ perception of autonomy, beneficence, non-maleficence, fidelity and competence is different from Western countries,
which may be due to a lower knowledge of ethics and other factors such as culture. The results of this study may be used to
develop ethical codes for Iranian occupational therapists both during training and on the job.
Keywords: occupational therapy, professional ethics, children
mailto:kamali.mo@iums.ac.ir
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Introduction
Competence and sufficiency in a profession is a
combination of knowledge, skill and conduct.
Knowledge and skill are formed through
professional education, experience and continued
learning, but these factors are not the sole
requirements for creating a capable and reliable
therapist. A therapist should behave in a way that
would promote and maintain the welfare of the
society and protect the reputation of employers and
the profession (1).
Rapid scientific and technological advances in health
sciences have influenced research related to
occupational therapy. Meanwhile, one important
concern is the graduates’ ability to think critically
and make decisions based on correct values and
professional ethics (2). Therefore, occupational
therapy associations and boards in different countries
have described core values and professional ethics
according to their culture and needs (3-6). Values are
a set of beliefs to which an individual is committed,
and form an important part of any profession.
Moreover, actions and attitudes are the reflections of
individual values. Attitudes are our tendencies in
giving positive or negative responses to an object,
individual, concept or situation. All professional
actions and interactions, therefore, originate from
values and beliefs (3).
Although there are specific professional values in
every line of work, individuals also hold their own
personal beliefs and values. Ethics are related to the
structure and culture of the society (7), and provision
of occupational therapy services without a link to the
values and needs of the community is detrimental to
the clients in the long run (8). In order to develop
appropriate ethical codes and professional behavior
in the field of occupational therapy in Iran, the
elements of ethics and ethical practice must be
identified from the points of view of Iranian
occupational therapists.
Occupational therapists work with different age
groups that may suffer from physical, mental or
social disabilities or limitations. Children are very
vulnerable due to their age and decision-making
capacity (9). The present study aimed to describe
Iranian occupational therapists’ perception of
professional ethics when working with children.
Method
This study was conducted using a conventional
qualitative content analysis. Ethical issues and
implications of ethical practice in pediatric
occupational therapy were investigated based on the
experiences of Iranian occupational therapists. It
should be added that qualitative content analysis is a
method for subjective interpretation of written
content through a process of systematic classification
of codes and determination of themes and patterns
(10).
Setting and Participants
Participants in this study included ten (5 female and
5 male) Iranian occupational therapists selected by
purposeful sampling. Two of the occupational
therapists were PhD students, three of them had
master’s degrees, and the remaining five had
bachelor’s degrees in occupational therapy. All
participants had between 6 and 25 years of
experience in working with children. In selecting the
participants, we tried to consider maximum diversity
in gender, work experience, academic degree and
workplace. All participants took part in this study
voluntarily. One of the participants worked in a
hospital, one in a school for special education, two in
centers of the State Welfare Organization, four in
private clinics, and two in university clinics. Four
participants also provided home care services. The
study was conducted between 2013 and 2014 in
Tehran, Iran.
Data Collection
Data were collected through a total of 11 semi-
structured interviews with ten participants at their
workplaces. Duration of interviews varied between
30 and 60 minutes. Research goals were explained to
the participants before the interviews, and their
written informed consent was obtained. Participants
were encouraged to share their experiences of
professional ethics in pediatric occupational therapy,
and then exploratory questions were asked for more
detailed information. Interviews continued until data
saturation, that is, until the data were repeated and no
new information emerged.
Ethical Considerations
The present study was approved by the Ethics
Committee of Iran University of Medical Sciences.
After providing the necessary information, written
informed consent was obtained from all participants.
Consent was also obtained for recording the
interviews. Participants were assured that the data
would be kept confidential, and the interviews were
coded accordingly. The participants were told that
they had the right to withdraw from the study at any
time.
Data Analysis
Recorded interviews were transcribed and then
analyzed using a content analysis approach. Each
interview was double-checked by coauthors, and
units of meaning were extracted and then coded and
categorized. The analysis process was repeated upon
addition of each interview and the codes and
categories were modified (10). In this study,
credibility, dependability and confirmability
measures were used in order to determine accuracy.
For this purpose, prolonged engagement was attained
by dedicating approximately 6 months to performing
interviews and obtaining codes. Diversity in
participants was another measure that was employed
to enrich data, and therefore participants with
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different academic degrees and job experiences were
selected from various settings. The participants were
allowed to review their transcribed interviews to help
them maintain consistency. During several meetings
our research team members modified and revised the
extracted codes until reaching a consensus, and for
external check, an expert occupational therapist, who
was familiar with both qualitative research and
working with children, reviewed the results in the
context.
Results
Three categories were extracted in connection with
ethical practice when working with children:
personal attributes, responsibility toward clients, and
professional responsibility. Each category included
some subcategories (12 subcategories in total),
which described specific aspects of ethical practice
when working with children (see Table 1).
Table 1- Categories and subcategories extracted
from the participants’ responses
Categories Subcategories
Personal Attributes Veracity
Altruism
Empathy
Competence
Responsibility toward
Clients
Equality
Respect for Clients
Confidentiality
Autonomy
Non-Maleficence
Beneficence
Professional
Responsibility
Fidelity
Development of
Professional Knowledge
Promotion and Growth of
the Profession
Personal Attributes
The subcategories of personal attributes are as
follows:
1) Veracity
Our participants believed veracity to be of high
importance in providing services. Truthfulness with
clients and their family members, providing realistic
information, avoiding deception and creating
unrealistic expectations were among the ideas
mentioned by most participants. One occupational
therapist said:
“I realized that I should be honest if I want to be
effective. This is the ethical rule of veracity.”
[Occupational Therapist 6]
Some occupational therapists preferred veracity over
their financial interests when expressing the
prognosis. One participant said:
“At times, I have had to explicitly tell the kid’s
prognosis to the mother, even though I knew that she
might not bring her kid to the clinic again.”
[Occupational Therapist 2]
2) Altruism
The participants believed that it was one of the
personal attributes of a good occupational therapist
to do their job in any condition and provide
appropriate services even when there is no
supervision. One occupational therapist said:
“Sometimes I was not in a good mood, but I
provided all services as if someone was supervising
me. It was very important for me. I adhere to ethical
principles.” [Occupational Therapist 2]
3) Empathy
The participants pointed out that understanding the
family, considering their financial situation and
helping them were among the personal attributes of
an occupational therapist. One of our participants
said:
“I have tried to develop empathy with them and help
them as far as I could, and to give a discount if they
had financial problems. I have received nothing for
some sessions.” [Occupational Therapist 5]
4) Competence
The participants believed that occupational therapists
should keep their professional knowledge current, as
this depicts their competence for providing
therapeutic interventions.
“Sufficient knowledge of therapeutic interventions is
very important because the negative consequences of
mistakes in interventions may be much more
irrecoverable in children than in adults.
Occupational therapists should have up-to-date
information.” [Occupational Therapist 10]
Definition of competence, however, seemed to be
different for each participant. On the subject of
recruiting students in private clinics before their
graduation, one occupational therapist said:
“If supervised, students in their final semester can
work because 8th semester students have enough
experience to work.” [Occupational Therapist 9]
Responsibility toward Clients
This category mainly focuses on ethical practice by
way of equality, respect for clients, confidentiality,
autonomy, non-maleficence, and beneficence.
1) Equality
Non-discrimination in provision of services was a
fact indicated by most participants, who believed
that the cultural, religious and social conditions of
families should not lead to any discrimination among
the patients. One occupational therapist said:
“The cultural, religious and social conditions of a
family have no effect on admission of patients.
[Factors like that] do not affect me. I had a patient
coming from Iraq, another one was very religious,
another not. I try to carry out my duties.”
[Occupational Therapist 9]
In order to establish social equality, some
occupational therapists tried to make use of public
facilities for their patients so that financial problems
would not prevent them from continuing treatment.
One of the participants said:
“… I have written letters for them to receive money
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from charities so that they could continue their
sessions and not miss any.” [Occupational Therapist
2]
2) Respect for Clients
The participants believed that observing children’s
rights and respecting their culture and religion were
important issues that should be considered when
providing services. One occupational therapist
believed that observance of this ethical rule would
attract clients because families also expect respect.
“The most important part of communication is to
respect the patients. Both the patients and their
families should feel respected. What attracts patients
is observance of these ethical rules because their
families understand that they are respected.”
[Occupational Therapist 9]
Another occupational therapist saw inappropriate
conditions in clinics as disrespectful to the clients
and stated:
“I cannot work in a humid and dark basement. It is
not human. I want to provide human services, so the
conditions should be suitable for humans.”
[Occupational Therapist 6]
3) Confidentiality
According to the participants, professional ethics
require that occupational therapists keep patients’
information confidential and respect their privacy.
One participant believed:
“Rules of professional ethics should be observed and
the patient’s information should be kept confidential.
Therapists should not take off the child’s clothes for
examination in the presence of others. The child or
the family, especially those with strong religious
beliefs, may not approve of that.” [Occupational
Therapist 6]
4) Autonomy
Our participants believed that giving the family the
right to decide about their responsibilities is among
the rules that should be preserved for the patients.
“Before discharging a patient, I explain to the family
that the sessions are enough in my opinion and the
kid needs no further sessions, and tell them that
further treatment is up to them.” [Occupational
Therapist 1]
Moreover, most participants stated that in working
with children, their consent is a must and they should
not be forced to cooperate. One occupational
therapist said:
“I try to establish rapport with the kid for two or
three sessions. They should accept me and adapt to
the environment, so that I can work with them.”
[Occupational Therapist 3]
The participants believed that families should
receive the necessary information about the
techniques and therapeutic procedures. Some
occupational therapists emphasized the education of
families and their presence during the sessions.
“I work for 30 minutes, and train the mother for 15,
and the family attends the treatment session.”
[Occupational Therapist 7]
Another occupational therapist said:
“I certainly involve the family in treatment. In my
opinion, the role of families in the treatment process
is close to 80%. But I do not ask their opinion in
setting the goals because they may not have realistic
expectations.” [Occupational Therapist 9]
5) Non-Maleficence
The participants stated that they believed it was their
duty to avoid behavior that may have potentially
harmful consequences. One participant said:
“Occupational therapists should not practice
excessive pressure, as aggression may cause the
patient to suffer…. I can only ask them in all
seriousness if they did what I said, and how they
exercised.” [Occupational Therapist 6]
In order to protect the patient, one occupational
therapist said that if the mental health of the parents
is not established, they should not be asked to do the
exercises at home.
“As for procedures that need excessive pressure, if
the family is not mentally competent, techniques of
violent nature should not be assigned to the mother.”
[Occupational Therapist 6]
“Giving a colleague a hint when facing unethical
behavior” was a matter reflected by another
occupational therapist:
“I warn my colleagues when I see unethical
behavior, even if it influences my relationship with
them.” [Occupational Therapist 2]
Another occupational therapists showed more
flexibility in confronting with unethical behavior:
“If I somehow feel that they do not misinterpret my
words and do not act defensively, and if their
characters are known to me, I will give them a hint
that it is better not to do so. But at times I have had
to remain silent.” [Occupational Therapist 3]
Another occupational therapist spoke about the steps
to follow in this regard:
“I have warned my colleague several times and I do
not care if they feel uneasy. I don’t mind telling the
supervisor, and I may even ask the patient to submit
a complaint to the ward authorities.” [Occupational
Therapist 10]
6) Beneficence
Our participants all believed that the patient’s
interests should be put in priority. One occupational
therapist said:
“The head of the clinic wanted me to increase group
therapy sessions to add more cases to my list, but I
refused. I said, ‘You are trying to make money, but I
am thinking of my job. This kid does not fit in this
group at all.’” [Occupational Therapist 3]
Regarding their responsibility toward patients, one
occupational therapist mentioned evidence-based
treatment:
“We cannot apply all techniques to all patients.
When it comes to evidence-based treatment, there
should be scientific experience on the one hand, and
the patient’s demand on the other. The patient
should also accept the treatment.” [Occupational
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Therapist 6]
The participants believed that they had to inform the
family of the child’s condition and ask for their
cooperation:
“Instead of understanding the child’s condition and
adapting her expectations to the kid’s ability, the
mother regularly shouted at the child. I provided the
mother with the necessary information without
considering the time and expenses, and helped her to
assist the child rather than struggle and make
negative remarks.” [Occupational Therapist 1]
Professional Responsibility
This category focuses on professional responsibility
and its subcategories, that is, fidelity, development
of professional knowledge, and promotion and
growth of the profession.
1) Fidelity
One occupational therapist believed that it is not
ethical to interfere with another colleague’s job, and
when necessary, we should support them rather than
defame them:
“In general, I do not consider it ethical to interfere
in the affairs of any specialist. I never comment on
my colleague’s performance… I tell the mother that I
can’t comment on my colleague’s work when I have
not even met them. I cannot make a judgment
because I might choose the same course of action if I
was in their shoes.” [Occupational Therapist 3]
2) Development of Professional Knowledge
The participants believed that occupational therapists
should consult various resources to obtain the
necessary information about the disease, and should
always keep their knowledge updated. One
occupational therapist said:
“Typically, I dedicate one session to assessment. If
necessary, I search for information… and try to
consult experienced specialists. For instance, I tell
them ‘The kid has uncontrolled convulsion, do you
think it advisable to do these exercises?’”
[Occupational Therapist 9]
One occupational therapist pointed out that we
should develop professional knowledge by sharing
our experiences:
“I try to share what I have learned scientifically. I
don’t keep things to myself. If I learn a new
technique, I make sure to tell others about it.”
[Occupational Therapist 9]
3) Promotion and Growth of the Profession
As viewed by our participants, it is necessary for the
promotion and growth of the profession, to avoid
inappropriate advertisement. Thus, any action that
casts doubts on the performance of occupational
therapists should be prevented so that the position
and dignity of the profession is maintained. One
occupational therapist said:
1) “If someone is making questionable
advertisments about the profession, they
should be informed. We should preserve our
unity. If someone works individualistically,
we will be damaged [as members of a
profession].” [Occupational Therapist 9]
Another occupational therapist said:
“I believe we should not act when in doubt. It is
better not to do that… Why should we insist on doing
something that may be criticized?” [Occupational
Therapist 6]
Another point emphasized by the participants in
relation to the growth of the profession was
advertisement and introduction of the profession.
One occupational therapist said:
“Enough information should be provided. Ads will
be helpful for public information. They are about
introducing our profession [to the public] and the
capabilities we have.” [Occupational Therapist 10]
Discussion
Findings of this study indicated that ethical practice
in working with children could be divided into three
categories: personal attributes, responsibility toward
clients, and professional responsibility. The
participants in this study believed that personal
attributes included veracity, altruism, empathy, and
competence. World Federation of Occupational
Therapists (WFOT) has assigned a code to personal
attributes, suggesting that occupational therapists
should comply with principles of personal integrity,
loyalty, open-mindedness, and reliability in their
profession (11). The subcategories extracted in this
study have also been mentioned in the ethical codes
of different countries. For example, the American
Occupational Therapy Association has addressed
truthfulness under the title of “veracity” and defined
it as conveying “comprehensive, accurate and
objective” information to the clients and promoting
their comprehension of such information (5). This is
necessary for establishing a good partnership
between the therapist and the patient (6), and good
practice has been found to decrease the possibility of
misunderstanding and help occupational therapists
avoid moral distress (12). In core values and
attitudes of occupational therapy practice, Kanny and
Kyler state that the values and attitudes in
occupational therapy have been organized around
seven main concepts: altruism, equality, freedom,
justice, dignity, truth, and prudence (2). Pleoquin
identifies empathy as the origin and base of ethics.
She believes that empathy is an ethical tendency, and
ethical practice is possible through empathy (13).
The capacity to empathize with another individuals
is the art of practice in occupational therapy (14). In
the Code of Ethics and Professional Conduct of the
British Occupational Therapy Association (3) and in
the Ethical Codes of the Australian Association of
Occupational Therapists, competence has been
proposed as a professional standard (15). Many
mistakes in clinical practice are due to lack of skill,
and this explains why competence is included in
ethical codes of occupational therapy associations
(16). Nevertheless, further studies need to be
conducted on the concept of competence among
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Iranian occupational therapists. Although it is illegal
to work before graduation due to lack of sufficient
acquaintance with ethical codes and rules, some
Iranian occupational therapists recruit senior students
in clinics.
Another finding of this study was responsibility
toward clients. The participants believed that
equality, respect for clients, confidentiality,
autonomy, non-maleficence, and beneficence are
necessary for ethical practice in working with
children. WFOT identifies respect, non-
discrimination, consideration of the client’s values
and priorities, and confidentiality among the
responsibilities of occupational therapists toward all
service receivers (11). These concepts have also
been included in ethical codes of the United States,
Australia and Canada, although the implications are
somehow different. For example, in the United
Kingdom, Australia and the United States, autonomy
means to give the client the right to choose and have
active participation in therapeutic decisions and
procedures, and the client’s consent is necessary
before the treatment process (3, 5, 15). In this study,
some participants saw autonomy as seeking the
child’s consent and not forcing them to attend
treatment sessions, or communicating the treatment
plan to the family due to the client’s age. Children
are more dependent on others (their parents in
particular) compared to adults. The important
question here is, who is the actual client, the child or
the family? Children can have different views from
their parents and should therefore be consulted about
the treatment process as far as possible.
In pediatrics, the family-centered approach is more
common than the client-centered approach (17).
Although being family-centered is a core value in
working with children, participation of the family in
determining treatment goals and decisions is not
fully enforced. Some of our participants suggested
that they could not follow the demands of the family
because their expectations were not realistic. For
most participants, autonomy meant asking about the
family’s goals and informing and educating them
about the treatment plan.
The occupational therapists in this study stated that
clients do not actively participate in the treatment
process and mentioned the inappropriate
expectations and low educational level of some
families to be the reason. This may be partly due to a
lack of moral education in occupational therapists,
although some of the participants were PhD students
and had passed ethics courses. The study conducted
by Pettersen and Svilaas in India showed that culture
influenced client-centered treatment, and that Indian
occupational therapists tried to apply some elements
of client-centered treatment (18). Ludwick and Silva
suggested that in some cultures, health decisions
were not made by an individual, but by a group, that
is, the family or the society. It is therefore necessary
to address the values prominent in such cultures in
order to promote ethical thinking (19). As for
beneficence, some Iranian occupational therapists
seem to go to extremes in their commitment to this
rule. Although some of our participants believed that
the child should be at peace during the sessions,
others thought that crying was inevitable and should
be ignored to make the best use of the treatments.
They stated that some parents preferred that their
children be treated with higher intensity. It seems
that participants in this study were so involved in
beneficence that they overlooked the rule of non-
maleficence, which needs further research.
Another category of ethical practice in this study was
found to be professional responsibility. The
participants believed that professional responsibility
included fidelity, development of professional
knowledge, and promotion and growth of the
profession. With respect to fidelity, Rule 7 of the
American Occupational Therapy Code of Ethics
states: “Occupational therapy personnel shall treat
colleagues and other professionals with respect,
fairness, discretion, and integrity” (5). This
definition is consistent with the responses of Iranian
occupational therapists, although fidelity should not
interfere with fulfillment of ethical commitments. If
an occupational therapist is in doubt about his/her
colleague’s behavior, he/she may submit a complaint
to competent authorities (15). Occupational
therapists should assume their professional
responsibility and deliver safe, ethical and effective
treatments and report unethical or incompetent
conduct (20). Nevertheless, most participants in this
study sidestepped confrontations and did not report
unethical conduct to the authorities so as to maintain
relationships with their colleagues or avoid isolation.
Some participants had passed ethics course and were
familiar with ethical rules, but uncertainty was
evident in their responses as well. It seems that such
behavior stems from the culture rather than
unawareness of ethical rules. As a rule, cultural
factors influence people’s conduct to a great extent
(21), and further studies on this issue are therefore
suggested.
The participants believed that development of
professional knowledge and promotion and growth
of the profession are among our duties in working
with children. Development of professional
knowledge through continuing and post-professional
education programs may provide occupational
therapists with the knowledge, skills and attitudes
that will help them perceive themselves as competent
practitioners (22). Brown (2010) suggested that
continuing education may be required to ensure
evidence-based treatment and research utilization
among pediatric occupational therapists (23).
Guidelines on continuing education have been
compiled due to the importance of developing
professional knowledge (24). For instance in the
United Kingdom, occupational therapists are
expected to assume responsibility for the education
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of the public and the promotion of health and welfare
in order to decrease the influence of disease and
disability (3).
Conclusion
Based on our findings, the views of Iranian
occupational therapists on ethical practice in
working with children were similar to those of
occupational therapists of Western countries in some
aspects. Nevertheless, their understanding of
concepts such as autonomy, beneficence, non-
maleficence, competence and fidelity were different
from those of Western occupational therapists. It can
be concluded that various people may develop
different interpretations of the same concept. This
may be due to lack of education, which should be
considered in undergraduate curricula as well as
ethical courses and workshops for Iranian
occupational therapists. In this regard, other possible
factors such as culture should also be taken into
account.
Acknowledgements
The authors would like to kindly appreciate all
occupational therapists who participated in this
research. Without their assistance, this study would
not be possible. This article is part of a PhD thesis by
the first author submitted in Iran University of
Medical Sciences.
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