Microsoft Word - VenglarFINAL The Journal of Scholarship of Teaching and Learning, Vol. 7, No. 1, May 2007, pp. 64-76. Case-Based Ethics Education in Physical Therapy Mollie Venglar and Michael Theall1 Abstract: Physical therapist students often think ethics content to be less relevant than other course material. The purpose of this study was to assess whether changing from lecture to case-based method, would impact ethics awareness and integration. In focus groups, students in the case-based course reported greater perceived value of the ethics content and felt that the material was easier to integrate into practice, while students in lecture-based course reported that content should be compressed into a shorter period of time and did not integrate it as effectively. The model was also effective in improving critical thinking in clinical practice situations. Key Words: ethics; case-based; physical therapy. I. Background and Purpose. In physical therapist education, instructors teach clinical skills by dealing with tissue (such as muscle, ligament, tendon, etc.), diagnosis, or through the use of cases. Students are taught how to evaluate a problem, determine the physical therapy diagnosis, and plan a treatment appropriate to the diagnosis integrating the psychosocial, past medical history, financial, and pharmacologic co-variants in the plan of care. Carry-over of the didactic instruction of clinical skills content from the academic setting to the clinic is evident through performance assessment during clinical education internships and is required to pass the physical therapist education program. Clinical skills competencies are emphasized through practical examinations, clinical education, and clinical performance evaluation tools (Anonymous. 1997). Traditionally, ethical issues are not integrated into the teaching of the clinical decision- making process involved in patient care. The American Physical Therapy Association (APTA) has indicated some concern about this aspect of professionalism as the physical therapy profession completes the transition to the direct access role. Direct access allows individuals to seek physical therapy services without physician referral. In the APTA statement on professionalism, ethical consideration of patient care is prevalent, thus indicating that ethics education and the carry-over of that knowledge to the clinical setting is vital in professional clinical practice (American Physical Therapy Association, 2003). The Realm-Individual Process-Situation (RIPS) Model of Ethical Decision-Making (Swisher LL, Arslanian LA, & Davis CM, 2005) was designed to assist physical therapist clinicians in identifying clinical situations that could include ethical issues. The model directs the clinician to determine the party with the greatest responsibility for the situation, determine the moral background, and determine the nature of the situation. In doing so, the clinician is better able to understand the potential stake holders of any given ethical situation. The clinician is then empowered to direct the situation to the primary stakeholder and facilitate a solution. Table 1. The Realm-Individual Process-Situation Model of Ethical Decision-Making. 1 Department of Physical Therapy, Youngstown State University, One University Plaza, Youngstown, OH 44555, mcvenglar@ysu.edu and Department of Teacher Education, mtheall@ysu.edu Venglar, M., and Theall, M. The Journal of Scholarship of Teaching and Learning, Vol. 7, No. 1, May 2007. 65 (Swisher LL et al., 2005) Realm Individual Process Situation Individual Organizational/Institutional Societal Moral Sensitivity Moral Judgment Moral Motivation Moral Courage Issue or problem Dilemma Distress Temptation Silence The RIPS model is based on the work of Glaser,(Glaser JW, 1994; Glaser JW, 2005) Rest and Narvaez,(1994), Rest, Narvaez, Bebeau, and Thoma (Rest JR & Narvaez D, 1994; Rest JR, Narvaez D, Bebeau MJ, & Thoma SJ, 1999) Purtillo (2005) and Kidder (1995). Since it is designed for clinical use, the model is appropriate to use in the academic education of entry-level physical therapists. By using cases or scenarios, much like those in the clinical skills content, an instructor can use the RIPS model as a viable method for teaching ethics content. The RIPS model directs the student to evaluate the situation, diagnose the components of the situation, identify the stakeholders, and plan necessary action as appropriate; the same steps taken in therapist intervention of a physical problem. An example of how the RIPS model can be used in provided in the Appendix. Lecture-style teaching has been criticized for producing passive learners and preventing critical thinking in the classroom (Limbach BJ & Waugh WL, 2005). In contrast, many medical education studies have reported the positive impact of using cases to help students learn course content (Hudson JN & Buckley P, 2004; Jonassen DH & Hernandez-Serrano J, 2002; Keefer M & Ashley KD, 2001; McGinty SM, 2000; Triezenberg HL & McGrath JH, 2001). Hudson and Buckley (2004) studied the perception of case-based teaching in the physiology curriculum for pre-medical students. They found that the case-based method increased confidence of the students when they moved to the clinical courses. The case-based method allowed the students to study physiology in reference to hypothetical patient scenarios, thus creating a non-threatening environment in which the students could attempt to solve the case without fear of consequence (Hudson JN et al., 2004). Keefer and Ashley (Keefer M et al., 2001) reported the comparison of student response to ethicists’ responses to ethical problems. They determined that the student responses were based on common morality; the ethicists’ responses were based on professional morality. Although common morality is no less important than professional morality the lack of knowledge of moral issues that relate to the professional world limited the students’ abilities to perceive the complete threat and the wide realm of potential solutions (Keefer M et al., 2001). Without exposure to professional ethics, in a manner that expresses the importance of professional ethical decision- making, students can not be expected to grasp the variability of solutions. Triezenberg and McGrath (Triezenberg HL et al., 2001) report students’ perceptions following an applied ethics course in which the primary teaching method was through the use of narratives. The authors reported that students perceived the method in a positive manner and that narratives enhanced their learning of the integration of ethical theory and professional behavior (Triezenberg HL et al., 2001). Historically, physical therapist students are taught ethics content in a remote, nearly third person, sense. Unlike the physical intervention and client management content, ethics content is not treated as relevant to daily physical therapy practice. The purpose of this paper is to describe the outcomes of a teaching methodology change in an ethics class in a physical therapist education program, and the effects of that change on perceived value of ethics education Venglar, M., and Theall, M. The Journal of Scholarship of Teaching and Learning, Vol. 7, No. 1, May 2007. 66 following subsequent clinical education for master’s level students in a physical therapy program. II. Method/Model Descriptions and Evaluation. The ethics curriculum at the author’s university is half of a two semester-hour course entitled “Legal and Ethical Issues in PT”. The course has two instructors, one for the primary legal content, and one for the primary ethics content. Traditionally, the ethics content was taught in a lecture format. The students were assessed via a cumulative course examination (both legal and ethics content) and a paper/presentation based on a directed interview with a clinician. The lecture format for the ethics content was abandoned by the instructor, and a case- based format was adopted by the same instructor using the same topics as in the traditional lecture format. In addition, the traditional textbook was abandoned and replaced with popular articles that were relevant to the topics discussed in the class. Eight key aspects of professional ethics were chosen on which to base the case discussions. Prior to attending class all students were provided with an article to read that incorporated a case related to the topic of discussion for that day. At the start of class the topic was briefly presented and the students were asked to identify and discuss the key aspects of ethics most prevalent in the article. The students were also asked to discuss the realm, individual process, and situation most prevalent in the article as defined by the RIPS model. Articles were chosen based on relevance to the topic of discussion for that day, and relevance to a health care professional. The articles were not specific to physical therapy so as to provide students with a more global view of ethical concerns in the health care environment as well as to prepare the students for potential participation in a wide variety of ethics-based discussions later in their professional roles. Additionally, each student completed two narrative papers on articles discussed during the course. The papers were designed to allow each student to express his/her opinion, with appropriate defense of his/her opinion, prior to initiating in-class discussion. In the paper, as in class discussion, the student was required to identify the aspects of professional ethics most prevalent in the article as well as the realm, individual process, and situation. The student was then required to defend his/her choices of the above in the paper, quoting sources as appropriate. Finally, the student was asked to provide insight for how he/she, as a physical therapist, might be impacted by the situation, and thus how he/she would handle the situation. In addition, cases from concurrent clinical skills courses were used in the discussion of the daily topic. The use of cases from other courses allowed for the transfer of the ethics topics to clinical skill-related courses with the emphasis that ethics transcends the defined ethics class and is truly important in everyday clinical practice. Assessment of student performance in the course was made via a midterm and final examination (both legal and ethics content), two narratives, and the paper/presentation of a directed clinician interview. III. Evaluation Methods. In the summer following presentation of the ethics curriculum the students at the authors’ university embark on their second clinical education experience. Students from the final year of the traditional lecture format, and students from the first year of the case-based format were asked to participate in focus group discussions following the clinical education experience. The Venglar, M., and Theall, M. The Journal of Scholarship of Teaching and Learning, Vol. 7, No. 1, May 2007. 67 focus groups were run by an individual, unrelated to the department of physical therapy, and experienced in educational methodology and group assessment. The instructor for the class was not present. Answers to the focus group questions were presented to the instructor/author in aggregate format by the individual who performed the focus group assessments. Because the ethics content is half of the “Legal and Ethical Issues in PT” course, students were asked to reflect on the course as a whole with particular attention to the ethics content. The answers of the two focus groups were compared to determine if the change of curricular format impacted the perceived value of the material presented in the ethics class as well as increased awareness or integration of ethics knowledge during the subsequent clinical education experience. Focus groups were used because qualitative methods (Patton, 1990) were expected to be more effective for exploration of attitudes and opinions in a situation where it was not possible to collect on-site, quantitative data, and where implementation of ethical principles and behaviors first required progressive gains in the affective domain (Krathwohl, Bloom and Masia, 1956). The incorporation of ethical principles into professional practice can be expected only if students have reached levels three through five of the affective taxonomy (valuing, organization, and characterization by a value or value complex). In other words, ethical values will be exhibited through behaviors that can be assessed qualitatively rather than through measurement in traditional quantitative tests. IV. Limitations. This study involved two classes of physical therapist students with a total of 19 students (10 in Year A and 9 in Year B). Thus, given the sample sizes, sophisticated quantitative analyses, and hypothesis testing would have been questionable. While the comments of individual students in the focus group activities might have been isolated, coded, and quantified, using for example, coded responses and student demographics as variables, it would have been problematic to apply even non-parametric tests such as chi square due to small cell sizes. Indeed, part of the focus group process involves striving for consensus to extract major issues and thus, individual student comments do not form part of typical reports of results and are not collected as such. Another issue to consider is that the incorporation of ethical considerations into professional behaviors and practice is, as noted above, related to the affective domain and thus, the most accurate way to observe and record the incorporation of beliefs into a value system is to observe those beliefs as evidenced by behaviors over time. Longitudinal studies were not possible at this stage and even if planned, they would require both time and (again with such small samples) the collection of enough data to allow appropriate analysis. Such investigation also requires financial support and at the moment, the studies are in the realm of action research or classroom research, for which funding is limited at best. The way to overcome both of these limitations would be to secure funding for a study on a larger scale involving several physical therapist programs and a collaborative research agenda that would allow comparison and analyses of students’ behaviors and attitudes. During this study, this kind of exploration was not possible. V. Outcomes. Venglar, M., and Theall, M. The Journal of Scholarship of Teaching and Learning, Vol. 7, No. 1, May 2007. 68 In both groups, the students were reportedly candid and open in their responses. Responses, as reported by the group facilitator, to each questions are presented below. Year A is the class taught via traditional lecture format. Year B is the class taught via the case-based format. A. Question 1. “What were the three most important (valuable) things you learned in the course?” Year A: Students were pragmatic in their views, noting the value of 1) knowing relevant laws; 2) interacting with in-service clinicians; 3) understanding HIPAA and Medicare rules; and 4) reviewing job descriptions. Year B: 1) Students reported that they had gained a broader perspective on ethical issues due to having to consider various stakeholder views. The complexity of the issues was also clearer as a result of students having to respond to the cases employed in the course. 2) A related opinion was that the case-based approach led to more application of the knowledge gained in the course both during the course and later, in clinical experiences. 3) Students also said that they had gained more/better knowledge of legal issues [through discussion of ethical issues] and that their clinical experiences supplemented this knowledge. B. Question 2. “Were you able to integrate the course content into your practice/profession when you were taking the course? If yes, then how? If no, then why not?” Year A: The consensus was that students were able to integrate content during the course because they had to: 1) recognize situations with legal/ethical implications; 2) follow regulations (e.g. Health Insurance Portability and Accountability Act); and 3) learn to observe practice in clinical situations. Year B: The consensus was that students benefited from the case-based approach because it required this kind of integration. While they felt (as had the previous group) that they entered into the course with mature understanding of ethical issues and the ability to make appropriate ethical decisions, the practical benefit of the case method was that it demonstrated that they could improve their problem-solving skills. C. Question 3. “When you had your clinical experience after the course, were you able to better integrate the course content into your practice/profession? If yes, then how? If no, then why not?” Year A: Students felt that their clinical experiences improved their ability to integrate course content. They cited straightforward responsibilities such as billing, the delegation of appropriate responsibilities to others, and the opportunity to observe a variety of situations, particularly those that repeated previous situations and thus re-emphasized their prior learning and experience. When asked about the extent to which they experienced any direct instruction or assistance (i.e. did they receive any training on the job) they said that any dialogue on Venglar, M., and Theall, M. The Journal of Scholarship of Teaching and Learning, Vol. 7, No. 1, May 2007. 69 legal/ethical issues had been initiated by their observations or questions and that they had not received any direct training. In effect, one had to be observant and willing to ask if/when legal/ethical issues arose. No one reported resistance to questions, but there was an indication that students felt that some long-term clinicians might not be as well informed about new regulations as they were. In effect with these individuals, there was no point in asking for advice from someone who didn’t have current knowledge. Year B: Students felt that their clinical experiences improved their ability to integrate course content. The combination of active practice through the cases and the clinical experience allowed further development of their awareness and the practical application of ideas in the sense of blending legal and ethical knowledge when making professional decisions. D. Question 4. “Do you believe that the course is important/valuable? If yes, then why? If no, then why not?” Year A: Students felt that the content was valuable, but the course was less so. They indicated that more emphasis should be placed on legal aspects because they needed specific knowledge of laws and regulations. They indicated that they felt capable of making ethical decisions without as much course work, saying, ‘…we are mature enough to understand ethical dilemmas and consequences.’” Year B: Students felt that the course was both important and valuable. All felt that they needed to be aware of the issues so that they could deal with situations that arise in professional practice. The extent of this feeling varied as a function of the intended career paths of the individuals. Those who were considering private practice or management roles indicated that they would deal with complex legal-ethical issues more often than would those whose career interests were more focused on direct provision of patient/client care. The main legal-ethical issue that students noted was the balance between the business/economic requirements faced by care providers and the need to provide clients with the most appropriate amount of care for the most appropriate amount of time. In applied terms, this issue involved deciding how much care to provide given two possibly conflicting agendas: the need for the clinic to make a profit (i.e. using available insurance coverage to provide services that bring a return to the clinic) and the need to preserve the client’s fiscal protection (i.e. not using up all of the insurance coverage so that the client could get further services if needed). E. Question 5. “What would you recommend that would make the course more valuable?” Year A: Responses to the previous question relate to students feelings that this course requires more time than is necessary. They suggested that this course could be combined with management or positive health courses. One reason offered for this opinion was that when students reported on their visits to clinics and interviews with clinicians, they found very similar situations and got very similar responses. Thus, when in-class reports were Venglar, M., and Theall, M. The Journal of Scholarship of Teaching and Learning, Vol. 7, No. 1, May 2007. 70 given, the reports were repetitive. After the first few reports, nothing new was learned from hearing those remaining. Year B: Students offered the idea that more regular integration of legal and ethical topics would help them to develop more sophisticated decision-making skills. They said that having one topic on one day and the other topic on another day tended to separate rather than integrate the two content areas. Since they felt that their professional decisions would most often require a blending of legal and ethical considerations, they also felt they would benefit from more frequent combinations of the topics. Students also said the use of the case-based methods in treating legal content would help them to develop better problem solving skills in this area. Finally, students noted a desire for more discussion. This can be related to the use of cases that require more activity and engagement than do passive methods such as lecture. In the context of discussing cases, students have to verbalize their thinking and respond to each other. Discussions would be expected to supplement the thinking required by the cases and to make the various decision options more obvious (i.e. there are many possibilities) as well as more clear (i.e. discussion may reveal the most appropriate courses of action). VI. Discussion. The focus group comments indicate that the students taught using the traditional lecture format for ethics content apparently valued little of the content following the course. Responses to all of the questions are largely focused on the legal content taught in the course. Apparently the content covered during the ethics portion of the course was either already known (as stated in the answer to Question 4), or considered less relevant/valuable while the students were in the clinic. In addition, the group comment in question five, asking how to make the course more valuable, indicates that the content is not of value and should be condensed in lieu of other more pressing topics. Although knowledge of the legal aspects of the physical therapy profession is vital, ethical practice is also vital. This point, however, was apparently not conveyed well in the traditional lecture format. The responses from the students in Year B indicate that using cases and encouraging students to voice and defend their opinions, caused the students to better recognize and integrate what they had learned in class to their clinical experiences. An unanticipated outcome was the report that the case-based format of the ethics content allowed for better integration of the legal and ethical aspects of the class. The class is not formatted such that the two topics are intentionally integrated; however, in all of the case discussions students raised questions of law as well as the pertinent ethical aspects. These students did not feel the course content should be condensed, as had previous students, but rather recommended intentional integration of the legal content and the ethics content with further use of cases. The case-based method, requiring critical thinking and problem-solving for case discussion, appears to have sensitized the students to the ethical subtleties in clinical practice during their subsequent clinical experience. Given the importance that the APTA has attached to incorporation of ethical standards into professional practice, future investigation is necessary into effective methods of teaching about ethical issues, helping students to understand and apply ethical principles, and motivating students to attend to these issues in their classes, clinical experiences, and professional lives. The Venglar, M., and Theall, M. The Journal of Scholarship of Teaching and Learning, Vol. 7, No. 1, May 2007. 71 limitations in this study suggest that an appropriate and perhaps necessary strategy for definitive research would be to secure funding for large-scale exploration of the issues across multiple institutions and over time. With sufficient data, more rigorous analysis could be applied to determine direct cognitive gains with the target of raising the taxonomic levels of learning to application at minimum, and to higher levels in practice. Additionally, the duration of the effects could be assessed through longitudinal study of professional practices of individuals accompanied by a practical assessment of the impact of workplace environments, management practices, and operational behaviors in clinical, out-patient, and other settings. VII. Conclusions. In the physical therapy profession we teach students to treat individual patients and to treat patients as individuals. Each patient is a “case” with its own unique characteristics, but with traits that put that case into a general category for diagnosis and treatment. The expectation that students will naturally translate generalized knowledge into appropriate cases without practice is perhaps unrealistic. Students have limited exposure to clinical situations prior to becoming physical therapists, thus they require sensitizing not only to those situations that require clinical skill, but also to those situations which may impact them ethically. The above outcomes demonstrate that the use of cases, relating ethical issues to cases in other courses, and allowing students to explore the articles/cases using a guided decision-making process improves students’ awareness of ethical issues, enhances critical thinking in non-clinical aspects of a client case, and increases the value of ethics education for the students. The students had an opportunity to participate in the critical thinking needed to make the content personally relevant and incorporate it into their approach to patient care (Atton C, 2005; Limbach BJ et al., 2005). The effort of the American Physical Therapy Association to improve professionalism in physical therapy involves ethical decision-making. This approach to ethics education resulted in subjective student reports of increased perceptions of the value of the content, increased awareness of ethical situations, and increased understanding of the prevalence and significance of ethical decision-making in the clinical setting. Although the method presented is only one option for teaching ethics content, the outcomes indicate that teaching ethics in a format similar to that used in teaching clinical skills is effective for increasing understanding of the issues, enhancing the value of the content, raising awareness of ethical issues in clinical settings, and developing higher-level professional problem-solving skills. Acknowledgements Dr. Venglar wishes to express sincere appreciation to the center for teaching and learning at Youngstown State University (CATALYST) for assistance in developing this teaching strategy. This strategy has made teaching of the content much more interesting, as it has apparently improved the interest of learning this content among students. In addition, Dr. Venglar wishes to thank Dr. Swisher, author of the RIPS model, for her guidance in the use of the model with student instruction. Her encouragement and interest in this effort were inspiring. References Venglar, M., and Theall, M. The Journal of Scholarship of Teaching and Learning, Vol. 7, No. 1, May 2007. 72 Physical Therapist Clinical Performance Instrument. (1997). Alexandria, VA. American Physical Therapy Association. Professionalism in Physical Therapy: Core Values. (2003). Alexandria, VA. American Physical Therapy Association. Atton, C. (2005). Using Critical Thinking as a basis for library user education. Journal of Academic Librarianship, 20, 310-315. Cross, K. P. and Steadman, M. H. (1996) Classroom research: implementing the scholarship of teaching. San Francisco: Jossey Bass. Gabard, D. L., Martin, M. W. (2003). Physical Therapy Ethics. Philadelphia: F. A. Davis Company. Glaser, J. W. (1994). Three Realms of Ethics. (1 ed.). Kansas City: Sheed and Ward. Glaser, J. W. (2005). Educating for Moral Action: A Sourcebook in Health and Rehabilitation Ethics. Philadelphia: FA Davis. Hudson, J. N., and Buckley, P. (2004). An evaluation of case-based teaching: evidence for continuing benefit and realization of aims. Advances in Physiology Education, 28, 15-22. Hutchings, P. (Ed.) (2000). Opening lines: approaches to the scholarship of teaching and learning. Menlo Park, CA: Carnegie Foundation for the Advancement of Teaching. Jonassen, D. H., and Hernandez-Serrano, J. (2002). Case-based reasoning and instructional design: using stories to support problem solving. Education Technology Research and Development, 50 (2), 65-77. Keefer, M., and Ashley, K. D. (2001). Case-based approaches to professional ethics: a systematic comparison of students' and ethicists' moral reasoning. Journal of Moral Education, 30 (4), 377- 398. Kidder, R. M. (1995). How Good People Make Tough Choices: Resolving the Dilemmas of Ethical Living. New York: Fireside. Krathwohl, D. R., Bloom, B. S., and Masia, B. B. (1956) Taxonomy of educational objectives. Handbook II: the affective domain. New York: David McKay. Limbach, B. J., and Waugh, W. L. (2005). Questioning the Lecture Format. Thought and Action, 21, 47-56. Maiorana, V. (2005). The Road from Rote to Critical Thinking. Community Review 11, 53-64. McGinty, S. M. (2000). Case-method Teaching: An overview of the pedagogy and rationale for its use in physical therapy education. Journal of Physical Therapy Education, 14 (1), 48-51. Venglar, M., and Theall, M. The Journal of Scholarship of Teaching and Learning, Vol. 7, No. 1, May 2007. 73 Patton, M. Q. (1990). Qualitative evaluation and research methods. Newbury Park, CA: Sage Publications. Purtilo, R. B. (2005). Ethical Dimensions in the Health Professions (4th ed.). Philadelphia: Elsevier. Rest, J. R., and Narvaez, D. (1994). Moral Development in the Professions: Psychology and Applied Ethics. Hillsdale, NJ: Lawrence Erlbaum Associates. Rest, J. R., Narvaez, D., Bebeau, M. J., and Thoma, S. J. (1999). Postconventional Moral Thinking: A Neo-Kohlbergian Approach. Mahwah, NJ: Lawrence Erlbaum Associates. Swisher, L. L., Arslanian, L.A., and Davis, C. M. (2005). The Realm-Individual Process- Situation (RIPS) Model of Ethical Decision-Making. HPA Resource, 5 (3), 1, 3-8. Triezenberg, H. L., and McGrath, J.H. (2001). The use of narrative in an applied ethics course for physical therapist students. Journal of Physical Therapy Education, 5 (3), 49-56. Venglar, M., and Theall, M. The Journal of Scholarship of Teaching and Learning, Vol. 7, No. 1, May 2007. 74 Appendix 1. Scenario of RIPS Decision-making Model. This is a brief scenario to serve as an example of the RIPS decision-making model. Students are asked to identify the Realm, Individual Process and Situation, and then to provide appropriate rationale for their choices of each. There is discussion prior to initiating this activity that all opinions are respected when accompanied by adequate rationale, and any legal influence should be considered when it impacts the ethical decision-making. Following this activity the class discusses appropriate courses of action based on the results of the model. Scenario: John is a therapist with a contract to provide services to the patients of a managed care company. The company is very clear in its contract that John is to follow the critical pathways. He can treat patients for less time than anticipated, but he cannot extend additional care without approval. He is not free to refer patients to outside therapists, nor is he in any way to “undermine” the credibility of the care offered by the company. In the course of treating a 42 year old man for injuries resulting from multiple- trauma, John realizes that his patient should have the care of a certified hand therapist. He also realizes that he will not be able to help the patient reach his potential within the number of visits approved by the managed care company. The company has never honored any of his previous requests for extension of visits. If John does not petition for an extension and the patient is harmed, then John may be liable for the harm. But another petition from him might reduce the likelihood that his contract will be renewed and even put him at risk for dismissal. If he informs the patient that he needs a therapist with expertise in hand therapy, and if the patient then demands from the managed care company the expertise that John recommends, John will most certainly be dismissed. However, if John uses his social skills and convinces the patient that he is getting the very best care, it is unlikely there will be any negative repercussions for John. (Adapted from “Physical Therapy Ethics” by Donald Gabard and Mike Martin; Copyright 2003, FA Davis) There are two possible arguments in this scenario: RIPS Argument A Argument B Realm – environmental context Individual – John, as the individual employee, is the primary stakeholder of this situation. As the person working directly with the patient, he is the one to make the decisions that will impact the patient’s care and progress. Therefore, he “owns” the decision-making Organizational – The managed care company, the organization, is the primary stakeholder. Their policies have created a situation in which patients can only receive expert care if the expert is already part of the company. Managed care companies are often chastised for putting finances ahead of patient Venglar, M., and Theall, M. The Journal of Scholarship of Teaching and Learning, Vol. 7, No. 1, May 2007. 75 ability/responsibility care. The scenario appears to fit that notion. If the managed care company allowed patients, even on a case-by-case basis to be referred outside of the company for care not available within the company, this ethical situation may not have existed. Individual Process- aspect of morality Moral Sensitivity – Moral sensitivity is the ability to recognize and interpret a situation as one with ethical concern. John recognized that the need of the patient conflicted with the policies of the managed care company. He also recognized that the steps to follow to meet the patient’s needs have been unsuccessful in the past with previous patients. Moral Courage – Moral courage means having courage to practice ethically as well as persisting in one’s efforts to implement ethical care. John appears to be struggling with moral courage. This may be due to past efforts being unsuccessful; this may be due to concern for his job/livelihood. He appears to know what the ethical course of action is, but is lacking full courage to implement the action. Moral Motivation – Moral motivation is the act of prioritizing ethical values over other values. This scenario demonstrates a lack of moral motivation on the part of the managed care company. Although John is in the position to advocate for the patient, the policies of the company will, and have previously, limit the success of his advocacy. The company appears to prioritize finances over ethical, and quality, treatment of patients. Situation – nature of the ethical concern Dilemma – A dilemma is two apparently “right” courses of action; taking one “right” course compromises the other “right” course. Both can not exist together. John has a dilemma in that if he chooses to request an extension of time or refer the patient to an expert he will likely lose his job. If John chooses to convince the patient he is getting better, the patient Temptation – Temptation is the choice of right vs. wrong in which one stands to profit from choosing wrong. Although the company can not state they are choosing to do “wrong” by their patients, the actions of the company in preventing employees from referring a patient for the most appropriate care appear wrong. In preventing the action from Venglar, M., and Theall, M. The Journal of Scholarship of Teaching and Learning, Vol. 7, No. 1, May 2007. 76 does not receive the most appropriate care, but John maintains his job. If John serves the patient he puts himself at risk; if he serves himself he neglects the full needs of the patient. Distress – Distress is when the stakeholder knows the right thing to do but is not empowered to act. John is in distress because his clinical expertise tells him his patient needs the skills of an expert hand therapist. He is restricted by the managed care company in his effort to make the appropriate referral for his patient. He is not empowered to provide the best care for the patient. occurring, the company benefits financially.