352 B. Medicaid 1. A joint state and federal program mandated by system. Title XIX of the Social Security Act. (1) Based on diagnostic-related groups 2. Provides health care services to the poor, elderly, and disabled who do not receive Medicare regard- (DRG's). less of age. (a) Classification system that groups 3. Benefits vary from state to state. 4. Preauthorization is needed by a physician before patients into disease categories or treatment can begin. groups. 5. Individual states can determine the scope, duration, (b) Basis for Medicare's prospective pay- and amount of services provided. ment system. (2) Hospital paid a specific amount per diagno- C. Worker's Compensation sis regardless of the length of stay, number 1. Regulated by state statutes and administered by of services provided, or tests performed. private insurers, self insured employers, or other 4. Medicare Part A benefits. agencies in some states. a. Hospital insurance, covering: 2. Provides health care for individuals injured on the (1) Inpatient hospital care. job. (a) Limits number of hospital days. 3. Some states limit the number of visits per diagno- (2) Skilled nursing facilities - first 100 days. sis, and/or require a pre-approval process be fol- (3) Home health agencies (HHA). lowed for reimbursement. (4) Hospice care. 4. Other states require the total number of visits or b. Provides basic protection against the cost of total number of weeks (duration) and the number health care. of treatments per week (frequency) to be usual, c. Does not cover all medical expenses or the cost customary and reasonable. of long term care. 5. Employers only contribute to the fund. d. Provides coverage for patients who have been a. All large employers (10 or more employees) or on social security disability for 24 months. high risk employers must contribute to e. Annual deductible fees paid by the patient. Worker's Compensation. 5. Medicare Part B. a. Medical insurance, covering: D. Private Health Insurance (1) Physician visits. 1. Includes commercial insurance, fee for service or (2) Outpatient laboratory tests and x-rays. traditional indemnity plans, or employers who are (3) Ambulance transportation. self insured. (4) Outpatient physical and occupational ther- 2. Patients have freedom to choose his/her providers. apy services (hospital and private practice). 3. Preauthorization may not be needed. (5) Home healthcare provided by a physical 4. The number of physical therapy visits should be therapist in independent practice (PTIP). usual, customary, and reasonable, which are often (6) Durable medical equipment (e.g., wheel- contractually defined in the insurance policy. chairs, canes, walkers), that is determined to be \"medically necessary\". E. Managed Health Care Systems (7) Medical supplies that hospital insurance 1. Third party payers direct patients to certain does not cover. providers and monitor services to avoid excessive (8) Residents of long term care facilities and inappropriate treatment and limit access. b. Each patient must pay a monthly premium. a. Third party payers frequently use \"gatekeep- c. Physical therapy treatment does not need to be ers\" (usually the PCP), to manage access to given on a daily basis. certain providers, including physical therapy. d. The physician responsible for the care of the b. Use techniques as pre-admission certification, patient referred for physical therapy must \"cer- concurrent reviews, financial incentives, or tify\" the plan of care. penalties. e. Only physical therapy care that is considered to c. Goal is to contain costs and ensure favorable be \"skilled\" and \"necessary\" and \"certified\" by patient outcomes. the referring physician will be reimbursed by 2. Health Maintenance Organization (HMO). Medicare.
a. A form of managed care which provides a Professional Roles & Management 353 broad spectrum of health services to individu- als and families for a preset amount of money. covered service. (1) Expressed as a percentage, e.g., 80% paid b. Employers contract for these services as a ben- efit to their employees. by insurance company and 20% paid by insured. c. Employees may pay a small fee per visit (co- d. The provider is at financial risk if services are pay), e.g., I5/visit. over-utilized. This is called \"shared-risk\". F. Health Savings Accounts d. Patients are locked into using the system of 1. Tax free savings account that can be used to pay member health care providers and affiliating for health-related expenses and retiree health facilities. expenses. 2. Must have a High Deductible Health Plan which is e. Some HMOs allow patients to seek care \"out of an insurance product that covers catastrophic network\" care, but at a higher, or additional health occurrences. cost to the patient. G. Personal Payment and Free Care 1. Individuals without health insurance must person- f. Primary care physicians chosen by individuals ally pay for all medical care. act as \"gatekeepers\" for medical care beyond 2. Individuals who cannot pay for health care can their scope of practice. receive \"pro bono\" or free care through philan- (1) Must authorize physical therapy services thropic donations and services. before they can be provided. 3. Many states have programs that offset some of the expense of providing \"free care\" provided by not g. Total number of visits per diagnosis is limited. for profit organizations. h. Types of HMO's: H. Restructuring the Healthcare System 1. Co t containment created incentives for healthcare (I) Individual Practice Associations (IPA). providers and hospitals to control both cost and (a) Physician groups contract independ- utilization of inpatient services by: ently with the HMO. a. Decreasing average length of hospital stay. (b) Physician work out of their own b. Decreasing routine and/or unnecessary diag- offices instead of a central facility. nostic testing and treatment. c. Increasing use of outpatient diagnostic testing (2) Prepaid Group Plan (PGP). and treatment. (a) Phy ician practice out of a central d. Increasing utilization of home care and skilled location. long term care. I. Health Insurance and Portability Accountability 3. Preferred Provider Organization (PPO). Act (HIPAA) a. A group of providers, usually physicians or 1. Elements of the act. hospitals, which offer health care services as an a. Standards and safeguards to assure an individ- entity to employers. ual's right to continuity in healthcare. b. Providers discount their fees to attract patients. b. Privacy and security of healthcare records. c. Patients are not locked into PPO providers, but c. Portability of health insurance. receive financial incentives to use services 2. HIPAA Privacy Rule. through the PPO network. a. Patient confidentiality is maintained in all oral, d. An employer can offer its employees a tradi- written and electronic forms. tional healthcare plan, HMO, or PPO. b. Technical, administrative and physical safe- e. Preauthorization is needed before services can guards for privacy. be provided. c. All persons must be informed of a facility's pri- vacy policies. 4. Both HMO's and PPO's contain one or more of the d. Written consent must be obtained before any following elements: personal health information i to be disclosed a. Capitation: a system whereby providers are or used for other purposes. paid a certain amount per case no matter how many visit are rendered. b. Co-payment: insured's charge for the covered ervice. (1) Made at the time of service. (2) Predetermined amount. c. Co-insurance: insured's share of the cost of the
354 (1) The provider may refuse but must provide a rationale. (1) Exemptions to written consent may be made in emergencies or if a delay will pre- (2) The provider may comply and provide a vent timely care. reason for amending the record. Original documentation is not removed. (2) If language barriers preclude signed con- sent in emergent or crucial situations, treat- IV. Defensible Documentation ment may commence if the physician believes that consent is implied. A. Medical Records 1. Complete, timely, and accurate documentation is e. Prior to discussing a person's status with a fam- essential for: ily member or other providers, the person may a. Patient safety. grant permission or object. b. Accurate communication between healthcare (1) Providers can use clinical judgment as to providers. whether to discuss a case if the person can- c. Compliance with federal and state regulations. not give permission or even if there is an d. Appropriate utilization for third party payers. objection. e. Historical record for potential legal situations. (a) Documentation for this decision is 2. General guidelines for documentation. essential. a. All documentation must comply with all appli- cable state, federal and regulatory agency laws f. All information disclosed must be the mini- and regulations. mum needed for the immediate purpose. b. Compliance with Medicare guidelines and any other guidelines required by the local insurance 3. Practice implications. carrier to ensure reimbursement. a. Physical identifiability of patients must be c. Patient's right to privacy must always be reduced. respected, protected. b. Charts and other documentation must be stored d. Release of any medical information must be out of public view and be secured. authorized by the patient. c. Any information stored or transmitted by com- e. Records must be kept in a safe and secure puters must be safeguarded. place, for a certain number of years. (varies d. Faxes must be sent with cover sheets on dedi- from state to state; usually 7 years). cated lines to secure locations. 3. Basic principles of documentation. (Refer to e. All e-mails should be password protected. Guide to Physical Therapist Practice, APTA). f. All conversations regarding a person's health a. Documentation should be consistent with status must be done in private areas with min- Guidelines for Physical Therapy Documen- imal disclosure. tation, APTA. g. Covers should be used on clipboards which b. All documents must be legible. contain patient paperwork. c. Only medically approved abbreviations or h. Treatment may be provided in groups or open symbols can be used. clinics. Discussions regarding these treatments d. Mistakes should be cro sed out with a single should be done quietly and in a private space. line through the error and initialed and dated by 1. There is no guarantee of 100% confidentiality. the therapist. Reasonable and vigilant safeguards are e. \"White-out\" or similar should never be used to required. correct text in a medical record. j. HIPAA does not override state laws with more f. Informed consent for treatment must only be restrictive privacy policies and it defers to state given by a competent adult. laws regarding minors. g. Non-competent adults or minors must have a parent or legal guardian give written 4. Patient rights. consent/proxy. a. An individual can access all of their medical h. Document each episode of treatment. records. i. Patient name and some other unique identifier (1) Providers have 30-60 days to respond. (2) A reasonable charge can be imposed for copying. b. An individual has the right to request that information in their record be amended.
hould be on each page; Professional Roles & Management 355 J. Date each entry (some payers require length of (1) Physical therapy students can complete if time per visit), particularly Medicare and co-signed by supervising therapist. Medicaid. k. Sign each entry with first and last name and 7. Discharge plan. professional designation a. Referrals, written or verbal, related to patient's 1. Record significant events, e.g., phone conver- continued care. sations with the physician or nurse. (1) Additional services. m. Document treatment rendered in objective, (2) Type of supervision the patient will require. measurable, and functional terms. (3) Home care. n. Document patient's response to treatment. (4) Family intervention. o. When goals and outcomes are reached, com- (5) Patient and family education requirements. plete a discharge plan. (6) Written home exercise program (HEP). 4. Progress notes. (7) List of equipment ordered, vendor's name, a. Document pecific treatment, equipment pro- and delivery date. vided; include signature of therapist providing (8) Social and community needs of the patient. care. (9) Date of discharge. b. Document patient response to treatment, func- (lO)A physical therapist should discharge a tional progress, goals achieved, revision of patient from physical therapy treatment goal , and treatment plan modifications. when maximum benefit is reached. c. Interim progress note can be written by: (11)Identifies needs of patient after discharge (1) Physical therapi t. from a facility. (2) Physical therapist assistant. (a) Preferable setting for discharge. (3) Student (PT or PTA) notes must be co- b. Must be written by a physical therapist. (1) Physical therapy students can complete if igned by upervi ing therapist. co-signed by supervising therapist. 5. Re-evaluationlsummary progress report. 8. Advance directives. a. Completed minimally every 30 days for all a. A legal document which delineates a patient's Medicare patients; includes: wishes for future medical care or no medical (1) Restatement of initial problem. care. (2) Length of time patient has been treated. b. Are implemented if the patient is cognitively (3) Progress or regression since last summary impaired. or initial evaluation. c. Can include living wills and durable power of (4) Rationale for continued care. attorney. (5) Revision of goals and outcomes. (6) Revision of plan of care. B. Common Reasons for Payment Denials (7) Changes documented are stated in behav- I. Incomplete/insufficient documentation. Documen- ioral, objective, measurable and functional tation that is submitted missing required documen- terms, e.g., range of motion, strength, sit- tation elements may cause a denial of payment. ting tolerance, etc. 2. Medically unnecessary. Poor documentation which does not fully explain the reasons for therapeutic b. Mu t be written by a physical therapist. interventions may result in denial of payment. (1) Phy ical therapy students can complete if 3. Incorrect coding: Failure to document the proper co-signed by supervising therapist. CPT, ICD-9, or other diagnosis or treatment codes can result in denial of payment. 6. Discharge summary includes: 4 Pay for performance. As pay for performance pro- a. Restatement of initial problem. grams (payment based on improved functional b. Length of time the patient has been treated. outcomes) grow, poor documentation may result in c. Progress since initial evaluation. reduced payments for services. d. Patient progre s toward goal and outcome achievement. v. Elements of Patient/Client Management e. Reason for discharge. f. Must be written by a physical therapist. From Guide to Physical Therapist Practice, 2nd edi- tion, APTA, 2001 and Standards of Practice for
356 2. Analysis of prolonged impairment, functional Iim- itation and disability. Physical Therapy, APTA, 2003. A. Initial Examination/EvaluationlDiagnosisIPrognosis 3. Analysis of living environment; potential dis- charge destination; and social supports. 1. The physical therapist performs an initial exami- nation and evaluation to establish a diagnosis and D. Diagnosis prognosis prior to intervention. 1. Encompasses a cluster of signs, symptoms, syn- dromes or categories. 2. The physical therapist examination: 2. Guides therapi t in determining appropriate inter- a. Identifies the physical therapy needs of the ventions strategy. patient or client. 3. Guides therapist in referring patient/client to an b. Incorporates appropriate tests and measures to appropriate practitioner for services outside the facilitate outcome measurement. scope of physical therapy. c. Produces data that are sufficient to allow eval- uation, diagnosis, prognosis, and the establish- E. Prognosis ment of a plan of care. 1. Includes predicted optimal level of improvement d. May result in recommendations for additional in function and amount of time needed to reach services to meet the needs of the patient of that level. client. 2. Can also predict levels of improvement at various e. Used to determine proper diagnosis and treat- intervals during the course of therapy. ment coding. F. Plan of Care B. Examination 1. The physical therapist establishes a plan of care 1. History. for the patient/client based on the examination, a. Patient's name, age, race, and ex. evaluation, diagnosis, prognosis, anticipated goal , b. Chief complaint and risk factors, relevance for and expected outcomes of the planned interven- physical therapy intervention, if applicable. tions for identified impairment, functionallimita- c. Referral source. tions, and disabilities. d. Pertinent diagnosis and medical history. 2. The physical therapist, in consultation with appro- e. Demographic characteristics, including perti- priate disciplines, plans for discharge of the nent psychological, social, cultural, and envi- patient/client, taking into consideration achieve- ronmental factors. ment of anticipated goals and expected outcomes, f. Concurrent medical services provided. and provides for appropriate follow-up or referral. g. Pertinent problems. 3. The physical therapist also addre ses risk reduc- h. Statement describing patient's understanding tion, prevention, impact on societal resources, and of problem. patient/client satisfaction. i. Goals of the patient and/or patient's family. 4. Identifies realistic long-term and short-term goals 2. Objective findings/systems review. and expected functional outcomes. a. Physiologic and anatomic status. a. Goals address impairment, functional limitations (1) Cognitive status, alertness, judgment, com- and/or the prevention of additional problems. munication. b. Goals should address: (2) Neurological status: pain, sensation, reflex- (1) Who will participate in the activity? es, balance, motor function, etc. (2) A detailed description of the activity. (3) Musculoskeletal: joint range of motion, (3) The connection of the activity to a specific strength, posture, etc. function. (4) Cardiovascular: vital signs, endurance, etc. (4) A specific measure for success. (5) Integumentary. (5) A time measure. b. Functional status: mobility, transfers, ADL, work, school, or athletic performance, etc. G. Intervention c. Communication ability, affect, cognition, lan- 1. The physical therapist provides, or directs, and guage and learning style. supervises, the physical therapy intervention con- sistent with the results of the examination, evalua- C. Evaluation tion, diagnosis, progno is, and plan of care. 1. Analysis of current impairments and effect on 2. The intervention: function.
a. Is provided under the ongoing direct care or Professional Roles & Management 357 upervision of the physical therapist. 2. Demonstrate progress in specific and functional b. Is provided in such a way that delegated terms. responsibilities are commensurate with the qualifications and the legal limitations of the 3. Document medical necessity and reasons for physical therapy support and professional per- skilled care. sonnel involved in the intervention. 4. Document to stand up in a court of law. Document c. Is altered in accordance with changes in fully, reduce the use of jargon and obscure abbre- response or status. viations. Sign and date all entries. Be factual and objective. d. Is provided at a level that i consistent with cur- rent phy ical therapy practice. VI. DepartmentaJ/Human Resources Management e. Is interdi ciplinary when necessary to meet the need of the patient or client. A. Interview 1. Performed by supervisor, director, and also possi- 3. Documentation of the intervention: blya member of the human resources department. a. Is dated and appropriately authenticated by the 2. Purpose is to meet with prospective employee. physical therapist or, when permissible by law, a. Exchange questions and answers to obtain by the physical therapist assistant, or both. enough information to make an informed deci- sion. H. Re-examination b. Questions asked are informational to encour- l. The physical therapi t re-examines the patient/ age discussion rather than those requiring \"no client as neces ary during an episode of care to or yes\" answers. evaluate progress or change in patient/client status c. No questions may be asked about a person's and modifies the plan of care accordingly or dis- age, religion, race, marital status, politics, continue physical therapy services. national origin, or number of children. 2. The physical therapist re-examination: d. Information regarding academic record, educa- a. Identifies ongoing patient/client needs. tional program or references cannot be b. May re ult in recommendations for additional obtained without consent. services, discharge, or discontinuation of phys- e. Many employers will require a criminal back- ical therapy needs. ground check, which requires the consent of the applicant to pursue. I. DiscbargeIDiscontinuation of Intervention f. Interviewer provides information about: I. The phy ical therapist discharges the patient/client (1) Advantages and disadvantages of the from phy ical therapy services when the anticipat- organization. ed goal or expected outcomes for the patient/ (2) Benefits available. client have been achieved. (3) Work hours. 2. The physical therapist discontinues intervention (4) Vacation, sick and personal time. when the patient/client is unable to continue to (5) Salary range. progress toward goals or when the physical thera- (6) Job description. pist determines that the patient/client will no longer 3. Employers look for the following information in benefit from physical therapy. an interview. 3. Discharge: a. Decision miling style. a. Occurs at the end of an episode of care and is b. Communications skills. the end of phy ical therapy services that have c. Interpersonal skills: poise, tact, ability to work been provided during that episode. in groups. 4. Discontinuation: d. Leadership. a. Also occur when the patient/client, caregiver, or e. Achievement record, and relevant employment legal guardian decline to continue intervention. experience. f. Sense of personal direction. J. Successful Documentation Practices 4. Documents reviewed for employment: 1. Incorporate evidence-based practice principles. Use standard tests and measures which are valid and reliable, and select interventions based on research and practice.
358 C. Performance Appraisal 1. Assesses an employee' performance in relation to a. Job application: is it complete? applicant's performance expectations established with objec- attention to detail. tive criteria. 2. Written report and discussed verbally. b. Previous employment experience. 3. Frequency can be 3-6 months or annually. c. Transcript from educational institution (espe- 4. Correlates to job description and goals of the organization. cially for new graduates): grade point average 5. Improves communication between the employee and courses taken may be important in inter- and employer. view process. 6. Feedback should be immediate, specific, and d. Resume: a brief written summary which high- directly communicated. lights personal, educational, and professional 7. Outcomes of performance apprai al can be moti- qualifications and experience. vating and used as a reward y tern, e.g., raise, e. References. bonuses, promotions, etc. May also identify per- (1) Professional: former employers, clinical formance issues and areas for improvement. 8. Examples of methods of review: upervisors, faculty. a. Essay appraisal: short paragraph on strengths (2) Character: family friend, clergy. and weaknesses. B. Job Descriptions b. Performance criteria based method: based on 1. General summary of responsibilities. functional job de cription u ing a weighted rat- a. Provides overview of position including super- ing scale (mo t important task gets highest rat- visor relationships. ing), e.g., patient evaluation, weighted average 2. Specific job responsibilities. of 5, and personal appearance 2. a. Identifies the specific responsibilities of the position. D. Unions b. Establishes performance standards. 1. Organized group of workers with the same goals c. Establishes skilled and non-skilled require- and objectives. ments of job. 2. Provides collective bargaining when negotiating d. Formalizes basic performance expectations by work contracts. describing duties in detail. a. Salaries. e. Establishes degree of decision making authori- b. Fringe benefits. ty and autonomy. c. Hours of work. f. Organizational and supervisory relationships d. Conditions of work site. of position. 3. Mediates grievances due to labor disputes, disci- (1) Position title. plinary problems, etc. (2) Department division. (3) Title of position's supervisor. E. Policy and Procedure Manual 3. Job specifications. 1. Provides extensive information on what shall be a. Educational requirements, e.g., graduate from done and how it shall be done in a physical thera- accredited physical therapy program. py department. b. State licensure. 2. Required by Joint Commi sion on the c. Previous experience requirements. Accreditation of Healthcare Organizations d. Essential job functions or specific physical and (JCAHO), Commission on Accreditation of mental demands of position. Rehabilitation Facilities (CARF), and other (1) Lifting requirements. accrediting agencies. Often required by other state (2) Transferring requirements. regulatory bodie , such as State Board of Public (3) Ambulatory or positioning requirements. Health. (4) Proficiency in reading/writing/comprehen- 3. Policies are broad statements that guide in decision making. They may include: sion. a. Scope of service. (5) Maintaining static postures: performing (1) Mission and Philosophy Statement. therapeutic procedures for several minutes. e. Ability to plan and organize time, and other work habits. f. Problem solving skills.
(2) Identifies the type of services provided, Professional Roles & Management 359 hours available, referral requirements (if applicable), staffing and other general regarding performance. information about the service. b. Good working conditions. b. Operational policies. (1) Essential equipment should be available for (1) Billing policies. proper patient care. (2) Referral policies (if appropriate). (3) Medical record management. c. Recognition of performance (praise or positive (4) Quality assurance and improvement activi- feedback, salary, bonuses, raises, and/or pro- ties. motions). (5) Other applicable clinical policies. d. Providing enhanced opportunity to achieve job c. Human resources policies. related goals. (1) Vacation: paid time off, varies according to (1) Outline of policies. length of employment, seniority or other (2) Development of a clear job description. criteria. (3) Outline job responsibilities. (2) Introductory period (also called \"proba- tionary period\"). e. Demonstrating concern as a supervisor, in (3) Job descriptions and performance appraisal resolving work related problems. policies. (4) Time off, leave of absence, sabbaticals. f. Acknowledge the contributions of the staff (a) Military service. towards realizing the mission, and scope of the (b) Maternity leave. service and/or institution. (c) Medical leave. (d) Jury duty. g. Fair compen ation is based on market factors, (5) Dres code. required qualifications, while ensuring equity among the staff of the department/service. 4. Procedures are specific guides to job behaviors for all departmental personnel, visitors, and patients h. Supervisor should consult with involved staff that standardize activities with a high level of risk. member regarding problems which affect his or a. Safety and emergency procedures. her employment. b. Equipment management, cleaning, maintain- ing, training requirements, safety in pections. 1. Realistic job expectations. c. Hazardous waste management. (1) Supervisor should avoid prorrusmg more d. Disciplinary procedure . than can be delivered, e.g., promising a (I) Manager present problem in clear and promotion to a senior position when no concise terms, and specifically references budget has been approved. the problem to the job description and expectations. G. Continuing Education (2) Discussion is on performance discrepancy. 1. Ongoing educational program activities. (3) Employee is given chance to respond. a. Enhances clinical knowledge. (4) Manager pre ents action to be taken and b. Exposes therapist to new techniques and tech- why. nology. (5) Follow-up date for re-evaluation is set. 2. Educational programs may be one day, a weekend, (6) Consequences of non-compliance are or week. e tablished. 3. Employer should support and may subsidize a (7) Documentation of meeting is objective. staff member's attendance, promoting profession- al and educational development. F. Staff Motivation 1. Sustaining an individual behavior towards attain- H. Meetings ment of an objective or goal by providing: 1. Staff meeting. a. Challenging work, varied treatment assign- a. Regularly held department meetings, with a ments with opportunity to receive feedback specific agenda set in advance of the scheduled meeting. b. Purpose is to discuss department or hospital! management business, state or national physical therapy issues, and educate the staff members. c. Agendas are predetermined to ensure that the objectives and purpose of the meeting are clear. 2. Supervisory meeting. a. Supervisor and staff meet regularly.
360 record, nor are they referenced in the medical record. (1) To discuss patient care issues. b. Used to document additional information, cir- b. One on one meeting designed to meet the needs cumstances, contributing factor that would not be appropriate to include in the medical record. of the staff member. c. Used to evaluate systems and processes that 3. Team meeting. may have contributed to the cau e, for the pur- pose of correcting and/or improving underly- a. Usually scheduled at least weekly. ing causes or contributing factors. b. Interdisciplinary (MD's, nurses, PT, OT, social d. Are part of an internal quality improvement program. services, etc.) to improve communication e. Can be u ed a a component of individual between all staff. employee performance apprai al and improve- c. Purpose is to: ment. (1) Discuss and coordinate patient care services. 2. A sentinel event is a specific patient-related occur- (2) Set goals and outcomes for individual rence in which an unexpected finding or outcome can be analyzed to improve processes, systems, or patients. therapist performance to reduce the likelihood of (3) Discuss goal/outcome achievement neces- reoccurrence. a. Is part of a comprehensive quality assurance sary for discharge. and improvement program. (4) Discuss discharge plans including destina- b. When a sentinel event occur , a \"root cause\" analysis is done to identify underlying prob- tion, equipment needs, homecare services, lems with processes, systems or performance etc. that can be improved to reduce the likelihood 4. Strategic planning. of reoccurrence. a. Organizational planning process for goal c. Many regulatory and accrediting agencies achievement and future goals. require sentinel event reporting and analysis be (1) Based on the organization's Mission and done, particularly on specific types of incidents. Philosophy Statement. (2) Used for developing plans for implementa- J. Healthcare Marketing tion to achieve identified goals. b. Results of strategic planning process summa- I. Assess the true needs and wants of the rized in strategic plan. patient/client. (external factors). (1) Provides focused direction so goals of organization are achieved. 2. Analyze the strengths and weaknesses of the (2) Identifies who is responsible for develop- organization to meet the needs of the customer ing and carrying out the plan, e.g., staff (internal factors). members, department director sets the timeline, and the expected outcomes. 3. A needs assessment should be done first, before (3) Informs external parties about organization. providing a service, planning a new facility, to (4) Goals are time related, e.g., one, three, or determine: five year plans. a. Where is the market? (consumer). (5) Methodology for evaluating the progress of b. Does a need for the service exist? (environment). the plan should be developed as part of the c. Who is the competition? plan. (6) Analysis of progress toward goals should 4. Needs assessment can be completed by: be done by the DirectorlManager at least a. In-depth analysi of the marketplace, including quarterly. demographic and epidemiological data. c. Strategic plans are always driven by and con- b. Reviewing the literature. sistent with the organization's mission and phi- c. Surveying colleagues. losophy. I. Incident/Occurrence and Sentinel Event Reporting 5. Marketing methods may include: 1. Incident/Occurrence report is used to document a. Brochures, new letters, educational pamphlets, incidents that involve patients and/or staff and newspaper article , internet, telemarketing, and which result in harm and/or the potential for harm so on. to the patient and/or staff. a. Incident reports are not part of the medical
b. Guest appearances on television, radio or at Professional Roles & Management 361 local organizations. (4) To convert an idea into a practice reality. c. Profes ional referral. b. Four basic steps of program development. d. Word of mouth. e. Yellow pages advertising. (1) Needs assessment. f. Direct marketing to managed care groups, e.g., (a) Describe the community, its physical, social, cultural and economic factors, sport injuries, low back pain, etc. and populations at risk. K. Service Management (b) Describe the target population's demo- graphics, disorder(s), functional level, 1. Management principles, functions, and strategies. and presenting problems. a. Management that has a positive attitude about (c) Identify specific needs of target popu- change and innovation fosters best practice. lation. b. Succe sful management supports open com- • Perceived needs of the population as munication, team building, decentralization of reported by others (e.g., family, resource and the haring of power. physicians, and other professionals). c. Management that utilizes strategic thinking in a • Perceived needs as stated by the systems model can respond proactively to mar- individual members of the target ket demands and changes. population. d. The u e of different management styles (i.e., • Real needs, which are the actual dis- the manager's characteristic way of performing abilities and functional limitations management tasks), has a significant impact on of the target population. productivity, change and growth. (d) Determine discrepancy between real e. Management's understanding and application needs and perceived needs. of theories of motivation and behavior facili- (e) Determine unmet needs according to tates appropriate and effective responses to sit- priority. uations, fosters program efficacy and promotes (f) Identify resources available for pro- employee satisfaction. gram implementation. f. Administrative functions of management • Formal or institutional resources include program development, fiscal and per- such as staff, supplies, money, sonnel management, and program evaluation. space. g. Management by Objective (MBa): a complete • Wormal resources such as family, system of management based upon a core set of friends, cultural or religious figures, goals to be accomplished by a program. self-help/consumer groups. (1) Mi sion and goals are established. (g) Needs assessment methods. (2) Measurable objectives are quantified. • Survey, interview or self report of (3) Specific time frames for accomplishment target population. A representative of objectives are established. sample is required. (4) Staff training needs and deterrents to • Key informant which involves the progress are identified. surveying of specific individuals (5) Program evaluation is instituted. who are knowledgeable about the target population needs. 2. Program development. • Community forums to obtain infor- a. Purpo es of developing specific programs. mation through public meetings or (1) To directly meet the needs of a specific panels. population(s) or group(s). • Service utilization review of records (2) To clearly focus evaluation and interven- and reports. tion efforts and activities. • Analysis of social indicators to iden- (3) To increase visibility and use of available tify social, cultural, environmental ervices (e.g., offering an outpatient cardiac and/or economic factors that can rehabilitation program is more visible than predict problems. individual referrals, re ulting in increased recognition and utilization of this service). (2) Program planning.
362 (a) Define a focus for the program based mum gain from the program, usual- on the needs assessment results. ly defined as the achievement of • Problem areas, functional limita- program goals. tions and unmet needs that are rele- (f) Describe the fiscal implications of pro- vant to the majority of the target gram plan. population are the priority focus. • Determine projected volume or • Program level of difficulty as deter- service demand to estimate revenue. mined by the range of population's • Identify resource utilization and pro- functional levels and the level jected expenses to estimate costs. required by the current and expected • Directly compare estimated revenue environment. and estimated expen es to determine financial viability of program. (b) Adopt a frame of reference that is most (3) Program implementation. likely to successfully address and meet (a) Initiate program according to timetable the needs that are program's focus. and steps set forth in the program plan. (b) Document program activities, proce- (c) Establish objectives and goals of the dures and use. program specifically related to primary (c) Communicate and coordinate with focus. other programs within the system. • Individual goals which will be met (d) Promote program to en ure it reaches by the program are set. target population. • Programmatic goals which establish (4) Program evaluation. standards for program evaluation are (a) Determine if program hould continue, determined. change or discontinue. (d) Describe integration of program into VIT. Budgets-Fiscal Management of Physical existing system of care. • Establish realistic timetable for pro- Therapy Services gram implementation. • Define staff roles, responsibilities A. Budget: is a financial plan, for a specific time period, and assignments. of the amount of funds allotted to cover specific • Identify methods for professional expenses of operating a physical therapy department collaboration. or private practice • Determine the physical setting and 1. An integral part of the planning process. space requirements. 2. Provides a mechanism of assessing the financial • Consider potential barriers to pro- success of the practice, programs, or projects. gram implementation. 3. Expresses anticipated income and expenditures • Develop methods to effectively deal over specific time periods in terms of: with identified obstacles before pro- a. Buildings. gram implementation. b. Space. c. Equipment. (e) Develop a system of referral for entry d. Supplies. into, completion of, and discharge 4. Operating budgets are usually planned for one from the program. year duration (e.g., the organization's fiscal year), • Evaluation protocols standardize and can be planned to be \"flexible\" or changed information to be obtained from depending on volume and other factors. each person referred to the program 5. A budget is planned for capital expense, which and assess the type of program serv- includes all major renovation expense or the pur- ices needed. chase of equipment that is reusable and will last a • Criteria for acceptance into the pro- minimum of three years. Capital budgeting should gram and for movement through be part of the strategic plan. program levels are set. • Discharge criteria determine when an individual has achieved maxi-
B. Expense Budgets Professional Roles & Management 363 1. Represent the amount of money spent by an organ- ization to provide good and services within a spe- D. Accounts Payable cific period of time. 1. Money owed to a creditor (someone who provides 2. There are two types of expense budgets: a service or equipment) for services rendered. a. Operating expense budgets. 2. A part of the budget where debts are listed. (1) Related to the day-to-day operation of the organization. E. Accounts Receivable (2) Include categories relating to: salaries, ben- 1. Money owed to a company (hospital, physical efits (sick, vacation, etc.), supplies, utilities, therapy practice) for providing a service, e.g., (telephone and electric), linen, housekeep- physical therapy treatment, on credit. ing, maintenance, continuing education, etc. 2. An asset expected to benefit future operations. b. Capital budgets. (1) Deal with the purchase of larger items VIll. Quality Assurance/Quality Improvement which will be utilized for more than three to five years, such as the purchase of new A. Quality Assurance: (QA) equipment or new buildings. 1. Monitor quality. (2) Capital expense is equipment which is 2. Monitor appropriatene of care. depreciable and usually costs more than 3. Resolve identified problems. 1000. B. Continuous Quality Improvement C. Costs 1. A systematic process that involves ongoing, delib- 1. There are direct and indirect, fixed and variable erate, and continuous monitoring of the systems and discretionary costs associated with providing a and processes affecting patient care to assure for physical therapy service. the highest quality outcomes possible. a. Direct costs are directly associated with the production of a service, including: C. Utilization Review (UR) (1) The cost of salaries for professional staff. 1. Written plan for: (2) Treatment supplies (ultrasound gel, mas- a. Determining appropriate use of resources. sage lotion, etc). b. Medical necessity of services provided. (3) Treatment equipment. c. Cost efficiency. (4) Continuing education. 2. Methods for UR. b. Indirect costs are necessary to produce a service a. Prospective review. but are indirectly associated with that service. (1) Evaluation of proposed treatment plan that (1) Utilities (telephone and electric). specifies how care will be provided. (2) Housekeeping, laundry. (2) Used by third party payers to approve pro- (3) Marketing services, etc. posed physical therapy treatment program. c. Fixed costs remain unchanged even with b. Concurrent review. changes in volume. (1) Evaluation of ongoing treatment program (1) Air conditioning. during hospitalization or treatment. (2) Rent. (2) Method to ensure appropriate care is being d. Variable co ts increase and decrease in direct delivered. proportion to the volume of activity. c. Retrospective review. (1) Linen and labor costs increase as the vol- (1) Audits of medical records after treatment ume increases. were rendered. e. Di cretionary expenses are those costs which (2) Method to ensure appropriate care was are not essential for providing physical therapy given. services. They may include budgeting for con- (3) Time consuming, expensive method for tinuing education, recognition activities or third party payers. other. d. Statistical utilization review (SUR). (1) Claims data, like pricing and utilization, are analyzed. (2) Determines which providers offer the most efficient and cost effective care. e. Peer review. (1) Performed by peer groups of health profes-
364 x. Caregiver DefinitionslRoles sionals. A. Physical Therapist (PT) (2) Retrospective and concurrent review of I. A skilled health professional with a minimum of a baccalaureate degree; current accreditation stan- clients records to determine if services pro- dards mandate post-baccalaureate degree (master' vided are necessary, appropriate, and com- or doctorate). prehensive in relation to the patient's needs. 2. Licensed by each state or jurisdiction following suc- (a) Educational, not punitive. cessful performance on ational Physical Therapy (b) Aim is improvement of quality of care. Examination. (c) Focuses on how well services are per- 3. Examines patient, evaluates data, e tablishes diag- nosis, prognosis, and plan of care, administers or formed in the delivery of care under supervises treatment. review. 4. Delegates portions of plan of care to supportive (d) Determines if the patient's needs have personnel, e.g., PTA. been met. 5. Supervises and directs supportive staff (PTA, PT (3) May also be performed by Peer Review aide) in designated tasks. Organization (PRO). 6. Re-evaluates and adjusts plan of care as appropriate. (a) Reviews services provided to Medicare 7. Performs and document final evaluation and and Medicaid beneficiaries and some establishes discharge and follow-up plans. managed care plans. 8. Consultation by giving professional opinions to (b) Determines appropriateness of services others to identify problem, recommend solutions delivered to patients. or produce a specific outcome. f. Audit or program evaluation. a. May be patient-related con ultation to evaluate (I) Assessment of the management of patients the quality of PT services. with a specific diagnosis. b. May be client-related con ultation to a busines , (a) Objectives are established for patients, school, organization or government agency. e.g., total hip replacements. (1) Expert witness. (b) Outcomes are evaluated in terms of (2) ADA compliance. range of motion, strength, pain, function, (3) Work-related injury prevention. gait level, ability to climb stairs, etc. (4) Request for a second opinion. (c) Comparisons made between treating therapists, other facilities, etc. B. Physical Therapy Director (d) Programs can be modified or improved I. Oversees function, responsibilities, and relation- when indicated. ships of all personnel. 2. Establishes, revi e and en ures policies and pro- IX. Professional Standards cedures are carried out according to established policy and procedures. (See also Appendices A, B, C, and D) 3. Acts as liaison with facility administration. A. Standards are developed by professional associa- 4. Sets department goals and strategic plan. tions and are only binding on association members C. Physical Therapy Supervisor I. Code of Ethics helps physical therapists (PTs) and I. Qualified experienced physical therapist with a variety of skills including: physical therapist assistants (PTAs) understand a. Professional knowledge and kill of tasks per- how to act morally and professionally formed. (Appendices A and C). b. Ability to motivate subordinates. a. Code of Ethics (APTA) has been codified as c. Ability to evaluate staff and give oral and writ- ten feedback. law in many state practice/licensure law and d. Interviewing new staff and developing their regulations. It is often adopted by many institu- skills. tions as the standard of behavior for physical e. Delegating tasks to appropriate taff. therapists. 2. Guide for Professional Conduct assists in the inter- pretation of the Code of Ethics (Appendix B). 3. Guide for Conduct of the Physical Therapist Assistant (PTA) determines the propriety of their conduct (Appendix C).
2. Patient care mayor may not be primary responsi- Professional Roles & Management 365 bility of the upervisor. e. Secretarial or hou ekeeping dutie . D. Physical Therapist Assistant (PTA) 5. Aides are not licensed by the state and orne state 1. Skilled physical therapy technologist, usually with a two year associate's degree. laws limit or prohibit treatment procedures by 2. Must work under the direction and supervision of aides. a physical therapist in all practice settings. F. Physical Therapy and Physical Therapist Assistant a. When the PT and PTA are not within the same Student physical setting, delegated functions by the 1. Performs duties commensurate with level of edu- PTA must be safe and legal physical therapy cation. practice based on: 2. PT clinical instructor (CI) is responsible for all (1) Complexity and acuity of the patient's actions and duties of affiliating student. needs. 3. PT may supervise both physical therapy and phys- (2) Proximity and accessibility to the PT. ical therapist assistant students. (3) Supervision available in the event of emer- 4. PTA may only supervise an assistant student. gencies. G. Physical Therapy Volunteer (4) Type of setting in which the service is pro- 1. Member of the community. vided. a. Interested in assisting PTs with departmental b. In home health, regularly scheduled and docu- mented upervisory meetings are established activities. between the PT and PTA, the frequency of b. Takes phone messages, does filing or other which i determined by the needs of the patient and the needs of the PTA and include: basic secretarial tasks. (1) On- ite re-assessment of the patient. c. May not provide or et up patient treatment, (2) On-site review of the plan of care with appropriate revision or termination. transfer patients, clean whirlpools, or maintain (3) Assessment and recommendation for uti- equipment. lization of outside re ources. H. Home Health Aide 3. Able to adju t treatment procedure in accordance 1. A non-licensed worker (e.g. nursinglrehabilitation with change in patient status within the scope of assistant) specifically trained to: the e tabli hed plan of care. a. Provide personal care and home management 4. May not evaluate, develop or change plan of care, services. or write di charge plan or summary. b. Assist patients to remain in the home environ- 5. May carry out routine operational functions ment. including supervi ion of the physical therapy aide 2. Supervised by a nurse, physical or occupational and documentation of patient progress. therapist. 3. Responsibilities include: E. Physical Therapy Aide a. Bathing, grooming, light housework, shopping, 1. A non-licensed worker, specifically trained under or cooking in some circumstances. the direction of a PT or PTA. b. Supervision of home exercise program (HEP) 2. Functions only with the continuous onsite supervi- as directed by the PT, e.g. ambulation. sion of a PT or, where allowable by law or regula- I. Occupational Therapist (OTRIL) tion, the PTA. 1. A skilled health professional that holds a minimum 3. Performs designated routine tasks related to the of a baccalaureate degree, and passes a national operation of a physical therapy service. certification examination. ar's are licensed by 4. Job respon ibilities may include: some but not all states. The ar provides: a. Functional and ambulation activities. a. Education and training in activities of daily liv- b. Application of specific heat, cold and ing. whirlpool treatments. b. Fabrication of orthoses (splints). c. Equipment maintenance. c. Guidance in selection and use of adaptive d. Patient tran portation. equipment. d. Therapeutic activities to enhance functional performance, and cognitive/perceptual func- tion. e. Consultation concerning the adaptation of
366 N. Respiratory Therapy Technician Certified (CRRT) 1. A skilled technician holding an as ociate's degree physical environments for the handicapped. from a 2 year training program accredited by the f. Creative activities in treatment of physically Committee in Allied Health Education and Accreditation. and emotionally disabled patients. a. Passes a national exam to become registered. 2. Services are provided on an in-patient basis, out- 2. Administers respiratory therapy as prescribed and supervised by a physician. patient basis and in industrial environments. a. Performs pulmonary function tests. b. Treatments consist of oxygen delivery, J. Occupational Therapist Assistant (COTA) aerosols, and nebulizers. c. Maintains all respiratory equipment and assists 1. Skilled technician holding an associate's degree patients in their use, i.e., ventilators, oxygen, and passing a national certification examination. pressure machines, etc. d. Coordinates care with pulmonary physical 2. Works under the direction of an occupational ther- therapy treatments. apist in carrying out established treatment. a. Cannot evaluate, establish or revise a plan of O. Primary Care Physician (PCP) care. 1. A practitioner, usually an internist, general practi- tioner, or family medicine physician, providing 3. Performs duties in a rehabilitation or home setting. primary care services and managing routine health a. Concerned with functional deficits in activities care needs. of daily living, including dressing, grooming, 2. Acts as the \"gatekeeper\" for patients covered by hygiene, housekeeping, etc. managed health care. a. Authorizes referrals to other specialty physi- K. Speech-Language Pathologist (Speech Therapist) cians or services, including physical therapy. 1. A skilled health professional holding a master's degree in communication disorders completed one P. Physician's Assistant (PA) year of field experience, and passed a national 1. Skilled allied health profe ional, graduate of an examination to obtain the Certificate of Clinical accredited program. Competence authorized by the American Speech a. Required to pass national certification exami- and Hearing Association. nation. 2. Conducts remedial programs to restore or improve b. One year direct patient contact required. communication of patients with language and 2. Under the supervision of the supervisory physi- speech impairments. cian, performs routine diagnostic, therapeutic, pre- a. May arise from physiological or neurological ventative and health maintenance services in any disturbances and defective articulation. setting in which the phy ician renders care. 3. Works with OT to correct swallowing problems a. Specialties include: family medicine, obstetrics, and cognitive processing deficits; and with PT in pediatrics, orthopedics, emergency medicine, the area of positioning and mobility. and others. 3. Works under the direction and supervision of a L. Certified Orthotist (CO) physician. 1. Designs fabricates, and fits orthoses (braces, 4. Able to write physical therapy orders under some splints, collars, corsets) prescribed by physicians circumstances. 2. Successfully completed the examination by the American Orthotist and Prosthetic Association. Q. Physiatrist 3. Provides these devices to patients with disabling 1. A physician specializing in physical medicine and conditions of limbs and spine. rehabilitation. 4. Works directly with physicians, physical and occu- a. Certified by the American Board of Physical pational therapists. Medicine and Rehabilitation. b. Diagnoses and treats patients with disabilities M. Certified Prosthetist (CP) involving musculoskeletal, neurologic, cardio- 1. Designs, fabricates, and fits prostheses for patients vascular or other body ystem . with partial or total absence of a limb (amputa- tion). 2. Successfully completed the examination by the American Orthotist and Prosthetic Association. 3. Work directly with physicians, physical and occu- pational therapists. 4. Individuals may be certified in both orthotics and prosthetics (CPO).
2. Primary focus on maximal restoration of physical, Professional Roles & Management 367 psychological, social, and vocational function, and alleviation of pain. 2. A specialist in hearing disorders and evaluation who works to rehabilitate individuals with hearing 3. May lead the rehabilitation team in coordinating loss. patient care. a. Uses audiometric tests to assess sensitivity of a. Works directly with physical, occupational and sense of hearing. speech therapists. b. Uses speech audiometric tests to assess ability to understand selected words. R. Chiropractor (DC) c. Audiometrist is the technician trained to 1. Alternative medical practitioners usually licensed administer audiometric tests selected and eval- by a state board. uated by the audiologist. a. Deals with relationship of the nervous system and the spinal column in the restoration and V. Consultant maintenance of health. 1. A person who by training and experience has 2. Services are covered for individuals in most group acquired a special knowledge in a subject area health plans. which has been recognized by a peer group. 3. Patients may see a chiropractor and physical ther- 2. A person who analyzes situations, offers advice, apist at the same time. and solutions to problems. a. Physical therapist, with patient's permission, a. For example: physician referral for consulta- should contact chiropractor to coordinate care. tion or advice regarding diagnosis or treatment of a patient. S. Registered Nurse (RN) b. Consultant reviews history, examines patient, 1. A skilled health professional who is a graduate of and writes opinion. an accredited program, licensed by state board fol- c. Responsibility of patient care not delegated to lowing successful performance on licensure exam. consultant. 2. Primary liaison between the patient and the physi- cian. W. Athletic Trainer (ATC) a. Communicates to physician changes in 1. A health professional with a minimum of a bac- patient's medical or social condition. calaureate degree and is an integral part of the b. Educates the patient and family to facilitate health care system associated with sports. recovery. a. Usually works under supervision of a physi- c. Makes referrals to other services under physi- cian. cian's direction. b. Provides injury prevention, recognition, treat- d. Supervises other levels of nursing care (licensed ment, and rehabilitation after athletic trauma. practical nurse [LPN], home health aide). 2. Settings for delivery of care: e. Administers medication but cannot change a. Secondary schools, colleges and universities, drug dosages. professional athletic organizations, and private f. Carries out range of motion, bed exercises, or hospital based clinics. transfers, and ambulation as instructed by the physical therapist. X. Social Worker (MSW) 1. Usually completed a master's degree from a T. Rehabilitation Counselor (vocational rehabilita- school of social work accredited by the Council on tion counselor) Social Work Education. After one year of practical 1. Counsels physically and mentally handicapped field work they are licensed or registered by the persons. state. a. Helps patients improve their ability to function 2. Acts as a resource director assisting patients and optimally in society. families with necessary applications for financial b. Administers vocational tests, procures voca- resources, appropriate discharge destinations tional training and provides occupational infor- (skilled nursing facility, custodial care facility, mation for job placement. etc.), rental and loaner equipment, and support groups, etc. U. Audiologist 3. Acts as a personal or family counselor. 1. A health professional with a graduate degree in 4. Educates the patient and family about their med- audiology. ical problems. Also educates the home health staff
368 (2) Members' primary allegiance is to hi /her discipline. Some formal communications helping them understand patient and family inter- occur between team members. action and crisis management. 5. Acts as an advocate for the patient in dealing with (3) Limited communication may re ult in lack outside agencies and procuring support services. of understanding of different per pectives. 6. Mediates between the patient and family by allevi- ating fears, developing realistic expectations of the (4) Resources and re ponsibilities are individ- patient to the family, interpreting the patient and ually allocated between disciplines; there- families' situation to outside rel~tives and the fore, competition among team members home health care team. may develop. Y. Alternative Support Staff (massage therapists, exercise therapists, acupuncturists, etc.) b. Interdisciplinary. I. May work within the supervision of a physical (I) All disciplines relevant to the case at hand therapist. agree to collaborate for decision making. 2. Employed under their appropriate titles. (2) Evaluation and intervention is still conduct- 3. Involvement in patient care activities should be ed independently within defined areas of within the limits of their education and in accor- each profession's expertise. However, there dance with applicable laws and regulations and the is a greater understanding of each disci- discretion of the physical therapist. pline's perspective. Z. Team Roles and Principles of Collaboration (3) Outcomes and goals are team directed and I. Overview. not bound to discipline specific roles and a. A team is a group of equally important individ- functions. (4) Members tend to u e group proce s skills uals with common interests collaborating to effectively, (e.g., during team planning develop shared goals and building trusting rela- meetings). tionships to achieve these shared goals. (5) The exchange of information, prioritization b. Members of the team include the patient/client/ of needs, allocation of re ources and consumer; his/her family, significant others, responsibilitie are ba ed on members' and/or caregivers, healthcare professionals; and expertise and skill , not on \"turf' issue . the reimburser's gatekeepers. (6) Ongoing training, upport, upervision, c. Professional members on team will vary cooperation, and consultation among disci- according to practice setting. plines are important to thi model, ensuring d. The consumer, family, significant other, and/or that professional integrity and quality of caregiver role on the team has become increas- care is maintained. ing important. Collaboration with these indi- viduals is even mandated by law (e.g., OBRA, c. Intradisciplinary. IDEA). (1) One or more members of one discipline 2. Principles of collaboration. evaluate, plan and implement treatment of a. Factors that influence effective team function- the individual, e.g., PT, PTA, PT consultant. ing. (2) Other disciplines are not involved; commu- (1) Member skill and knowledge. nication is limited, thereby limiting per- (2) Membership stability. spectives on the ca e. (3) Commitment to team goals. (3) This \"team\" is at risk due to potential nar- (4) Good communication. rowness of perspective. (5) Membership composition. (4) Comprehensive, holistic care can be ques- (6) Common language and goals. tionable. (7) Effective leadership. 3. Type of tearns. d. Team efficacy. a. Multidisciplinary. (l) Interdisciplinary teams are the most com- (1) A number of professionals from different mon and considered the most effective in today's health care system. disciplines conduct asses ments and inter- ventions independent from one another.
XI. Illegal Practice and Malpractice Professional Roles & Management 369 A. Statutory Laws: passed by the legislature and 2. The Age Discrimination and Employment Act of impact physical therapy 1967. 1. Licensure laws. a. Prohibits employers from discriminating 2. Worker ' Compensation Acts. against persons from 40-70 years of age in any 3. MedicarelMedicaid. area of employment. 4. American with Disabilities Act. 3. 1973 Rehabilitation Act. B. Goals of Statutory Laws Impacting Physical a. Prohibits employment discrimination based on Therapy disability in: I. Professional licensing laws are enacted by all (1) Federal executive agencies. states. (2) All institutions receiving Medicare, a. Protect the consumer against professional Medicaid, and other federal support. incompetence and exploitation by opportunists. b. Determine the minimal standards of education 4. The Americans with Disability Act (ADA), 1990. (1) Graduation from an accredited program or a. Prevents discrimination against people with its equivalent in physical therapy. disabilities. (2) Succe sful completion of a nationallicens- b. Ensures their integration into mainstream ing examination. American life. (3) Ethical and legal standards relating to con- c. The definition of \"disabilities\" encompasses a tinuing practice of physical therapy. wide range of physical and mental conditions. (4) All physical therapists must have a license d. It requires businesses of 15 or more employees to practice. to accommodate needs of people with disabili- (5) Each tate determines criteria to practice ties to facilitate their economic independence and i ue a license. in both the public and private ector. (6) Licensure examination and related activi- e. Equal Employment Opportunity Commission ties are the responsibility of the Federation (EEOC) oversees issues and interprets regula- of State Boards of Physical Therapy. tions. (a) All states belong to this association. f. Reasonable accommodation to the workplace by removing barriers must be done unless it C. Nondiscrimination Laws: prevent a facility from would cause \"undue hardship\" (an action discrimination against employees regarding race, requiring significant difficulty or expense). color, religion, gender, or national origin. (1) Installing an elevator so the individual 1. Title VII of the Civil Rights Act of 1964 prohibits could access upper floors might be consid- employment discrimination based on: ered an undue hardship. a. Race. g. Physical therapists serve as consultants to: b. Color. (1) Employers helping them meet their respon- c. Sex. sibilities. d. Religion. (2) Disabled helping them achieve their reha- e. National origin. bilitation potential and rights under law. f. Sexual haras ment. (1) Unwanted advancements. 5. Individuals with Disabilities Education Act (2) Creation of a sexually hostile or intimidat- [IDEA]. ing work environment. a. Enacted in 1975 with the most recent revision (3) Inappropriate conversations, joking, touch- in 2004, ensures that children with disabilities ing, or interference with job performance. receive appropriate free public education. (4) Victim or harasser can be either a man or b. IDEA provides statutes and guidelines for woman. states and school districts regarding the provi- (5) Victim does not have to be the one sion of special education and related services. harassed, only someone adversely affected c. Establishes Early Intervention Programs [EIP] by the offensive behavior. which includes physical therapy, occupational therapy, speech language pathology and other services as needed. (1) Services are provided to children with
370 (3) Outbreaks of disease which may affect public safety (i.e., influenza). developmental delays (physical, emotional, cognitive or communicative). (4) \"Reportable\" occurrences such as violence (2) Infants or toddlers \"at risk\" for developing against patients, occurance where signifi- delays. cant harm is caused to the patient (i.e., (3) Provision for necessary adaptive equip- nursing home patient with a fall resulting in ment. severe fracture or death). d. Requires creation of Individualized Education Plans [IEPs]. f. Annual certification/recertification of staff in (l) Guides the team; however, child has the cardiopulmonary resu citation (CPR). option of not attending the actual planning meetings for the IEP. 2. Malpractice: physical therapist are personally (2) Considers evaluation results and child's responsible for negligence and other acts that concerns. result in harm to a patient through professional! (a) Functional needs, strength, ROM. patient relationships. (b) Factors such as English proficiency, a. Negligence. (I) Failure to do what reasonably competent behavioral issues, vision, hearing and practitioners would have done under simi- communication needs. lar circumstances. (c) Need for assistive devices. (2) To find a practitioner negligent, harm must D. Assuring Patient Safety and Reducing Risk in the have occurred to the patient. Healthcare Environment (3) Every individual (PT, PTA, student PT or I. Risk management programs. student PTA) is liable for their own negli- a. Identify, evaluate, and take corrective action gence. against risk. b. Supervisors or superiors may also be found (l) Potential patient, employee, and/or visitor negligent because of the actions of their work- injury. ers if they provided faulty supervision or inap- (2) Property loss or damage with resulting propriate delegation of responsibilities. financial loss or legal liability. c. Physical therapist fails to perform a duty caus- b. Efforts taken to decrease risk in physical therapy. ing harm. (1) Equipment maintenance, e.g., biannual d. Ethical principles are violated in caring for maintenance of electrical equipment. patients, e.g., acting without consent, breaking (2) Staff education, e.g., safety training for of confidentiality, lack of respect for patients, staff in use of equipment. etc. (3) Regular check of essential safety equip- e. Patients may also contribute to negligence if ment. they do not follow directions of the therapist. (4) Policies to clean equipment and reduce the f. The institution usually is found negligent if a potential for spreading infection patient was harmed as a result of an environ- c. Patient and staff safety. mental problem. (1) Report and review all occurrence/incident (l) Slippery floor. reports. (2) Fall in a poorly lit hall. d. Identify risk factors in patient care or patient g. The institution is also liable if an employee was and therapist safety; e.g., greater than three incompetent or not properly licensed. incidents of patient falls on the rehabilitation h. Physical therapist, phy ical therapist assis- floor may require an in-service in transfer tants or students may be liable for: training. (1) Adverse reaction to treatment such as e. Proper and timely reporting of adverse patient bums, e.g., leaving a hot pack on too long., occurrence or reactions as required by federal falls during gait training, injuries from ther- or state statute. These may include: apeutic exercise, harm caused by defective (l) Adverse reactions to regulated medicines. equipment. (2) Incidents involving abuse or neglect of (2) Any action or inaction that is inconsistent patients. with the Code of Ethics, or the Standard of
Practice that results in harm to a patient. Professional Roles & Management 371 i. Patients, parents, or legal guardians can refuse 1. A physical therapist shall provide and make avail- treatment by a student practitioner. able accurate and relevant information to j. A physical therapist may be asked to be an patients/clients about their care and to the public about physical therapy services. expert witness or testify in a malpractice case for: J. Principle 9 (1) The plaintiff (victim). (2) The defendant (accused). 1. A physical therapist shall protect the public and the profession from unethical, incompetent, or ille- Appendix A gal acts. I. Code of Ethics K. Principle 10 1. A physical therapist shall endeavor to address the A. Preamble health needs of society. 1. This Code of Ethics of the American Physical Therapy Association sets forth ethical principles L. Principle 11 for the ethical practice of physical therapy. All I. A physical therapist shall respect the rights, physical therapists are responsible for maintaining knowledge, and skills of colleagues and other and promoting ethical practice. To this end, the health care professionals. physical therapist shall act in the best interest of the patient/client. This Code of Ethics shall be (American Physical Therapy Association, PT Magazine binding on all physical therapists. October 2000; p. 100, with permission) B. Principle 1 Appendix B 1. A physical therapist shall respect the rights and dignity of all individuals and shall provide com- I. Guide for Professional Conduct passionate care. A. Purpose C. Principle 2 1. This Guide for Professional Conduct (Guide) is I. A physical therapist shall act in a trustworthy man- intended to serve physical therapists in interpret- ner towards patients/clients, and in all other ing the Code of Ethics (Code) of the American aspects of physical therapy practice. Physical Therapy Association (Association), in matters of professional conduct. The Guide pro- D. Principle 3 vides guidelines by which physical therapists may 1. A physical therapist shall comply with laws and determine the propriety of their conduct. It is also regulations governing physical therapy and shall intended to guide the professional development of strive to effect changes that benefit physical therapist students. The Code and the patients/clients. Guide apply to all physical therapists. These guidelines are subject to change as the dynamics E. Principle 4 of the profession change and as new patterns of 1. A physical therapist shall exercise sound profes- health care delivery are developed and accepted by sional judgment the professional community and the public. This Guide is subject to monitoring and timely revision F. Principle 5 by the Ethics and Judicial Committee of the 1. A physical therapist shall achieve and maintain Association. professional competence. B. Interpreting Ethical Principles G. Principle 6 1. The interpretations expressed in this Guide reflect I. A physical therapist shall maintain and promote the opinions, decisions, and advice of the Ethics high standards for physical therapy practice, edu- and Judicial Committee. These interpretations are cation, and research. intended to assist a physical therapist in applying general ethical principles to specific situations. H. Principle 7 They should not be considered inclusive of all sit- 1. A physical therapist shall seek only such remuner- uations that could evolve. ation as is deserved and reasonable for physical therapy services. C. Principle 1 1. A physical therapist shall respect the rights and I. Principle 8
372 need physical therapy services, the physical therapist should take steps to transfer the dignity of all individuals and shall provide com- care of the patient to another provider. passionate care. b. Truthfulness. a. Attitudes of a physical therapist. (1) A physical therapist has an obligation to provide accurate and truthful information. (1) A physical therapist shall recognize, A physical therapist shall not make state- respect, and respond to individual and cul- ments that he/she knows or should know tural differences with compassion and sen- are false, deceptive, fraudulent, or mislead- sitivity. ing. c. Confidential information. (2) A physical therapist shall be guided at all (1) Information relating to the physical thera- times by concern for the physical, psycho- pist/patient relationship is confidential and logical, and socioeconomic welfare of may not be communicated to a third party patients/clients. not involved in that patient's care without the prior consent of the patient, subject to (3) A physical therapist shall not harass, abuse, applicable law. or discriminate against others. (2) Information derived from peer review shall be held confidential by the reviewer unless D. Principle 2 the physical therapist who was reviewed 1. A physical therapist shall act in a trustworthy man- consents to the release of the information. ner towards patients/clients, and in all other (3) A physical therapist may disclose informa- aspects of physical therapy practice. tion to appropriate authorities when it is a. Patient/physical therapist relationship. necessary to protect the welfare of an indi- (1) A physical therapist shall place the vidual or the community or when required patient/client's interest(s) above those of by law. Such disclosure shall be in accor- the physical therapist. Working in the dance with applicable law. patient/client's best interest requires d. Patient autonomy and consent. knowledge of the patient/client's needs (1) A physical therapist shall respect the from the patient/client's perspective. patient's/client's right to make decisions Patients/clients often come to the physical regarding the recommended plan of care, therapist in a vulnerable state and normally including consent, modification, or refusal. will rely on the physical therapist's advice, (2) A physical therapist shall communicate to which they perceive to be based on superi- the patient/client the findings of his/her or knowledge, skill, and experience. The examination, evaluation, diagnosis, and trustworthy physical therapist acts to ame- prognosis. liorate the patient's/client's vulnerability, (3) A physical therapist shall collaborate with not to exploit it. the patient/client to establish the goals of (2) A physical therapist shall not exploit any treatment and the plan of care. aspect of the physical therapist/patient rela- (4) A physical therapist shall use ound profes- tionship. sional judgment in informing the (3) A physical therapist shall not engage in any patient/client of any substantial risks of the sexual relationship or activity, whether recommended examination and interven- consensual or nonconsensual, with any tion. patient while a physical therapist/patient (5) A physical therapist shall not restrict relationship exists. Termination of the patients' freedom to select their provider of physical therapist/patient relationship does physical therapy. not eliminate the possibility that a sexual or E. Principle 3 intimate relationship may exploit the vul- 1. A physical therapist shall comply with laws and nerability of the former patient/client. regulations governing physical therapy and shall (4) A physical therapist shall encourage an open and collaborative dialogue with the patient/client. (5) In the event the physical therapist or patient terminates the physical therapist/patient relationship while the patient continues to
trive to effect changes that benefit patients/ Professional Roles & Management 373 client. a. Professional practice. that are outside the scope of the physical therapist's knowledge, experience, or (1) A physical therapist shall comply with laws expertise, the physical therapist shall so governing the qualifications, functions, and inform the patient/client and refer to an duties of a physical therapist. appropriate practitioner. (7) When the patient has been referred from b. Just laws and regulations. another practitioner, the phy ical therapist (I) A physical therapist shall advocate the shall communicate pertinent findings adoption of laws, regulations, and policies and/or information to the referring practi- by providers, employers, third party payers, tioner. legislatures, and regulatory agencies to pro- (8) A physical therapist shall determine when a vide and improve access to necessary patient/client will no longer benefit from health care ervices for all individuals. physical therapy services. b. Direction and supervision. c. Unjust laws and regulations. (1) The supervising physical therapist has pri- (1) A physical therapist shall endeavor to mary responsibility for the physical therapy change unjust laws, regulations, and policies care rendered to a patient/client. that govern the practice of physical therapy.' (2) A physical therapist shall not delegate to a less qualified person any activity that F. Principle 4 requires the professional skill, knowledge, I. A physical therapist shall exercise sound profes- and judgment of the physical therapist. sional judgment. c. Practice arrangement . a. Profe sional responsibility. (1) Participation in a business, partnership, (I) A phy ical therapist shall make profession- corporation, or other entity does not al judgments that are in the patient/client's exempt physical therapi ts, whether best interests. employers, partners, or stockholders, either (2) Regardle of practice setting, a physical individually or collectively, from the obli- therapist has primary responsibility for the gation to promote, maintain or comply with physical therapy care of a patient and shall the ethical principles of the Association. make independent judgments regarding (2) A physical therapist shall advise his/her that care consistent with accepted profes- employer(s) of any employer practice that sional standards. causes a physical therapist to be in conflict (3) A physical therapist shall not provide phys- with the ethical principles of the ical therapy services to a patient/client Association. A physical therapist shall seek while his/her ability to do so safely is to eliminate aspect of his/her employment impaired. that are in conflict with the ethical princi- (4) A phy ical therapist shall exercise sound ples of the Association. professional judgment based upon his/her d. Gifts and other consideration(s). knowledge, skill, education, training, and (1) A physical therapist shall not invite, accept, experience. or offer gifts, monetary incentives, or other (5) Upon accepting a patient/client for physical considerations that affect or give an appear- therapy services, a physical therapist shall ance of affecting his/her professional judg- be responsible for: the examination, evalu- ment. ation, and diagnosis of that individual; the (2) A physical therapist shall not offer or prognosis and intervention; re-examination accept kickbacks in exchange for patient and modification of the plan of care; and referrals. the maintenance of adequate records, G. Principle 5 including progress reports. A physical ther- 1. A physical therapist hall achieve and maintain apist shall establish the plan of care and professional competence. hall provide and/or supervise and direct a. Scope of Competence. the appropriate interventions. (6) If the diagnostic process reveals findings
374 (2) When a physical therapi t provides contin- uing education, he/she shall ensure that (1) A physical therapist shall practice within course content, objectives, faculty creden- the scope of his/her competence and com- tials, and re ponsibilities of the instruction- mensurate with his/her level of education, al staff are accurately stated in the promo- training and experience. tional and instructional course materials. b. Self-assessment. (3) A physical therapist shall evaluate the effi- (1) A physical therapist has a lifelong profes- cacy and effectivenes of information and sional responsibility for maintaining com- techniques presented in continuing educa- petence through on-going self-assessment, tion programs before integrating them into education, and enhancement of knowledge his or her practice. and skills. e. Research. c. Professional development. (1) A physical therapist participating in (1) A physical therapist shall particIpate in research shall abide by ethical standards educational activities that enhance his/her governing protection of human subjects basic knowledge and skills. and dissemination of results. (2) A physical therapist shall support research H. Principle 6 activities that contribute knowledge for 1. A physical therapist shall maintain and promote improved patient care. high standards for physical therapy practice, edu- (3) A physical therapi t shall report to appro- cation and research. priate authoritie any acts in the conduct or a. Professional standards. presentation of research that appear unethi- (1) A physical therapist's practice shall be con- cal or illegal. sistent with accepted professional stan- dards. A physical therapist shall continu- I. Principle 7 ously engage in assessment activities to 1. A physical therapist shall seek only such remuner- determine compliance with these stan- ation as is deserved and reasonable for physical dards. therapy services. b. Practice. a. Business and employment practices. (1) A physical therapist shall achieve and (1) A physical therapist's business/employ- maintain professional competence. ment practices shall be consistent with the (2) A physical therapist shall demonstrate ethical principles of the Association. bis/ber commitment to quality improve- (2) A physical therapist shall never place ment by engaging in peer and utilization her/his own financial interest above the review and other elf-assessment activities. welfare of individuals under his/her care. c. Professional education. (3) A physical therapist shall recognize that (I) A physical therapist shall support high- third-party payer contracts may limit, in quality education in academic and clinical one form or another, the provision of phys- settings. ical therapy services. Third-party limita- (2) A physical therapist participating in the tions do not absolve the physical therapist educational process is responsible to the from making sound professional judgments students, the academic institutions, and the that are in the patient's best interest. A clinical settings for promoting ethical con- physical therapist shall avoid underutiliza- duct. A physical therapist shall model ethi- tion of physical therapy ervice. cal behavior and provide the student with (4) When a physical therapi t's judgment i information about the Code of Ethics, that a patient will receive negligible benefit opportunities to discuss ethical conflicts, from physical therapy services, the physi- and procedures for reporting unresolved cal therapist shall not provide or continue ethical conflicts. to provide such services if the primary rea- d. Continuing education. son for doing 0 is to further the financial (1) A physical therapist providing continuing self-interest of the phy ical therapist or education must be competent in the content area.
his/her employer. A physical therapist shall Professional Roles & Management 375 avoid over-utilization of physical therapy services. ation for endorsement or advertisement of (5) Fees for physical therapy services should products or services to the public, physical be reasonable for the service performed, therapists, or other health professionals considering the setting in which it is pro- provided he/she discloses any financial vided, practice costs in the geographic area, interest in the production, sale, or distribu- judgment of other organizations, and other tion of said products or services. relevant factors. (3) When endorsing or advertising products or (6) A physical therapist shall not directly or services, a physical therapist shall use indirectly request, receive, or participate in sound professional judgment and shall not the dividing, transferring, assigning, or give the appearance of Association rebating of an unearned fee. endorsement unless the Association has (7) A physical therapist shall not profit by formally endorsed the products or services. means of a credit or other valuable consid- c. Disclosure. eration, such as an unearned commission, (1) A physical therapist shall disclose to the discount, or gratuity, in connection with the patient if the referring practitioner derives furnishing of physical therapy services. compensation from the provision of physi- (8) Unless laws impose restrictions to the con- cal therapy. trary, physical therapists that provide phys- ical therapy services within a business enti- J. Principle 8 ty may pool fees and monies received. Physical therapists may divide or apportion 1. A physical therapist shall provide and make avail- these fees and monies in accordance with able accurate and relevant information to the business agreement. patients/clients about their care and to the public (9) A physical therapist may enter into agree- about physical therapy services. ments with organizations to provide physi- a. Accurate and relevant information to the cal therapy services if such agreements do patient. not violate the ethical principles of the (1) A physical therapist shall provide the Association or applicable laws. patient/client accurate and relevant infor- b. Endorsement of products or services. mation about his/her condition and plan of (1) A physical therapist shall not exert influ- care. ence on individuals under his/her care or (2) Upon the request of the patient, the physi- their families to use products or services cal therapist shall provide, or make avail- based on the direct or indirect financial able, the medical record to the patient or a interest of the physical therapist in such patient-designated third party. products or services. Realizing that these (3) A physical therapist shall inform patients individuals will normally rely on the phys- of any known financial limitations that may ical therapist's advice, their best interest affect their care. must always be maintained, as must their (4) A physical therapist shall inform the right of free choice relating to the use of patient when, in his/her judgment, the any product or service. Although it cannot patient will receive negligible benefit from be considered unethical for physical thera- further care. pists to own or have a financial interest in b. Accurate and relevant information to the public. the production, sale, or distribution of (1) A physical therapist shall inform the public products/services, they must act in accor- about the societal benefits of the profession dance with law and make full disclosure of and who is qualified to provide physical their interest whenever individuals under therapy services. their care use such products/services. (2) Information given to the public shall (2) A physical therapist may receive remuner- emphasize that individual problems cannot be treated without individualized examina- tion and plans/programs of care. (3) A physical therapist may advertise his/her services to the public.
376 (1) A physical therapist shall seek consultation whenever the welfare of the patient will be (4) A physical therapist shall not use, or partic- safeguarded or advanced by consulting ipate in the use of, any form of communi- those who have special skills, knowledge, cation containing a false, plagiarized, and experience. fraudulent, deceptive, unfair, or sensational statement or claim. b. Patient/provider relationships. (1) A physical therapist shall not undermine (5) A physical therapist that places a paid the relationship(s) between his/her patient advertisement shall identify it as such and other healthcare professionals. unless it is apparent from the context that it is a paid advertisement. c. Disparagement. (1) Physical therapists shall not disparage col- K. Principle 9 leagues and other health care professionals. 1. A physical therapist shall protect the public and the profession from unethical, incompetent, and (American Physical Therapy Association,JAPTA 2004, with illegal acts. permission) a. Consumer protection. (1) A physical therapist shall provide care that Appendix C is within the scope of practice as defined by the state practice act. I. Guide for Conduct of the Physical (2) A physical therapist shall not engage in any Therapist Assistant conduct that is unethical, incompetent or illegal. A. Purpose (3) A physical therapist shall report any con- 1. This Guide for Conduct of the Physical Therapist duct that appears to be unethical, incompe- Assistant (Guide) is intended to serve physical tent, or illegal. therapist assistants in interpreting the Standards of (4) A physical therapist may not participate in Ethical Conduct for the Physical Therapist any arrangements in which patients are Assistant (Standards) of the American Physical exploited due to the referring sources' Therapy Association (APTA). The Guide provides enhancing their personal incomes as a guidelines by which physical therapist assistants result of referring for, prescribing, or rec- may determine the propriety of their conduct. It is ommending physical therapy. also intended to guide the development of physical therapist assistant students. The Standards and L. Principle 10 Guide apply to all physical therapist assistants. 1. A physical therapist shall endeavor to address the These guidelines are subject to change as the health needs of society. dynamics of the profession change and as new pat- a. Pro bono service. terns of health care delivery are developed and (1) A physical therapist shall render pro bono accepted by the professional community and the publico (reduced or no fee) services to public. This Guide is subject to monitoring and patients lacking the ability to pay for serv- timely revision by the Ethics and Judicial ices, as each physical therapist's practice Committee of the Association. permits. b. Individual and community health. B. Interpreting Standards (1) A physical therapist shall be aware of the 1. The interpretations expressed in this Guide reflect patient's health-related needs and act in a the opinions, decisions, and advice of the Ethics manner that facilitates meeting those needs. and Judicial Committee. These interpretations are (2) A physical therapist shall endeavor to sup- intended to guide a physical therapist assistant in port activities that benefit the health status applying general ethical principles to specific situ- of the community. ations. They should not be considered inclusive of all situations that a physical therapist assistant may M. Principle 11 encounter. 1. A physical therapist shall respect the rights, knowledge, and skills of colleagues and other healthcare professionals. a. Consultation.
c. Standard 1 Professional Roles & Management 377 I. A physical therapist assistant shall respect the ticipate in any arrangement in which right and dignity of all individual and shall pro- patients/clients are exploited. Such vide compassionate care. arrangements include situations where a. Attitude of a physical therapist as istant. referring sources enhance their per onal (1) A phy ical therapist assi tant shall recog- incomes by referring to or recommending nize, respect and respond to individual and physical therapy services. cultural difference with compassion and c. Truthfulness. sensitivity. (1) A physical therapist assistant shall not (2) A physical therapist assistant shall be guid- make statements that he/she knows or ed at all times by concern for the physical should know are false, deceptive, fraudu- and psychological welfare of patients/ lent, or misleading. clients. (2) Although it cannot be considered unethical (3) A physical therapist assistant shall not for a physical therapist assistant to own or harass, abuse, or discriminate against others. have a financial interest in the production, sale, or distribution of products/services, D. Standard 2 he/she must act in accordance with law and 1. A physical therapist assistant shall act in a trust- make full disclosure of his/her interest to worthy manner towards patients/clients. patients/clients. a. Trustworthiness. d. Confidential information. (1) The physical therapist assistant shall (1) Information relating to the patient/client is always place the patients/clients interest(s) confidential and shall not be communicated above those of the physical therapist assis- to a third party not involved in that tant. Working in the patient's/client's best patient's/client's care without the prior con- interest requires sensitivity to the sent of the patient/client, subject to applica- patient's/client's vulnerability and an effec- ble law. tive working relationship between the (2) A physical therapist assistant shall refer all physical therapist and the physical therapist requests for release of confidential informa- a sistant. tion to the supervising physical therapist. (2) A physical therapist assistant shall not E. Standard 3 exploit any aspect of the physical therapist 1. A physical therapist assistant shall provide select- assistant - patient/client relationship. ed physical therapy interventions only under the (3) A phy ical therapist assistant shall clearly supervision and direction of a physical therapist. identify hirn/herself as a physical therapist a. Supervisory relationship. assi tant to patients/clients. (1) A physical therapist assistant shall provide (4) A physical therapist assistant shall conduct interventions only under the supervision himlherself in a manner that supports the and direction of a physical therapist. physical therapist - patient/client relation- (2) A physical therapist assistant shall provide ship. only those intervention that have been (5) A physical therapist assistant shall not selected by the physical therapist. engage in any sexual relationship or activi- (3) A physical therapist assistant shall not pro- ty, whether consensual or nonconsensual, vide any interventions that are outside with any patient/client entrusted to his/her his/her education, training, experience, or care. skill, and shall notify the responsible phys- (6) A physical therapist assistant shall not ical therapist of his/her inability to carry invite, accept, or offer gifts or other consid- out the intervention. eration that affect or give an appearance of (4) A physical therapist assi tant may modify affecting his/her provision of physical ther- pecific interventions within the plan of apy intervention . care established by the physical therapist in b. Exploitation of patients. response to changes in the patient's/c1ient's (1) A phy ical therapist as istant shall not par- status.
378 (1) A physical therapist assistant shall discon- tinue immediately any interventions(s) that, (5) A physical therapist assistant shall not per- in bis/her judgment, may be harmful to the form examinations and evaluations, deter- patient/client and hall di cu s hi /her con- mine diagnoses and prognoses, or establish cerns with the physical therapist. or change a plan of care. (2) A physical therapist assistant shall not pro- (6) Consistent with the physical therapist assis- vide any interventions that are outside tant's education, training, knowledge, and his/her education, training, experience, or experience, he/she may respond to the skill and shall notify the responsible physi- patient'slclient's inquiries regarding inter- cal therapist of his/her inability to carry out ventions that are within the established the intervention. plan of care. (3) A physical therapi t assistant shall not per- (7) A physical therapist assistant shall have form interventions while his/her ability to regular and ongoing communication with do so afely is impaired. the physical therapist regarding the patient's/client's status. b. Judgments of patient/client status. (1) If in the judgment of the phy ical therapist F. Standard 4 assistant, there is a change in the 1. A physical therapist assistant shall comply with patient/client status he/she shall report this laws and regulations governing physical therapy. to the responsible physical therapist. a. Supervision. (1) A physical therapist assistant shall know c. Gifts and other considerations. and comply with applicable law. (1) A physical therapist assistant shall not Regardless of the content of any law, a invite, accept, or offer gifts, monetary physical therapist assistant shall provide incentives or other consideration that affect services only under the supervision and or give an appearance of affecting his/her direction of a physical therapist. provision of physical therapy interventions. b. Representation. (1) A physical therapist assistant shall not hold I. Standard 7 him/ber elf out as a physical therapist. 1. A physical therapist assistant shall protect the pub- lic and the profession from unethical, incompetent, G. Standard 5 and illegal acts. 1. A physical therapist assistant shall achieve and a. Consumer protection. maintain competence in the provision of selected (1) A physical therapist assistant shall report physical therapy interventions. any conduct that appears to be unethical or a. Competence. illegal. (1) A physical therapist assistant shall provide b. Organizational employment. interventions consistent with his/her level (1) A phy ical therapi t assistant shall inform of education, training, experience, and his/her employer(s) and/or appropriate skill. physical therapist of any employer practice b. Self-assessment. that causes him or her to be in conflict with (1) A physical therapist assistant shall engage the Standards of Ethical Conduct for the in self-assessment in order to maintain Physical Therapi t Assistant. competence. (2) A physical therapist as istant shall not c. Development. engage in any activity that puts him or her (1) A physical therapist assistant shall partici- in conflict with the Standards of Ethical pate in educational activities that enhance Conduct for the Physical Therapist his/her basic knowledge and skills. Assistant, regardless of directives from a physical therapist or employer. H. Standard 6 1. A phy ical therapist assistant shall make judg- (American Physical Therapy Association.JAPTA 2004; with ments that are commensurate with their education- permission) al and legal qualifications as a physical therapist assistant. a. Patient safety.
Appendix D Professional Roles & Management 379 I. Standards of Practice for Physical Therapy 4. Administration. and the Criteria a. A physical therapist is responsible for the direction of the physical therapy service. A. Preamble 1. The physical therapy profession's commitment to 5. Fiscal management. society is to promote optimal health and function a. The director of the physical therapy service, in in individuals by pursuing excellence in practice. consultation with physical therapy staff and The American Physical Therapy Association appropriate administrative personnel, participates attests to this commitment by adopting and pro- in planning for, and allocation of, resources. moting the following Standards of Practice for Fiscal planning and management of the service is Physical Therapy. These Standards are the profes- based on sound accounting principles. sion's statement of conditions and performances that are essential for provision of high-quality pro- 6. Improvement of quality of care and performance. fessional service to society and provide a founda- a. The physical therapy service has a written plan tion for assessment of physical therapy practice. for continuous improvement of quality of care and performance of services. B. Legal/Ethical Considerations 1. Legal considerations. 7. Staffing. a. The physical therapist complies with all the a. The physical therapy personnel affiliated with legal requirements of jurisdictions regulating the physical therapy service have demonstrated the practice of physical therapy. competence and are sufficient to achieve the b. The physical therapist assistant complies with mission, purposes, and goals of the services. all the legal requirements of jurisdictions regu- b. The physical therapy service has a written plan lating the work of the assistant. that provides for appropriate and ongoing staff 2. Ethical considerations. development. a. The physical therapist practices according to the Code of Ethics of the American Physical 8. Physical setting. Therapy Association. a. The physical setting is designed to provide a b. The physical therapi t assistant complies with safe and accessible environment that facilitates the Standards of Ethical Conduct for the fulfillment of the mission, purposes, and goals Phy ical Therapist Assistant of the American of the physical therapy service. The equipment Physical Therapy Association. is safe and sufficient to achieve the purposes and goals of the service. C. Administration of the Physical Therapy Service 1. Statement of mission, purposes, and goals. 9. Collaboration. a. The physical therapy service has a statement of a. The physical therapy service collaborates with mission, purposes, and goals that reflects the all appropriate disciplines. needs and interests of the patients and clients served, the physical therapy personnel affiliat- D. Patient Client Management ed with the service, and the community. 1. Patient client collaboration. 2. Organizational plan. a. Within the patient client management process, a. The physical therapy service has a written the physical therapist and the patient client organizational plan. establish and maintain an ongoing collabora- 3. Policies and procedures. tive process of decision making that exists a. The physical therapy service has written poli- throughout the provision of services. cies and procedures that reflect the operation of 2. Initial exarninationJevaluationidiagnosis/prognosis. the service and that are consistent with the a. The physical therapist perform an initial Association's standards, mission, policies, examination and evaluation to establish a diag- positions, guidelines, and Code of Ethics. nosis and prognosis prior to intervention. 3. Plan of care. a. The physical therapist establishes a plan of care and manages the needs of the patient/client based on the examination, evaluation, diagno- sis, prognosis, goals, and outcomes of the planned interventions for identified impair- ments, functional limitations, and di abilities.
380 8. Education. a. The physical therapist is re pon ible for indi· b. The physical therapist involves the patient vidual professional development. The physica client and appropriate others in the planning, therapist assistant is responsible for individua implementation, and assessment of the plan of career development. care. b. The physical therapist and the physical thera pist assistant, under the direction and supervi c. The physical therapist, in consultation with sion of the phy ical therapist, participate in thl appropriate disciplines, plans the discharge of education of the students. the patient client taking into consideration c. The physical therapist educates and provide: achievement of anticipated goals and expected consultation to consumers and the general pub outcomes, and provides for appropriate follow- lic regarding the purposes and benefits of phys up or referral. ical therapy. d. The physical therapist educates and provide: 4. Intervention. consultation to consumers and the general pub a. The physical therapist provides, or directs and lic regarding the roles of the physical therapist supervises, the physical therapy intervention the physical therapist assistant, and other sup consistent with the results of the examination, port personnel. evaluation, diagnosis, prognosis, and plan of care. 9. Research. a. The physical therapist applie research finding 5. Re-examination. to practice and encourage , participates in, an, a. The physical therapist re-examines the promotes activitie that e tabli h the outcome patient/client as necessary during an episode of of patient/client management provided by thl care to evaluate progress or change in physical therapist. patient/client status and modifies the plan of care accordingly or discontinues physical ther- 10. Community responsibility. apy ervices. a. The physical therapist demonstrates communi b. The physical therapist re-examination. ty responsibility by participating in communi~ (1) Identifies ongoing patient/client needs. and community agency activities, educatinl (2) May result in recommendations for addi- the public, formulating public policy, or pro tional services, discharge, or discontinua- viding pro bono physical therapy services. tion of physical therapy needs. 11. Glossary. 6. Discharge/discontinuation of intervention. a. Client - An individual who is not necessaril: a. The physical therapist discharges the sick or injured but who can benefit from patient/client from physical therapy services physical therapist's consultation, profession2 when the anticipated goals or expected out- advice, or services. A client also is a busines! comes for the patient/client have been a school system, or other entity that may bene achieved. fit from specific recommendations from b. The physical therapist discontinues interven- physical therapist. tion when the patient/client is unable to contin- b. Diagnosis - Both the process and the end resul ue to progress toward goals or when the physi- of the evaluation of information obtained fror cal therapist determines that the patient/client the patient examination. The physical therapi! will no longer benefit from physical therapy. organizes the evaluation information int defined clusters, syndromes, or categories t 7. Communication/coordination/documentation. determine the most appropriate interventio a. The physical therapist communicates, coordi- strategies for each patient. nates and documents all aspects of c. Evaluation - A dynamic process in which th patient/client management including the results physical therapist makes clinical judgmen1 of the initial examination and evaluation, diag- based on data gathered during the examinatiOI nosis, prognosis, plan of care, interventions, d. Examination - The process of obtaining a hi! response to interventions, changes in tory, performing relevant ystem review, an patient/client status relative to the interven- tions, re-examination, and discharge/discontin- uation of intervention and other patient client management activities.
Professional Roles & Management 381 selecting and administering specific tests and measures. e. Intervention - The purposeful and skilled inter- action of the physical therapist with the patient or client. Intervention has three components: direct intervention; instruction of the patient or client and of the family; and coordination, communication, and documentation. f. Patient - An individual who is receiving direct intervention for an impairment, functional lim- itation, disability, or change in physical func- tion and health status resulting from injury, dis- ease, or other causes; an individual receiving health care services. g. Physical therapist patient management model - The model on which physical therapists base management of the patient throughout the episode of care, including the following ele- ment : examination, evaluation and re-evalua- tion, diagnosis, progno i , and intervention leading to the outcome. h. Plan of care: A plan that specifies the long-term and short-term outcomes/goals, the predicted level of maximal improvement, the specific interventions to be used, the duration and fre- quency of the intervention required to reach the outcomes/goals, and the criteria for discharge. I. Progno is - The determination of the level of maximal improvement that might be attained by the patient and the amount of time needed to reach that level. j. Treatment - One or more interventions used to ameliorate impairments, functional limitations or di ability or otherwise produce changes in the health tatus of the patient; the sum of all interventions provided by the physical therapist to a patient during an episode of care. All contents ©2003 American Physical Therapy Association, with permission. Acknowledgement to Judith D. Hershberg, PT, DPT, MS; Catherine S. Lane, PT, DPT, MS; Linda Arslanian, PT, DPT, MS and Rita P. Fleming Cottrell, MA, OTL, FAOTA for their original contributions in formulating this chapter.
CHAPTER 13 TEACHING & LEARNING Susan B. O'Sullivan I. Physical Therapist Roles and Responsibilities for local, state, and federal agencies. 3. Instruction and educational programs are provided A. Patient/Client Related Instruction 1. The process of informing, educating, or training for the general public to increase awareness of patients/clients, families, significant others, and health issues and roles of the physical therapist. caregivers in order to promote and optimize physi- C. Clinical Education of Students cal therapy services (APTA Guide To Physical 1. Instruction and upervision of physical therapy or Therapist Practice, 2nd ed. Phys Ther 81: 47, 2001). physical therapist assistant students is provided by 2. Instruction is provided across all settings for all Clinical Instructors during scheduled clinical edu- patients/clients on promoting understanding of: cation experiences. a. Current condition, impairments, functional 2. Close communication and collaboration with the limitations, and disabilities. school and the Academic Coordinator of Clinical b. Anticipated goals and expected outcomes, the Education is necessary. plan of care, specific intervention elements, and self-management strategies. II. Educational Theory c. The elements necessary for the smooth transi- tion to home or an alternate setting, work, and \"Learning is the process whereby knowledge is creat- community. ed through the transformation of experience\" Kolb, d. Individualized family service plans (IFSPs) or 1984. individualized education plans (IEPs). A. Learning Styles e. Safety awareness, and risk factor reduction and 1. Characteristic mode of gaining, processing, and prevention. f. Health promotion, wellness, and fitness. storing information. Learning styles differ aero s dimensions. B. Educational Programs 2. Tactics: analytical versus intuitive. 1. Instruction and educational programs are provided a. Analytical/objective learner. for other therapists, health care providers, staff, and/or students in academic and/or clinical set- (I) Processes information in a step-by-step tings. These programs can be formal or informal. order. 2. Instruction and educational programs are provided (2) Perceives information in an objective man- ner; is able to u e facts and easily under- stand relationships between them.
(3) Perceive information in an abstract, con- Teaching & Learning 383 ceptual manner; information does not need to be related to personal experience. (a) Accuracy of reinforcement is critical, e.g., use of rewards that are meaningful (4) Learns best with structure, tep by step to the individual. learning; may have difficulty comprehend- ing the big picture. (b) Timing of reinforcement is critical: immediate versus distant or delayed, b. Intuitive/global learner. e.g., use of a reinforcement schedule. (I) Processes information all at once, in a simultaneous manner; not in an ordered (3) Negative behaviors are ignored; unrein- sequence. forced behaviors are weakened and eventu- (2) Perceives information in a subjective man- ally extinguished. ner: reflects on personal experiences. (3) Perceives information in a concrete man- (4) Behavior which has aversive conse- ner: information assimilated about the quences (punishment) is less likely to practical, real-life experiences. occur again; aversive conditioning is less (4) Learns best if information connected to powerful as a tool for learning than positive personal experiences, presented in practi- reinforcements. cal, real-life context. If not, may be disre- garded. May have difficulty ordering steps (5) The environment is altered to promote cor- and comprehending details. rect responses, e.g., a closed environment with reduction of distractors. 3. Rea oning: inductive versus deductive. a. Inductive reasoner (assimilator): observes sim- (6) Repetition is a necessary prerequisite for ilarities, can develop theoretical models to learning. explain relationships. b. Deductive rea oner (converger): analyzes prob- (7) Clinical uses: limited, e.g., may be used lems in depth; applies information, theoretical when working with adults with impaired or model to practical situations. limited cognitive abilities (traumatic brain injury, stroke) or young children. 4. Initiative: active versus passive learner. a. Active/aggre sive learner: exhibits lllltlatlve, c. Prominent theorists: B.F. Skinner, G. Watson. actively seeks information; may reach conclu- 2. Cognitive theory. sions quickly before all information is gathered. b. Passive learner: often exhibits little initiative; a. Basic premises. responds best to directed learning. (1) Focus is on cognitive development of intel- lectual abilities and skills, from: B. Learning Theories (a) Symbolic function (ages 2 to 8). 1. Behaviori t (stimulus-response theory). (b) Concrete mental operation (ages 8-12). a. Basic premises. (c) Conceptual thought (ages 12 and up). (1) Behavior is modified in response to a given (2) Thinking emerges with language develop- stimulus. ment. (2) Behavior is determined by its conse- (3) Perceptual features are important condi- quences; the response of one behavior tions of learning, e.g., figure-ground, direc- becomes the stimulus for the next response tional signs, sequence, etc. (chaining). (3) Learning occurs because the behavior is b. Cognitive strategies are used, e.g., repeated reinforced (learned association). challenges to thinking. b. Behavior can be controlled or shaped by operant (1) Knowledge is organized by the teacher; the conditioning (behavior modification techniques). teacher is the expert; a pedagogical (1) Desired or correct behaviors are identified. approach (the art and science of teaching (2) Frequent and scheduled reinforcements are children). given to reinforce the desired behaviors, (2) Learning is culturally relative. e.g. praise, encouragement, candy, etc. (3) Cognitive feedback is used to confirm and correct knowledge. (4) Goal-setting by learner is important for motivation. (5) Both divergent and convergent theory is nurtured. c. Prominent theorists: J. Piaget, J.S. Bruner.
384 bering and recalling knowledge, thinking, prob- lem-solving, creating. 3. Humanist. a. Level 1.0 Knowledge: involves recall of previ- a. Basic premises. (1) Personal freedom and dignity of the individ- ously learned information, e.g., knows specific ual is emphasized in the learning process. facts, terminology, criteria, methodology; the (2) Understanding of the learners' needs and learner is able to: feelings is sought. (1) Remember or recall information, e.g., (3) The learner experiences unconditional pos- itive regard, acceptance and understanding. defines, de cribe . b. Teaching is student-centered, e.g., self-discovery, (2) Organize and reorganize information, e.g., self-appropriated learning, experiential learning. (1) Promotes active learning (self-initiated) matches, reproduces. rather than passive, e.g., knowledge is b. Level 2.0 Comprehension: involves understand- organized by the learner, not for the learner. (2) Learning addresses relevant problems and ing at its lowest level; the learner is able to: issues. (1) Translate, interpret, and extrapolate informa- (3) A positive learning climate is facilitated. (4) The teacher is a facilitator and resource- tion, e.g., defends, distinguishes, explains. finder. (2) Use information, e.g., predicts, infers. (5) Learning is evaluated by the learner, e.g., c. Level 3.0 Application: involves use of abstrac- self-assessment. tions; the learner is able to: c. Prominent theorists: Carl Rogers, A.H. (1) Apply knowledge and concepts to situa- Maslow. tions, e.g. modifies, changes, relates. 4. Adult learning (andragogy). (2) Formulate and utilize rules or generalize a. Basic characteristics of adult learners. (1) The learner is self-directed: goal oriented, methods, e.g. predicts, manipulates. seeks knowledge for own sake. d. Level 4.0 Analysis: involves the breakdown of (2) Has a rich core of experience which serves as a broad base for learning. information into component parts to enable (3) Demonstrates a readiness to learn. clear understanding; the learner is able to: (4) Demonstrates a problem-centered orienta- (1) Clarify information, e.g., recognizes tion to learning. b. Teaching is learner-centered. unstated assumptions, fallacies in reason- (1) The teacher interacts with the learner: helps ing; correctly an wer questions on licen- to clarify the learning problem, structure sure examination. the learning environment to enhance learn- (2) Indicate how the information is organized ing, provide resources. or arranged, e.g., analyze relationship or (2) Learners share the responsibility for plan- organizational structure. ning the learning experience, actively par- (3) Distinguish facts from inferences, hypothe- ticipate in the learning process. ses, e.g., differentiates, di criminates. (3) The learning process makes use of the e. Level 5.0 Synthesis: involve putting together of experiences of the learner. elements to form a whole; the learner is able to: c. Prominent theorists: M. Knowles, J.R. Kidd. (1) Produce unique communications, e.g., write a report, relate a clinical experience B. Behavioral Objectives from the Educational effectively. Domains (2) Formulate a plan of care or re earch proposal. References: Taxonomy of Educational Objectives: f. Level 6.0 Evaluation: involves making judg- Handbook I Cognitive Domain and Handbook II ments about the value of material or methods; Affective Domain by Bloom, B, KrathwoW, D et al. the learner is able to: New York: David McKay Co., 1956 (1) Produce a judgment about the accuracy of 1. Cognitive: objectives concern mental processes, information u ing internal criteria, e.g., the acquisition of intellectual skills, e.g., remem- judge the accuracy, con i tency of a written research report. (2) Produce a judgment of material using external criteria, e.g., use major theories to evaluate material, judge the value of a clin- ical report.
2. Affective: objectives concern feelings and emo- Teaching & Learning 385 tions, e.g., interests, attitudes, appreciations, values, emotional sets or biases. 3. Psychomotor: objectives concern motor skills, a. Level 1.0 Receiving (attending): objectives e.g., writing, speaking, performing motor acts or involve attending to phenomena and stimuli; skills; objectives include an aspect of perform- the learner demonstrates: ance; the learner demonstrates ability to: (1) Awareness, e.g., describes the clinical envi- a. Write a plan of care smootWy and legibly. ronment (objects and structures around b. Set up clinical equipment quickly and correctly. him), people, and situations. c. Operate clinical equipment safely and skillfully. (2) Willingness to receive, e.g., listens to oth- d. Perform manual therapeutic exercise skills cor- ers, demonstrates tolerance and sensitivity rectly and effectively. to human needs, cultural differences. e. Perform functional mobility skills safely and (3) Selected attention, e.g., attends closely to correctly. discussions of human values or judgments. f. Perform activities of daily living independently b. Level 2.0 Responding: objectives involve and safely. responses or actions; the learner demonstrates: (1) Compliance, e.g., willingness to respond to Establish Therapeutic Diagnostic Process: hospital rules. Relationship Mutual Inquiry (2) Acceptance of responsibility, e.g., protects confidentiality of patients. Communicate respect and Physical and movement (3) Satisfaction in responses, e.g., takes pleas- care via: diagnosis ure in communicating effectively with patients and families. Positive verbal and nonverbal Begin behavioral diagnosis c. Level 3.0 Valuing: objectives involve accepting interactions process and internalizing worth or value; the learner demonstrates: Active listening Identify disease beliefs (1) Consistency of response in situations based on holding a value, e.g., respects human Responsive touch Identify treatment beliefs dignity of patients through appropriate actions in varying situations. Identify valued activities (2) Preference and commitment for a value, e.g., actively participates in discussions Identify potential barriers about viewpoints such as euthanasia. to treatment d. Level 4.0 Organization: objectives involve organization of a value system; the learner Context: Family system demonstrates: and health care system (1) Conceptualization, e.g., recognizes or forms judgments based on a value; accepts person responsibility for own behavior. (2) Ordered relationships, e.g., able to look at Qiseas~iIInesv health care policies affecting the elderly and formulates a life plan for advocacy. Integrate: Prevention e. Level 5.0 Characterization by a value or value and health promotion complex; objectives involve: (1) Persistent and consistent behaviors influ- Intervention and Followup: Negotiate Common enced by a well developed value system, Teach and Problem Solve Ground e.g., displays safety consciousness, self- reliance in working independently. Teach performance skills, Continue with behavioral (2) Consistent adherence to a professional provide knowledge of how diagnosis code of ethics, e.g., displays consistent pro- to implement and monitor fessional behaviors. self-treatment, design Identify best treatment patient reminder strategies is likely to follow link to valued activity Evaluate for treatment effect Identify specific barriers to Evaluate for adherence treatment Problem solve to eliminate Assess self-efficacy barriers to adherence Make a mutual agreement for Modify success indicators as long- and short-term goals patient progresses Figure 13-1: Patient-Practitioner Collaborative Model. From Shepard K and Jensen G: Handbook of Teaching for Physical Therapists. Butterworth-Heinemann, Boston, 1997, p. 252, with permission.
386 II. Instruction e. Identify available resources, e.g., information about facilities, materials, time available for A. Instructional Process (Figure 13-1) the instructional process. 1. Analysis of the learner/needs assessment: identify relevant characteristics and needs of the learner 2. Analysis of data, formulation of objectives of prior to the educational experience. instruction. (Figure 13-2). a. Determine what the learner needs to know. a. Specify what the learner should learn (goals (1) Current level of knowledge. and behavioral objectives). (2) Plans/needs for the future. (1) Identify what the learner will do, e.g., b. Determine what the learner brings to the learn- describe, discuss, explain. ing experience. (2) Identify what the criteria of performance (1) Educational background, previous knowl- are, e.g., given a list of risk factors, the edge and experiences. learner will correctly identify. (2) All instruction should take into account the (3) Specify the conditions of the performance, influences of age, culture, gender roles, e.g., 75% of the time. race, sex, sexual orientation, and socioeco- (4) Set goals that are attainable, mutually nomic status. agreed upon by learner and instructor. c. Determine the learner's readiness to learn. (5) Use clear, unambiguous, and measurable (1) Learning style. terms, e.g., family/caregiver will demon- (2) Capabilities, attentiveness, energy level. strate understanding of safety measures to d. Identify impairments that may impact on learn- prevent falls by correctly describing proper ing: e.g., perceptual deficits, visual impair- use of brakes and transfer sequence 100% ments, communication impairments, confu- of the time within 2 weeks. sion, memory loss, emotional dysregulation. b. Set priorities. (1) Determine which educational goals are Teacher Institution Audience Class Size Datemme Objectives Philosophical Orientation + Learning Theory + Domain of Learning + Student learning Style + _ Behavioral _ (%) (%) (%) (%) 1. _ Cognitive Processing- Behaviorism _ Cognitive _ Concrete Experience 2. _ GestaltlProblem- _ Reasoning Solving Experience Affective Reflective Observation Problem Solving Academic Rationalism _ Psychomotor Abstract- 1. _ Technology _ PiagetlCognitive _ Perceptual Conceptualization 2. _ Social Adaptation Structure _ Spiritual _ Active Experimentation Social Reconstruction Personal Relevance Outcome _ 1. 2. Teaching Aids + Format of Delivery + Student Evaluation + Teaching Environment + Subject Background Prep A. Audiovisual (content, sequence, time, _ Computer Generated (%) (%) _ Room Arrangement skill, demonstration) Lecture Practical Exam Room Environment: Blackboard Written Short Answers temperature, light, j _ Overhead Projector _ Laboratory acoustics, cleanliness Seminar-Discussion _ Written Essay Teacher Materials: Slides _ Report or Project podium, chalk/pens, _ Videotape; film _ Independent Study media setup B. Handouts The Learning Experience _ Class Objectives _ Small Group Tasks _ Assigned Readings Lecture Outline _ Laboratory Exercises Figure 13-2: The preactive teaching grid. From Shepard K and Jensen G: Handbook of Teaching for Physical Therapists. Butterworth-Heinemann, Boston, 1997, p. 40, with permission.
most important, what equence is needed. Teaching & Learning 387 (2) En ure maximum utilization of available (2) Provide an overview of the learning teaching time. process: objectives, purposes, the nature of (3) Avoid bombardment, e.g., too much, too the task and the procedures to follow. soon. (3) Stimulate recall of previous learning; relate (4) Repetition is important for learning; build present learning to past and future learning.. in experiences that reinforce instruction. (4) Monitor and control the learning. 3. Analysis of instruction/planning (what, how, (a) Organize learning units over a period of time. where, when). (b) Break down learning into a series of a. Select what materials to use; options include steps or units. (c) Determine the best sequence(s) of print, audiovisual media, computer as isted learning units and experiences, e.g., instruction, models, etc. sequence from familiar to unfamiliar, b. Select what methods of teaching are appropri- simple to complex, concrete to ate; options include individual instruction, abstract. group discussion, organized classes/lecture, (d) Provide ample opportunity for practice demonstration and modeling, tutorials, etc. and repetition. Also includes written or pictorial instruction, (e) Progress at a comfortable pace for the e.g., home exercise program, etc. learner. (I) Choice of method is dependent on: (f) Give timely feedback, provide accurate knowledge of results. (a) The individual learner/unique charac- (g) Reward successful behaviors. teristics, e.g., preferences for rate and style of learning, motivation, etc. (5) Monitor and control the environment. (6) Reduce conditions that have a negative (b) Objectives of instruction. (2) A variety of teaching methods is typically impact on learning, e.g., pain or discom- fort, anxiety, fear, frustration, feelings of helpful to reinforce the learning. failure, humiliation, or embarrassment, c. Select what activities are likely to help the boredom, time pressures, etc. 5. Evaluation. learner achieve the stated objectives. a. Initial evaluation. 4. Implementation: strategies to affect mastery of (1) Determine relevant previous achievement, learning skills. learning. (2) Utibze diagnostic tests. a. Individuals learn best when: (3) Determine aptitude/choice of learning approaches. (I) They are actively involved in goal setting b. Formative evaluation (diagnostic-progress and the learning process; learning is not assessment). dictated by the instructor. (I) Analyze what learning has occurred, what must still be learned. (2) Learners need to feel free to freely express (2) Institute appropriate changes/modifications their own ideas, beliefs, and concerns. in the teaching plan. c. Surnmative evaluation (outcome assessment). (3) There is respect and trust between learner (1) Assess attainment of learning objectives and instructor. and content/skills. (2) Determine effectiveness of teaching mate- (4) The instructor is supportive and nonjudg- rials/methods. mental. d. Sources: direct observation of behaviors, writ- ten and verbal feedback, formal checklists, b. Therapist/teacher should recognize that: questionnaires, pre and post-tests. (I) Individuals learn at different rates. 6. Documentation: provide a complete record of (2) Trial and error and introspection are an essential part of the learning process. (3) Experiential learning is more effective than didactic learning. (4) Reinforcement is necessary to ensure a sense of competence and success. c. Therapist/teacher roles and responsibilities. (I) Gain the learner's attention, motivation, and active participation.
388 permanent changes in the capability for skill.\" (Schmidt, 1999). activities and outcomes to assure accountability, A. Phases of Motor Learning (Fitts and Posner, 1967) continuity of care. Include: Refer to Table 2-9 a. The educational plan: objectives and activities. 1. Cognitive phase: the learner develops an under- b. Progression and modification of the educational standing of the ta k; the proce s of cognitive map- plan; document the need for change. ping allows the learner to determine what to do. c. Outcomes: document the learner's progress 2. Associative phase: the learner has determined a strategy, practices it, and makes adjustments in and attainment of the learning objectives. how the motor skill i performed. B. Interventions - Media 3. Autonomous phase: the learner has practiced the motor skill to the extent that the performance The selection of appropriate media can enrich the becomes largely automatic; characterized by high- learning experience, clarify and support a presenta- level skilled performance with few adjustments tion, and provide for self-instruction or individualized needed. tutorial. Selection should be based on the needs B. Motor Learning Evaluation assessment. Cost and availability are factors that may I. Performance: there is an acquired capability to also enter into the decision making process. Media perform the motor skill with practice. can include, but is not limited to: a. Performance may not always present an accu- I. Print: written handouts. rate picture of learning since it can be affected a. Advantages: low cost. by fatigue, motivation, or stress. b. Disadvantages: can be boring; inappropriate b. Determine efficiency (spatial and temporal organization or movement), level of effort, for educational level of individual; culturally automaticity, and peed of decision making. biased. 2. Retention: the skill can be demon trated after a 2. Computer assisted instruction. period of no practice, termed retention interval. a. Advantages: can be individually paced; novel. a. Vary the retention interval: minutes, hours, or day . b. Disadvantages: higher cost; limited availability b. Determine the capability to retain the skill, per- in clinical setting. form without decrement. 3. Audiovisuals. 3. Generalizability: there is an acquired capability to a. Overheads (transparencies). adapt the skill to permit performance of other sim- (1) Advantages: modest cost, can be used with ilar related tasks. a. Vary the skill: have the patient perform the same lights on to reinforce a presentation. skill in different postures, e.g., lower trunk rota- (2) Disadvantages: no motion; expensive to tion in sidelying, kneeling, standing, etc. b. Modify the skill: e.g., upper extremity PNF add color. patterns with elbow straight, elbow flexing, or b. Slides (PowerPoint, film). elbow extending. 4. Re istance to contextual change: there is an (I) Advantages: easy to add color, realistic. acquired capability to perform what is learned in (2) Disadvantages: no motion, cost, availability; other environments. a. Vary the environment: in the clinic, on the lights must be low during presentation. nursing unit, at home, in the community. c. Audiotapes. b. Determine the capability to retain the skill, per- form without decrement. (1) Advantages: self paced. C. Motor Learning Strategies (2) Disadvantages: most learners are visually I. Strategies vary by tage of motor learning. Refer to Table 2-9. oriented. 2. Ensure learner readiness. d. Film/videotapes. a. Optimal arousal facilitates learning; high (1) Advantages: demonstrates movement, 3- dimensional. (2) Disadvantages: expensive. e. Models. (1) Advantages: can provide visual and \"hands on\" experience. (2) Disadvantages: limited choices, cost. Ill. Motor Learning \"Motor learning is a set of internal processes associ- ated with practice or experience leading to relatively
arousal and low arousal states interfere with Teaching & Learning 389 learning (Inverted U theory). b. Optimal cognitive function: attention, concen- The learner needs to actively process intrinsic tration, memory ensures learning. information, self-correct responses. (I) Vary trategies with specific cognitive b. Select appropriate (intact) sensory systems: visu- al, auditory, tactile, proprioceptive feedback. impairments. c. Include both knowledge of results (KR) and (2) Avoid mental fatigue: give frequent rests. knowledge of performance (KP) information. c. Communicate, encourage, and support learner; d. Vary feedback schedules: reduce fear and apprehension. (1) Summed, fading, or bandwidth schedules 3. Identify and describe the skill. a. Identify the rea ons why the skill is important improve retention, enhances depth of cog- to learn; stress links to functional independ- nitive processing and active learning. ence, patient goals. (2) Feedback after every trial improves per- b. Promote insights into the relationship between formance, early learning. parts of the task and the whole task, current e. Provide motivational feedback: reinforce learning and previous learning. desired skills, behaviors. 4. Demonstrate the skill at ideal performance parame- 8. Demonstration and modeling is useful to reduce ters (spatial and temporal organization); provide the errors, improve learning and performance by imi- learner with an accurate reference of correctness. tation; use therapist demonstration, expert patients 5. Control the environment. with similar disabilities, videotapes, etc. a. A closed environment is important for early 9. Guided movement (active assisted movement). motor learning; reduce environmental distrac- a. Useful during early learning, not during asso- tors. ciative or autonomous learning. b. Later learning will benefit from a shift toward b. Useful for slow positioning tasks, e.g., the ther- a more open environment; vary the environ- apist actively assists the patient in moving from ment, introduce distractors. supine to sitting or sitting to standing. 6. Schedule appropriate practice sessions. c. Useful to reduce anxiety and inspire trust; a. Promote practice of variations of the task to ensure safety. promote generalizability, improved retention. 10. Use transfer training as appropriate. b. Promote practice of the ta k in varying envi- a. Parts-to-whole transfer: for complex tasks with ronments to promote resistance to contextual highly independent parts. change. (1) Demonstrate the integrated whole skill. c. Use distributed practice with frequent rest peri- (2) Break the skill down into component parts. ods for learners who demonstrate poor (3) Practice the individual component parts. endurance, cognitive impairments (poor atten- (4) Practice the integrated whole skill (each tion, concentration, memory); or when the task treatment session); delaying practice of the is complex, long, and energy costly. integrated whole skill may interfere with d. Vary practice schedules. learning (parts to whole transfer). (1) Variable practice (random or serial practice b. Bilateral transfer: practice movements with sound limb before practice with involved limb, order of tasks) improves retention, e.g., the patient with stroke. enhances depth of cognitive processing and II. Evaluate outcomes. active learning. a. Level of independence, safety. (2) Constant practice, blocked practice order b. Level of function, ease of movement effort. improves performance, early learning. e. Use mental practice: to cognitively rehearse task, preview movement, decrease apprehension. 7. Provide appropriate feedback. a. Maximize active learning: allow for trial and error learning; don't bombard with feedback.
CHAPTER 14 RESEARCH & EVIDENCED-BASED PRACTICE Susan B. O'Sullivan I. Physical Therapist Roles and Responsibilities to assist practitIOner and patient decisions. Developed through: A. Physical Therapists Use Evidence-based Practice a. Expert consensus. (EBP) b. Systematic reviews and meta-analysis. 1. EBP is the \"conscientious, explicit and judicious c. Analysis of patient preferences combined with use of current best evidence in making decisions about the care of individual patients.\" Sackett DL et outcome-based guidelines. al: Evidence-based Medicine: How to Practice and 5. The APTA has developed \"a clinical research Teach EBM. Churchill Livingstone, 2000, p 24. 2. Clinical decisions are based on: agenda to support, explain, and enhance physical a. Systematic research evidence: studies are rig- therapy clinical practice by facilitating research orous and clinically relevant. that is primarily useful to clinicians\". Guccione A, b. Clinical expertise of the therapist: the patient's Goldstein M Ellicott S. Clinical Research Agenda health status, and needs are identified; the risks for Physical Therapy. Phys Ther 80:499, 2000. and benefits of possible interventions are iden- B. Physical Therapists Conduct Research in Clinical tified. and Academic Settings c. Patient values: are identified and integrated 1. The research question/proposal is developed and into the clinical decisions. submitted for ethical approval and funding. 3. EBP is a four-step process. 2. The research study is conducted. Step 1: a clinical problem is identified and an 3. The research data is analyzed and reported. answerable research question is formulated. Step 2: a systematic literature review is conducted II. Research Design and evidence collected. Step 3: the research evidence is summarized and A. Methods critically analyzed. Common denominators include: statement of the Step 4: the research evidence is synthesized and problem, formation of a research question, collection applied to clinical practice. and analysis of data, results, and conclusions. 4. Evidence-based clinical practice guidelines 1. Historical research: involves investigation of a (EBCPGs): systematically developed statements variety of data sources. a. Uses sources of data already available. (1) Primary sources: original documents, eye- witness accounts, direct recordings of events.
(2) Secondary sources: description of an event Research & Evidence-Based Practice 391 by other than an eyewitness, summary information in textbooks, newspaper a. Describes relationships, predicts relationships accounts. among variables without active manipulation of the variables. b. Investigates authenticity of the data (external criticism). b. Limitations. (1) Cannot establish cause and effect relation- c. Evaluates worth of the data (internal criticism). ships; limits interpretation of results. (1) Ensures data is accurate (validity). (2) May fail to consider all variables that enter (2) Ensures data is reliable. into a relationship. d. Data synthesis: researcher determines relation- c. Degree of relationship is expressed as correla- ships based on analyses and inferences; draws tional coefficient, ranging from -1.00 to +1.00. conclusions. (1) If the correlation is near +1.00, the vari- ables are positively correlated. 2. Descriptive research: involves collecting data (2) If the correlation is near 0.00, the variables about conditions, attitudes, or characteristics of are not related. subjects or groups of subjects. (3) If the correlation is near -1.00, the variables a. Determines and reports existing phenomena. are inversely related. b. Data collection: typically done through ques- tionnaire survey, interview, or observation. d. Examples of correlational research. (1) Permits classification, identification. (1) Retrospective: investigation of data collect- (2) Data can be used for prediction, decision- ed in the past. Prospective: recording and making. investigation of present data. c. Examples of descriptive research. (2) Descriptive: investigation of several vari- (1) Case studies or clinical reports: in-depth ables at once; determines existing relation- investigation of an individual, group, or ships among variables. institution. (3) Predictive: useful to develop predictive (2) Developmental research: studies of behav- models. iors that differentiate individuals at differ- ent levels of age, growth, or maturation. 4. Experimental: attempts to define a cause and effect (3) Longitudinal studies: differentiate changes relationship through group comparisons. in an individual or group of individuals a. Alleged cause or treatment (the independent over time; e.g., developmental sequences. variable) is manipulated. (4) Normative research: investigates standards b. Effect or difference (the dependent variable) is of behavior, standard values for given char- determined. acteristics of a sample, e.g., gait character- c. Designs. istics. (1) True experimental design: includes random (5) Qualitative research: seeks facts or causes assignment into experimental group (receives of social phenomena, complex human treatment) or control group (no treatment). behavior. All other experiences are held similar. (a) Utilizes people's own written or spoken (2) Cohort design: quasi-experimental design, words, behaviors through interview or subjects are identified and followed over observation. time for changes/outcomes following expo- (b) Develops concepts, insights, and sure to an intervention; lacks randomiza- understanding from patterns in the tion, mayor may not have a control group. data; uses inductive reasoning. (3) Within subject design (repeated measures): (c) Emphasis is on understanding of subjects serve as their own controls; ran- human experience, e.g., holistic view domly assigned to treatment or no treat- of people and settings. ment blocks. (4) Between subject design: comparisons made 3. Correlational research: attempts to determine between groups of subjects. whether a relationship exists between two or more (5) Single-subject experimental design: quantifiable variables and to what degree. involves a sample of one with repeated measurements and design phases.
392 B. Variables 1. Independent variable: the acttvlty or factor (a) A-B design: involves two phases, a believed to bring about a change in the dependent pretreatment or baseline phase fol- variable; the cause or treatment. lowed by an intervention or treatment 2. Dependent variable: the change or difference in phase. behavior that results from the intervention (inde- pendent variable); the outcome that is being evalu- (b) A-B-A design (multiple baseline ated. design): involves three phases, a base- line phase, treatment phase, followed C. Hypothesis by second baseline phase. I. A tentative and testable explanation of the rela- tionship between variable; the results of an exper- (c) A-B-A-B (multiple baseline, multiple iment determine if the hypothesis is accepted or treatment): includes baseline, treat- rejected. ment, and additional baseline, and a. Directional hypothesis (research hypothesis): a treatment phases. generalization that predicts an expected rela- tionship between variables. (6) Factorial design: refers to the number of b. Null hypothesis: states that no relationship independent variables utilized, e.g., single exists between variables, a statistical hypothe- factor, multifactor. sis; any relationship found is the result of chance or sampling error. 5. Causal-comparative: attempts to define a cause and (1) The null hypothesis is rejected meaning a effect relationship through group comparisons. significant difference was observed a. Ex post factor research: the cause or independ- between groups or treatments. ent variable has already occurred; cannot be (2) The null hypothesis is accepted meaning no manipulated, e.g., sex, or should not be manip- significant difference was observed ulated, e.g., type of brain injury. between groups or treatments. b. Groups are compared based on the dependent variable. D. Data Types (Table 14-1) 1. Nominal scale: classifies variables or scores into 6. Epidemiology: the study of disease frequency and distribution in a community; the science con- cerned with examining and determining the spe- cific causes of health problems and interrelation- ships of factors. TABLE 14-1 - EXAMPLES OF STATISTICAL ANALYSES ACCORDING TO THE STUDY'S PURPOSE AND THE DATA'S LEVEL OF MEASUREMENT PURPOSES LEVELS OF MEASUREMENT STATISTICS Describe the Variable Nominal ...... Frequency, Percentage Relationship Ordinal ...... Median, Mode, Range Difference Interval Mean, Median, Mode, Range, Standard Deviation, Skew of the Distribution Nominal ...... Ordinal ...... Chi Square Interval Spearman's Rank Order or Kendall's tau Correlations ...... Pearson's Product Moment Correlation, Partial Correlation, Multiple Nominal Correlation, Multiple Regression ...... Ordinal ...... One group: Chi Square Interval Two groups: Independent: Chi Square; Paired: McNemar Test ...... More than two groups: Independent: Chi Square; Paired: Cochran's Q ...... Two groups: Independent: Mann-Whitney U; Paired: Wilcoxon Signed Rank More than two groups: Independent: Kruskal-Wallis; Paired: Friedman ANOVA Two groups: Independent: t-test; Paired: Paired t-test; Statistical Control: ANCOVA More than two groups: Independent: ANOVA; Across time: Repeated ANOVA; Statistical Control: ANCOVA nominat. characteristics into categories ordinat. rank ordering, no specific intervals between ranks intervat. values rank ordered on a scale that has equal distances (intervals) between points on that scale Table 14.1: Prepared by Nina Coppens, PhD, RN, University of Massachusetts, Lowell.
two or more mutually exclusive categories based Research & Evidence-Based Practice 393 on a common set of characteristics; the lowest level of measurement; e.g., subjects are classified and benefits; ethical disclosure. a male or female, tall or short, etc. a. Information about the general nature of what is 2. Ordinal cale: classifies and ranks variables or core in terms of the degree to which they possess to take place. a common characteristic; intervals between ranks b. Any risks to the individual and what will be are not equal; e.g., subjects are ranked in a gradu- ating class according to grade point average; man- done to minimize the risks. ual muscle te t grades (normal, good, fair, poor, c. Po sible benefits. trace, zero) are ranked as an ordinal scale. d. An ethical disclosure. 3. Interval scale: classifies and ranks variables or cores based on predetermined equal intervals; III. Problems Related to Measurement does not have a true zero point; e.g., an I Q test with scores ranging from 0 to 200; temperature A. Control scales (Fahrenheit or Celsius). 1. The researcher attempts to remove the influence of 4. Ratio scale: classifies and ranks variables or scores any variable other than the independent variable in based on equal intervals and a true zero point; the order to evaluate its effect on the dependent vari- highest, most precise level of measurement; e.g., able. goniometry, scales for height, weight, or force a. Control group: the group in a research study allow the use of precise physical measures (ratio that resembles the experimental group but who data) for research. do not receive the new or different treatment, E. Sampling e.g., treated as usual; provides a baseline for 1. The selection of individuals (a sample) for a study interpretation of results. from a population; the sample represents the larg- b. Experimental group: the group in a research er group from which they were selected. study that receives a new or novel treatment a. Random: all individuals in a population have that is under investigation. c. Intervening variable: a variable which alters the an equal chance of being chosen for a study. relationship (intervenes) between the independ- b. Sy tematic: individuals are selected from a ent and dependent variable; may not be directly observable or easy to control, e.g., anxiety. population list by taking individuals at speci- fied intervals, e.g., every 10th name. B. Validity c. Stratified: individuals are selected from a pop- 1. The degree to which a test,n instrument, or proce- ulation from identified subgroups based on dure accurately measures what it is supposedin- some predetermined characteristic, e.g., by tended to measure. height or weight, sex. a. Internal validity: the degree to which the d. Double-blind study: a experiment in which the observed differences on the dependent variable subject and the investigator are not aware of are the direct result of manipulation of the inde- group assignment. pendent variable, and not some other variable. e. Effect size: the size (quantity, magnitude) of b. External validity: the degree to which the the differences between sample means; allows results are generalizaple to individuals (general a statistical test to find a difference when one population) or environmental settings outside really does exist. the experimental study. f. Generalizability: the degree to which a study's c. Face validity: the assumption of validity based findings based on a sample apply to an entire on the appearance of an instrument as a rea- population. sonable measure of a variable; may be used for F. Instrumentation-Gold Standard initial screening of a test instrument but psy- 1. An instrument with established validity can be chometrically unsound. used as a standard for assessing other instruments. d. Content validity: the degree to which an instru- G. Informed Consent ment measures an intended content area. 1. The obtaining of consent of an individual prior to (I) Determined by expert judgment. participation in a study with full disclosure of risks (2) Requires both item validity and sampling validity. e. Concurrent validity: the degree to which the scores on one test are related to the scores on
394 b. Intrarater (intratester) reliability: the degree to which one rater can obtain the same rating for another criterion test with both tests being a given variable on multiple measurement tri- given at relatively similar times; usually als; an individual's consistency of rating. involves comparison to the gold standard. f. Predictive validity: the degree to which a test is c. Test-retest reliability: the degree to which the able to predict future performance. scores on a test are stable or consistent over g. Construct validity: the degree to which a test time; a measure of instrument stability. measures an intended hypothetical abstract concept (non-observable behaviors or ideas). d. Split-half reliability: the degree of agreement C. Threats to Validity when a test is split in half and the reliability of 1. Sampling bias (selection bias): the researcher first half is compared to the second half; a introduces systematic sampling error, e.g., a sam- measure of internal consistency of an instru- ple of convenience (the use of volunteers or avail- ment. able groups) instead of random election of sub- jects. E. Threats to Reliability 2. Failure to exert rigid control over subjects and I. Errors of measurement: random errors or system- conditions: intervening variables interact with the atic errors, e.g., repeat measurements of blood dependent variable, e.g., in a longitudinal pediatric pressure may vary due to physiological changes study, the outcome is due to the maturation of the (fear, anxiety). child rather than the treatment intervention. 3. The administration of the pretest influences scores F. Objectivity: agreement among expert judges on what on the posttest., e.g., a learning effect occurs as a is observed or what is done, e.g., scoring of a percep- result of taking a test. tible sign or symptom is the arne regardless of who is 4. The measurement instrument is not accurate, the observing the phenomena (e.g., Licensure Exam). test does not measure the characteristic it purports to measure, e.g., measures muscle strength, not G. Subjectivity: refers to a testing format that may differ motor control. depending upon the person grading the test (e.g., fig- 5. Pretest-treatment interaction: subjects respond dif- ure skating judging) ferently to the treatment because of the pretest. 6. Multiple treatment interference: more than one H. Sensitivity treatment is being given to the subjects at the same 1. An assessment of the value of a test, or observa- time; or carry-over effects from an earlier treat- tion; a test's ability to correctly identify the pro- ment influence the results of a later treatment, e.g., portion of individuals who truly have a disease or effects of ultrasound following application of a hot condition (a true positive). pack. a. False positive: individuals are identified by a 7. Experimenter bias: expectations of the researcher test as having a condition when they do not. about the expected outcomes of the study influ- b. False negative: individuals are identified by a ence the results of a study. test as not having a condition when they do. 8. Hawthorne effect: the subject's knowledge of par- c. A negative (low sensitivity) result rules out the ticipation in an experiment influences the results diagnosis (SnOut). With SnOut, there is a very of a study. low likelihood ratio. Likelihood ratios are a 9. Placebo effect: subjects respond to a sham treat- measure of the power of ensitivity/specificity. ment with positive effects, e.g., taking a sugar pill instead of an experimental drug results in a I. Specificity: a test's ability to correctly identify the change. proportion of individuals who do not have a disease or D. Reliability condition (a true negative). 1. The degree to which a test consistently measures a. A positive re ult (high specificity) rules in the what it is intended to measure. diagnosis (SpIn). A high likelihood ratio puts a a. Interrater (intertester) reliability: the degree to SpIn on diagnostic impact. which two or more independent raters can obtain the same rating for a given variable; the J. Scientific Rigor by Type of Research Design consistency of multiple raters. 1. Level I studies, highe t scientific rigor: systemat- ic reviews and meta-analyses of large randomized clinical trials (RCT). 2. Level 2 studies: cohort design and low-quality, smaller RCTs. 3. Level 3 studies: case-control studie (case-com- parison) and single case-control de ign.
4. Level 4 studies: Case-series and poor quality Research & Evidence-Based Practice 395 cohort and case-control studies; studies are largely de criptive. time; comparison is made to a matched group that does not have the condition. 5. Level 5 tudies, lowest scientific rigor: expert 4. Homogeneity: SR free of variations (heterogene- opinion without explicit critical appraisal. ity) in the directions and degree of results between individual studies. K. Scientific Rigor by Type of Research Design 5. Case control study = A retrospective (backward- Evidence-based Practice: Levels of Evidence and in-time) study; a group of individuals with a sim- Grades of Recommendation ilar condition (disease) is compared with a group 1. Level!. that does not have the condition to determine fac- a. Systematic review (SR) of multiple random- tors that may have played a role in the condition. ized controlled trials (RCTs) with homogeneity 6. Case report (study) = Type of descriptive research and a large number (N) of subjects. in which only one individual is studied in depth, b. Individual RCT with narrow confidence inter- often retrospectively. Adapted from Centre for val. Evidence-based Medicine, Oxford-Centre for Evidence-Based Medicine c. Grade of Recommendation =A (highest scien- (http://www.cebm.net/levels of evidence.asp) tific rigor). IV. Data Analysis and Interpretation 2. Level 2. (Table 14-1 and Figure 14-1). a. SR (with homogeneity) of cohort studies. A. Descriptive Statistics: Summarize and Describe b. Individual cohort study or low quality RCT Data (small N). 1. Measures of central tendency: a determination of c. Outcomes research. d. Grade of Recommendation = B. average or typical scores. 3. Level 3. a. Mean: the arithmetic average of all scores (x). a. SR (with homogeneity) of case-control studies. b. Individual case-control study. (I) Add all scores together and divide by the c. Grade of Recommendation = B. number of subjects (N). 4. Level 4. a. Case-series and poor quality cohort and case- (2) The most frequently used measure of cen- tral tendency; appropriate for interval or control studies (largely descriptive). ratio data. b. Grade of Recommendation = C. 5. Level 5. b. Median: the midpoint, 50% of scores are above a. Expert opinion without explicit critical the median and 50% of scores are below; appraisal, or based on physiology, bench appropriate for ordinal data. research or first principles. b. Grade of Recommendation = D (lowest scien- c. Mode: the most frequently occurring core; tific rigor; expert opinion without explicit crit- appropriate for nominal data. ical appraisal). L. Definitions 2. Measures of variability: a determination of the 1. Systematic Review (SR) including meta-analysis: spread of a group of scores. a review in which the primary studies are summa- a. Range: the difference between the highest rized, critically appraised, and statistically com- score and the lowest score. bined; u ually quantitative in nature with specific b. Standard deviation (SD): a determination of inclu ion/exclusion criteria. variability of scores (difference) from the 2. Randomized Controlled Trial (RCT): an experi- mean. mental study in which participants are randomly (I) Subtract each score from the mean, square assigned to either an experimental or control group each difference, add up all the squares, to receive different interventions or a placebo. divide by the number of scores. 3. Cohort study: a prospective (forward-in-time) (2) The most frequently used measure of vari- study; a group of participants (cohort) with a sim- ability. ilar condition is followed for a defined period of (3) Appropriate with interval or ratio data. c. Normal distribution: a symmetrical bell-shaped curve indicating the distribution of scores; the mean, median, and mode are similar. (l) Half the scores are above the mean and half
396 the scores are below the mean. d. Percentiles and Quartiles: describe a score's (2) Most scores are near the mean, within one position within the distribution, relative to all other scores. standard deviation; approximately 68% of (1) Percentiles: data is divided in 100 equal scores fall within +1 or -1 SD of the mean. parts; position of score is determined. (3) Frequency of scores decreases further from (2) Quartiles: data is divided into 4 equal parts the mean. and position of score is placed accordingly. (a) Approximately 95% of scores fall B. Inferential Statistics within +2 or -2 SD of the mean. 1. Allow the determination of how likely the results (b) Approximately 99% of scores fall of a study of a sample can be generalized to the whole population. within +3 or -3 SD of the mean. a. Standard error of measurement: an estimate of (4) Distribution may be skewed (not symmetri- expected errors in an individual's score; a measure of response stability or reliability. cal) rather than normal: scores are extreme, clustered at one end or the other; the mean, median, and mode are different. 1. If examining for relationships (correlations): ,..:...------- Are there only two variables? 1 No Are the data ranked? 2. If examining for differences between groups: r--------------------, Are there only two groups? Friedman 2-way ANOVA Figure 14-1: Clinical decision making: Flow diagram for determining appropriate statistics. Key: follow flow diagram to the right with yes answers; follow flow diagram to left with no answers. Adapted from materials prepared by Dr. L Zaichkowsky, Boston University.
b. Tests of significance: an estimation of true dif- Research & Evidence-Based Practice 397 ferences, not due to chance; a rejection of the null hypothesis. used to compare two group means and (1) Probability levels are associated with infer- identify a difference at a selected probabil- ential analyses. Alpha level: preselected ity level (e.g., 0.05). level of statistical significance. (a) T-test for independent samples: com- (a) Most commonly set at 0.05 or 0.01; indicates that the expected difference is pares the difference between two inde- due to chance, e.g., at 0.05, only 5 pendent samples; randomly formed. times out of every 100 or a 5% chance, (b) T-test for nonindependent samples: often expressed as a value of P. compares the difference between two (b) Allows rejection of the null hypothesis: matched samples. there are true differences on the meas- (c) One-tailed t-test: based on a direction- ured dependent variable. al hypothesis; evaluates differences in (2) Degree of Freedom: based on number of data on only one end of a di tribution, subjects and number of groups; allows either negative or positive; e.g., determination of level of significance based patients who receive a certain treat- on consulting appropriate tables for each ment exhibit better rehabilitation out- statistical test. comes than those who do not. (3) Errors. (d) Two-tailed t-test: based on a nondirec- (a) Standard error: expected chance varia- tional hypothesis; evaluates differences tion among the means, the result of in data on both positive and negative sampling error. ends of a distribution; tests of signifi- (b) Type I error: the null hypothesis is cance are almost always two-tailed; rejected by the researcher when it is e.g., either group of patients (treatment true, e.g., the means of scores are con- or control) may exhibit better rehabili- cluded to be truly different when the tation outcomes. differences are due to chance. (3) Analysis of variance (ANaYA): a paramet- (c) Type II error: the null hypothesis is not ric test used to compare three or more inde- rejected by the researcher when it is pendent treatment groups or conditions at a false, e.g., the means of scores are con- selected probability level. cluded to be due to chance when the (a) Simple (one-way) ANaYA: compares means are truly different. multiple groups on a single independ- (d) By increasing sample size, using ran- ent variable, e.g., three sets of posttest dom selection, and having valid meas- scores (balance scores from a Balance ures the chance of both Type I and II Master) are compared from three dif- errors is decreased. ferent categories of elderly: young eld- erly (65-74); old elderly (75-84); and c. Parametric statistics: testing is based on popu- old and frail elderly (> 85). lation parameters; includes tests of significance (b) Factorial ANaYA (multifactorial) based on interval or ratio data. compares multiple groups on two or (1) Assumptions. more independent variables, e.g., (a) A normal distribution exists in the pop- injured patients with severe ankle ulation studied of the variable meas- sprain, moderate ankle sprain, and con- ured or distribution is known. In a trol groups are compared for muscle large, representative sample, the activation patterns and sensory percep- assumption of normal distribution is tion in each limb. probably met. (4) Analysis of covariance (ANCOYA): a para- (b) Random sampling is performed. metric test used to compare two or more (c) Yariance in the groups is equal. treatment groups or conditions while also (2) T-test: a parametric test of significance controlling for the effects of intervening variables (covariates), e.g., two groups of subjects are compared on the basis of gait
398 (5) Common variance: a representation of the degree that variation in one variable is parameters using two different types of attributable to another variable. assistive devices; subjects in one group are (a) Determined by squaring the correlation taller than subjects in the second group; coefficient, e.g., a correlation coeffi- height then becomes the covariate that must cient of 0.70 means that the common be controlled during statistical analysis. variance is 49%, i.e., the variation in d. Nonparametric statistics: testing not based on one variable can be explained by the population parameters; includes tests of sig- other 49% of the time. nificance based on ordinal or nominal data. (1) Used when above parametric assumptions cannot be met. (2) Less powerful than parametric tests, more difficult to reject the null hypothesis, e.g., can be used with small sample, and with ordinal or nominal level data. (3) Chi square test: a nonparametric test of sig- nificance used to compare data in the form of frequency counts occurring in two or more mutually exclusive categories e.g., subjects rate treatment preferences. e. Correlational statistics: used to determine rela- tionships between two variables; e.g., compare progression of radiologically observed joint destruction in rheumatoid arthritis and its rela- tionship to demographic variables (gender, age), disease severity, and exercise frequency. (1) Pearson product-moment coefficient (r): used to correlate interval or ratio data. (2) Spearman's rank correlation coefficient (rs): a nonparametric test used to correlate ordinal data. (3) Intraclass correlation coefficient (ICC): a reliability coefficient based on an analysis of variance. (4) Strength of relationships. (a) Positive correlations range from 0 to +1.00: indicates as variable X increas- es, so does variable Y. o High correlations: > 0.76 to +1.00. o Moderate correlations: 0.51 to 0.75. o Fair correlations: 0.26 to 0.50 o Low correlations: 0.00 to 0.25. o 0 means no relationship between variables. (b) Negative correlations range from -1.0 to 0: indicates as variable X increases, variable Y decreases; an inverse rela- tionship.
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