9/11/00
Ethical Knowledge = Collaborative Power: AOTA's Code of Ethics provides key guidelines for OT/OTA role delineation
David A. Leary and Jacalyn Mardirossian
Note: The Occupational Therapy Code of Ethics (2000)1 is available on AOTA's Web site at www.aota.org. It will also be published with other official documents in the November/ December 2000 issue ofAJOT. The term occupational therapy practitioner refers to both occupational therapists and occupational therapy assistants.
We have worked together at the University of Southern California for several years and have introduced students to AOTA's official documents. We have also collaborated on a module on supervision and role delineation for the occupational therapist and occupational therapy assistant. It has been really surprising to us that our students are often better informed about AOTA's official documents than some of our practicing colleagues, since the answers to so many practice questions are found in these documents.
The key element of our basis for applying all of our professional knowledge is The Occupational Therapy Code of Ethics(2000)1. This is the foundation for all of the other official documents of our profession.
Here are just four principles from the Code of Ethics(2000)1 that are relevant to role delineation:
- Principle 4E: Occupational therapy practitioners shall protect service recipients by ensuring that duties assumed by or assigned to other occupational therapy personnel match credentials, qualifications, experience, and scope of practice.
- Principle 4F: Occupational therapy practitioners shall provide appropriate supervision to individuals for whom the practitioners have supervisory responsibility in accordance with Association policies; local, state, and federal laws; and institutional values.
- Principle 5C: Occupational therapy practitioners shall require those they supervise in occupational therapy- related activities to adhere to the Code of Ethics.
- Principle 5E: Occupational therapy practitioners shall record and report in an accurate and timely manner all information related to professional activities.
An occupational therapy practitioner familiar with the Code of Ethicsand its application to practice will be able to relate its principles to AOTA's Guide for Supervision of Occupational Therapy Personnel in the Delivery of Occupational Therapy Services.2 This ability is especially important in the current health care climate because changes in practice are occurring very quickly, and funding issues can conflict with quality service.
For example, a recent graduate who had started a new job called one day to ask for some advice. "Joan" was hired as the only occupational therapist (OT) in her practice setting and was told that an occupational therapy assistant (OTA) would be interviewed shortly. She was then told that she would be traveling to several satellite clinics throughout the week to do evaluations. When Joan expressed concern about how to treat her clients after the evaluations while traveling to different sites, she was offered the support of a rehabilitation aide.
Joan's supervisor, who was not an occupational therapist, told her that the aide would deliver her treatments throughout the week. Joan believed that this service delivery would not be ethical, so she reviewed the Guidelines for the Use of Aides in Occupational Therapy Practice.3 This document states that "Only carefully selected, specific aspects of service delivery can be safely and ethically delegated to aides" (p. 595). It also says that "Aides are primarily used to support the delivery of occupational therapy by assuming responsibility for non-client-related tasks" (p. 595). Most importantly for Joan, it says that "For best practice, tasks delegated to aides should receive continuous supervision.... Continuous supervision means that the occupational therapy supervisor is in sight of the aide who is performing delegated client-related tasks" (p. 596).
Joan's supervisor had also been under the impression that an occupational therapy assistant would not require any supervision from Joan. Joan referred to the Occupational Therapy Roles4 document, which states "COTAs at all levels require at least general supervision by an OTR. The level of supervision is related to the ability of the COTA to safely and effectively provide those interventions delegated by an OTR.... COTAs will require closer supervision for interventions that are more complex or evaluative in nature and for areas in which service competencies have not been developed. Service competency is the ability to use the identified intervention in a safe and effective manner" (p. 1090).
After relaying this information to her supervisor and explaining the supervisory requirements of the occupational therapist/occupational therapy assistant team, Joan became involved in the interview process for the occupational therapy assistant. She was able to ask insightful questions regarding service competency and previous supervision experiences with the candidates to determine their skill levels. By educating her supervisor and taking on additional responsibilities, she had followed Principle 5D of AOTA's Code of Ethics(2000)1: "Occupational therapy practitioners shall take reasonable steps to ensure employers are aware of occupational therapy's ethical obligations, as set forth in this Code of Ethics, and of the implications of those obligations for occupational therapy practice, education, and research."
MYTH OR REALITY?
Many occupational therapy practitioners who leave the medical model and begin community-based practice have questioned the continued applicability of the OT/OTA supervisory guidelines. This relationship is not based on setting, but on whether each person is functioning in an occupational therapy role. By determining whether the following statements are a myth or reality, practitioners may better understand how the OT/OTA team can work together ethically and effectively, regardless of practice setting.
Statement: None of AOTA's official documents indicate the requirement of a cosignature, so notes written by an OTA do not have to be cosigned.
Myth: Although AOTA's official documents do not stipulate the requirement of a cosignature, state law or third-party reimbursers may, and they are the ruling authority. Often, this cosignature on documentation is seen as evidence of collaboration between the OT and the OTA. Check with your state regulatory board and reimbursers to determine whether OTA notes must be cosigned by an OT.
Statement: The OT has full responsibility for supervising all of the occupational therapy treatment that the OTA administers.
Reality: The OT is indeed responsible for all OTA treatment. However, according to the Guide for Supervision,2 the level of supervision varies, based on "an assessment of the OTA's skills, the demands of the job, the needs of the service recipients, and the service setting requirements" (p. 593). "In all cases, it is the occupational therapy practitioner's ethical responsibility to ensure that the amount, degree, and pattern of supervision are consistent with the service competency demonstrated" (p. 594).
Statement: The OT has all the responsibility of delegating every task in an occupational therapy department that consists of an OT, two OTAs, and one OT aide.
Myth: The Occupational Therapy Roles4 document and the Guide for Supervision2 support supervisory roles for both the OT and the OTA. Although an OTA always requires at least a general level of supervision from an OT, the OTA can provide supervision to a less experienced OTA or an OT aide. This supervision would always involve collaboration with an OT.
For example, if the OT has 3 years' experience and one of the OTAs has 5 years' experience, the OT will provide routine or general supervision. After service competency has been established, it is likely that treatment collaboration would take place less frequently and for a shorter amount of time than it would with a less experienced OTA.
If the other OTA has only 6 months of practice experience, he or she will require close supervision. The more experienced OTA, working in collaboration with the OT, may provide some of this supervision. After the OTA's service competency is established by the OT, delegating appropriate tasks might include the OTA selecting and delegating appropriate tasks to the OT aide, in collaboration with the OT.
Statement: The OT has to know how to do everything an OTA does in order to supervise.
Myth: This statement refers to the idea of service competency. If an OTA has 10 years of experience in making splints and the OT who is partnered with this OTA has 1 year of experience but is knowledgeable about the theory, rationale, contraindications, and other issues regarding splinting, the OT can still establish service competency. If the OT has evaluated the OTA's ability and skills in splinting and believes that he or she is competent, and there are collaborative discussions addressing which clients receive splints, the types of splints to use, and other related questions, then supervision may look more like a professional dialogue and interaction.2
AOTA describes supervision as a "mutual undertaking between the supervisor and the supervisee that fosters growth and development..." (p. 592).2 This collaboration benefits service recipients by enhancing the education and clinical skills of both the OT and the OTA.
Statement: There is little value in demonstrating to OT students how to provide supervision to OTAs because they will learn it on the job.
Myth: Many OT/OTA teams don't work well because they don't understand each other's roles, responsibilities, and skills. Establishing the basics of this relationship during their education will help practitioners work together, particularly in settings where good models for this relationship do not exist.
Statement: The decision regarding who should do a specific assessment should be based on experience, theory base, and regulatory requirements.
Reality: According to AOTA's Commission on Practice, evaluation refers to the process of obtaining and interpreting data necessary for intervention, and assessment refers to specific tools or instruments used during the evaluation process.6 The OT is responsible for completing the comprehensive evaluation of a client's occupational performance issues. This evaluation may require specific, detailed assessments. An OTA can assist with the data collection, provided the OT has established his or her service competency. The OT must be confident that the assessments will be administered in the standardized manner by the OTA, and that the results will be gathered safely and effectively. During this process, the OTA will always require some level of supervision, based on experience. The decision regarding which assessments may be helpful would be determined solely by the OT or collaboratively with the OTA. The OTA role does not include independently evaluating a client's occupational performance.4
Statement: Theory base and the ability to interpret evaluation results are good definers of the difference between an OT's and an OTA's education.
Reality: According to "Standard IV: Evaluation" in the Standards of Practice for Occupational Therapy,5 "A registered occupational therapist analyzes, interprets, and summarizes assessment data to determine the client's current functional status and to develop an appropriate intervention plan. The certified occupational therapy assistant may contribute to this process under the supervision of a registered occupational therapist" (p. 867).
Statement: Good communication involves the occupational therapist telling the occupational therapy assistant what to do clearly and precisely.
Myth: According to "Standard I: Professional Standing and Responsibility" in the Standards of Practice for Occupational Therapy,5 "A registered occupational therapist provides supervision for a certified occupational therapy assistant in a collaborative manner...." (p. 866) In cases where the OTA has more experience than the OT, the OT has an ethical responsibility to take advantage of this knowledge. Principle 4G of the Code of Ethics(2000)1 states that "Occupational therapy practitioners shall refer to or consult with other service providers whenever such a referral or consultation would be helpful to the care of the recipient of service...."
Statement: Occupational therapists do not do activities of daily living assessments.
Myth: The Occupational Therapy Roles4 document states that the OT "screens individuals to determine the need for intervention" and "evaluates individuals to obtain and interpret data necessary for planning intervention and for intervention" (p. 1088).
Statement: If you do not create an effective team immediately, it is too late.
Myth: The most effective way to begin creating an effective team of occupational therapy practitioners is to look at the experiences and skills of each person. The OT and OTA will have different education and skills. Both will be responsible for following our profession's official documents. The Code of Ethics (2000)1 states that this is the responsibility of boththe OT and the OTA. If a third party is needed to facilitate effective communication and agreement, then both the OT and OTA must seek this support. Knowledge of the roles of each member of the profession will enhance our ability to collaborate, which is why knowledge = power.
CONCLUSION
The Occupational Therapy Code of Ethics (2000)1 guides the collaboration between occupational therapists and occupational therapy assistants, as well our practice decisions. The ability to think clearly and incorporate accurate, current resources into our professional problem solving is critical to our success as occupational therapy practitioners. We have a valuable resource in all of our official documents, which guide us, support us, and empower us.
References
1. American Occupational Therapy Association. (in press). Occupational therapy code of ethics (2000). American Journal of Occupational Therapy.
2. American Occupational Therapy Association. (1999). Guide for supervision of occupational therapy personnel in the delivery of occupational therapy services. American Journal of Occupational Therapy, 53, 592-594.
3. American Occupational Therapy Association. (1999). Guidelines for the use of aides in occupational therapy practice. American Journal of Occupational Therapy, 53, 595-597.
4. American Occupational Therapy Association. (1993). Occupational therapy roles. American Journal of Occupational Therapy, 47, 1087-1099.
5. American Occupational Therapy Association. (1998). Standards of practice for occupational therapy. American Journal of Occupational Therapy, 52, 866-869.
6. American Occupational Therapy Association. (1995, July 13). Commission on Practice clarifies terms. OT Week,p. 10.
FOR MORE INFORMATION
Making Connections With Others: A Handbook for Interpersonal Practice
By D. Davidson & S. M. Peloquin, 1998. Bethesda, MD: American Occupational Therapy Association. (Participant and facilitator manuals available. $28 for members; $35 for nonmembers. To order, call toll free 877-404-AOTA.)
OTA Information Packet: A Guide for Supervision
By the American Occupational Therapy Association. Bethesda, MD: Author. ($15 for members, $18 for nonmembers. To order, call toll free 877-404-AOTA.)
OTA/OT Education Unit
By the American Occupational Therapy Association, 1997. Bethesda, MD: Author. ($10 for members and nonmembers. To order, call toll free 877-404-AOTA.)
Reference Guide to the Occupational Therapy Code of Ethics
By the American Occupational Therapy Association, in press. Check AOTA's Web site at www.aota.org for updates.
David A. Leary, MS, OTR, is an occupational therapist with more than 10 years' experience in the field of physical disabilities, geriatrics, and management. He has taught part time in the OTA program at Mount St. Mary's College and is currently a faculty member at the University of Southern California. He has extensive teaching experience in the academic and clinical settings and has a strong commitment to implementation of professional guidelines regarding role delineation and supervision. He has served on the OTAC Education Committee in 1994 and has been an active member of OTAC and AOTA since 1988.
Jackie Mardirossian, BS, COTA, AP, is a certified occupational therapy assistant with more than 15 years' experience in the field of physical disabilities, mental health, pediatrics, and education. She was academic fieldwork coordinator and lecturer at Mount St. Mary's College and is currently Clinical Administrator of the Occupational Therapy Faculty Practice for the Department of Occupational Science and Occupational Therapy at the University of Southern California. She is the AOTA COTA State Contact Person for the state of California and on the AOTA Education SIS Nominating Committee. Locally, she is the associate director of the San Gabriel Valley Chapter of OTAC.
