7/02/01
Successful OT-OTA Partnerships: Staying Afloat in a Sea of Ethical Challenges
Pam Toto and Diane M. Hill
Your employer reduces the occupational therapist's hours to part-time status for "evaluations only" while increasing the use of occupational therapy assistants to provide all direct patient treatment in efforts to reduce costs....
The occupational therapist, who also serves as the department head, regularly reduces the hours of the occupational therapy assistant when productivity and census are low so that she can maintain her own full-time status....
Your employer no longer reimburses you for time not spent providing direct patient care; OT-OTA supervision must be completed on your own time and at your own expense....
Do any of these scenarios sound familiar? If so, you are not alone. Dramatic changes in our health care system, especially those related to reduced reimbursement, have perpetuated unanticipated conflicts and issues among teams at all levels in the health care field. Since the surge of practitioners entering the profession, and perhaps even earlier, occupational therapy leaders have struggled to define specific roles for occupational therapists and occupational therapy assistants in traditional health care models. Emerging and expanding practice areas, as well as new holistic approaches to existing health care programs, further challenge one's ability to define this unique partnership. For many occupational therapy practitioners, these changes in practice have affected relationships, communication, and even ethics. In her book Occupational Therapy Leadership, Grace Gilkeson, EdD, OTR, FAOTA, wrote, "Change is inevitable, but how you handle it makes all the difference between success and failure, satisfaction and disappointment" (p. 158).1
OT-OTA collaboration can be powerful when both parties embrace ethical and legal decision-making and problem-solving processes. This affirmative partnership can be successful as long as all practitioners have a common set of values in their therapeutic relationships and use of self. The American Occupational Therapy Association (AOTA) provides practitioners with guidelines for ethical practice through the AOTA Occupational Therapy Code of Ethics (2000).2 This document, combined with specific state regulations, provides a framework through which effective OT-OTA partnerships can be established and maintained. The following examples are common situations that may challenge professional ethics and the relationship of OT-OTA teams in practice. Solutions and strategies for maintaining strong and healthy OT-OTA partnerships also are offered.
SUPERVISION CHALLENGES
An occupational therapist has regularly been traveling among her company's inpatient, outpatient, and home health departments to complete evaluations and discharges. In each of these settings, occupational therapy assistants regularly provide all treatment. Because of limited time and scheduling conflicts, the occupational therapist rarely performs her supervisory role; she frequently cosigns notes without reading them, does not provide input on changes to the treatment plan, and relies on the occupational therapy assistants to determine independently when discharge is appropriate.
This situation addresses ethical and legal supervision issues, role delineation, and whether current practice patterns facilitate the best and most efficient patient care (Occupational Therapy Code of Ethics, Principle 5). Overriding these issues is the certainty that this OT-OTA team lacks, at the very least, effective communication.
Communication is one of the most critical variables for effective OT-OTA relationships, yet current practice trends offer significantly reduced opportunities for traditional methods of sharing information. One of the simplest ways for occupational therapists and occupational therapy assistants to communicate efficiently is through hands-on client care opportunities. If a picture is worth a thousand words, a treatment session is worth a million words!
Establish systems to ensure that the occupational therapist provides hands-on treatment at least once a week or on a regular basis for each client. In environments where the clients do not change quickly, such as long-term-care settings, consider switching caseloads 1 day per week or rotating workdays or work times for part-time employees. If the occupational therapist has time constraints that prohibit caseload changes, consider splitting the client's treatment session between the occupational therapist and the occupational therapy assistant, with the occupational therapist addressing those issues that most significantly affect goal changes and treatment plan upgrades. Providing opportunities for the occupational therapist to actually observe changes in function instead of relying on second-hand information for documentation and discharge planning can foster efficient communication between team members.
The pressure to maintain productivity standards sometimes seems to "force" practitioners to choose between direct client care and indirect, yet vital, communication. Practitioners should try to maintain more constant productivity percentages by managing and monitoring treatment caseloads throughout the week, thus allowing consistent productivity with adequate time for nonbillable necessities. It is also prudent to explore the many different modes of communication readily available as alternatives to face-to-face discussion. For example, storing information in a central, secure area or a communication book allows efficient access by all team members. Checklist notes and communication boards further increase efficiency by providing easy visual status of both direct and indirect client information. OT-OTA teams may also choose to create checklist forms to manage documentation and billing details or to ensure that all goals and performance areas and components are being addressed. (Not doing so is a common error when multiple clinicians are managing caseloads.) Laminated, wall-mounted communication boards can provide interdisciplinary team members with valuable information regarding evaluation and discharge dates, day and treatment minutes, and caseload assignments. E-mail and voicemail allow clinicians to exchange clinical information at their convenience. These alternatives, as well as regularly scheduled telephone conferences, reduce wasted time from playing "telephone tag" and interruptions during valuable direct client care.
SCOPE OF PRACTICE CHALLENGES
The occupational therapy assistant is the only full-time therapy practitioner providing services in one specific school-based setting. As such, he serves as the occupational therapy representative at family meetings and interdisciplinary team conferences. Often, due to their lack of knowledge, parents and faculty members refer to the assistant as the "occupational therapist" and seek his judgment on issues that affect the entire operation of occupational therapy services at the school. Because of time factors and the need for others to have immediate information, the occupational therapy assistant feels obligated to address all issues as they arise. As a result, the occupational therapist, who travels to several schools and, thus, spends limited time in any single setting, feels as though she is "out of the loop" and is angry that the assistant is assuming roles that she believes are beyond the scope of practice for an occupational therapy assistant.
Ethics can be challenged when practitioners assume roles not representative of their credentials (Occupational Therapy Code of Ethics, Principle 6A). Conversely, practitioners must acknowledge and permit fellow team members to explore all opportunities that are within their scope of practice as defined by AOTA3 and state regulations.
The complex elements required for effective teamwork can challenge even the strongest OT-OTA partnerships. The best way to resolve conflict is to anticipate issues and avoid problems through clearly established roles and responsibilities. In a 1999 OT Practice article, Barbara Hanft, MA, OTR, FAOTA, and Barbara Banks, COTA, identified expectations of occupational therapists and occupational therapy assistants that must be met for success in teamwork.4 Occupational therapy assistants expected occupational therapists to share professional knowledge, help link interventions to meaningful outcomes, provide feedback that the occupational therapy assistant has value, be dependable, and provide tangible supervision. Conversely, the occupational therapist requested that the occupational therapy assistant ask questions, follow the treatment plan, and provide feedback for modifications. It is critical that OT-OTA teams take the time to recognize and address each other's needs.
If conflict arises, assertive communication and negotiation are generally the most effective way of addressing it. Both parties should attempt to keep an open mind, remain relaxed, and agree at the outset to seek a resolution. According to Pat Crist, PhD, OTR, FAOTA, conflict is first noted as a "trigger--any action or word that causes a negative response. Triggers can include body language or gestures (rolling of eyes); a loud stressed voice; physical actions; or even not taking action when it is expected" (p. 5).5 Passive or aggressive behavior can result from triggers or from any situation that causes one to perceive a threat of rejection or disapproval. When dealing with conflict, remain aware of others' trigger points and focus on the issues at hand rather than on negative emotions. Along with respect and active listening, Crist noted that using summary and reflection, incorporating "I" statements to describe the situation (e.g., "I feel..."), expressing your feelings, and noting the change you desire and the expected consequence are advantageous. Conflict is resolved in one of three ways--through authority, compromise, or consensual integration of the disagreeing parties' ideas. Consensus is the best choice in terms of team satisfaction but, unfortunately, is also the most difficult and time consuming. The sooner conflicts are managed, the easier the resolution. In this example, the occupational therapist and occupational therapy assistant should work together to identify the various job responsibilities crucial to success in this setting. Keeping their respective scopes of practice in mind, they should determine which roles are best suited for each. They will need to communicate this information to the school administrators and establish strategies to meet the needs of parents, students, and fellow professionals in a timely fashion. Lastly, the occupational therapist and occupational therapy assistant should establish a system to improve communication within their department, with an additional commitment to remain open-minded and address issues as they arise.
NOVICE PRACTITIONER CHALLENGES
An occupational therapy department in an acute care hospital recently increased service availability from 5 days per week to 7 days per week. The department supervisor has left the task of determining work schedules up to the staff. Occupational therapists and occupational therapy assistants with the most seniority have exerted their influence in this decision-making process, and as a consequence, the new graduate therapist and entry-level assistant regularly are left to work alone on the weekends. Although these novice clinicians have expressed their concern over a lack of guidance and mentorship, as well as frustration with permanent weekend duties, their complaints have not been answered.
This situation presents several concerns. From an ethical standpoint, the practitioners who are forced to work weekends regularly do not believe that they are receiving adequate supervision (Occupational Therapy Code of Ethics, Principle 4F). Additionally, respect for fellow team members has been replaced by personal working preferences. For OT-OTA teams and departments to develop and maintain healthy relationships, a commitment to flexibility is crucial. At a minimum, flexibility must be examined from the two key aspects of scheduling and work hours. Scheduling considerations include seeing clients at the best time of the day to meet the client's goals (e.g., seeing a client in the morning for activities of daily living [ADL] retraining) and allowing opportunities to share caseloads. Depending on the work setting, opportunities may arise to develop creative schedules that meet clients' needs more effectively. For example, when providing therapy in a skilled nursing facility, the most valuable treatment interventions may require practitioners to alternate disciplines and treatment days, save their minutes, or barter for minutes with other disciplines to provide a complete occupation-based treatment session. One comprehensive session that addresses a specific performance area in an appropriate context may meet client-centered goals more effectively than several short sessions that only allow enough time to focus on limited performance components.
Often, the distribution of duties is lopsided, with the occupational therapy assistant performing most or all of the direct client care. By caseload sharing, an OT-OTA team commits to establishing a balance of duties involved with daily practice at a given site. This balance results in improved communication and enables both the occupational therapist and the occupational therapy assistant to enjoy other aspects of the job, such as program development, interdisciplinary team participation, and administrative functions.
For many veteran clinicians, the end of the traditional work schedule has been one of the hardest new trends to accept. OT-OTA teams must continuously analyze admission patterns and schedule workdays and hours to provide the best treatment at the best time to meet their clients' goals. Some facilities may regularly schedule admissions in late afternoon, which might mean that the occupational therapist needs to start the workday later. A caseload may be heavy with clients who require ADL retraining, and thus, the occupational therapy assistant may need to start work earlier than usual. Weekend and evening services should be rotated, or positions should be established and marketed as permanent off-hours assignments. Occupational therapy practitioners should also remain cognizant of legal and ethical obligations regarding entry-level practitioners. Teaming new clinicians with more experienced therapists and assistants not only will minimize supervision issues, but will also facilitate learning opportunities for both parties. As new graduates "learn the ropes" from their counterparts, senior clinicians may gain exposure to the current theories, new assessment techniques, and emerging trends in occupational therapy education. Flexibility demonstrates commitment to the profession and respect for colleagues. Remember, it is better to bend than to break.
MAINTAINING COMPETENCY CHALLENGES
The occupational therapy department staff in a local skilled nursing facility has been reduced from six practitioners to one full-time occupational therapist and one full-time occupational therapy assistant. They consider themselves to be "survivors," having maintained employment and a commitment to their profession in spite of the many changes in reimbursement, documentation, supervision, and service delivery as a result of implementation of the prospective payment system (PPS). After the turmoil associated with PPS, they welcomed the renewed sense of normalcy and routine. However, this OT-OTA team now finds itself in somewhat of a rut. Each day seems remarkably the same as the pattern of meetings, documentation procedures, and treatment regimes is repeated; the budget no longer provides for continuing education; the employer does not reimburse for membership in professional associations; and there never seems to be time for program development. A profession that once offered novelty and excitement to these practitioners now seems monotonous.
As with an optimist who sees the glass half full, so too can practitioners embrace change as an opportunity for improvement. In the March 1999 issue of the AOTA Gerontology Special Interest Section Quarterly, Pamela Lindstrom, MS, OTR/L, and Jennifer Westropp, MS, OTR/L, provided an explicit example of using change as a catalyst for revitalization.6 They challenged practitioners to change their work environment to make it easier to engage in meaningful occupation-based treatment interventions. As part of their transformation, they rearranged supplies and physical space for activities and secured items such as clothing, horticulture materials, golfing equipment, and board games to help clients participate in meaningful tasks. They also created kits with supplies already assembled for occupation-based activities, such as grooming. These kits greatly reduced the time needed to set up activities. By facilitating a more occupation-based work environment, these authors improved service delivery and job satisfaction.
A commitment to excellence in occupational therapy requires us to examine our skills, practice patterns, and relationships continuously to define ways to maintain competency (Occupational Therapy Code of Ethics, Principles 4C and 4D). The value of new learning through continuing education or networking opportunities through membership in professional organizations may far outweigh their financial costs. OT-OTA teamwork presents an advantage to those seeking meaning and excellence in their practice through the sharing of knowledge and ideas. As the saying goes, "Two heads are better than one!"
CONCLUSION
Despite the challenges, OT-OTA teamwork is more critical than ever for advocacy and success in today's health care environment. As scrutiny increases over the efficacy of rehabilitation, including occupational therapy, occupational therapists and occupational therapy assistants must maintain healthy partnerships that enable the team to demonstrate the necessity of occupation to well-being. As our state and national professional associations work to improve OT-OTA role delineations and guides to practice, so too must we commit to engaging in team practice patterns that promote excellence in care and ensure viability of this essential partnership.
References
1. Gilkeson, G. (1997). Occupational therapy leadership. Philadelphia: F. A. Davis.
2. American Occupational Therapy Association. (2000). Occupational therapy code of ethics (2000). American Journal of Occupational Therapy, 54, 614-616.
3. American Occupational Therapy Association. (1993). Occupational therapy roles. American Journal of Occupational Therapy, 47, 1087-1099.
4. Hanft, B., & Banks, B. (1999). Competent supervision: A collaborative process. OT Practice, 4(5), 31-34.
5. Crist, P. (1998, February 16). Hearing, understanding, resolving. Advance for Occupational Therapists, 5.
6. Lindstrom, P. R., & Westropp, J. (1999). Renewed energy following an epiphany at Annual Conference. Gerontology Special Interest Section Quarterly, 22(1), 1-3.
FOR MORE INFORMATION
Guidelines to the Occupational Therapy Code of Ethics
By the American Occupational Therapy Association, 1998. American Journal of Occupational Therapy, 52, 881-884.
Guidelines for the Use of Aides in Occupational Therapy Practice
By the American Occupational Therapy Association, 1999. American Journal of Occupational Therapy, 53, 595-597 [correction: 54, 235].
Guide for Supervision of Occupational Therapy Personnel in the Delivery of Occupational Therapy Services
By the American Occupational Therapy Association, 1999. American Journal of Occupational Therapy, 53, 592-594 [correction: 54, 235].
OTA Information Packet: A Guide for Supervision
By AOTA's Practice department, 1995. Bethesda, MD: American Occupational Therapy Association. ($20 for members; $25 for nonmembers. To order, call toll free 877-404-AOTA.)
OTA-OTR 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
Edited by P. Kyler, 2000. Bethesda, MD: American Occupational Therapy Association. ($20 for members; $25 for nonmembers. To order, call toll free 877-404-AOTA.)
Pam Toto, MS, OTR/L, BCG, is an adjunct instructor at the University of Pittsburgh and Philadelphia University. She also provides occupational therapy services as a direct care provider in home health care and completes functional assessments as part of a National Institutes of Health-funded research project through the Mind-Body Research Center at the University of Pittsburgh Medical Center. Pam is the current editor of the Gerontology Special Interest Section Quarterly and the state secretary of the Pennsylvania Occupational Therapy Association.
Diane M. Hill, COTA/L, AP, is a direct care provider at an adult living community, Longwood at Oakmont, in a suburb of Pittsburgh, Pennsylvania. She is a member of the AOTA Standards and Ethics Commission and Advance Practice Program Committee.
She has 14 years of experience as a practitioner and has earned the AOTA AP (advanced practitioner) credential in the specified area of geriatrics.
The authors co-wrote the article "OT/OTA Team Building in the SNF Environment: Meeting the Challenge" for the June 2001 issue of theGerontology Special Interest Section Quarterly.
