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PROMOTING QUALITY PRACTICE
Professional Obligations and Conflict Resolution
College of Occupational Therapists of Ontario
May 1998
Practice Scenarios:
1. A depressed client on a psychiatric unit has been referred by the attending psychiatrist to OT for an identified goal which involves attendance at the OT Lifestyles Group. On completing the OT assessment which included determining the client's priorities, reviewing the OT findings with the client and explaining the purpose of the group, the client adamantly refuses to attend the group.
2. A referral is made to a home care OT for a wheelchair assessment. On completing the assessment, the OT recommends a manual wheelchair. The client is very angry; he only wants an electric wheelchair. The OT, using her best professional judgement, believes this is not warranted and explains the reasons to the client. The client still insists on an electric wheelchair. ADP would be funding the wheelchair.
3. A client with a history of congestive heart failure is referred to an OT for energy conservation techniques education. The OT completes the assessment which includes determining the client's values and goals, and gains consent for the treatment intervention. The OT starts by discussing re-organization of the client's kitchen. The client becomes angry and states she is not willing to change her life.
4. An OT working within the insurance industry sector is asked by her employer to modify her written report and change her recommendations. The employer is insistent; he is concerned about maintaining his working relationship with the insurance company.
Probing Questions
1. What is the responsibility of the OT when she/he encounters a primary clinical client or other relevant stakeholder who does not accept the OT's professional judgement/opinion or whose lack of compliance with the proposed treatment plan could be perceived as uncooperative or unmotivated, despite the best intervention on the part of the OT?
2. What strategies could the OT use to deal with these conflicts?
3. Should the OT reflect on his/her proposed intervention? Should the OT review the expectations and priorities of the primary clinical client, as well as other stakeholders? Should the OT take into account the evidence for the proposed intervention?
4. Has communication with the primary clinical client been adequate? Has the client consent for the intervention been obtained? Is this being respected?
5. Has the OT's communication with all stakeholders (referral source, employer, etc.) been adequate?
6. When is it appropriate to transfer the primary clinical client to another therapist or discharge the client?
7. What is adequate documentation in these situations?
College Response
Whenever people work together, regardless of the setting, there is certainly the potential for conflict. Today, conflict is often viewed as negative – associated with stress, tension, and anger. However, conflict can be of value: it can result in more effective solutions for all stakeholders involved.
Deciding how best to approach a potentially controversial situation is a complicated task. While certain principles must be taken into account, each situation is unique and must be considered in context and requires the therapist to use his or her professional judgement and skills. Consultation with and support from peers and/or the College to clarify the issues and possible approaches to resolve the conflict may be appropriate.
Professional Obligations
Occupational therapists practise in a client-centred manner. In the provision of occupational therapy
services, OTs are often accountable to multiple clients. While
the needs of all stakeholders must be considered, the primary
client remains the recipient of direct clinical care. OTs have
a standing duty to respect and promote the free choices of competent
primary clinical clients. These clients have the right to receive
and to refuse a therapeutic intervention to make choices
consistent with their own values. An OT cannot, in general, substitute
his or her wishes and preferences for those of a competent primary
clinical client, even if what the OT wants seems more likely
to promote the person's best interests. This approach is supported
by the College's professional misconduct regulation, code of
ethics, Standards of Practice, as well as legislation (Health
Care Consent Act) and case law.
However, 'clashes' between the client's preferences and the OT's or other stakeholder's view of the client's best interest, do arise and unfortunately are not uncommon. This does not mean the OT does nothing or automatically follows the client's wishes if the client's wishes conflict with the OT's professional recommendations. The client has been referred to the OT for his or her professional opinion and most likely does not expect to have his or her wishes automatically granted. However, in all cases, the OT must use reasonable care, skill and judgement to balance the client's wishes, his or her professional need to 'do what is best for the client', and ethical, regulatory and legal obligations. The OT has an obligation as a professional to further question and negotiate with the client or other stakeholders to clarify issues and to problem solve. Clear communication, preferably in writing, to all stakeholders is essential.
Note, the health practitioner is not
obligated to respect the wishes of a client if the wishes place
the practitioner in a position that would be considered "engaging
in conduct or performing an act that would reasonably be regarded
by members as disgraceful, dishonourable, or unprofessional" (Item 28, Professional Misconduct Regulation).
This could include such client-requested actions as assisting the client with self-destructive urges or illegal activities (e.g. assist patient with suicide), breaching confidentiality, practising while in a conflict of interest, providing a report that does not accurately reflect the OT's professional judgement, recommending equipment that is not appropriate for the client, and so forth.
In summary, comprehensive clinical practice is a complicated task. The OT is expected to respect client autonomy and the right to consent to treatment, but not to forget his/her own independent professional judgement. In properly exercising that professional judgement, the OT must know not only when to respect the client's wishes and help him/her achieve their goals, but also know when to avoid contravening ethical, regulatory and legal obligations.
Conflict Resolution
When the OT and the primary clinical client or other stakeholders clash, unnecessary power struggles or simply conceding to the clients expectations should be avoided. Anticipating potential conflicts may often assist in preventing problems before they arise. If they should occur, the OT should aim to maintain neutrality.
Principled negotiation should be attempted. A common ground should be sought through mutual understanding, respect, and clear communication. The client's feelings, expectations, worries, and – due to illness – changing functioning in the world, should be examined. The OT would be better to devise/revise a treatment plan that combines the client's wishes with the OT's obligations.
Effective communication is one of the best means to prevent conflicts. The Sexual Abuse Prevention Guidebook outlines practical suggestions for effective communication in all practice settings. Guideline 6: Effective Communication suggests the following:
- continually explaining the assessments or procedures in advance;
- explaining how the assessment or procedure will benefit the client;
- summarizing what has been done and the client's on-going responsibility;
- asking the client to 'play-back' his/her understanding of what is/will be happening and why.
Explaining and understanding the client's or other relevant stakeholder's concerns, even when they cannot be resolved, results in significant decreases in anxiety and minimizes the possibility of conflicts.
Once a conflict has arisen, a problem-solving approach to the negotiations is most likely the most effective approach. Other approaches – such as avoidance, smoothing over the conflict, forcing the conflict, or compromising – tend not to be as effective.
This approach is set out in Standard 4 of the College Standards of Practice. A problem solving approach involves diverse viewpoints being taken into account, issues being clarified, and constructive feedback being given and sought. It is incumbent upon the OT to state her or his views about the issues under consideration in clear, non-judgmental language. The core issues must be sorted out – areas of agreement from areas of non-agreement. The OT must listen carefully to each person's point of view, periodically checking for understanding of the disagreement by re-stating the core issues in her or his own words.
Tactics for conflict intervention include organizing a meeting, preferably face-to-face, with all relevant stakeholders, including the client and:
- carefully preparing for meeting, including prepared written materials setting out the rationale for the proposed service;
- using interactive listening and constructive feedback skills throughout the meeting;
- helping all participants to hear and understand the key elements of the conflict;
- try to help uncover the core issues in the conflict and move the participants to a resolution (which may include alternatives to occupational therapy).
However, in some situations, where the OT and the client or other stakeholders are unable to resolve the conflict, despite the best efforts of the OT, discharging and transferring the client to another OT should be considered. Discharge should take place thoughtfully and slowly – the client should be informed of the potential transfer in advance, the reasons, and be assured that the second OT will approach the client in a neutral manner. Discontinuation of treatment should take place only in accordance with item #6 in the Professional Misconduct Regulation.
Comprehensive documentation, including dated written summaries of conversations (kept by the OT) and follow-up memos or letters to the client and client-approved stakeholders, are recommended. This is to ensure common understanding of the issues by all parties.
Responses to Scenarios
1. OT is obligated to review the client's decision with the client. If the client continues to refuse to consent to attend the group, the OT should continue to professionally (in a polite and positive manner) seek alternative means to achieve the goals developed jointly by the client and OT. The OT must inform the referral source of the current treatment goals and plans, including the rationale for the proposed intervention. Should the client refuse to participate in any planned activities, the OT should respect the decision of the client and inform the referral source and the team. This is not an issue where the OT would be placed in a position where she or he would be contravening an ethical, regulatory or legal obligation.
2. This is a difficult situation, especially as ADP has explicit criteria for funding. The OT is obligated to review the issues with the client, perhaps even requesting a second or third opinion from an OT with greater expertise in seating assessments, to review or meet with the client, or ask the client to contact ADP directly. If the client is willing to pay privately for the wheelchair, the OT is obligated only to ensure there are no safety risks to the client and that the related costs are carefully explained. The OT would be contravening the professional misconduct regulations to prescribe the electric wheelchair if safety concerns existed or the costs were not thoroughly outlined.
3. The OT must recognize the impact of the illness on the client and should professionally review the goals with the client. Perhaps starting with another area would be more appropriate. Should the client continue to refuse the planned intervention, the OT should respect the decision of the client and inform the referral source. Again, this is not an issue where the OT would be placed in a position where she or he would be contravening an ethical, regulatory or legal obligation.
4. The OT has been asked for her professional opinion. In this situation, problem-solving could include seeking clarification from the employer of the outstanding issues and engaging in dialogue to ensure that the report is clear – for example, the OT assessment is clearly documented (including the evaluation measures used and the results), the recommendations are reflective of the OT assessment, the rationale for the recommendations are clearly set out, and the report is within the scope of the OT's role. If the OT is satisfied that the report is reflective of her or his independent professional judgement and the above issues are clearly articulated, the report should not be modified. If modifications to a report (e.g., correction of factual information) are considered necessary by the author after the report has been distributed, these should only be accomplished through the use of addendums. Copies of the addendum should be sent to all recipients of the original document.
The information in the Promoting Quality Practice column applies to all practice sectors. Again, occupational therapists must be objective, transparent and clear in all dealings with clients.
Your response to this practice scenario is appreciated. Please contact Elaine Kuretzky, Manager, Quality Programs, or Susan James, Director of Professional Practice, with your comments (telephone number: 416-214-1177, or 1-800-890-6570).
Resources:
- * College of Occupational Therapists of Ontario – Professional Misconduct Regulation, 1993
- * College Code of Ethics, 1996
- * College Standards of Practice, 1996
- * Health Care Consent Act, 1996
- * College – A Guide to the Health Care Consent and Substitute Decisions Legislation for Occupational Therapists, 1996
- * College Sexual Abuse Prevention Guidebook, 1996
References:
Hebert, P. Doing Right, A Practical Guide to Ethics for Medical Trainees and Physicians. Toronto: Oxford University Press, 1996
Scholtes, P., Joiner, B., Streibel, B. The Team Handbook, Second Edition. Madison: Joiner Associates Inc., 1996
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