VA Recognizes World AIDS Day

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Medical Facilities Promote HIV Testing and Care

 

WASHINGTON – The Department of Veterans Affairs is observing World AIDS Day on Thursday, Dec. 1, the 30th anniversary of the identification of the disease caused by the human immunodeficiency virus (HIV).  Some of the first cases of HIV/AIDS (acquired immunodeficiency syndrome) were seen by VA clinicians.  Since then, VA has continued to be a national model for outstanding HIV care and has made significant strides in treatment of Veterans infected with the virus.
“The Department of Veterans Affairs is a leader in this important area of health care and continuing to provide world-class care to Veterans with HIV/AIDS,” said Secretary of Veterans Affairs Eric K. Shinseki.  “Significant progress in HIV diagnosis, treatment, and research has been made at VA.  The Department will continue to strive to provide excellent care to all Veterans infected with the virus.”

VA is the largest provider of care in the country to those living with HIV, serving more than 24,000 Veterans with the infection.  The VA is one of the lead federal agencies implementing the National HIV/AIDS Strategy to strengthen and coordinate a national response to the domestic HIV/AIDS epidemic.

In the 30 years since HIV/AIDS was discovered, significant progress has been made in the fight against this disease. Patients can expect to live longer, healthier lives if they have access to and are adherent to antiretroviral therapy for their HIV infection. For example, 91 percent of Veterans with HIV who are candidates for antiretroviral therapy are currently on treatment and more than 96 percent of newly HIV-positive Veterans were linked to care within 90 days of diagnosis.

The federal government’s theme for this year’s World AIDS Day is “Leading with Science, Uniting for Action.” VA is a leader in research on HIV and aging through the large-scale Veterans Aging Cohort Study, run by Dr. Amy Justice at the VA Connecticut Healthcare System.  More than 50 percent of Veterans with HIV are over the age of 50.  The average age of the HIV-positive patients in the VA is about 15 years older than the HIV-positive patients in the rest of the U.S.  By better understanding how HIV affects other non-HIV related illnesses, the Veterans Aging Cohort Study will help to prepare the rest of the nation to care for the aging of its HIV-positive patients.

VA has increased its outreach for HIV testing, ensuring that all Veterans with HIV receive high-quality care, and continue to reduce any health disparities.  VA has also made HIV testing of all Veterans part of routine care with the goal of having all Veterans in care tested at least once.

For more information on HIV/AIDS care in VA, please visit www.hiv.va.gov.

The “ethic of care” in physical therapy practice and education: Challenges and opportunities





Journal of Physical Therapy Education January 1, 2000 | Romanello, Mary ABSTRACT. Numerous forces affect the development of caring relationships between health care practitioners and their patients. The purpose of this article is to use moral philosophy to elucidate and discuss care and caring as we explore what it means to practice an ethic of care in the physical therapy work environment. We discuss the importance of an ethic of care to physical therapy practice, the barriers to an ethic of care found in contemporary physical therapy work, and considerations for educators attempting to develop an ethic of care in physical therapy students. Though we recognize the difficulty in building and maintaining caring relationships with patients in the present health care environment, we believe health care dynamics necessitate that we combine scientific and moral knowledge with caring skills in order to discover forms of physical therapy practice that consider the patient first while achieving physical therapy outcomes.

Key Words: Care, Ethic, Physical therapy.

The terms “care” and “caring” are important ethical concepts in our professional terminology, as is evidenced by their use in professional guides and language. Physical therapy practitioners often use the word “care” in discussing how we provide physical therapy services. We develop plans of care that give direction to treatment, and we consider ourselves members of a health care team. In the American Physical Therapy Association (APTA) Guide for Professional Conduct,1 intended to help APTA members interpret the Code of Ethics,2 principle 1.1 regarding attitudes of physical therapists states that physical therapists are to be guided by concern for the physical, psychological, and socioeconomic welfare of those individuals entrusted to their care. Although we use the term “care” in our discussions and references to physical therapy practice, the term evokes multiple meanings. Though the dictionary lists nine meanings of the word “care,” the term can be socially constructed to have many more meanings or interpretations. A few examples include: to have cares or worries, to grieve, the object of attention, and caution in avoiding harm or danger.3 The concept of caring wields much influence in the physical therapy profession, but it is often a vague and unspecific descriptor of our ethical obligations to patients.

Our purpose here is to use moral philosophy to elucidate and discuss an ethic of care, and what it means to practice an ethic of care in a physical therapist’s work environment. In doing so, we draw from the theories of care that have been a powerful influence in moral philosophy for almost two decades.4-11 After describing the importance of the ethic of care to the practice of physical therapy, we extend our discussion to explore the barriers to an ethic of care confronting physical therapy clinicians and educators practicing in contemporary work settings. We argue that, increasingly, the ethic of care is being replaced in practice by a simple, though inadequate, professional ethic based on benevolence. We conclude with suggestions for re-establishing the importance of, and the knowledge base relating to, the ethic of care in physical therapy education and practice.

INTRODUCTION TO AN ETHIC OF CARE Care Literature in Philosophy Traditionally, ethics has been the domain of duties and rules. One leading ethicist wrote that the typical approach to ethical dilemmas is a two-step process: we locate a rule (eg, “do this,” “avoid that”), and then we assume or judge that it applies to our situation.12 Professional ethics in Western philosophical thinking has been the terrain of following correct ethical rules as set forward by professional role and professional cultures. Professional codes of ethics exist, but these rules are often too vague or broad to help us in our daily moral dilemmas. Examples from the APTA Code of Ethics include principle 3, “Physical therapists accept responsibility for the exercise of sound judgment,”2(p1) and principle 4, “Physical therapists maintain and promote high standards for physical therapy practice, education, and research. “2(p1) These rules give us little practical guidance for dealing with the everyday moral choices of physical therapy practice. In addition, the Code of Ethics2 only suggests for physical therapists to act benevolently, showing kindness toward the patient, and to demonstrate beneficence by promoting the patient’s good as a requirement for right action. Codes of ethics often provide general rules that represent the general commitments of a profession, but they are neither self-justifying nor self– clarifying. 13 These rules do not consider specific contexts or circumstances, nor are they clear in dictating right acts between two or more conflicting goods. Codes are important, but inadequate, lists of moral principles that only partially guide practitioners and educators in our field. go to website physical therapy salary

With the emergence of women’s voices and experiences in philosophy and public life in the 20th century, alternative ethical models began to emerge, challenging the commonly held idea that morality was a domain of laws, rules, and duties. Drawing from traditional female experiences of caregiving, a group of philosophers have successfully refrained ethics not as a set of rules but as a relationship:

There are two parties in any relation: the first member is the “one caring”; the second is “the cared for.” The one-caring is motivationally engrossed or “displaced” in the cared-for. S/he makes it a point to attend to the cared-for in deeds as well as in thoughts. When all goes well, the cared-for actively receives the caring deeds of the one-caring, spontaneously sharing his/her aspirations, appraisals, and accomplishments with him/her. 14(p 109) Caring is an ethical relationship between individuals that involves, according to Nel Noddings,6 receptivity, engrossment, and reciprocity. Receptivity is the act of receiving the cared-for and understanding their reality through displacing one’s own motivational energies. Engrossment refers to the motivational shift that occurs when the one-caring receives the feelings of the cared-for and attempts to “see and feel with the other.”6(p30) Reciprocity marks a caring relationship in that the cared-for receives the caring deeds of the one-caring through acknowledgments and responses of various kinds. Noddings6 described caring as a dynamic relationship (Figure).

Noddings6 stated that to care for someone is to have an inclination toward him or her, to have a regard for his or her views and interests. There is reception by the one-caring of the cared-for and, in turn, recognition by the cared-for of an attitude of warm acceptance and trust.6(p65) Care in the relationship between the physical therapist and the patient often has been seen as that activity that reflects an attitude of sensitivity to the patient’s deepest values and concerns and constructively addresses them.is As an example, the physical therapist is presented with a patient who is a self-employed businessman and father of two toddlers. He earnestly wants to resolve his physical deficits resulting from his pathology, but admits that time and scheduling are two of possibly many obstacles influencing his recovery process. The expert physical therapist engaging in patient-centered practice listens to the patient’s concerns, uses knowledge of past experiences and ongoing efforts of problem solving to determine the nature of the patient’s problem, and investigates factors surrounding the patient’s life that affect the specific problem. 16 Placing the patient’s pathology in the context of his daily life using an ethic of care, the therapist displaces his or her own motivation to see and feel with the patient, understanding the situation through the patient’s eyes. By centering the treatment plan on the patient’s concerns, the patient will more likely be an active participant in his rehabilitation, thus facilitating his recovery. In developing a caring relationship, the therapist treats the patient with respect, seeks to understand the patient’s goals for treatment, and collaborates with the patient to develop a plan of care that considers the influences the patient’s life experiences have on the rehabilitation process.

Physical Therapy and Related Medical Literature on Caring Scholars of caring and professional practice warn that, in our current environment, the ethic of care is not a widely held institutional value. Institutional practices and professional apathy reinforce what Benner described as the general consideration of care in the United States when she stated that “caring practices continue to be rather invisible, devalued, and typically inadequately accounted for in our institutional designs and public policy.”10(p43) Benner joins other health care researchers who note the challenges to an ethic of care in today’s changing world of health care.17 A host of structural changes in our society have made an impact on physical therapy practice (Table).

In the political sphere, governments concerned with cost-containment are tightening up funds for health services. In the economic sphere, the move to managed care has transformed the medical landscape, shifting fiscal responsibility to the patient and professional. As our society changes, our professional worlds become less personal and more bureaucratic. All of these changes present a challenging environment in which to practice an ethic of care. In their study of nursing practices, Benner and Gordon18 recognized a shift in attitudes away from caring for the patient. They provided evidence that society has moved away from an ethic of care that involves a set of skills, reflections, and activities that allows one to be with and do for another. Instead of an ethic of care dictating health care practices, Benner and Gordon18(p.41) described a society that has developed an idea of care that is more a feeling of generalized benevolence.

Benevolence is, as Frankena described it, “a habit, tendency, or trait of character that one has. It is a way of being that is manifested in action.” 19(p66) Benevolence is a virtue possessed by individuals and involves the simple, but challenging, admonition to do good for others without self-serving motivations. To act benevolently toward a patient, the physical therapist seeks to enhance the patient’s well-being as related to the patient’s health concerns. For example, the therapist wants his or her patients to get well, experiencing less or no pain. The therapist may experience sadness when bad things happen to his or her patients. But benevolence falls short of an ethic of care that allows health care practitioners “to truly and consistently connect with, be with, attend to and do for their patients.”18(p41) A relational ethic of care is a critical component of physical therapy that compels practitioners to construct this relationship with patients as subjects, rather than objects, of the healing encounter. Benevolence is an important virtue, but it is not a sufficient ethic to guide practitioners in today’s work climates. The ethic of care goes beyond benevolence to build a relationship based on the needs and goals that arise out of the physical therapist-patient relationship.

The ethic of care presents an appropriate philosophical and moral grounding for the work of physical therapy. Because physical therapy practice is so embedded in the relationship between therapist and patient, the one-caring as therapist and cared-for as patient offers a useful model for applying the ethic of care to physical therapy work. In working from the ethical domain of caring, the physical therapist, as the one-caring, receives the feelings of the patient through engrossment. The physical therapist assumes a dual perspective, attempting to see things from his or her own as well as the patient’s perspective.9(p25) The physical therapist recognizes the skills he or she needs to address the patient’s problem and his or her own biases toward expected outcomes based on the patient’s age, sex, ethnicity, work status, and other influencing factors. At the same time, the physical therapist must be receptive to the wants and needs of the patient for the caring relationship to occur.

The patient, as the cared-for, accepts the physical therapist’s guidance and assistance in developing, executing, and revising the treatment plan. In recognition of the therapist’s attitude toward him or her, the patient allows the physical therapist to intervene in his or her medical care with the intent to help improve the patient’s physical function. In accepting treatment, the patient reciprocates the caring action by responding to the therapist’s attention and engrossment. The caring relationship is thus completed through the apprehension of caring by the cared-for, the patient. Caring is, in sum, a relational encounter involving the one-caring’s receptivity of the cared-for and the cared-foes reciprocity to the one-caring (Figure). In a caring relationship between physical therapist and patient, the physical therapist demonstrates an attitude that reflects a sensitivity to “the patient’s deepest values and concerns and constructively addresses them.” 15(p2100) Clinical and Educational Issues Involved in an Ethic of Care Constructing More Equitable Relationships: Patient as Subject, Not Object The burden is on the therapist to construct the professional-patient relationship on equitable terms. Lebacqz12(p114) noted that the role of the professional is one of authoritative power, which is given to the professional by society. She stated that professionals have power in that they do not simply fix a patient’s problem, but define the problem as well. 12(p 119) Brody20(pp 1617) discussed the three types of power that physicians and other heaters have in our society: the power of knowledge/training, the power of charisma and personal characteristics that appeal to patients, and the power of social status held by members of the medical profession in our society. Physical therapists wield much authority in working with patients, and this power imbalance between patient and therapist can impede the development of a caring relationship. Pelligrino21 contended that the inequality between the health care professional and the patient must be removed as fully as possible before the humanity of the patient is restored. It is the responsibility of the therapist to diffuse a paternalistic relationship if a caring relationship is to develop. Lebacqz12 stated that “the first priority of a professional ethic must be the restoration of autonomy of the client and liberation of the client from unequal power.”12(p 117) By focusing on patient-centered practice where the patients goals and desired outcome for treatment are central to developing the treatment plan,22 the therapist enhances a more equitable therapist-patient relationship. A therapist-client relationship that gives the patient a voice by listening to the patient and understanding how he or she thinks empowers the patient to fully participant in the rehabilitation process. Such a relationship engages the therapist and the patient to recognize their own as well as the others’ strengths and weaknesses and how each influences the course of treatment. The physical therapist and the patient need to be partners in developing a caring relationship, using each therapist-patient encounter to determine what is of greatest importance to meet the patients goals of treatment. At times physical therapy sessions may address the patients physical needs, whereas at other times the impact of family and societal influences may require attention before further physical progress can be realized. In a caring relationship, responsibility lies with both the patient and the physical therapist. The degree of responsibility possessed by each individual in the relationship is determined by each situational encounter during the course of treatment.

Unfortunately, certain aspects of physical therapy training and education predispose professionals to regard patients as objects of care– people that we must help or cure through use of our knowledge and technical skills-rather than as subjects or participants in a caring relation. Physical therapy professionals frequently enter practice with a scientific mind-set, believing that if we determine the patients problem and establish a plan for the patient to follow, the patient will experience a successful outcome. Professional ethics dictates that many other factors must be considered, primarily the patient and what he or she brings to the encounter. The patient has fears and concerns due to the uncertain outcomes of physical therapy, economic implications for the patient’s family, work pressures, and the limitations of the patient’s lifestyle during the course of rehabilitation. Injuries or disease that cause the patient to be removed from his or her home, school, or work environment can result in the patient feeling disconnected. Sometimes the patient may experience feelings of inadequacy because he or she is unable to meet self-imposed expectations to complete tasks of daily living. Questioning one’s ability to return to his or her “normal” predisability status may weigh heavily on the patient’s mind as he or she experiences the rehabilitation process. Ignoring these issues makes treatment difficult for both the physical therapist and the patient. It is for this reason that a physical therapist, to be an effective practitioner, needs to develop a caring relationship with the patient.

Educating the Caring Practitioner For the therapist to construct such a relationship with a patient, more than scientific knowledge is needed; moral knowledge and skills are required. For a physical therapist to put scientific knowledge to work in an ethical, responsible manner, philosophical knowledge in the field of ethics is necessary. The distinction, for example, between the patient as a subject of treatment versus an object of treatment relies on distinctions in moral philosophy that are critical for an emerging professional to understand when embarking upon a career of affecting patient lives. Physical therapy educators must facilitate and encourage students’ development and use of a discerning, educated eye to make the distinction between one’s ethical duty to not harm a patient and one’s role in a relational ethic of care. Understanding the concepts of engrossment, motivational displacement, and reciprocity requires not only more background in philosophical and ethical knowledge in the classroom, but skill-building and on-the-job training as well. For students and emerging physical therapy professionals to understand and utilize these concepts in professional practice, physical therapy educators need to incorporate these concepts into many aspects of the entire physical therapy curriculum. We must go beyond training students in the Code of Ethics,2 and help them to reflect-using philosophical texts, case studies, and observations in the field-on ethical dilemmas that will challenge the students ethical assumptions and moral knowledge. Physical therapy educators should expect students to understand moral philosophy and how it applies to the professional environment.23 The Importance of Listening and “Paying Attention” Manifesting the ethic of care requires a certain set of skills. An ethic of care in physical therapy marries medical and moral knowledge with skills typically associated with empathy: looking, listening, and hearing. The skill and art of listening begins with the physical therapist– patient introduction and continues through the conclusion of each therapy session. Truly listening involves what Robert Bellah called “paying attention,”24(p28) giving something one’s full consciousness. Listening engages the physical therapist to sense the patient’s reality by gaining an understanding of the patients experiences and functional limitations caused by disease or injury. This notion is extremely important in the practice of caring; it follows, therefore, that the art and skill of listening should be a staple of physical therapy practice throughout treatment.

It begins with the physical therapist listening to the initial history of the patient to understand the mechanism of injury, the location of the pain, the date of injury, and the goals of the patient. Desiring a clearer picture of the patient’s situation, the therapist seeks responses to questions about the home situation, the psychological stresses the patient experiences, and the fears the patient possesses regarding his or her condition. The physical therapist must be concerned about how these factors influence the patient’s rehabilitation process. Such factors play a critical role, for example, when a patient who is undergoing treatment for his or her own functional limitations is also caring for a friend or relative. Consideration of the patient’s daily physical and emotional condition, as well as time restraints, becomes an essential component of the treatment modifications. The physical therapist may need to adjust exercises so they can easily be incorporated into the patient’s daily routine. Emphasis on body mechanics may be necessary to protect the patient from further injury. Such changes can only be included in the patient’s plan of treatment if the physical therapist works relationally with the patient, being aware of the patients pathology and life experiences simultaneously. “Paying attention” also involves understanding the patient’s spoken words and gaining a sense for the need to question what is unspoken. Practicing physical therapy with an ethic of care entails attentiveness and engrossment that allows the physical therapist to receive the feelings of the patient, thereby understanding the concerns, wants, needs, and fears of the patient and their influences throughout the course of the patient’s treatment.

Risks and Conflicts Associated With Caring While the ethic of care is vital to physical therapy practice, it brings about risks and conflicts for the practitioner. Caring demands time and energy on the part of both the physical therapist and the patient. Wuthnow explained the significant energy required of those in a caring relationship: physicaltherapysalarynow.net physical therapy salary

To say that [caring] does not require time and energy, to deny that one can become worn out in doing good, to obscure the fact that real dangers and risks may be necessitated, is simply to lure people into a false understanding of caring that is unlikely to prove enduring.25(p105) Caring relationships in physical therapy practice entail risks for the therapist, such as doing too much for the patient or the patient providing no acknowledgment of or response to the therapist’s efforts. Sometimes the therapist does too much for the patient by minimizing the patient’s role in the treatment plan rather than developing a plan with the patient that can be incorporated into the patient’s daily activities. The patienttherapist- relationship may lack reciprocity if the patient refuses to share treatment expectations, hopes, and fears or demonstrates little effort in the recovery process.

These risks of physical therapy treatment can create conflict. The physical therapist may experience conflict when, for example, engrossment is divided by incompatible demands of several individuals or groups. Incompatible demands can exist when an insurance company decides to discontinue treatment against the recommendations of the therapist. The physical therapist’s understanding of the normal course of treatment and the patient’s extenuating factors (complications of the condition or additional pathology) may warrant an extension of treatment authorization, yet an insurance provider may deny further remuneration regardless of these factors.

Another risk of caring involves the therapist becoming overburdened with the responsibilities as the one-caring. Engaging in caring relationships requires enormous energy and time in a job that is already demanding and stressful. The therapist may, in addition, have to engage in political battles, expending significant energy to fight institutional or legislative mandates that deny treatment to those patients in need.

Finally, caring relationships may generate conflict when the therapist works with a patient who wants to engage in activities or treatments that the therapist believes are opposed to the patient’s best interests. For example, a patient may choose to ambulate without an assistive device despite lower-extremity stability and balance problems that could result in falls and subsequent injury. The ethic of care requires that the therapist find a way to work with the patient’s desire for more freedom of movement without engaging in activities that will cause more harm. These experiences frequently create conflict and stress for the therapist. Such situations may also induce guilt in the physical therapist if the treatment results fail to meet the patient’s goals or desired outcome.

As Bellah24 suggested, one can become worn out from daily dealings with these risks of caring, particularly those that create conflict. Noddings6(p38) argued that conflict and guilt are inescapable risks of caring and recommended that we not waste time on guilt, but that we act on those things that can be remedied by action. Purtilo and Haddad26 also remind us that we, as professionals, may find ourselves in positions where we must define the limitations of our involvement. Defining our limitations, however, does not mean minimizing an ethic of care. As Purtilo and Haddad stated, “Placing care at the center of relationships becomes crucial when human suffering is involved because caring is a salve to human suffering.”26(p219) An ethic of care may require, at times, that we define the limitations of our professional involvement, but the caring relationship must nevertheless remain central to physical therapy work.

If we are to develop caring relationships with our patients, we must expect to deal with risks that produce conflict and guilt. Although there are no easy answers to confronting these risks, it is clear that the patient-therapist relationship is primary. In the midst of competing demands for time and attention and of conflicting desires between patients and therapists, therapists practicing an ethic of care commit themselves to their patients. This task could be made less difficult if physical therapy educators develop curricula that provide students with opportunities to understand the interconnections among the science of evidenced-based practice, moral philosophy, the structure of medical institutions, and the economic conditions under which the health care practitioner works. The complex health care environment calls for physical therapists to possess the ability to evaluate physical therapy practice and determine how an ethic of care can be incorporated into their professional work. Physical therapy educators have the opportunity to cultivate in their students the necessary knowledge, reflective abilities, and skills required for caring practices.

The World of Physical Therapy Practice: Barriers to an Ethic of Care Health Care Changes and Institutional Constraints on Caring As the world of health care changes at a lightning pace, the contextual complications of practicing an ethic of care in physical therapy work are numerous and daunting. Many physical therapists are finding it more and more difficult to develop and nurture an ethic of care in their practice due to time constraints, pressures to focus on the profit margin or “bottom-line” of their work, and institutional structures that discourage personal contact. For the physical therapist, this problem of diminishing time with the patient continues to worsen as insurance companies and administrators require increasing amounts of documentation for treatment authorization and patient treatment. The physical therapist is often caught between spending time with the patient in patient care and the administrative duties needed to continue physical therapy treatment. Failure to complete documentation or acquire insurance authorization results in reimbursement for physical therapy services being denied.

Lebacqz12(p139) discussed how the structure of the working environment and institutional expectations can have an effect on professional ethical practice. She cited administrative duties required of the professional that decrease the time the professional is able to spend with the client as only one example. Requests for physical therapists to treat more patients in a limited time to counteract decreased remuneration per patient visit or to establish an organizational structure that emphasizes efficiency, predictability, and control17 rather than individual care are additional examples. Failing to value the physical therapist-patient relationship and the interaction required to foster such a relationship prevents an ethic of care simply from being nurtured, and patients are more likely to be treated as objects of care rather than as subjects or partners in caring relationships with their therapists.

Accountability of Physical Therapists Physical therapists are, increasingly, not simply or even perhaps primarily accountable to their patients. The physical therapist is accountable to the patient, to the employer, and to the paying agencies, and this situation of multiple accountabilities produces a wealth of moral dilemmas for the therapist to resolve. The patient wants a positive outcome to the therapy process, whether that outcome is an improved gait, good balance to prevent falls, or ability to reach a book on an overhead shelf. Insurance companies mandate fiscal accountability, desiring to pay only for those physical therapy services that are of proven value. The employer wants the physical therapist and patient to acknowledge the fiscal responsibility transferred to them by the third-party payer, meeting the patient’s goals for treatment and satisfying the employer’s financial obligations to remain economically solvent. In juggling these competing demands, the physical therapist is faced with many moral dilemmas and personal conflicts that make it more difficult to maintain an ethic of care in physical therapy treatment.

Physical therapists possess the knowledge to improve or manage patients’ disabilities or functional limitations, yet they face the challenge of focusing on patient interests while simultaneously being cognizant of reimbursement dynamics and insurance company and employer interests. Understanding all sides will help physical therapists find ways to facilitate excellent patient outcomes, but without an ethic of care, we risk losing our emphasis on the caring relationship that must be at the center of the rehabilitation process. Health care dynamics necessitate that we use our scientific knowledge, our moral knowledge, and the skills of caring in order to discover forms of physical therapy practice that achieve a successful physical therapy outcome for each patient. There is no question that maintaining an ethic of care in physical therapy practice is difficult when dealing with these conflicts, yet it is vital if physical therapy professionals are to provide a quality service to the public and protect the rights of patients receiving physical therapy services.

The present-day health care setting makes the type of relational work we argue for here difficult to accomplish. Due to time constraints and fiscal accountability, therapists increasingly are asked to surrender treatment to aides and assistants. Physical therapists often are expected to render a speedy diagnosis rather than work with the patient as a whole being, a relational other. Institutional structures and administrative demands to meet the “bottom-line” play major roles in these difficulties. Lammers and Geist17 referred to such practices when discussing health maintenance organizations, stating that though they were originally envisioned to address the whole patient, managed care as practiced today breaks down rather than maintains the patient as a social being. Rather than considering patients as whole beings, they are placed in social categories of people with health conditions that define their eligibility for financial remuneration for health care services. An ethic of care where receptivity and recognition of the other are part of the relational encounter reinforces the patient as a social being. If physical therapists lose consistent contact with patients and their families, they allow the importance of caring in daily practice to be minimized. This, then, decreases the physical therapist’s ability to influence the restoration of the patient’s physical function through the humanizing, healing practices of physical therapy. In today’s work settings, physical therapy and other medical arenas can all too easily become dehumanizing experiences for patients. This is not just simply an undesirable state of affairs; it is an immoral neglect of our ethical duties as physical therapists.

CONCLUSION The relative importance of economics in physical therapy practice can dramatically affect patient care and the development of caring relationships between patients and physical therapists. Physical therapists must decide to what extent they are willing to deal with these conflicts. Physical therapists would benefit from self-reflection in deciding how far they are willing to go to advocate for the long-term interests of patients and provide a beneficial service to the public. In regard to this, Bellah stated that “the poignant reality of helping others is that it often does involve sacrifice and by no means always makes one feel good.”24(p23) Physical therapists must address this dilemma before we lose sight of our purpose. Swaby-Ellis27(p89) stated that finding a solution to the crisis of care in the medical professions requires some self-examination. The practice of “journaling” or reflective writing can facilitate physical therapists questioning their values and beliefs about patients, physical therapy practice, and the health care environment. Storytelling of case studies, shared among therapists and with students, provides excellent opportunities to examine our concept of care and the moral dilemmas therein. In addition, our professional association and physical therapy educators could ignite broader conversations and activism on the topics of patient interests, and the central role that an ethic of care should play in the profession.

Susan Phillips9 has stated that experience is important for a helping professional to develop visions and standards of excellence. But it would behoove physical therapists to recognize that experience alone will not foster an ethic of care in physical therapy practice. Physical therapist students can develop an ethic of care if physical therapy educators provide them with opportunities to understand moral philosophy and what an ethic of care entails. Students should be invited to examine their values and beliefs about meeting the challenges of contemporary physical therapy practice. How to consider a patient’s wants, needs, concerns, and values can be interwoven with the teaching of evaluation and therapeutic exercise skills so students learn to combine an ethic of care with their scientific knowledge in order to put the patient’s interests first before their own. Although physical therapy clinicians and educators may argue that social and political forces influencing practice make it difficult to incorporate an ethic of care, physical therapy educators can explore with students how they might integrate an ethic of care, scientific knowledge, and the demands of patients, payers, and employers in ways that enable them to maintain a moral character and integrity in daily physical therapy practice. Such an approach will most likely result in a new model for providing physical therapy services that includes no less, and possibly more, concern for the patient’s well-being. Though social, political, and economic forces make practicing an ethic of care more challenging, an approach that combines an ethic of care and scientific knowledge while considering these forces may help health care professionals, insurance company personnel, and the general public gain an understanding of the importance of caring relationships to positive patient outcomes.

To develop benevolent professional-patient relationships without the incorporation of a caring relationship will result in the physical therapist excluding too many factors that affect the patient’s ability to heal and return to more normal function. As physical therapy professionals, it is important we ask ourselves whether physical therapy practice involves the application of moral principles, such as benevolence, or whether it involves the development of a relational ethic that considers the patient first and foremost. In her discussion of professional ethics, Lebacqz12 emphasized the importance of our choices in professional practice. She stated, “Our choices about what to do are also choices about whom to be.”12(p83) As we make choices about our professional practice, it is imperative that we face the conflicts generated between the dominant social, political, and economic forces on modern medicine and the incorporation of an ethic of care in physical therapy practice. We need to recognize how the modern bureaucracy can control, define, and narrowly limit our professional ethics; yet, if we are to maintain our purpose as a profession, it is vital that we choose to support an ethic of care and the implications it has for professional education and practice.

[Reference] REFERENCES [Reference] 1. Guide for Professional Conduct. Alexandria, Va: American Physical Therapy Association, 1997.

3. The American Heritage Dictionary. Second College Edition. Boston, Mass: Houghton Mifflin Co; 1985.

4. Gilligan C. In a Different Voice. Cambridge, Mass: Harvard University Press; 1982.

5. Gilligan C, Ward JV, Taylor JM, eds. Mapping the Moral Domain. Cambridge, Mass: Harvard University Press; 1988.

6. Noddings N. Caring: A Feminine Approach to Ethics and Moral Education. Berkeley, Calif. University of California Press; 1984.

7. Noddings N. The Challenge to Care in Schools: An Alternative Approach to Education. New York, NY: Teachers College Press; 1992.

[Reference] 8. Noddings N. The cared-for. In: Gordon S, Benner P, Noddings N, eds. Caregiving: Readings in Knowledge, Practice, Ethics, and Politics. Philadelphia, Pa: University of Pennsylvania Press; 1996: 21-39.

9. Phillips S, Benner P, eds. The Crisis of Care: Affirming and Restoring Caring Practices in the Helping Professions. Washington, DC: Georgetown University Press; 1994.

10. Benner P. Caring as a way of knowing and not knowing. In: Phillips S, Benner P, eds. The Crisis of Care: Affirming and Restoring Caring Practices in the Helping Professions. Washington, DC: Georgetown University Press; 1994: 42-65.

11. Noddings N. Care, justice, and equity. In: Katz MS, Noddings N, Strike KA, eds. Justice and Caring: The Search for Common Ground in Education. New York, NY: Teachers College Press; 1999:7-20.

[Reference] 12. Lebacqz K. Professional Ethics: Power and Paradox. Nashville, Tenn: Abingdon Press; 1985.

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[Author Affiliation] Mary Romanello, PT, MS, SCS, ATC Kathleen Knight-Abowitz, PhD [Author Affiliation] Ms Romanello is a doctoral student in the Department of Educational Leadership, Miami University, Oxford, OH 45056 ([email protected]). Dr Knight-Abowitz is Associate Professor, Department of Educational Leadership, Miami University, Oxford, OH 45056 ([email protected]).

Romanello, Mary

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