Module 4: Values and Ethics for Interprofessional Practice

Objectives

Explain the relevance of interprofessional values and ethics in provision of safe, efficient, and effective patient-centered care.
Describe the ethical principles that guide all aspects of patient care and team work.
Identify commonalities and differences between your profession’s Code of Ethics and that of other professions.
Facilitate development of skills to engage in respectful discussion with other health profession students and professionals, from the same and different professions.

Overview

In order to deliver quality health care, health care professionals must be well-informed about the contributions of their own profession and other health professionals. Ethics is a shared, relevant concern among health care professions and is an ideal vehicle for students and faculty from different fields to learn about one another’s professions and to participate in interprofessional discussions and problem-solving (IPEC, 2011; WHO, 2010). Collaborative care respects the individual expertise of each profession, and mutual respect and trust are critical components for effective interprofessional working relationships for delivering collaborative care across health professions. Gittell (2009) noted the relational link between interprofessional values and effective care coordination when describing the nature of relational coordination in health care: “Even timely, accurate information may not be heard or acted upon if the recipient does not respect the source” (p. 16). The purpose of this module is to introduce the role of values and ethics in effective interprofessional practice. The Core Competencies for Interprofessional Collaborative Practice address Values and Ethics of the Interprofessional team as Competency Domain #1, and state “Interprofessional values and related ethics are an important, new part of crafting a professional identity, one that is both professional and interprofessional in nature” (IPEC, 2011, p. 17).

Defining Interprofessional Values and Ethics

Interprofessional values and related ethics are patient centered with a community/population orientation, and reflect a shared commitment to creating safer, more efficient, and more effective systems of care. Each profession has core competencies focused on patient-centered care, and interprofessional values and ethics build on these. Interprofessional values should “undergrid relationships among the professions, joint relationships with patients, the quality of cross-professional exchanges, and interprofessional ethical considerations in delivering health care and in formulating public health policies, programs, and services” (IPEC, 2011, p.18). Interprofessional ethics. Traditional professional values, ethics, and codes can be explored regarding their place in interprofessional collaborative practice, and the extent to which these need to be rethought and re-imagined regarding interprofessional collaborative practice. Confidentiality of the practitioner-patient relationship in team-based care delivery is a common example illustrative of this element of the domain (Banks et al., 2010; Clark, Cott & Drinka, 2007; Schmitt & Stewart, 2011; IPEC, 2011). Values and ethics are represented in a variety of ways in interprofessional competency frameworks, wherein values are integrated into other competencies as the attitude/value dimension of those competencies, such as in Quality, and Safety Education in Nursing (QSEN) competencies in nursing (Cronenwett et al., 2007, 2009), and A National Interprofessional Competency Framework (Canadian Interprofessional Health Collaborative, 2010); or as a separate competency such as in the University of Toronto Interprofessional Education Curriculum (University of Toronto, 2008). Each health profession has educational and accreditation requirements around professionalism, which provides an opportunity for curricular integration of interprofessional competencies related to values and ethics (University of Minnesota, Academic Health Center, Office of Education, 2009).

It is important for health professions students to recognize the roles and responsibilities of other health professionals early in their education. As students learn how to provide clinical care, they will have opportunities to work in a team. Equally as important, is the appreciation of the role of interprofessional values and ethics in providing patient-centered collaborative care that is safe, efficient, and effective. Ultimately, our patients will benefit from care provided by health professionals who are prepared to practice in a collaborative health care team.

Ethical Principles and Terminology

An initial step in learning about interprofessional values and ethics is to first be familiar with the code of ethics of one’s own profession. A code of ethics is “a statement encompassing the set of rules based on values and the standards of conduct to which practitioners of a profession are expected to conform” (Code of Ethics, n.d.). It has also been defined as “a set of principles of conduct within an organization that guide decision making and behavior” (Code of Ethics Law & Legal Definition, n.d.). The code of ethics serves as a guideline for making ethical choices and reflects the values of the profession.

It may be helpful to take some time now to review Ethics Terms and Terminology as a foundational element to further understanding of professional Codes of Ethics. These ethical principles serve as a guide for health professionals regarding all aspects of patient care and team work.

Ethics Terms and Terminology
Altruism – Regard for others.
Autonomy – As most commonly defined, autonomy points in the direction of personal liberty of action in accordance with a plan chosen only by oneself.^a A philosophic term meaning self governance, whereby one has the right, power, or condition of self governance. The individual has self determinism and freedom from external control or coercion.^b
Beneficence – Moral principle that one should help others further their important and legitimate interests......one is obligated to act to benefit others when one can do so with minimal risk, inconvenience or expense.^a The ethical position whereby one attempts and is actually obligated to do no harm, remove harm, prevent harm, and actually do good.^b
Confidentiality – The principle that one should keep one's promises about information (re)disclosure.
Duty – Action, or an act, that is due by moral or legal obligation.
Fidelity – The principle that one should keep one's promises.
Justice – Commonly described as fairness, but more closely aligned to the concept of "desert" (pronounced like, but not to be confused with, "dessert" of the ice-cream et al variety): One has acted justly toward a person when one gives that person what is due or owed, and therefore what is deserved. Common to all definitions of justice is the minimal principle that relevantly similar cases (persons) be treated alike.^aA universal moral value in which the essential nature of fairness and equity should be applied to all peoples. Justice in sport refers to "making the field" level either in constitutive rules or for past inadequacies, social injustices, or physical/mental handicaps.^b
Nonmaleficence – Moral principle that one should refrain from harming others ("first, do no harm").
Rights – That which is due to individuals, based on core ethical principles. Rights create parallel duties on the part of others, or on society as a whole. So-called negative rights are rights of non-interference (e.g., with one’s speech, conscience, associations), typically grounded in the principle of autonomy. Positive rights, by contrast, are rights of "recipience" (e.g., to education, health care), typically grounded in the principle of justice.
Veracity – The principle that one should tell the truth ("honesty is the best policy").
Sources: Ethics Terms and Terminology, LaSalle University^a http://lasalle.edu/~price/Hon%20365%20ethics%20terms.htm Glossary of terms frequently used at the Center for ETHICS, University of Idaho Center for Ethics^b http://www.webpages.uidaho.edu/center_for_ethics/About%20Us/glossary.htm#sectB

After reviewing Ethics Terms and Terminology, complete the following interactive learning exercise to assess your knowledge.

Exploring Professional Codes of Ethics

Every profession has a code of ethics outlining the ethical responsibilities of practicing as a member of that profession. Codes of ethics from different professions may focus on issues that are specific to practice in that field, but all share common elements regarding the importance of honesty and taking no actions that may bring harm to others (Brown, 2015). These codes typically address issues involving the relationship between care provider and care recipient, as well as that between individual providers (Clark, Cott, & Drinka, 2007).

Let’s begin with examining the Codes of Ethics for a variety of professions. Click on the profession below to locate your own profession’s code, or if your profession does not appear, conduct a quick Internet web search to find your profession’s code.

Other Codes of Ethics:

Public Health: https://www.apha.org/~/media/files/pdf/membergroups/ethics_brochure.ashx

Occupational Therapy: https://www.aota.org/-/media/corporate/files/practice/ethics/code-of-ethics.pdf

As you review your own profession’s Code of Ethics, consider these questions:

What are the key principles or concepts of your profession’s code of ethics?
What is the duty to the patient, family, or community?
How does the code address collaboration?
How does the code address social justice, culture/diversity, autonomy?
Does the code of ethics seem to primarily address the patient, the provider, or some other group?
Does the code of ethics seem to be created more to enforce standards or to protect the client or provider?

After re-familiarizing yourself with your profession’s Code of Ethics, respond to these Questions for Reflection below.

What did you originally believe about your profession in regards to ethics, and interprofessional collaboration?
What do you now understand differently about your profession in regards to ethics, and interprofessional collaboration?

Next, let’s review two other profession’s Code of Ethics utilizing the same six (6) questions you considered previously as your reviewed your own profession’s Code of Ethics. This exercise will allow you to conduct a comparison among professions, to further your understanding of the values and ethics of professions other than your own. You will be able to clearly identify the commonalities and differences that exist between your professional code and that of other professions. Utilization of a chart, such as the one below, may be useful as you complete a side-by-side comparison of codes.

Example:

	Medicine	Nursing
Key principles/concepts	Competence, Compassion, Respect for human dignity and rights	Compassion, Respect for human dignity, Protect privacy and confidentiality rights
Primary duty to the patient, family, or community	Provision of safe care, Do no harm	Provision of safe care, Do no harm
Collaboration	Opinions on interprofessional relations – nurses, allied health professionals, chiropractors	Collaborate with other health professionals to protect human rights, promote health diplomacy, & reduce health disparities
Social justice, culture/diversity, autonomy	Opinions on professional rights & responsibilities; Caring for the poor, Respect for law & human rights, Patient free choice	Respect for human dignity, Patient advocacy, Right to self-determination, Primacy of patient’s interest, Integrate principles of social justice into nursing & health policy
Primarily addresses the patient, the provider, or some other group?	Patient and Provider	Patient and Provider
Created more to enforce standards or to protect the client or provider?	Set forth standards for protection of client and provider	Set forth standards for protection of client and provider

Adapted from: Akerson, E., Stewart, A., Baldwin, J., Bryson, B., Gloeckner, J., & Cockley, D. (2013)

Teaching Tip

The Interprofessional Ethics Activity can be modified for use as an instructional tool for your students. Simply place students in pairs or small groups, and allow each student to select a different profession to focus on for the websearch and completion of the interprofessional ethics grid.

Engaging in Respectful Dialogue with Professional Colleagues

With the intention to address ethical issues in patient care, it is important for health care professions students and professionals to develop skills to engage in respectful discussion with other health profession students and professionals, from the same and different professions. While there is recognition by professional bodies regarding the moral responsibilities of health care professionals to act collaboratively, there is a paucity of information in the literature of the ethical issues that are encountered when a group of health care providers interact with each other (Clark, Cott, & Drinka, 2007). Beyond an understanding of one’s own profession and how other professions function, health care professionals need to understand how the patient is viewed by other professions, and the strengths and limitations of each profession in order to practice teamwork. Clark, Cott, & Drinka (2007) state:

There will be disagreements between providers and disciplines. The efficiency of teamwork has to do with establishing ongoing methods to capture the strength of these disagreements, and to use this strength to increase the effectiveness of care. Further, the goals and rules of the organization need to support the efforts of the team at achieving this efficiency and effectiveness. To approach this level of care it is necessary to address the ethical problems inherent in the way that team members interact with each other and their responsibilities for defining, developing, and maintaining the efficiency and effectiveness of the team.

Better patient care is the ultimate goal of effective teamwork, and this usually involves consideration of ethical principles of beneficience, non-malficence, respect for autonomy, and justice (Beauchamp & Childress, 1994). The ethics of patient care is influenced by several factors including interpersonal factors, professional obligations, organizational issues, and legal contraints (Melia, 2001). Clark, Cott, & Drinka (2007) posit an Interprofessional Ethics Framework for understanding the ethical dimensions of interprofessional teamwork that includes three levels: individual, team, and organizational. The factors identified in this framework are: 1) Principles: General guidelines for behavior, 2) Structures: Established forms of knowledge and patterns of behavior, and 3) Processes: Procedural aspects of ‘‘how things are done’’.

EPIC-2

Principles. Each health care provider should be guided by norms, principles, and responsibilities reflective of their own personal background and professional education. At the team level, the different members of the team still retain their personal and professional guidelines for conduct, and along with these are new team-based expectations that may at times be a source of conflict with their own or their profession’s precepts (Carney, 2006). Common principles governing interpersonal relationships in health care settings are respect, truth-telling, beneficence, and justice. Team members have a responsibility to promote these principles in their relationships with each other. Teams share an “obligation to address communication problems and to constructively confront conflict that interferes with the team’s ability to work effectively on solving complex clinical problems” (Clark, Cott, & Drinka, 2007, p. 595). Further, a part of this duty includes developing a mutual understanding and integration of value differences among the health disciplines (Clark, 2006; Drinka & Clark, 2000). Ethical principles governing health care organizations may be similar to those that govern individual behavior. These responsibilities involve the organization’s provision of quality care in a compassionate and respectful environment (Clark, Cott, & Drinka (2007).

Structures. Individuals are socialized to traditions and expectations for thought and behavior when they enter a health care profession, and professional codes of ethics reinforce these expected behaviors for practitioners. With increasing experience in collaboration, health care providers should develop a sense of loyalty to the shared practice, and members have a responsibility to promote and protect the team from challenges that may emerge from within the team or outside of the team. At the organizational level, there is a responsibility to provide a sufficient resources for health care teams to accomplish their mission; supporting the team’s development and maintenance (Clark, Cott, & Drinka, 2007).

Processes are the actions that take place within each of the structures mentioned above. Team members should use respectful communication with each other, and discuss controversies and problems with the appropriate providers on the team. New members should be assimilated into the expected processes that govern how the team works together. Open communication regarding the different values acquired in different professional socialization processes is needed in teamwork, particularly with complex situations where conflicts between ethical principles lead to moral dilemmas (Clark, 1995, 1997; Irvine, Kerridge, McPhee, & Freeman, 2002). Moody (1988) related that a ‘‘communicative ethic’’ based on deliberation and negotiation leads to improved communication, clarification, and consensus-building” in these complex situations that can occur in teams. At the organizational level, support for team development and function can involve providing an experienced external facilitator to assist the team and its leadership to develop processes for communication and exploration of ethical concerns. The facilitator can also mediate team conflicts that the team cannot resolve (Clark, Cott, & Drinka, 2007).

Now that a foundational background related to factors that influence teams and teamwork has been laid, let’s examine a case study wherein ethical issues are encountered in a health care team. Watch this case as it provides an interprofessional perspective on ethical decision-making in health care teams.

Case study adapted from Clark, 2002

The framework proposed by Clark, Cott, & Drinka (2007) can be used to identify ethical issues and suggest ways to address them. Several questions are raised when the framework described by Clark, Cott, & Drinka (2007) is applied to the case study (See chart below. Adapted from: Table II. Ethical issues in integrating a new team member into a community health care organization (Clark, Cott, & Drinka, 2007).

Individual Level

Principles: Do team members respect Judy or social workers in general? Do they understand mental health issues of their patients? Do members understand practice standards of others on the team?
Structures: Do team members teach each other discipline-based knowledge? Do they recognize a responsibility to share their discipline-specific values? Do they teach new members of the team about their own professions and roles on the team?
Processes: Have team members discussed how each one represents a unique personal and professional viewpoint? Have they discussed how Judy differs from previous social worker? Do they show mutual respect in their communication, and are they doing so effectively? Are team members taking individual responsibility for their actions?

Team Level

Principles: Do team members base relationships on respect and beneficence? Are they addressing communication and conflict problems? Are their personal feelings interfering with responsibility to the team?
Structures: Does the team have time at its meetings to discuss conflict and communication problems? Has it established standards for socializing of its members?
Processes: Has the team developed a shared moral language around interpersonal relationships? Why have team members not openly discussed ethical issues in socializing?

Organizational Level

Principles: Does the organization recognize its responsibility to educate team members about ethical standards for socializing?
Structures: Does the organization have educational structures to ensure team member understanding of professional responsibilities of other disciplines? Does the facilitator have the necessary training?
Processes: Is the organization providing the team with time to discuss its processes of teamwork? Is the facilitator monitored and evaluated?

Chart adapted from: Clark, Cott, & Drinka, 2007

There may not be simple answers to complex issues that arise in interprofessional teamwork, and discussion surrounding teamwork ethics may be needed to address these issues. Clark, Cott, & Drinka (2007) state in their article, “One of the major reasons that many clinical teams do not survive over the long term is that these principles, structures, and processes are not put into place to address the ethical issues that inevitably arise” (p. 600).