handouts • saturday, may 2 leadership in becoming an...

Becoming the Autonomous Professional of Choice (C1) May 1-3, 2009 • Pittsburgh, PA

Handouts • Saturday, May 2 Leadership in Becoming an Autonomous

Practitioner

12 pages total

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LEADERSHIP IN BECOMING AN AUTONOMOUS PRACTITIONER

LAMP C1 CourseMay 2, 2009

Stacey Zeigler, PT, DPT, MS, [email protected]

Objectives

1. Define and describe key characteristics of autonomous practice

2. Link the characteristics of effective leaders to becoming and supporting autonomy at multiple levels

3. Discuss barriers and challenges to autonomous practice4. Create an action plan for improving performance in

leadership toward autonomy

Autonomy Self-Assessment

Autonomy – what is it??

Greek word: autonomos“auto” = self“nomos” = lawSelf-law

Dictionary – the quality or state of being self-governing; self-directing freedom and moral independenceHealth Dictionary17 – the quality of having the ability or tendency to function independently

“Autonomous practice is not a revolution – it is an evolution.”

Steve McDavitt, PT, MS, FAAOMPT; APTA Board Member

Vision 20201 States

Physical therapy, by 2020, will be provided by physical therapists who are doctors of physical therapy and who may be board-certified specialists. Consumers will have direct access to physical therapists in all environments for patient/client management, prevention, and wellness services. Physical therapists will be practitioners of choice in patients'/clients' health networks and will hold all privileges of autonomous practice.Physical therapists may be assisted by physical therapist assistants who are educated and licensed to provided physical therapist directed and supervised components of interventions.

(HOD P06-00-24-35)


Autonomous Practice

Autonomous physical therapist practice is characterized by independent, self-determined professional judgment and action. Physical therapists have the capability, ability and responsibility to exercise professional judgment within their scope of practice, and to professionally act on that judgment.2

(BOD P03-03-12-28)

Autonomous Practice Privileges2

Each of these elements imbeds two over-arching concepts: recognition of and respect for physical therapists as the practitioners of choice, and recognition of and respect for the education, experience, and expertise of physical therapists in their professional scope of practice.

1. Direct and unrestricted access:The physical therapist has the professional capability and ability to provide to all individuals the physical therapy services they choose without legal, regulatory, or payer restrictions.

2. Professional ability to refer to other health care providers:The physical therapist has the professional capability and ability to refer to others in the health care system for identified or possible medical needs beyond the scope of physical therapist practice.

3. Professional ability to refer to other professionals:The physical therapist has the professional capability and ability to refer to other professionals for identified patient/client needs beyond the scope of physical therapist practice.

4. Professional ability to refer for diagnostic tests:The physical therapist has the professional capability and ability to refer for diagnostic tests that would clarify the patient/client situation and enhance the provision of physical therapy services.

(BOD P03-03-12-28)

Characteristics of Autonomous Physical Therapist Practice3

Independent, self-determined professional judgment within one's scope of practice, consistent with the profession’s codes and standards, and in the patient's/client's best interest.Responsibility and acceptance of risk for all aspects of the physical therapist patient/client management.Ability to refer to and collaborate with health care providers and others to enhance PT patient/client management.Recognition of circumstances that necessitate a request for consultation and initiation of consultation when in the best interest of the patient/client.Clinical decision making that is independent of external financial considerations.PT's governance and control of physical therapy practice in all settings.

(HOD P06-06-18-12)

Task Force on Strategic Plan to Achieve Vision 20204

Autonomous Physical Therapist Practice Operational Definition:Physical therapists accept the responsibility to practice autonomously and collaboratively in all practice environments to provide best practice to the patient/client. Autonomous physical therapist practice is characterized by independent, self-determined, professional judgment and action.

“Of all the elements, the Task Force felt that autonomous practice is the most challenging aspect of Vision 2020 to achieve and the least tangible and most difficult to measure.”

There it is…

Activity 1:Think of a scenario in your practice in which you feel autonomy was demonstrated. Check off elements of that encounter with the characteristics and privileges on your worksheet.Write down any barriers to those not checked or to elements of the definition of autonomous practice.

A Vision of Becoming an Autonomous Profession

AutonomousPractitioner

Doctor of

Physical Therapy

Direct Access

Professionalism

Evidence -BasedPractice

Practitioner of

Choice


Autonomy Research

Professional Autonomy Literature

Professions Total Different 14 Nursing 211 Physicians 21 Physical Therapy 5 Occupational Therapy 2

Speech Pathology 1 Psychology 2 Countries Total Different 19 US 133 England/UK 42 Canada 16 Australia 13 Journals Total Different Journals 112 Data from currently unpublished work of Zeigler S, Denesha N, LaVine E. “Defining Autonomy in Healthcare: A Systematic Review.”

Common Denominators

InterdependenceTwo Basic Elements:

Capacity for rational deliberationAbsence of constraint

Three Levels at which Autonomy OccursProfessionPractitionerPatient

Interdependence

Independence

Dependence

Continuum of Maturity to Autonomy5,6

Task Force on Strategic Plan to Achieve Vision 20204

“Autonomous practice requires an interdependent approach and thus involves autonomous and collaborative practice with others to create the best outcomes for the patient/client. The Task Force believes that as a profession, we are currently between dependence and independence, whereas as individuals we exemplify all three levels of maturity. The goal for the members of the profession as well as for the profession itself is interdependence, and autonomous practice incorporates this concept.”

Professional Autonomy: Two Basic Elements7

Absence of Constraints

(control over actions)

Capacity for Rational

Deliberation(opportunity for

influence)

Autonomy


Debate:Ownership and Autonomy

Friedson’s Two Types of Professional Autonomy10:Technical Autonomy – right to use discretion and

judgment in the performance of work.Socioeconomic autonomy – ability of the worker to

ascertain and allocate the economic resources needed to complete his or her work.

Debate: Ownership and Autonomy

“Clinical autonomy does not reside in the individual practitioner but, rather, in the contractual space in which they practice.9”Social relationship Specification of

Contract

Degree of Autonomy

Opportunities

“The goal of professional autonomy should not distract the profession from its first responsibility: to meet the needs of the public who require physical therapy services while preserving their individual autonomy in relation to their health.”10

- Robert Sandstrom, PT, PhD

Levels of Autonomy Application

1) Professional (group) autonomy

2) Practitioner autonomy

3) Patient/Client autonomy

Leading Up

Leading Across

Leading Down

Autonomy 360 Leadership19

Leadership Style & Follower Maturity20

High Moderate Low

Mature ----------------------------------------------------------------- Immature

M4 M3 M2 M1

Defining Attributes Applied to all Three Levels of Autonomy18

IndependenceKnowledgeCapacity for decision-makingJudgment

Self-determination

Trust, credibility, influenceDecision making (collaborative)Behavior – model the wayACTION, empowerment

Antecedents of Autonomy Leadership Skills


Consequence of Autonomy

Specification of Contract

Degree of Autonomy

Autonomy or Something Else?

“Each of us, regardless of the setting or circumstance, is accountable to someone or something, and in the health professions, we are certainly accountable to society at large. Autonomy may suggest a professional form of accountability, but the concept of empowerment more accurately expressed how an individual working with other individuals can enhance the process and outcomes for themselves, their profession, and their employer.”12

- Roxane Spitzer-Lehmann, PhD, MBA, MA, RN, FAAN

Leadership“We should abandon the notion of autonomy in favor of a more appropriate claim to professionalism and respect: a claim made not through words but through actions that model superb practice and cutting-edge education. Just as the DPT will mean little unless it represents a degree that better prepares practitioners, the notion of autonomy will ring hollow unless there is a deeper meaning that is exemplified by the manner in which we practice.”13

– Jules Rothstein

Caution with Autonomy

“There is a risk that nurses who claim autonomy, rather than promoting their ability to act responsibly and competently within their scope of practice, are like the emperor in his new clothes – they believe they stand in splendour when in fact they are naked. The problem is that their nakedness is seen by the general public and fellow health care professionals. And instead of being trusted and respected, they appear self-interested and ridiculous.”11

- Aileen Walsh, PGCE, BSc, DipHE Nursing

LEADING THE WAY:AUTONOMY ACTION PLANNING

Profession, Practitioner, Patient

Profession: What APTA is focusing on14

Framing ScenarioTask Force on Strategic Plan to Achieve Vision 2020 identifying objective measures for each element of the VisionWarding off infringement efforts by other practitioner groupsBattling referral for profit situationsEngaging heavily in the legislative process (direct access, incident to rule, etc.)Promotion of further discussion related to vision elementsPhysical therapy and society summit (PASS) –contractual space


Profession: Lead Up19

Seek first to understandAdd value to the visionBecome engaged and active Champion the causeModel the wayInspire others

Practitioner: Maximizing Autonomy in Education22

Faculty and CI must role model autonomyCurriculum should be learner centeredInclude interdisciplinary coursesInclude courses related to professional issues, leadership, change theory and role theoryTheoretical focused curriculum (rather than practicing skills)

Maximizing Autonomy in Education22

Emphasize collegiality, cooperation, and shared governanceProvide opportunities for developing values, attitudes, and behaviorsInvestigate models that support joint appointments between the university and service settingsLab experiences should simulate situations requiring the exercise of autonomyEmpower the students

Maximizing Autonomy in Clinical Education

During internships, clinical sites and clinical instructors should demonstrate autonomy

How can we support the development of autonomous thinking and action in the clinical environment? (www.aptahpa.org; resources; section related

resources; CSM 2007 Lamp related learning ideas for the clinical environment)

Maximizing Autonomy in the Clinic

Lead Across Lead Down when necessaryLead by exampleEncourage the HeartIdentify barriersDevelop an action planLearn from pioneers23

Leading Across and Down:Autonomy Action Plan15,16

1) Establish a Therapeutic Relationship

• Respect our colleagues who aren’t yet ready for change (follower maturity). Be patient with differing views.

• Respect patient decisions when provided with all pertinent information – encourage involvement and decision making at all levels - “The patient is the boss”


Autonomy Action Plan

2) Diagnose Resistance to Change Through Mutual Inquiry

• Through open dialogue identify the barriers that interfere with success at implementing change.

• Collectively and collaboratively make an action plan to overcome barriers


3) Find Common Ground Through Negotiation

• Identify achievable goals that build on collective and individual strengths.

• Encourage discussion and debate• Consider the contract with the patient


4) Problem Solve

• Identify strategies for success that are achievable.• Speak with Autonomous Language – ‘practice’ rather

than ‘work’, ‘consult’ rather than ‘order’, ‘colleagues or partners’ rather than ‘staff or employee’


5) Consider the contractual space in which you practice

Ownership and equity modelsSelf-governance within employment situationsOutline opportunities and make a plan to overcome barriers

Autonomy Action Planning

6) Think independently, act interdependentlyConsider other professional opinionsRespect the judgment of others for the good of the patientAccept accountability for decisions made

Self-Assessment

Autonomous practice is not a revolution-it is an evolution

AND it requires leadership skills to achieve it!


References

1. Vision 2020. APTA Vision Statement for Physical Therapy 2020. HOD P06-00-24-35. Available at: http://www.apta.org/AM/Template.cfm?Section=Vision_20201&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=285&ContentID=32061. Accessed April 1, 2008.

2. Autonomous Physical Therapist Practice: Definitions and Privileges. BOD 03-03-12-28. Available at: http://www.apta.org/AM/Template.cfm?Section=Policies_and_Bylaws&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=25746. Accessed April 7, 2008.

3. Autonomous Physical Therapist Practice. HOD P06-06-18-12. Available at: http://www.apta.org/AM/Template.cfm?Section=Policies_and_Bylaws&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=47133. Accessed April 7, 2008.

4. Strategic Plan to Achieve Vision 2020 (RC 20-06) Report to the 2007 House of Delegates. Available at: http://www.apta.org/AM/Template.cfm?Section=House_of_Delegates1&Template=/MembersOnly.cfm&ContentID=3899. Accessed April 7, 2008.

5. Covey SR. The seven habits of highly effective people. New York: Fireside Book; 1990.

6. Johnson MP, Abrams SL. Historical perspectives of autonomy within the medical profession: considerations for 21st century physical therapy practice. J Orthop Sports Phys Ther. 2005; 35 (10): pp. 628-636.

7. MacDonald C. Nurse autonomy as relational. Nursing Ethics. 2002; 9(2): pp. 194-201.

8. Principles of Professionalism Guiding Physical Therapist Business Relationships. BOD P03-06-18-45. Available at: http://www.apta.org/AM/Template.cfm?Section=Policies_and_Bylaws&CONTENTID=34425&TEMPLATE=/CM/ContentDisplay.cfm. Accessed April 1, 2008.

9. Cash K. Clinical autonomy and contractual space. Nursing Philosophy. 2001; 2: pp. 36-41.

10. Sandstrom RW. The meanings of autonomy for physical therapy. Physical Therapy. 2007; 87 (1): pp. 98-106.

11. Walsh A. Nurse autonomy is neither an achievable nor a desirable goal. Nursing Times. 2005; 101 (40): p. 17

12. Spitzer-Lehmann R. From autonomy to empowerment. Seminars for Nurse Managers. 1993; 1 (2): p. 55.

13. Rothstein JM. Autonomy or Professionalism? [editor’s note]. Phys Ther. 2003; 83:206-207.

References

14. Mallon FJ. Chief Executive Officer’s report to the 2007 House of Delegates. Available at: http://www.apta.org/AM/Template.cfm?Section=House_of_Delegates1&Template=/MembersOnly.cfm&ContentID=38955 Last accessed: April 1, 2008.

15. Jensen GM, Lorish CD, Shepard KF. Handbook of Teaching for Physical Therapists. 2002

16. Hack LM. “Board Perspective”, PT Magazine, March 2008: pp. 38-40.

17. Mosby’s Medical, Nursing, & Allied Health Dictionary. 6th ed. Mosby: Philadelphia. 2002.

18. Keenan J. A concept analysis of autonomy. Journal of Advanced Nursing. 1988. 29(3), 556-562

19. Maxwell JC. The 360 Degree Leader: Developing Your Influence from Anywhere in the Organization. Nashville, TN: Nelson Books; 2005.

20. Keenan MJ, Hoover PS, Hoover R. Leadership theory lets clinical instructors guide students toward autonomy. Nursing and Healthcare. 1988; 9(2): 82-86.

21. Hersey P, Blanchard K. Management of Organizational Behavior 4th ed. Englewood Cliffs, NJ: Prentice-Hall, 1982. p. 248.

22. Wade GH. Professional nurse autonomy: concept analysis and application to nursing education. Journal of Advanced Nursing. 1999. 30 (2): 310-318.

23. Brown MA, Draye MA. Experiences of pioneer nurse practitioners in establishing advanced practice roles. Journal of Nursing Scholarship. 2003. 35 (4): 391-397.


Leadership in Becoming an Autonomous Practitioner Worksheet

Activity 1

Operational Definition of Autonomous Practice: Physical therapists accept the responsibility to practice autonomously and collaboratively in all practice environments to provide best practice to the patient/client. Autonomous physical therapist practice is characterized by independent, self-determined, professional judgment and action. Privileges of Autonomous Practice (BOD P03-03-12-28) ______ Direct and unrestricted access ______ Professional ability to refer to other health care providers ______ Professional ability to refer to other professionals ______ Professional ability to refer for diagnostic tests Characteristics of Autonomous Practice (HOD 06-06-18-12) ______ Independent, self-determined professional judgment within one's scope of practice, consistent with the profession’s codes and standards,

and in the patient's/client's best interest. ______ Responsibility and acceptance of risk for all aspects of the physical therapist patient/client management. ______ Ability to refer to and collaborate with health care providers and others to enhance PT patient/client management. ______ Recognition of circumstances that necessitate a request for consultation and initiation of consultation when in the best interest of the

patient/client. ______ Clinical decision making that is independent of external financial considerations. ______ PT's governance and control of physical therapy practice in all settings. List barriers to autonomous practice within your practice setting:


Leadership in Becoming an Autonomous Practitioner Worksheet

Activity 2 (group work)

Level of Action Autonomy Element Promoted Barrier to Autonomy

Leadership Action item(s)

Lead

Up

Lead

Acr

oss

Lead

Dow

n

Inte

rdep

ende

nce

Abs

ence

of

Cons

train

t

Capa

city

for

ratio

nal

delib

erat

ion

Bene

fit o

f Pa

tient

/Soc

iety

Example: Lack of time/resources to be an advocate for the patient and to coordinate care beyond physical therapy.

1. Research productivity levels of autonomous practitioners based on respected evidence and champion new standard as needed. 2. Determine and acquire need for greater staffing and appropriate distribution of workload. 3. Empower patients to advocate for themselves (training on how to manage within the healthcare system, etc.)

X X

X

X

X X X

? ? X

X ? X

X X X


Leadership in Becoming an Autonomous Practitioner Pre-Post Assessment

Indicate your primary practice setting(s): ________________________________________________ Directions: Prior to today’s session, please answer the following questions by placing a vertical line on the scale for each question below. Label this line with an ‘S’ above it indicating that this is your starting assessment of yourself. Following today’s presentation, answer the questions again now labeling the line with an ‘C’ for your current assessment. After tomorrow’s activity on this topic, answer the questions again now with the line as ‘F’ for final assessment. These will then be collected to help the presenters draw conclusions on the effectiveness of today’s presentation. Questions: 1. I can define autonomous physical therapist practice and its characteristics as described by the APTA.

______________________________________________________________________________________

No, not at all No, but might wing it Maybe Yes, Somewhat Yes, Definitely 2. I would be comfortable talking to another healthcare professional about autonomous physical therapist practice.

______________________________________________________________________________________

Not comfortable at all Very Comfortable 3. On any given day, I feel that I am practicing autonomously:

______________________________________________________________________________________ 0% of the time 50% of the time 100% of the time 4. I feel that I am aware of specific leadership actions to move toward maximizing autonomy of myself and others:

_____________________________________________________________________________________ No, not at all Yes, Definitely


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