Have You Ever Asked Yourself, What’s the Point of the Professional Issues Self Assessment (PISA)?

Respectfully submitted:
Diana Hopkins-Rosseel
Physiotherapist, Cardiac Rehabilitation Centre, Hotel Dieu Hospital
and Professor, School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario  


Since 2009, I have received an annual email from the College of Physiotherapists of Ontario inviting me to complete the PISA. The College promotes PISA as a tool for the registrant’s professional development and as a process working towards protection of the public.

So, I Ask Myself: ‘Do I Believe it?’

The first time I took on the PISA it felt daunting. So, I jumped in all hands and feet, opening and reading every relevant document I could find on the College’s website, and passed with flying colours! My conclusion, the ‘test’ must be OK. The next year, still some trepidation before challenging the questions and this time, one wrong answer. I did admit to myself, though, that I had once again learned everything from how to navigate the College website to the underlying content of the questions. My conclusion, the ‘test’ must be OK.

Now it was 2015 and I found myself welcoming the undertaking and wonder what the focus would be this year. Once more I came up against a couple of questions which I found challenging but easy to source responses for online, or so I thought. Take Question #3, it was clear to me the answer was (a).

You work in home care. You notice that the elderly patient you are treating has bruising across his back. Over time, you've developed a high level of trust with this patient. Eventually he confides that his partner hurt him, but does not want the information shared or for you to report it to the authorities. You are concerned. What are your obligations?

Answers:

A) There is a legal obligation to report the information to the police, the College or someone else.

B) There is no legal obligation to report the information to the police, the College or anyone else. However, you have an ethical duty to do something.

C) There is a legal obligation to follow the patient's wishes and respect his confidentiality and do nothing.

I got it wrong! The online feedback from the College via the PISA results appeared as:

This may be surprising to you, but you have no legal obligation to report his bruising to the police, the College or anyone else. However, you always have an ethical obligation to act in the best interests of the patient. If you believe your patient is in danger, you may decide to break the patient's trust and confidentiality and report the abuse to authorities. You might also consider speaking with him and trying to persuade him to seek help or give you permission to report the abuse.

I must admit I like to be right (hate to be wrong) but I also realized that I wasn’t sure I agreed. Spurred on by the fact that another 43.98% of the PTs who had responded agreed, I decided to do some digging. I re-read the question and reconsidered the feedback, went back to the College website and did some careful reading, and then decided to contact the College. Here is what I wrote:

“I would like to provide one piece of feedback on one of the questions: Question #3 relating to the possible physical abuse of a client. In this case approximately ½ of respondents chose mandatory reporting as their answer to the question posed. I believe this is the case because the ‘Professional Reporting Document’ on page 17 suggests that:

Under judge-made law (called the common law or case law), registrants may, in some circumstances, have a duty to warn. A duty arises where an identifiable person or group is at substantial risk of serious harm or death from another person. Registrants should have reasonable grounds (is it more likely than not that there is potential risk) for making such a report. The report can be made to the person or group at risk and to the authorities.

Given this stipulation, and given that the respondent answers without access to the CPO’s Practice Advisor during the test, and in this instance the practitioner trusts the client – it would be reasonable to assume that there may be a ‘Duty to Warn’. The key is whether or not there is ‘substantial risk of serious harm’ in this specific case. As battery of any individual, especially an elderly individual, is likely to cause serious harm, then I would perceive a duty to warn. As the bruising is in the thoracic area, this is of even greater concern. In addition, the criteria that the registrant have ‘reasonable grounds’ to make such a report would rest, in this case, on the integrity of the client. The case seems to suggest that the practitioner does ‘trust’ the client. Therefore, as a respondent, I must assume that the risk is credible.
 
Therefore, to suggest that there is ‘no legal obligation’ to report the information is as likely to be incorrect as having an ethical obligation is likely to be correct.
 
I would suggest that this question, if used at any point in the future for educational purposes or for PISA, be retooled with responses that recognize the critical thinking that would lead the practitioner to (i) contact the Practice Advisor and barring that option, (ii) choose to report in an effort to ensure protection of their client (and thus, the public). A great case for discussion!”

And then the discussion began. From the College...

“I understand the point you are making and I can see how this could be interpreted in the way you presented. In the Briefing Note—Professional Reporting Obligations, the description of ‘Duty to Warn’ is included in under the section: Mandatory Reporting Obligations to Other External Organizations…the intent was to highlight the fact that this did not create a legal obligation under a specific law, e.g. the Long Term Homes Act or the Retirement Homes Act. Duty to warn is an expectation that arises based on outcomes of previous cases or common law…”

After a couple more emails and a phone chat, I asked myself again: If approximately half of the PISA responses were incorrect for this question, was it related to the way the question was stated? Or, could it represent an area on which the College may wish to provide more education to PTs? I decided the answer was actually: neither.

The pure genius of PISA and this annual process is that it does, in fact, trigger individual investigation and encourages discussion among peers and with the College.

This promotion of critical thinking and professional reasoning is incredibly healthy for both our personal professional development and our profession’s development. What we end up with is an interactive, accessible, non-punitive and iterative process for problem solving through real dilemmas. As a self-regulated professional, I am grateful for this opportunity and support.

Finally, it goes without saying that PISA is not only an excellent tool for the registrant, it is a terrific device and process for protection if the public.