Ethical Dilemmas in OT Practice: What Would You Do?

Ethical Dilemmas in OT Practice

Alright, therapists – let’s play a little game I like to call: “Is it ethical?”

Occupational therapists are good people. I think I can rightfully make that statement, don’t you? Hopefully a therapist can’t make it through school, fieldwork, and daily practice without being a decent person. However, there are still many situations when the right answer isn’t always the easiest answer.

Have you ever realized how many of these situations you might be encountering on a daily basis as an OT? When I really sat down and thought about it, it wasn’t hard to see some ethical blunders that happen quite a bit in our realm.

The following situations are all dilemmas that either I or my colleagues have faced in our jobs around the country. While my moral compass points to “unethical” for pretty much all of these, it doesn’t mean that’s how everyone else will feel. That’s why I would love to hear your opinions… what would you do in these situations?

Photocopying assessments instead of ordering them.

The scenario: (Alright, so this is pretty obviously copyright infringement. Perhaps I should have started with something less obvious?) How many of you have worked in a clinic that photocopied their assessments? Have you ever gone so long without seeing a “real” VMI that you forgot they come on colored paper? Have you been unable to accurately score an assessment because the scoring template couldn’t match up with the image warped by a million trips through the copy machine? Your boss says, “This is what you get. We aren’t paying an arm and a leg for new score sheets.” Do you refuse to use the copied assessments?

Why this scenario occurs: Well, in some situations, it’s just how the clinic owner runs it. Larger therapy clinics are prepared to absorb this sort of cost in their overhead, but in small private clinics, this cost obviously hurts the profit margin.

Should you go on strike until the proper assessments are purchased? Or as one student suggested, “Why don’t you just buy your own assessments if you feel uncomfortable?” Well sure, adorable little OT student, but let me know how long you hold out on that ethical dilemma. Assessments aren’t cheap. A package of 25 VMI full forms is $104, and a clinic could burn through those in 1-2 weeks. But is that a proper excuse? No, of course not.

Giving a parent preferential (or less preferential) treatment for therapy times.

The scenario: You get an open spot on your schedule. Client “A” has been on the waiting list for 7 months, but you know the mother is intense and kind of mean. Client “B” is the little brother of one of your current clients that just decided they wanted to start OT services. So, who gets the spot? Do you show preferential treatment for a family you know, or go by the waiting list?

Why this scenario occurs: Therapists are human! It would be easy to give an awesome family that prime after school spot, not the mean people that have been waiting forever. This also depends on who is doing the scheduling, the therapist or someone in the front office.

Seeing a child for therapy past the point of progress.

The scenario: Billy has been seen for 5 years at a therapy clinic. He hasn’t really made progress in the last 3. At what point does the therapist call it quits? The decision eventually has to be made about billing for services when the child a) doesn’t participate, or b) hasn’t made a stitch of progress in months/years.  Some therapists might attempt to make goals so incredibly low or incremental that the child somehow meets a miniscule goal every 6 months or so in order to document progress. If they aren’t making progress, do you continue to see the child?

Why this scenario occurs: Again, therapists are human. How hard is it to say that a child will never really progress further with intervention? Also, there are times when OT becomes more of a therapy for the parent than the child. The parent needs someone to engage with; a moment of sanity. However, is that a billable service for OT, or is it just good ol’ fashioned “therapeutic use of self”? Regardless, it might be too gut wrenching for a therapist to tell a parent that their child isn’t even a candidate for services.

Administering treatment while waiting for a license.

The scenario: A therapist has just moved from another state. Their paperwork hasn’t come in yet, but they are an experienced and capable clinician. The boss says, “Just go ahead and see the kids; we’ll have one of the other OT’s co-sign your notes.”

Or, in another example, say a new graduate was hired, but either their license hasn’t come in yet, or they haven’t received the results of their national boards. The boss says, “What’s a week or two without a license?” If you are the therapist, do you practice without a license? If you are the name going on the paperwork, do you allow it?

Why this scenario occurs: This could happen due to poor planning. A clinic is in a pinch because they lined up a bunch of new clients, but a paperwork delay causes a kink in the cash flow. It isn’t to say that a therapist wouldn’t do a great job, but wow, would you be willing to risk it?

An OTR signing off on a COTA’s work that they have never met.

The scenario: A COTA works in home health, but has never met her supervising OTR. She turns in her documentation and an OTR signature magically appears. If you are the COTA, do you feel comfortable with this level of supervision? If you are the supervising OTR, are you willing to sign off on someone you have never met?

Why this scenario occurs: Scheduling! Plus, how often is a company going to let an OTR spend a day shadowing a COTA? That’s paying two people to do one job.

States have different requirements for supervision of COTAs, but most of the time they require some sort of face to face meeting or observation of skills. Some states require more supervision if the COTA has been practicing for less than a year. Plus, there are a lot of amazing COTAs that probably don’t need close supervision, but the law is the law. However, that’s what happens when a therapist is under the pressure of a rigorous schedule or high productivity level expectations.

A COTA completes an initial evaluation.

The scenario: An experienced COTA has a time slot open for a child to begin therapy, but the OTR does not. The boss has said, “Just let the COTA do the initial evaluation and you can sign off on it.” Do you allow that to happen?

Why this scenario occurs: It could simply be a way to get a child on the schedule to begin therapy quickly.

A fieldwork student carries their own caseload without direct supervision.

The scenario: Come on now, who hasn’t had at least one fieldwork experience when the Fieldwork Educator said, “Just go for it.” I remember transferring some woman as a student in the nursing home and absently thinking, “Huh, I hope nothing bad happens.” Or how about seeing clients when the Fieldwork Educator is on vacation? Technically, a licensed therapist should be within eyesight of a student at all times. Again, this is regardless of their amazing skill level. As a student, do you request more supervision? As a supervising Fieldwork Educator, do you allow the student to practice alone?

Why this scenario occurs: Profit, scheduling, productivity: take your pick. The high demands of a therapist lead to tight schedules and not enough time to do some things the way they should be done. A clinic might also look at a student as a way to increase their revenue and load them up. However, sometimes the Fieldwork Educator just takes a student as a way to take a “break” from the rigors of practice.

Working on a skill that is outside of the OT scope of practice.

The scenario: This could happen a million different ways, so I’ll just give you an obvious scenario. You notice that Billy isn’t saying his /r/ correctly. His parents can’t afford a second therapy session a week for speech, so they ask if you can just help him work on his sounds during therapy. Do you play the dual therapist?

Why this scenario occurs: Sometimes, therapists just want to help. Parents come to us with off the wall problems, assuming that OT should address it, so we do our best to assess the situation and try to correct it. On the other hand, sometimes an OT decides that they can tackle anything, and refuse to refer out to someone else. The harm comes when a therapist does something that might negatively impact a child, or when the therapist isn’t doing as good of a job as someone else could.

Billing for an entire session, even when the client wasn’t there for the whole amount.

The scenario: You are working with a child, but they barf all over you halfway through the session. Or, what about the client that consistently arrives 20 minutes late? Your boss says, “Bill for the whole hour, you had it blocked on your schedule that way.” How do you bill it?

Why the scenario occurs: Occupational therapy is billed by units. These are time intervals of 15 minutes, beginning with at least 8 minutes. For example, 1 unit = 8-22 min., 2 units = 23-37 min., 3 units = 38-52 min., 4 units = 53-67 min., and so on. Some places round these numbers up by a generous amount due to the fact that if they don’t, it costs them money.

Backdating or altering dates on paperwork.

The scenario: You accidentally forgot that a child’s re-evaluation was due. You missed the deadline by a few weeks, but continued to see them for therapy. Their insurance will not cover therapy unless there is a valid evaluation on file for the current calendar year. Darn, that means there are three visits that the clinic will have to pay back, unless you change that number on your report. Do you backdate the file?

Why this scenario occurs: This sort of dilemma can stem from the pressure a therapist receives from their superiors. A support staff member might just change dates without a second thought, or a therapist might be asked to sign off on a different date than when something actually happened.

So yes, OT’s are good people, but life often throws out a few curve balls, and it can be challenging to always be on the “right” side of every situation. I don’t doubt that every one of us has encountered at least one of these issues in our practice, but hopefully we have all reacted with the most ethical of intentions.


About TheAnonymousOT

Pediatric Occupational Therapist
This entry was posted in Insider Information, Occupational Therapy, Therapy Process, Uncategorized and tagged , , , , . Bookmark the permalink.

12 Responses to Ethical Dilemmas in OT Practice: What Would You Do?

  1. Sherry says:

    I learn so much from this blog! Thank you!

  2. Beth says:

    Nicely done. There should be more of us out there in the Ethernet being supportive of each other and our profession!

  3. Nicole says:

    I was curious how you our other therapists would handle seeing a colleague, possibly another OT, avoid providing therapy for students? For example in the school system the therapist makes the claim that child’s class wasn’t in the room, or the child was taking a test so they couldn’t come to therapy however this goes on for 90% of the sessions and you later find out the child was available, do you report it to staff in the school or a supervisor?
    Thank you for this article it reminds us of the little ethical thinks you may overlook at times.

    • Oh wow Nicole, that is sad to hear. I think you definitely need to address the issue in some way, since it means that children aren’t receiving the services they need. I would talk to a therapy supervisor, since they know the protocol for making sure children are seen for their sessions. Anyone else have a good tip? Best of luck with that situation!

  4. Renée says:

    The guidelines for supervision of a fieldwork student have changed, and the appropriate level required is now determined by the supervising clinician, as I’ve recently discovered

  5. Laura says:

    The College of OTs of Ontario (Canada) has multiple ethical decision making tools including : which is its decision making standard which includes a worksheet. Something to look into if you haven’t previously encountered it .

  6. Scraggly says:

    So I just found that this Occupational Therapist I know of is a swinger, she only started her job in our local hospital in January, after finishing Uni last September.
    We’re not like friends or anything, so I can’t just offer her some friendly advice.
    However her & her boyfriend are on a swingers website where they upload many photos of her flaunting herself on the Internet,
    They regularly “sleep” around with people, attend sex parties and swingers clubs with people who could potentially become her clients. (They leave verifications on the aforentioned swingers site, for those they’ve “entertained”)
    I’m concerned her actions are violating the OT code of conduct. What should I do? Should I report her?

  7. Chris says:

    This was an awesome article that really helped me so much! I’m looking into becoming an OT so it’s nice getting a deeper look into the profession and seeing some of the issues that outside people won’t see. Thank you so much for the article!

  8. Renée says:

    A swingers website? Nowhere else?
    Sounds pretty private. If she was a cashier on the side, you think it would be bad for her to meet a potential patient in the community as a customer? It’s a big world. Maybe you should keep your nose out of some parts. It’s not public


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