Which of the following is an individual factor that influences the level of ethical behavior

Med J Islam Repub Iran. 2015; 29: 282.

Published online 2015 Oct 25.

Abstract

Background: It is the responsibility of each occupational therapist to always act ethically and professionally in a clinical setting. However, there is little information available concerning the factors influencing ethical behavior of occupational therapists at work. Since no study has been conducted in Iran on this topic, this qualitative study aimed to identify the factors influencing ethical behavior of pediatric occupational therapists.

Methods: Twelve pediatric occupational therapists participated in this study. The sampling was purposeful, and the interviews continued until reaching data saturation. All interviews were recorded and transcribed. The data were analyzed by qualitative content analysis, and the ethics of qualitative research was considered.

Results: The factors influencing ethical behavior were classified into four main categories including organizational factors, therapist related factors, client’s family issues, and social factors.

Conclusion: This study identified numerous factors influencing the ethical behavior of pediatric occupational therapists that could be used to train occupational therapists, human resources managers, professional policy makers, and could also be used to conduct future researches, and produce tools.

Keywords: Ethical Behavior, Occupational Therapy, Content Analysis, Qualitative Research

Introduction

Ethical behavior means compliance with the standards related to right or wrong actions, and accomplishment of such ethical codes as autonomy, equality, beneficence, nonmaleficence, veracity, confidentiality and fidelity (1). Ethical behavior is not to demonstrate a correct behavior at critical times, but it is to daily represent a commitment to other people and communication methods of human beings with each other in daily interactions (2).

Although codes of ethics have been compiled for directing the therapists towards ethical behavior, unethical behaviors may still be seen in many cases. For many years, the researchers have tried to find the reason for unethical behaviors of the individuals in the workplace, but it is not yet clear how and under what circumstances the individuals make unethical decisions (3).

According to previous studies, ethical behavior of health care providers is influenced by many factors. For example, Deshpande et al. (2006) studied the factors influencing ethical behavior of nurses and doctors in hospitals. They found that ethical behavior of the colleagues had the highest influence on the ethical behavior of each personnel, and unethical behavior of successful colleagues or managers put the personnel under very hard conditions (4). Another study by Borhani et al. (2013) in Iran suggested that personal and spiritual characteristics, education, mutual understanding, internal and external control and experience of an unethical behavior are the factors influencing ethical sensitivity of nurses (5). In a meta-analysis, Kish-Gephart et al. (2010>) investigated the sources of unethical decisions at work (mainly commercial settings with some health care settings). Their findings indicated that personal characteristics, ethical intensity and ethical climate and culture play a role in unethical performance of people at work (3). Among other factors influencing ethical behavior are mentor influence (6) and previous training in ethics (7).

There is a gap in the literature regarding ethical behavior of occupational therapists and related factors. The studies available in occupational therapy are more focused on ethical reasoning and decision-making. For example, Barnitt and Partridge (1997) investigated ethical reasoning of physical therapists and occupational therapists and suggested that uncertainty about the consequences, emotional results of the accident and social pressure to behave in a specific manner had negative impacts on the capacity to cope with ethical dilemmas, and previous experience, reflection time and support from peers had a positive impact on it (8). In a study of the impacts of emotional intelligence on clinical performance of the occupational therapy students, since any profession will face various ethical issues in providing the services due to the functions defined for it, and as it was mentioned, ethical behavior may be influenced by personal characteristics, policies and culture of any society, it seems necessary to conduct a study on Iranian occupational therapists who live in a context different from that of Western societies. On the other hand, occurrence of unethical behaviors in providing occupational therapy services (9,10) makes it more essential to identify the factors influencing ethical behavior in order to take appropriate actions. Since no study was conducted in this field, we intended to conduct a qualitative study on the factors influencing ethical behavior from the viewpoints of pediatric occupational therapists.

Methods

This study was conducted using conventional content analysis approach to explore the factors influencing ethical behavior from the viewpoints of pediatric occupational therapists. Qualitative content analysis is a method for subjective interpretation of written content through a process of systematic classification of codes and determination of themes and patterns (11).

In this study, credibility, dependability and confirmability measures were used to determine accuracy (11). For this purpose, prolonged engagement (6 months), triangulation (diversity in participants) methods and repeated review of and discussion about content of the interviews, initial codes and categories were used by the research team. In addition, some participants reviewed the findings and controlled their consistency with their experiences. For external check, an occupational therapy expert, who was familiar with both qualitative research and working with children and was not a member of the study team, reviewed the results, and agreement on findings was reached.

Participants

Participants were selected using purposeful sampling method. Inclusion criteria were holding BS, MS, or PhD degrees with at least two years of clinical experience in pediatric occupational therapy and tendency to participate in the study. In selecting the participants, we tried to consider the maximum diversity with respect to their gender, work experience, academic degree and workplace. Participants included 12 (5 male and 7 female) occupational therapists, with a work experience of 5 to 25 years, working in governmental clinics, hospitals, special education schools, and private clinics. Five participants held BS degree, 3 MS degree and 4 were PhD students.

Data Collection

Semi-structured interview was the main method for data collection. All participants were interviewed individually at their workplace between September 2013 and April 2014. Duration of each interview varied between 40 and 90 minutes. The interviews continued until data saturation was reached. Data saturation is the point in data collection when no new or relevant information emerges (12). We used an interview guide and we also began the interviews with the following two open-ended questions: “What is your view of ethical behavior in Pediatric Occupational Therapy? What factors affect ethical behavior?” In order to obtain more information, the interview continued with probing questions.

Data Analysis

Each interview was recorded and transcribed verbatim immediately. Data analysis began with repeatedly listening to audio files and reading the transcripts to capture a sense of the whole. Then, the text was divided into meaning units, which were summarized and assigned with a code. Different codes were compared and sorted into categories based on how different codes were related (12).

Ethical Considerations

The study was approved by Ethics Committee of School of Rehabilitation Sciences, Iran University of Medical Sciences. Before data collection, written consent was obtained from the participants and they were assured about the confidentiality of the information and the right to withdraw from the study.

Results

The following four categories were captured from the participants’ interviews: Organizational factors, therapist related factors, client’s family issues, and social factors. Each category included some subcategories characterizing the factors influencing the ethical behavior (Table 1).

Table 1

Emerged Categories and Subcategories

1. Organizational Factors

This category included five subcategories: Ethical climate, educational insufficiency, regulations and supervision, facilities, and work pressure. One of the items considered by some participants as a factor influencing the ethical behavior was ethical climate. In this regard, a participant stated:

“All are thinking to benefit. When the atmosphere is negative, the individuals try to provide the least service. Organizational behavior of the manager may impact any individual. Therapist’s behavior affects others, too.” (Occupational Therapist 12)

Educational insufficiency was another factor, which was referred to by the participants. They believed that the occupational therapists had not received education on communication skills and ethics during their study, which influences their ethical behavior.

Most occupational therapists noted a weakness in compilation of regulations and instructions on provision of occupational therapy services and a weakness in supervision systems (in collecting the comments of those who receive services, collecting the complaints and addressing the same).

Some occupational therapists found that lack of facilities such as lack of human resources and limited therapy space may influence the occurrence of unethical behavior:

“I was the only occupational therapist of the center. The organization did not employ anyone. I had to underdo.” (Occupational Therapist 7)

Workload was another factor mentioned by some occupational therapists. They believed that workload led to fatigue, decreased tolerance and mental and psychological exhaustion.

2. Therapist Related Factors

This category included three subcategories: Personal characteristics, therapist’s concerns and competence. Some occupational therapists believed that personal characteristics of the therapist (spiritualism, materialism, extent of self-esteem) influenced their ethical behavior:

“Those who have a humane and altruistic personality, show sympathy with the patient, give discounts, at least do not waste the patient’s time. I mean, comply with some codes.” (Occupational Therapist 6)

Some occupational therapists suggested that the therapist’s self-esteem impacts their ethical behavior. Especially, it seems that newly graduated therapists may not fulfill some of their ethical duties such as expression of the physician’s mistakes due to lack of self-esteem.

Therapist’s concerns were another factor pointed out by the occupational therapists. They believed that therapist’s financial and family problems and job dissatisfaction influence their behavior:

“Perhaps, financial problems may aggravate the situation, leading to mistakes; especially those who have private clinics will experience such mistakes due to financial issues.” (Occupational Therapist 10)

Competence was another factor expressed by the occupational therapists. In their opinion, lack of knowledge, skill and experience influence ethical behavior of therapists. They believed that the occupational therapists without experience are more likely to make mistakes in ethical decision-making.

3. Client’s Family Issues

This category was divided into two subcategories: Awareness of family, and views and beliefs of the family. For awareness of the family, one of the occupational therapists stated:

“Some families do not know their rights. Any occupational therapist provides services in a particular way, depending on physical and environmental conditions. The family does not know what occupational therapy is. They think what is being provided is what it should be.” (Occupational Therapist 11)

In participants’ opinion, some families consider important only the results not the treatment method; for example, when a child is crying, some parents tell the occupational therapists not to interrupt the session and continue, or some parents allow the therapist to punish the child.

4. Social Factors

Social factors included two subcategories: Support systems and attention to ethical values. Some occupational therapists believed that lack of financial and social support systems was a factor influencing the ethical behavior of occupational therapists.

“The mistakes we make are more due to weak family support systems. Welfare Organization does not provide any support. Occupational therapy is not covered by insurance at all. Due to the ineffective support system, we commit some mistakes.” (Occupational Therapist 6)

Some occupational therapists identified that fading of ethics in the society influenced ethical behavior: “Some time ago, if the patient had no money, ethics dictated us to provide the services anyway. However, now it is said that they should not come to the center if they do not have the money to pay for the services. Value criteria of the society influence the behavior of the individual.” (Occupational Therapist 12)

Discussion

The results of this study revealed that the factors influencing ethical behavior in pediatric occupational therapy could be divided into four categories: Organizational factors, therapist related factors, client’s family issues, and social factors.

From the viewpoint of occupational therapists, organizational factors may influence the development of ethical behavior. Influence of organizational culture and climate on ethical behaviors and existence of the regulations and instructions in providing occupational therapy services have been reported in previous studies (13, 14, 3). Ethical emotions experienced by an individual when witnessing appreciable behaviors of others motivates him/her to participate in such a behavior (15). In addition, a strong ethical culture that clearly defines the range of acceptable and unacceptable behaviors will reduce unethical decisions in the workplace (3). Another factor expressed by many occupational therapists in this study was providing training in ethics and communication skills during the study period. Importance of providing training on ethics and ethical decision-making in occupational therapy has been well identified during the past decades (16) so that ethics has been included in the BS programs in the United States since 1987 (17). However in Iran, ethics course is provided only in PhD programs in occupational therapy. Therefore, those who are involved in curriculum development should pay attention to this issue. In this study, the participants working in governmental centers mentioned the facilities, especially human resources, as a factor influencing ethical behavior. Occupational therapist is responsible for supplying productivity demands of the organization on the one hand, and their ethical duty requires to provide the best and most appropriate services to the patients on the other hand (18). Under such conditions, not making an appropriate decision may lead to unethical behavior.

Occupational therapists stated that personal characteristics, therapist’s competence and concerns affect their ethical behavior. The occupational therapists were influenced by their personal values and beliefs when confronting an ethical dilemma (8). In this study, the occupational therapists believed that type of personality (materialist or spiritualist) influenced ethical behavior. The participants believed that those occupational therapists who had lower self-esteem (especially those newly-graduated) were more influenced by unethical demands of others, having no courage to object even at the time of identification of unethical cases. According to Hamric et al. (2012), lack of assertiveness tends to limit the therapist’s ability to speak up in challenging situations (19). In addition, some mistakes that occur in providing occupational therapy services are due to skill deficiency. By ensuring the therapist’s competency, clinical mistakes may be prevented or decreased (20). Participants believed that financial problems made the therapist ignore some ethical codes in order to cover life expenses and gain more income. Furthermore, since some people are not able to separate their personal problems from their workplace, they bring their problems to the workplace. Not controlling the feelings is related to emotional intelligence that is a very important factor in decision-making and forms our ethical personality and reasoning (21).

Participants in this study noted that the family’s unawareness of their rights and unfamiliarity with occupational therapy influenced the ethical behavior of occupational therapist. A therapist who does not care about ethical codes may easily abuse the clients who are not aware of their rights and occupational therapy services. Occupational therapist has a duty to increase the level of public awareness of occupational therapy to promote the profession (22). It seems that Iranian occupational therapists have not done their duty properly. Many clients give more importance to treatment results and want the child to progress independently very fast. Thus, some therapists use aggressive methods to provide services in order to attract satisfaction of the family. The family has no objection because they think it is useful for the child. It seems that in addition to the development of professional behavior in occupational therapists, parents also need to be informed of the psychological consequences of aggressive procedures.

Social factors were among the factors proposed by the participants. For example, lack of financial support of the family leads to submitting incorrect report by the occupational therapist to the insurance agent so that the family could receive more money from the insurance agency. Participants identified the lack of appropriate adaptations in the society as the reason for their more attention to physical problems of the child and use of aggressive techniques at work to rapidly bring him/her to maximum physical independence. The participants believed that some values such as veracity, respect for others, observance of others’ rights, and empathy were fading in the society, and some behaviors were no longer considered indecent. Values involve our knowledge, thought and choices. It is through personal values that culture is defined and social guidelines are provided for desirable standards (23). Indifference to some values may result in no action or response in an individual when witnessing unethical behaviors, making them not feel guilty, while a sense of guilt may be effective in choosing ethical paths in life (15).

Conclusion

According to the results of this study, many factors influence ethical behavior of occupational therapists. A part of these factors is related to the occupational therapist (such as competence, personal characteristics, and concerns) and another part is related to organizational factors, society as well as client’s family. Therefore, in order to witness the ethical behavior of occupational therapists in clinical settings, multidimensional effort is needed. Providing training on ethics, promotion of competences of the graduates, compilation of instructions and regulations for clinical work, continuous supervision over occupational therapy clinics, and reinforcement and encouragement of ethical values in the family and society are among the efforts that seem to provide an appropriate context for ethical behavior of occupational therapists. However, final comment in this regard needs further research.

Limitation of the Research and Suggestions

In this study, all participants worked in Tehran. To increase the credibility of the findings of this research, it is necessary to explore the view point of therapists working in other cities especially small cities.

Acknowledgments

The authors would like to appreciate all occupational therapists who participated in this study, without whose assistance, conducting this study would not be possible. This study is part of the PhD thesis of the first author, which is in progress in Iran University of Medical Sciences.

Notes

Cite this article as: Kalantari M, Kamali M, Joolaee S, Shafarodi N, Rassafiani M. Factors affecting ethical behavior in pediatric occupational therapy: A qualitative study. Med J Islam Repub Iran 2015 (25 October). Vol. 29:282.

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