Ethics
Ethics in Athletic Training
Terminology
• Ethics:
• the moral principles that determine a person’s conduct
• Dictionary Def. - moral principles that govern a person's or group's behavior
• Origin - Greek word "ethos" meaning “character"
• Morals:
• beliefs based on a person’s ideas of what is right and wrong
• Dictionary Def. - a person's standards of behavior or beliefs concerning what is and is not
acceptable for them to do
• Origin - Latin word "mos" meaning "custom"
Ethics vs. Morals: What are they?
Ethics
Morals
• The rules of conduct recognized
in respect to a particular class of
human actions or a particular
group or culture.
• Where do they come from?
• Principles or habits with respect
to right or wrong conduct. While
morals also prescribe dos and
don'ts, morality is ultimately a
personal compass of right and
wrong
• Where do they come from?
• Social system – External
• Why do we do it?
• Because society says it is the right
thing to do.
• Individual – Internal
• Why do we do it?
• Because we believe in something
being right or wrong.
Ethics vs. Morals: The Gray
Ethics
Morals
• A person strictly following Ethical
Principles may not have any Morals
at all. Likewise, one could violate
Ethical Principles within a given
system of rules in order to
maintain Moral integrity.
• Flexibility –
• A Moral Person although
perhaps bound by a higher
covenant, may choose to follow
a code of ethics as it would
apply to a system. "Make it fit“
• Flexibility –
• Ethics are dependent on others for
definition. They tend to be consistent
within a certain context, but can vary
between contexts.
• Usually consistent, although can
change if an individual’s beliefs
change.
NATA Code of Ethics
1. Members shall respect the rights, welfare and dignity of all.
2. Members shall comply with the laws and regulations governing the
practice of athletic training.
3. Members shall maintain and promote high standards in their
provision of services.
4. Members shall not engage in conduct that could be construed as a
conflict of interest
Principle 1
• Members shall respect the rights, welfare and dignity of all.
• 1.1 Members shall not discriminate against any legally protected class.
• 1.2 Members shall be committed to providing competent care.
• 1.3 Members shall preserve the confidentiality of privileged information and
shall not release such information to a third party not involved in the patient’s
care without a release unless required by law.
Principle 2
• Members shall comply with the laws and regulations governing the
practice of athletic training.
• 2.1 Members shall comply with applicable local, state, and federal laws and
institutional guidelines.
• 2.2 Members shall be familiar with and abide by all National Athletic Trainers’
Association standards, rules and regulations.
• 2.3 Members shall report illegal or unethical practices related to athletic
training to the appropriate person or authority.
• 2.4 Members shall avoid substance abuse and, when necessary, seek
rehabilitation for chemical dependency.
Principle 3
• Members shall maintain and promote high standards in their provision of
services.
• 3.1 Members shall not misrepresent, either directly or indirectly, their skills, training,
professional credentials, identity or services.
• 3.2 Members shall provide only those services for which they are qualified through
education or experience and which are allowed by their practice acts and other
pertinent regulation.
• 3.3 Members shall provide services, make referrals, and seek compensation only for
those services that are necessary.
• 3.4 Members shall recognize the need for continuing education and participate in
educational activities that enhance their skills and knowledge.
• 3.5 Members shall educate those whom they supervise in the practice of athletic
training about the Code of Ethics and stress the importance of adherence.
• 3.6 Members who are researchers or educators should maintain and promote ethical
conduct in research and educational activities.
Principle 4
• Members shall not engage in conduct that could be construed as a conflict
of interest
• 4.1 Members should conduct themselves personally and professionally in a manner
that does not compromise their professional responsibilities or the practice of
athletic training.
• 4.2 National Athletic Trainers’ Association current or past volunteer leaders shall not
use the NATA logo in the endorsement of products or services or exploit their
affiliation with the NATA in a manner that reflects badly upon the profession.
• 4.3 Members shall not place financial gain above the patient‘s welfare and shall not
participate in any arrangement that exploits the patient.
• 4.4 Members shall not, through direct or indirect means, use information obtained in
the course of the practice of athletic training to try to influence the score or outcome
of an athletic event, or attempt to induce financial gain through gambling.
Cultural Competence
Terminology
• Cultural competence:
• an awareness of belief and values between cultures
• Other definitions:
• Possession of the knowledge and skills required to manage cross-cultural
relationships effectively.
• Cultural incompetence in doctors and other medical staff can seriously prejudice clinical
management.
• Social medicine; The ability to understand, appreciate, and interact with
persons from cultures and/or belief systems other than one's own
• Defined simply as the level of knowledge-based skills required to provide
effective clinical care to patients from a particular ethnic or racial group
Verbal Communication
1. Greet the person
2. Call them by name & pronounce his/her name correctly
3. Determine the person’s language and level of English proficiency
(speaking, reading and writing)
Non-Verbal Communication
1. Personal space
• *Close or distant personal space
• *Tactile person vs. non-contact person
• (Always follow the person’s lead!)
2. Gestures – not universal!
• *Pointing at a person - used to call someone or may be considered impolite
• *Smiling & nodding may indicate politeness, not understanding or agreement
• *Direct eye contact – considered disrespectful in some cultures
Non-Verbal Communication
3. Silence – what does it mean?
• *Thinking of an answer?
• *Doesn’t understand / confused?
• *Angry
4. Expressions of pain
• *Stoic (afraid to show pain / sign of weakness)
• *Emotive (open expression / likes to share)
Cultural Considerations
1. Language used in social vs. personal conversation
2. Social organization of the family (head = father or mother? Who
makes important decisions?)
3. Traditional or cultural practices (beliefs concerning injuries, healing,
use of medicine, etc.)
4. Spiritual or religious practices (ie, fasting during Ramadan)
Cultural Considerations
5. Observance of Ethnic & Religious holidays
6. Views of appropriate touch
•
•
•
Cultural meaning / significance
Religious considerations (body covered?)
Always ask for permission!
7. Health issues or disparities
•
•
Diet restrictions
Sickle cell & asthma more prevalent in African Americans
Cultural Considerations
8. Narrative or storytelling
•
•
Chronological (sequential)
Episodic history (highlights major events)
9. Orientation to time
•
•
Future time – value being early/on time
Present time – here & now, not worried about the future
Legal Liability
Terminology
• Negligence
• A failure to act as a reasonably prudent person would
• Gross negligence
• A step beyond negligence; failure to provide minimal care
• Assumption of risk
• An individual may be injured as a result of participating in sports
• Permission to treat
• Consent obtained from athlete or parent before a medical procedure is
performed
Terminology
• Proximate cause
• A direct connection between an individual’s actions and an injury to a second
person
• Breach of duty
• A failure to perform one’s job
Components of a Lawsuit
1. Duty
2. Breach of Duty
3. Actual Injury
4. Proximate Cause
Professional Ethics
Terminology
• National Athletic Trainers’ Association (NATA)
• The professional membership organization for athletic trainers
• Arizona Athletic Trainers’ Association (AzATA)
• The membership organization for athletic trainers in Arizona
• Board of Certification (BOC)
• Provides an entry-level certification program for AT’s, review the standards for
the practice of athletic training, and reviews the requirements for continuing
education for certified athletic trainers
• Continuing education units (CEUs)
• Contact hours of additional learning
NATA Requirements
1. EDUCATION
• Earn a bachelor’s or master’s degree in athletic training from an approved
athletic training program
• There are 360 entry-level programs throughout the United States
• To find a college or university with an approved program, go to http://www.caate.net/
2. CERTIFICATION
• Take and pass the Board of Certification (BOC) exam
• For information on the exam, see the BOC website:
http://www.bocatc.org/index.php?option=com_content&view=article&id=10&Itemid=8
NATA Requirements
3. STATE LICENSURE
• Comply with the laws of the state where he/she practices
• Each state has its own requirements for practicing athletic training
NATA Member Expectations
• Once a member, NATA expects its members to follow certain
standards
• One of these is the Code of Ethics
• For a copy of the NATA’s Standards and Sanctions, go to:
• http://www.nata.org/sites/default/files/membership-standards.pdf
Recertification Requirements
• Requirements for Recertification by the BOC*
1. Follow NATA standards
2. Maintain certification in Emergency Cardiac Care
3. Complete continuing education units (CEU’s) in different areas of study
• 50 CEUs every 2 years ( 10 need to be EBP CEUs)
4. Payment of recertification fee
http://www.bocatc.org/images/stories/athletic_trainers/recertificationrequirements2013.p
df
Requirements for State Licensure
• Each state has different requirements
• Arizona requirements
1.
2.
3.
4.
College transcripts
Proof of certification from BOC
Proof of citizenship / right to work in the United States
Fee for licensing process
• http://www.athletictrainingboard.az.gov/default.asp
• Renewal Requirements
• Annual renewal form
• Pay recertification fee
• For more information, see: http://www.athletictrainingboard.az.gov/board_info/statutes.asp
Supervisory Responsibilities
Terminology
• Certified Athletic Trainer (AT or ATC):
• An athletic trainer is a certified health care professional who practices in the
field of sports medicine.
• Certified athletic trainers are allied health care providers who specialize in the
prevention, assessment, treatment and rehabilitation of injuries and illnesses
that occur to athletes and the physically active. (NATA definition)
• Athletic Training Student Aides (ATSAs):
• students who act under the direct supervision of an athletic trainer
Responsibilities of ATSA’s
•
•
•
•
•
•
•
•
Stock first aid kit
Check equipment
Stock ice chest
Fill water bottles
Check injury list from previous practice or game
Communicate with AT and coaches
Check out equipment
Help with treatment & taping under direct supervision of their sponsoring
athletic trainer
• Clean training room before & after game or practice
• Update supply list
• Review activities
NATA Position Statement on Student Aides
• Excerpts:
• Student aides must only observe the licensed/certified athletic trainer outside
of the educational environment. Coaches and school administrators must not
allow or expect student aides to assist or act independently with regard to the
evaluation, assessment, treatment and rehabilitation of injuries. Additionally,
it is paramount that student aides not be expected, asked or permitted to
make “return to play” decisions.
• Specifically, licensed/certified athletic trainers, coaches and administrators
must not ask athletic training student aides to engage in any of the following
activities:
1.
2.
3.
4.
5.
Interpreting referrals from other healthcare providers
Performing evaluations on a patient
Making decisions about treatments, procedures or activities
Planning patient care
Independently providing athletic training services during team travel
Equipment Safety
Terminology
• National Operating Committee on Standards for Athletic Equipment
(NOCSAE):
• an organization that works to improve athletic equipment in order to
decrease sport-related injuries
• http://nocsae.org/
• Catastrophic injury:
• a sports injury resulting in a brain or spinal cord injury, or a fracture of the
skull or spine
Sports That Require Helmets
• Bicycling
• Skating
• BMX
• Downhill Mountain
biking
• Longboarding
• Skateboarding
• ATV
• Motocross
• Go-Karting
• Motorcycles
• Bull riding
• Horseback
(equestrian)
• Rock climbing
• Baseball
• Softball
• Football
• Ice hockey
• Lacrosse
• Polo
• Snowboarding
• Snowmobiling
NOCSAE Seal
• Why is NOCSAE seal so important?
1. Indicates that the helmet was made to meet certain standards
2. Even though the helmet is certified, an injury could still occur if it is
not used correctly !
Football Helmet Warnings
•
WARNING: Do not strike an opponent with any part of this
helmet or face mask. This is a violation of football rules and may
cause you to suffer severe brain or neck injury, including paralysis or
death. Severe brain or neck injury may also occur accidentally while
playing football. NO HELMET CAN PREVENT ALL SUCH INJURIES.
USE THIS HELMET AT YOUR OWN RISK.
Head Protection
• Direct collision sports require head protection due to impacts,
forces, velocities and implements
• Football Helmets
• Must be protective against concussive force
• While helmets must be certified, they may not always be fail-safe
• Athletes and parents must be aware of inherent risks
Head Protection
• Each helmet must have visible exterior warning label
• Label indicates that helmet should not be used to strike an opponent due to risk of injury
• Also indicates risk of injury accidentally and that athlete plays at own risk while using
helmet
• Athlete must be aware of risks and what label indicates
• Athlete reads and signs statement regarding warning label
• There are a number of helmet manufacturers, and even more have closed
due to lawsuits and liability cases
• Football Helmets are good for
Football Helmet Fitting Guidelines
1.
2.
3.
4.
5.
6.
7.
Helmet fits snugly around player’s head
Helmet covers the base of the skull
Sits two-finger widths above the eyes
Ear holes should line up
Cheek pads should fit snugly against the sides of the face
Chin strap should be centered and prevent movement
Facemask should be securely attached, about three finger widths
from the nose http://www.youtube.com/watch?v=mgoS-jnmEJY
Football Helmet Fitting Video
Emergency Action Plans
Emergency Action Plans
• Emergency Action Plan (EAP)
• a written document that outlines the steps to follow in case of an emergency
• Emergency action plans provide guidelines and templates for
documentation of emergency planning to help prepare individuals for
a catastrophic injury situation within sports.
• The EAP should be reviewed at least once per year with all athletic
personnel along with CPR and first aid refresher training.
• It is important to remember that this is a working document.
• Always being modified as things change or happen
Why are EAPs important?
• The top causes of sudden death in sport: cardiac, head injuries, heat
stroke, exertional sickling, asthma, anaphylaxis, direct trauma,
lightening, and hyponatremia
• 425 catastrophic injuries resulted in permanent disability injuries and
398 catastrophic injuries resulted in full recovery
• 4% of sport related deaths in the US in 2013 were youth athletes
under the age of 17
Components of the Emergency Action Plan
1.
2.
3.
4.
5.
6.
7.
Emergency Personnel
Roles of First Responder
Emergency Communication
Emergency Equipment
Emergency Transportation
Venue Directions with Map
Individual Sport EAPs
a.
b.
c.
d.
e.
f.
g.
8.
9.
Practice Football Field
Louis Crews Football Stadium
Volleyball, Women’s Basketball, Men’s Basketball
Tennis
Baseball and Softball
Men’s and Women’s Soccer
Track/Cross Country
On-Field Emergency Protocol
Emergency Action Plan Checklist for non-medical emergency
Essential Framework
• Key Personnel
•
•
•
•
•
Athletic Trainers
Coaches
Parents
Administrators
Emergency Medical Services
• Equipment
•
•
•
•
•
Keys to gates
AEDs and other emergency equipment
Lamination of EAP and posting
First Aid kit
CPR/AED Training for coaches
Essential Framework
• Implementation Sequence or Strategy
•
•
•
•
•
•
•
Identify what your organization does well
Identify what your organization can improve upon
Increase knowledge by reviewing example documents
Consider who key personnel are to your organization
Consider all possible venues
Draft a general EAP
Have several people review the EAP
• Including medical personnel, EMS, coaches and parents
• Create a final EAP
• Post the EAP in several different locations
• Revisit policy annually and revise as necessary
Potential Barriers
• Problems/Barriers:
1. Public fields may be hesitant to post EAPs on the fields when other people
also use them.
2. No medical staff at the event
3. Too many different venues with different addresses
4. What if people don’t understand the EAP? I can’t possibly go to every
person involved in our school and explain the whole thing to them!
Why its Important to have an EAP
• Ensure every school develops an EAP for managing serious and or
potentially life-threatening injuries
• Develop EAPs specifically for each venue, including appropriate contact
information for EMS, facility address, location and maps and/or specific
directions to that venue
• Identify personnel and their responsibilities to carry out the plan of action
with a designated chain of command
• Develop, coordinate, include and distribute the EAP to local EMS, venue
public safety officials, on-site medical personnel, staff members, health
care professionals or organization administrators
• Identify and list the equipment needed in an emergency situation
• Specify documentation actions that need to be taken post emergency
• Review and rehearse the EAP annually by all parties involved
Medical Records
TERMINOLOGY
• Pre-Participation Physical Examination (PPE):
• a checkup to evaluate a person’s health and determine if they are able to
participate in sports
WHY WE KEEP MEDICAL RECORDS
1.
2.
3.
4.
5.
6.
Required part of an AT’s professional practice
Communication purposes
Legal responsibility
Research
ROI (Records of Information)
Reimbursement
FACTS
• Create a detailed, chronological ‘story’ of a patient’s interaction with
health care providers.
• Explain why decisions were made, what care was provided, and what
outcome was outcome
• Help plan and evaluate treatments and monitor progress
WHAT WE KEEP FOR MEDICAL RECORDS
• Types:
1. Medical information forms
•
•
•
•
Personal medical history
Family medical history
Orthopedic history
Pre-participation physical examination (PPE)
2. Injury evaluation form
3. Treatment form
4. Referral form
HOW WE KEEP MEDICAL RECORDS
• In todays electronic era, we can keep more than “Paper” records.
• Types of methods
• Paper
•
•
•
•
•
Standardized blank forms by the school or heath care provider
Standardized insurance forms
“Journal –style” briefs or narratives
SOAP notes
Carbonless forms
• Computer
• Software Packages
• ATS, Presagia Sports, Sim Trak, Sportsware and more
• Length and Manner of storage can be an issue in both cases
10 Tips for Documenting From the Article
1. Label every page with the patient’s name and the date.
2. Indicate the date and time of each entry and sign the entry in ink, complete
with your professional title.
3. Use language that is specific, objective, concise and complete.
4. When in doubt, RECORD IT.
5. Stay up-to-date on your documentation. Record entries within 24 hours of
patient contact.
6. To correct an inaccurate record, make sure the original entry remains legible
and clearly state why it is being changed. NEVER obliterate any part of a record.
7. Document each episode of physical medicine and rehabilitative care and
treatment.
8. Maintain permanent records for every case.
9. Keep your files orderly and professional, complete, accurate and legible.
10. Use only standard English and only universally recognized medical
abbreviations. If an abbreviation would allow room for confusion, do not use it.
Release of Medical Records
Terminology
• Health Insurance Portability and Accountability Act (HIPAA):
• a federal law to protect the confidentiality of an individual’s medical records
• Family Educational Rights and Privacy Act (FERPA):
• a law to protect the privacy of parents and students with respect to education
records
HIPPA
• A federal law which states that an organization must follow certain
privacy rules if it is a ‘covered’ entity.
• A ‘covered’ entity means that the person or organization performs
electronic transactions of medical records.
• Most high school athletic training programs are not covered entities;
however, they do exchange information with these covered entities.
• AT’s must protect the information they receive. They can share it for:
A. Billing purposes (Insurance companies)
B. Treatment purposes (Other healthcare providers)
HIPP Authorization Forms
• ITEMS THAT MUST BE INCLUDED:
1.
2.
3.
4.
An expiration date (usually 1 year)
A statement of who the information will be released to (can be general)
A statement that no one will be denied treatment for not signing
A notice that authorization can be withdrawn anytime through a written
statement
5. A reminder that information released to an outside entity is no longer
protected
FERPA
• A federal law that protects the privacy interests of parents and
students with regards to education records
• It affects all educational institutions that accept federal funding (most
high schools and universities)
• It allows AT’s to share medical information with a school nurse, team
doctor or other medical profession who shares responsibility for the
athlete’s care
FERPA Authorization Form
• WHAT IS PROTECTED?
1.
Files, documents or materials (including films, photographs, videos, etc.) that
contain student information.
Student education records (report cards, surveys and assessments & special
education records) and school information about parents.
Medical & health records
2.
3.
• WHAT ISN’T PROTECTED?
• General (‘Directory’) Information





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Student’s name
Phone number
Address
Date and place of birth
Honors & awards
Dates of attendance
Compliance with FERPA
• Even though sharing of medical information is permitted through
FERPA, AT’s should still have a parent sign a release to prevent legal
issues!
• AT’s should also make sure that the information is protected by the
other health care providers.
Medical Billing
Terminology
• Third Party Payer:
• a group other than the patient (1st party) or health care provider (2nd party) that pays
for health services
• Health Maintenance Organization (HMO):
• a health service plan that provides care for its members in a central health center
• Preferred-Provider Organization (PPO):
• a health service plan that allows members to choose their own physicians and
hospitals within certain limits
• Current Procedural Terminology (CPT):
• a code from the American Medical Association that permits licensed health care
providers to bill for their services
• National Provider Identifier (NPI):
• Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a
standard way throughout their industry.
Third Party Reimbursement
• What is:
• A 1st party payer?
• The patient
• A 2nd party payer?
• The healthcare provider
• A 3rd party payer?
• The insurance company
• With a 3rd party payer, some or all of the patient’s healthcare services are paid for by
insurance
Types of Health Insurances
• Exclusive Provider Organization (EPO):
• A managed care plan where services are covered only if you use doctors, specialists, or
hospitals in the plan’s network (except in an emergency).
• Health Maintenance Organization (HMO):
• A type of health insurance plan that usually limits coverage to care from doctors who work
for or contract with the HMO. It generally won't cover out-of-network care except in an
emergency. An HMO may require you to live or work in its service area to be eligible for
coverage. HMOs often provide integrated care and focus on prevention and wellness.
• Point of Service (POS):
• A type of plan where you pay less if you use doctors, hospitals, and other health care
providers that belong to the plan’s network. POS plans require you to get a referral from your
primary care doctor in order to see a specialist.
• Preferred Provider Organization (PPO):
• A type of health plan where you pay less if you use providers in the plan’s network. You can
use doctors, hospitals, and providers outside of the network without a referral for an
additional cost.
Advantages of
rd
3
Party Reimbursement
1. Athletic trainers can show their value to the district by the number
of treatments they provide
2. Athletic trainers can get reimbursed for the treatments they are
already providing
3. The extra money coming in can be used to pay for supplies,
equipment, or possibly even part of the athletic trainer’s salary
Disadvantages of
rd
3
Part Reimbursement
1. Some athletes don’t have insurance
2. Athletic trainers have to spend more time on paperwork, leaving
them less time to help their athletes
3. Insurance companies may decide what the best care for the athlete
is rather than the athletic trainer
4. An athletic trainer’s salary may depend on reimbursement