Ethics and rehabilitation supervision.

The administrative/managerial, educational, and clinical/ therapeutic components of rehabilitation supervision provide numerous opportunities for supervisors to assist practitioners in identifying, understanding, and resolving ethical dilemmas. This article describes ways to incorporate ethics in supervision and delineates some ethical decision making guidelines and considerations.

Ethical issues in the field of rehabilitation are becoming more complex as rehabilitation professionals work in an expanded number of settings, providing increased services to a greater variety of individuals with more severe disabilities. Two recent studies (Emener, Wright, Klein, Lavender & Smith, 1987; Pape & Klein, 1986) suggested that one group of rehabilitation professionals rehabilitation counselors) need assistance in identifying and resolving ethical dilemmas. A logical individual to provide the needed assistance is the rehabilitation supervisor. Moreover, numerous research studies cited by Ferrell & Gresharn, 1985) have found that organizational factors, such as philosophy, expectations, policies, and supervision, often exert greater influence over ethical/unethical decisions than individual factors values, past experiences, knowledge, and attitudes). As the primary link between the organization and the practitioner, the rehabilitation supervisor is in an excellent position to develop, promote, and maintain ethical awareness and behavior in the individuals they supervise.

Although supervisory responsibilities relating to ethical issues have been addressed from the perspective of the emerging profession of rehabilitation administration (Hawley & Capshaw, 1981) and the legal responsibilities of supervisors (Matkin, 1980), ethics was not specifically addressed in a major study (Matkin, Sawyer, Lorenz, & Rubin, 1982) of the work assignments, training needs and curriculum recommendations of rehabilitation administrators. Nonetheless, numerous opportunities for facilitating the ethical behavior of rehabilitation practitioners exist within the following components of the supervisory role delineated by Fineberg (1981): administrative/managerial, educational, and clinical/therapeutic.

The Administrative/Managerial Role

Among the administrative/managerial responsibilities described by Fineberg (1981), orienting new workers, providing direction/motivation, reviewing and evaluating performance, and handling complaints directly include opportunities for addressing ethical issues and promoting the ethical behavior of practitioners. In providing an orientation for new workers, supervisors generally address the rules and regulations of the work setting. However, the orientation also provides an opportunity for supervisors to make sure that new employees understand the ethics, defined as "standards of conduct or actions in relation to others" Levy, 1972), of their position. In the field of rehabilitation the "others" generally include clients and their families, colleagues, employers, and other professionals. New employees should be encouraged to belong to appropriate professional organizations and adopt the code of ethics of their professional group. New employees should be provided a copy of the applicable professional code of ethics, if they are unfamiliar with them, since codes of ethics specify both standards of conduct and responsibilities for members of a profession and provide protection for the profession and professional as well as the client and society as a whole (Shertzer & Stone, 1974).

Most professions have ethical codes and the field of rehabilitation is no exception. Examples of rehabilitation professional associations which have codes of ethics include: the National Association of Rehabilitation Professionals in the Private Sector (NARPPS), the Vocational Evaluation and Work Adjustment Association (VEWAA), the National Rehabilitation Administration Association (NRAA), the National Rehabilitation Counseling Association (NRCA), and the American Rehabilitation Counseling Association (ARCA). The Job Placement Division (JPD) has Standards of Practice which closely parallel some of these codes.

To include ethics and codes of ethics in the orientation process, supervisors must be familiar with the codes of ethics of the individuals they supervise, as well as their own code(s) of ethics. In some cases, a professional code may include standards for individuals who are supervisors. For example, the Code of Professional Ethics of Rehabilitation Counselors consists of 10 canons and 72 rules, one of which specifically references the rehabilitation counselor as a supervisor. Rule 4. 11 states, Rehabilitation counselors who employ or supervise other professionals or students will facilitate the professional development of such individuals. They provide appropriate working conditions, timely evaluations, constructive consultation, and experience opportunities.' (Code of Professional Ethics, 1987, p. 28).

Of course supervisors also need to understand their own code of ethics. For example, four of the ten Principles which comprise the NRAA Code of Ethics describe managerial behavior which relates to employees and supervision: Professional Rehabilitation Managers must be easily available to subordinates for counseling, advice, assistance, complaints, or grievances... They must assist employees in the best performance of their job. Professional Rehabilitation Managers seek to assure a continuing concern for the legal aspects of their functions, including knowledge of their legal responsibilities, of due process, and of employees' and clients' rights. They shall strive to develop their own as well as their employees' capabilities to the fullest. (NRAA code of ethics, 1988, p. 135)

The orientation of new employees also provides the supervisor with an opportunity to prepare employees for ethical dilemmas which they may encounter. The following statement about rehabilitation counselors is applicable to most practitioners in the field of rehabilitation: Nearly every act of rehabilitation counselors during working hours (and to some extent during nonworking hours) offers potential ethical considerations and the concomitant possibility of damage to the client, the relatives and acquaintances of the client, the rehabilitation agency, the profession, the counselor involved, and even the community. (Flowers & Parker, 1984, p. 56).

In discussing ethical issues and ethical behavior supervisors should help employees understand that ethical behavior is much more than "simplistic, mechanical adherence to a code of ethics" (Tarvydas, 1987, p. 52). Codes of ethics only provide broad guidelines and may contain rules which are contradictory in a given circumstance Hummell, Talbutt & Alexander, 1985; Matkin, 1980; Stude & McKelvey, 1979). Therefore, supervisors, while promoting professional affiliation and adoption of the applicable code of ethics in the orientation process, should note that a code of ethics is just one resource in making ethical decisions.

Providing direction and/or motivation and reviewing and evaluating the work performance of employees are also administrative/managerial functions of supervisors which provide opportunities for addressing ethical issues. All aspects of the rehabilitation process have ethical dimensions; whether the issue is meeting with employers, following up on client referrals, or successfully rehabilitating more clients, supervisors can include the ethical obligations of practitioners in each of these areas. In many instances, agency or facility rules and regulations relate directly to ethical principles. For example, state agency rehabilitation counselors are required to develop plans for their clients and Rule 2.8 of the Code of Professional Ethics for Rehabilitation Counselors specifically addresses plan development.

Supervisors also provide channels of communication between practitioners and the administration and help formulate and interpret employer policies. Supervisors should be alert to agency/facility/company philosophies, expectations, and policies which conflict with ethical principles and communicate these to the administration. Including ethics in supervisory practices may highlight new policies which need to be formulated or existing policies which need to be changed or interpreted more broadly or narrowly. Research in business ethics on the "opportunity" variable also has implications for supervisors (and administrators) in formulating and interpreting policy. Opportunity results from a favorable set of conditions to limit barriers or provide rewards. Certainly the absence of punishment provides an opportunity for unethical behavior without regard for consequences. (Ferrell & Gresham, 1985, p. 92).

Zey-Ferreff and Ferrell (1982) found that the opportunity to engage in unethical behavior was a better predictor of an individual's behavior than the individual's personal beliefs or the beliefs of their peers. Van Hoose and Kottler (1985) called this the difference between attitudinal morality and behavior morality, "a difference between what one believes, what one says he believes, and what one does on the basis of his beliefs" (p. 25). Based on the poor correlation between ethical beliefs and ethical behavior, Ferrell and Gresham (1985) recommended the establishment and enforcement of codes of ethics or corporate policies on ethics to change individual beliefs and ethical behavior.

Supervisors handle complaints and grievances. Although the legal parameters of complaints generally receive the most attention, supervisors should consider the ethical aspects or implications of complaints, when applicable. Moreover, some complaints or grievances may suggest limitations in a code of ethics or company policy, as well as areas of training needed by practitioners. For example, a client complaint about counselor non-involvement in placement activities can be approached from an agency rule perspective counselors in state agencies are generally required to place clients on jobs), as well as an ethical dilemma perspective (what is the appropriate level of placement involvement which will result in appropriate, gainful employment and not promote client dependence).

The Educational Role

Included in the tasks associated with the educational role of supervisors are identifying training needs, designating trainees, determining the formats for training, creating the learning climate, and monitoring and reinforcing learning (Fineberg, 1981). The educational role offers numerous opportunities for supervisors to address ethics, ethical dilemmas, and ethical decision making. This role is particularly crucial for supervisors, because many rehabilitation practitioners have not received a systematic ethics education in their preservice programs.

Indeed, ethical behavior has often been equated with common sense and viewed as an inherent trait. However as Flowers and Parker (1984) have pointed out, "Ethical conduct goes beyond common sense, sound judgment, and work experience" (p. 62). Ethical decision making is a skill which can be learned by practitioners (Handelsman, 1986) and taught by supervisors. Four goals of ethics training which supervisors should consider include: (a) sensitizing individuals to ethical issues, (b) improving individuals' abilities to reason about ethical issues, (c) helping individuals develop "moral responsibility and ego strength to act in ethical ways," and (d) assisting individuals to tolerate "the ambiguity of ethical decision making" (Kitchener, 1986, p. 308).

Two recent studies of ethical issues and the ethical conduct of one group of rehabilitation professionals rehabilitation counselors) highlight the importance of training in ethics and ethical decision-making. In a survey of 267 ARCA-NRCA members of whom 49% were rehabilitation counselors and 21% were administrators, Pape and Klein (1986) found that (a) only 30% of the respondents referred to a code of ethics to resolve an ethical dilemma, (b) the major categories of dilemmas included counselor-client confidentiality (13.1%) and working within the system 11.2%), and (c) 45% of the respondents were aware of unethical behavior by a rehabilitation colleague, agency or company.

These findings were corroborated by Emener et al. (1987) who noted three primary response modes in ethical decision-making: (a) non-conscious awareness, where the individual responds without awareness of the ethic involved; (b) conscious self-awareness, where the counselor thinks about the ethic involved; or (c) consultation, where the counselor refers to a code of ethics, or consults with a colleague, supervisor, or professional group. Emener et al. (1987) found that almost half of the counselors responded to ethical dilemmas with "unconscious awareness" and only about 25% of the counselors sought some form of consultation regarding an ethical decision. They also found that 20 or more counselors would consult with their supervisors when the issues involved (a) confidentiality and a client's legal proceedings, b) conflicts between the client's interest and the welfare of the community, (c) illegal behavior of a client which may harm the client and/or the community, and (d) termination of the rehabilitation counseling relationship with a client.

These studies support the need for ethics training and highlight some major areas supervisors should consider for inclusion in training. Based on the results of these surveys, additional goals of ethics training might include: (a) decreasing the amount of "unconscious awareness," (b) increasing the practitioners' use of applicable codes of ethics, and (c) helping practitioners learn and use ethical decision- making skins.

In determining the training format, supervisors should not overlook staff meetings as a forum to sensitize employees to ethical issues, assist them in improving their ethical reasoning skiffs, and facilitate learning from each other, as well as from the supervisor. Although ethics should be incorporated in general topics of staff meetings, such as agency goals, there should also be meetings set aside for the sole purpose of imparting information on ethics and discussing existing or potential ethical dilemmas. For example, one or more staff meetings could be devoted to discussing ethical dilemmas, using Tymchuk's (1982) process for making ethical decisions:

Step 1. Describe the parameters of the situation

Step 2 Describe the potential issues involved

Step 3. Describe the guidelines already available that might affect each issue (e.g., values, law, codes, practice, research)

Step 4. Ennumerate (sic) the alternative decisions for each issue

Step 5. Ennumerate sic) the short term, ongoing, and long-term consequences for each alternative

Step 6 Present evidence (or the lack thereof) for those consequences as well as the probability of occurrence

Step 7 Rank order and vote on the decisions (p. 170).

Because ethical decision-making is such a complex process (Tarvydas, 1987), the following situation (Situation 1) provides an example of imparting ethical information while helping a practitioner evaluate a previous decision. Situation 2 is an example of a discussion item which could be used in staff meetings. Situation 1: Complaint about Counselor Placement Activities

In a situation where a client complains about the lack of counselor placement assistance, the supervisor begins by helping the counselor evaluate the original decision. In this case, the counselor's rationale for a minimal level of involvement in placement was that it would facilitate client independence and still result in appropriate gainful employment of the client. As a discussion tool, the supervisor might describe Kitchener's (1984) model of ethical justification, which delineated levels of moral reasoning. Kitchener (1984, 1986) suggested that the facts of a situation and an individual's basic beliefs (ordinary moral sense) form the basis for most actions. Thus her first level of moral reasoning is the intuitive level (basic response based on morals, beliefs, and prior learning and experience). She also pointed out, however, that "not all individuals have moral intuitions that lead the way to defensible ethical choices" (Kitchener, 1984, p. 44) and recommended a second level of moral reasoning, the " critical-evaluative" level, to help people deal with unexpected dilemmas and to evaluate their intuitive responses. The critical-evaluative level, composed of the following three tiers which move from most specific to least specific, is based on reasoned rather than immediate judgments: (a) Rules-Professional Codes, Laws, etc., (b) ethical principles, and (c) ethical theory.

The supervisor should point out that the counselor's intuitive response was that the client could secure his/her own employment. The client's complaint, however, provides an opportunity for the counselor to evaluate the intuitive response by using the tiers of the critical-evaluative level. In this instance, the supervisor and counselor would find that the Code of Professional Ethics for Rehabilitation Counselors (1987) does not address the level of involvement of the counselor. When a specific ethical rule does not address a situation or when contradictions exist between applicable ethical rules, individuals move to the second tier to consider the applicable ethical principles, which are more general than the rules and which serve as the justification for a particular rule in a code of ethics.

Following Kitchener's (1986) recommendation that the moral principles described by Beauchamp and Childress (1983) should serve as the foundation for ethical reasoning, the supervisor and counselor should discuss placement involvement in terms of- (a) autonomy (making one's own decisions and respecting the rights of others), b) non-maleficence (acting in a way that will not cause physical or emotional harm to others), (c) beneficence (acting in ways that will help others), and (d) justice (treating people fairly). The counselor may feel that the initial decision was supported by the principles of autonomy, beneficence, and justice, however, the supervisor can point out that these principles may need to be balanced against the client's feelings of emotional harm, if the client felt abandoned or not supported by the counselor. There are also ethical principles in the counselor's code of ethics which apply to the second tier evaluation. Canon 2 of The Professional Code of Ethics for Rehabilitation Counselors states that rehabilitation counselors must "respect the integrity and protect the welfare" of their clients and place the client's interest above their own. If the discussion centers around the counselor's competence in placement, then Canon 9 is applicable; it states that counselors "shall establish and maintain their professional competencies at such a level that their clients receive the benefit of the highest quality of services the profession is capable of offering" (Code of Professional Ethics, 1987, p. 28).

When ethical principles are unable to provide the necessary assistance, individuals consider the third tier, ethical theory. Decisions based on ethical theory reflect (a) what individuals "would want for themselves or for others they love who are in the same circumstances or (b) produces the least amount of avoidable harm" (Kitchener, 1986, p. 309). At this level, the supervisor and counselor might discuss what the counselor would want in placement involvement for a husband, wife, son, or daughter, if a family member was receiving services from the rehabilitation agency. Although the counselor (and supervisor) may arrive at the same conclusion originally reached by the counselor, this process highlights the importance of reasoned, rather than intuitive decisions. Situation 2: Confidentiality and Counselor Sexual Behavior 

Mary Smith, a rehabilitation counselor in a state VR agency has learned from one of her clients, that another counselor in the agency John Brown) is involved in a sexual relationship with one of his clients. Mary's client conveyed the information confidentially" and does not want Mary to say anything to anybody. The client broke a confidence to tell Mary and does not want to get John in trouble with the agency. What should Mary Smith do?

Mary's intuitive response is that such behavior is wrong; counselors do not have sexual relationships with clients. Moving to the critical-evaluative level of ethical justification, Mary begins with The Code of Professional Ethics for Rehabilitation Counselors. Her intuitive response is confirmed; the last sentence of Rule 2.3 states that "Sexual intimacies with clients are unethical." Mary also considers Rule 6.1, which states that "Rehabilitation counselors will inform clients at the outset of the counseling relationship of the limits of confidentiality." She knows her client is counting on the information remaining confidential. However, Levenson (1986) stated that confidentiality "is not an absolute good outweighing all other principles" (p. 64). Furthermore, Rule 4.9 states that when a counselor is aware of an ethical violation, minor violations should be resolved informally and more serious violations should be brought to the attention of the appropriate ethical committee.

In considering the ethical principles of autonomy, nonmaleficence, beneficence, and justice, Mary recognizes her client's right to request no action, even when informed that counselors are forbidden by their code to have sexual relationships with clients. Disregarding her client's wishes would not be consistent with the principle of nonmaleficence. However, if what her client told her is true, Mary cannot base her decision on the principle of beneficence in terms of being helpful to John's client. Justice becomes an area of concern for Mary in that she wants to be fair to John, to both of their clients, and to herself. In considering ethical theory and the least amount of avoidable harm, Mary must decide between John's client and the counseling relationship with her own client. Mary can also proceed through Tyinchuk's (1982) stages in listing the various alternative decisions (e.g., doing nothing, discussing the allegation with John, reporting the allegation to John's supervisor, or consulting with her own supervisor), and the short-term, ongoing, and long-term consequences for each of her alternative courses of action.

Situation 2 and others like it occur with some frequency in rehabilitation. These dilemmas may be resolved by using the balancing test previously described. An absolute answer is not provided, because (a) the policies of some agencies/facilities may dictate specific behavior, and b) Mary's supervisor may be able to initiate an investigation without involving Mary or her client. In the absence of agency/facility policies, Levenson's (1986) considerations in the unethical behavior of colleagues and guidelines for intervention will be helpful to the supervisor and practitioners. Practitioners (and supervisors) must also understand Van Hoose and Kottler's (1985) "ground rule" for practitioners: If one has a specific, responsible rationale for a given behavior, can defend it as justifiable under the circumstances, and the results turns out favorably, one is in the clear. If, however, the result turns out poorly and somebody complains or files suit the same action may be construed as irresponsible, unethical, incompetent or illegal. (p. 42) The Supervisor as a Model Fineberg (1981) also included behavior modeling in the educational role of supervisors; he stated, "modeling or teaching by example has long been pointed to as an essential ingredient of effective rehabilitation supervision" (p. 244). Modeling ethical behavior is essential if supervisors are to facilitate ethical behavior in the individuals they supervise. Citing studies which found the behavior of superiors as the major factor influencing ethical decision making, Ferrell and Gresnam (1985) included significant others as one of three contingency variables in an individual's response to an ethical issue or dilemma. (The other contingency variables include individual factors [knowledge, values, attitudes, intentions] and opportunity [professional codes, corporate policy, rewards/punishment].) Although Ferrell and Gresham (1985) acknowledged that upper management generally sets the "ethical tone to an organization," it is the rehabilitation supervisor who is in the closest proximity to practitioners and who has the status and authority to exert role pressure. Rehabilitation supervisors must behave ethically, if they are to foster ethical behavior in others. They must also demonstrate behaviorally that they value ethical behavior in the individuals they supervise.

The Clinical/Therapeutic Role

The clinical/therapeutic role of supervisors includes facilitating the growth and development of the supervised and assisting them in learning the skills, attitudes, and knowledge necessary to cope with the problems arising from their work situations..." (Fineberg, 1981, p. 245). In consulting on ethics and ethical issues, supervisors must understand that "ethical decisions at any given time represent a blend of feelings, beliefs, prejudices, and experiences Van Hoose & Kottler, 1985, p. 170); and most unethical behavior results from poor judgment, lack of knowledge, and/or the inability to recognize ethical situations. As an ethical consultant (and model), the supervisor helps practitioners establish and maintain acceptable standards of ethical practice. The supervisor is both a facilitator and resource to practitioners as they "continually monitor their own behavior, upgrade their skills, increase their knowledge, and perfect a personal theory of ethics with which to make decisions" (Van Hoose & Kottler, 1985, p. 108). The research results of Emener et al. (1987) and Pape and Klein (1986) also suggested some major areas in which supervisory consultation is generally requested, including counselor-client confidentiality, working within the system, conflicts between the client's interest and the welfare of the community, illegal behavior of a client which may harm the client and/or the community, and termination of the rehabilitation counseling relationship with a client.

As a consultant/clinical supervisor, it is important for the supervisor to help practitioners understand the decision-making process, appreciate the alternative choices, consider the possible results of those choices, and take appropriate action. In discussing the third goal of ethics education, the development of a sense of moral responsibility, Kitchener (1986) stated: It is not enough to be aware of and concerned about ethical issues, nor is it enough to think wisely about ethical issues. Professional practice requires that individuals take responsibility for acting and for the consequences of their actions. (p. 308).

Jones, Sontag, Becker, and Fogelin (1977) stated that "Ethics is not primarily concerned with getting people to do what they believe to be right, but rather with helping them to decide what is right" (p. 8).

Summary

The administrative/managerial, educational, and clinical/therapeutic components of rehabilitation supervision provide numerous opportunities for supervisors to assist practitioners in identifying, understanding, and resolving ethical dilemmas. The learning process is the first step for supervisors to consider in successfully incorporating ethics into the major components of their supervisory role. Supervisors need to learn about ethics, codes of ethics, and the process of ethical decision making. They need to examine their personal knowledge and behavior in the area of ethics, their interpersonal skills in facilitating ethical behavior, and their ability to impart information about ethics to practitioners. An inservice train-the-trainer format (training supervisors to train practitioners) may be the most expedient way for supervisors to acquire this knowledge and skills. Acting ethically is the second, concomitant step for supervisors. Supervisors need to examine their behavior and beliefs as they relate to ethics. They must behave ethically and value ethical behavior in the individuals they supervise. Lastly, supervisors must teach practitioners about ethics and ethical decision making. Teaching practitioners will strengthen the supervisor's skills and help them internalize the knowledge they have obtained. Teaching practitioners about ethics will promote ethical behavior by practitioners and reinforce the supervisors' ethical behavior. As a first step in this process, the following questions are designed to help supervisors evaluate their current functioning level:

1. How frequently do I incorporate ethics into my administrative/managerial, educational, and clinical/therapeutic roles?

2 Can I list the major ethical dilemmas facing the individuals I supervise?

3. Do I see ethical dimensions in all aspects of the rehabilitation process ?

4. Do I have copies of the applicable code(s) of ethics for the individuals I supervise?

5. Do I encourage professional membership to facilitate the adoption of professional codes of ethics by the individuals I supervise?

6. Do I have a Code of Ethics to which I adhere or consult?

7. What is my level of understanding of laws and agency policies which influence ethical/unethical behavior?

8. What is my personal skill level in recognizing ethical dilemmas?

9. What is my approach to ethical decision making?

10. Do I model and encourage ethical behavior in the individuals I supervise?

11. Does my behavior suggest that I value ethical behavior?

12 When providing consultation, do I provide answers or help individuals improve their own ethical decision making skills?

By remaining attentive to their role and using the opportunities they have to develop, promote, and maintain ethical awareness and behavior in the individuals they supervise, supervisors will also improve the quality of services provided to persons with disabilities.