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ATRA Code of Ethics: Impressions from the Profession.

To determine the knowledge, attitudes, and behaviors of recreational therapists about the professional code of ethics (COE), the American Therapeutic Recreation Association (ATRA) Ethics Committee conducted a survey in 2015 in which 269 individuals participated. Results indicated there were no significant differences between the number of years practicing as a CTRS and a person's ethics knowledge, behavior, and attitude. There were also no significant differences between the role of the recreational therapist related to knowledge and behavior and the COE. However, significant differences were found between being practicing recreational therapists versus educators in the attitude domain about the COE. Analysis of individual statements and respondent comments indicated the importance of and continued need for ethics education, the struggle of "gray areas" of ethics, the issue of COE terminology being outdated, and lack of consistency in practice. Future research should look at survey design as well as use of the COE in the different types of agencies and populations with whom CTRSs work.

Introduction

Professionals are defined by discipline specific standards and credentials, as well as practices, formalized higher education, training, service, and having a professional association (Carter, Smith, & O'Morrow, 2014). As professionals, it is critical to demonstrate competence, skill, and professionalism through attitudes, knowledge, behaviors, and ethical conduct in working with consumers (Cornett, 2006; Morrison, 2016) as this builds trust by those served (Mason, 2016). To achieve this, education, skill development, and a professional code of ethics are foundational to being a professional.

Being a professional means being "...governed by a code of ethics and professing [sic] commitment to competence, integrity and morality, altruism, and the promotion of the public good within their domain" (Cruess, Johnson, & Cruess, 2004, p. 75). A uniform standard of ethical conduct is the basis of a professional's obligations. Qualified recreational therapists, credentialed as Certified Therapeutic Recreation Specialists[TM] (CTRS[TM]), are expected to practice and adhere to principles that ensure ethical behavior, integrity, and trustworthiness (NCTRC, 2016a) while projecting a positive image of the profession. These governing principles are found in the American Therapeutic Recreation Association (ATRA) Code of Ethics (COE). The National Council for Therapeutic Recreation Certification (NCTRC) considers knowledge of the COE a major job task for the CTRS[TM] (NCTRC, 2016a) and issues sanctions based on negligence, malpractice, and/or misconduct that violates the professions COE (NCTRC, 2016b, p. 5).

Code of Ethics

A profession is described as "an occupation whose core element is work based upon the mastery of a complex body of knowledge and skills" (Cruess et al., 2004, p. 75). Through the development of specific and shared knowledge, beliefs, and skills, a profession is differentiated from a trade (Cruess et al., 2004). Demonstrated by observable behaviors, professionals communicate their professional calling and professionalism (Lesser et al., 2010; Morrison, 2016). In addition, there is a professional attitude that requires commitment that "reflects a set of internalized values that shape professional behavior" (Cornett & Chabon, 1988, p. 50).

Definition and purpose of COE. The values that shape behavior reflect shared morals and beliefs that provide a framework that influences professional behaviors, guides clinical judgments, and impacts interactions with consumers, co-workers, and other stakeholders (ATRA, 1998; Dollinger, 2000; Morrison, 2016). Within a profession, this moral framework is documented within a COE, which provides a shared language to guide ethical decisions (Carter et al., 2014; Greenfield & Jensen, 2010; Morrison, 2016), creates a professional identity (Delany, Spriggs, Fry, & Gillam, 2010; Morrison, 2016), and separates a profession from an occupation (Mason, 2016).

A professional COE's purpose is multifaceted. It should do the following:

* Define and explain ethical positions and behaviors of those practicing in a profession

* Communicate expectations of behavior to those professionals

* Provide guidance in decision making

* Contribute to the identity and recognition of a profession

* Assure the public of ethical conduct by professionals.

Ethical standards inform professionals in their daily behavior, providing guidelines for ethical conduct (Morrison, 2016; Shank & Coyle, 2002). Specifically, a COE "provides rules of duty and principles of responsibility to clients, the employer, peer professional, the profession as a whole, and society at large" (Shank, 1996, p. 32). Oftentimes, decisions may not be clear or straightforward; a COE provides a standardized framework and guidance to enable professionals to make the most appropriate choice (Carter et al., 2014; Morrison, 2016). Understanding and knowing a professions COE is essential to professional self-regulation and appropriate professional conduct (Kanny, 2000; Morrison, 2016).

History of Recreational Therapy COE. Developing a COE is considered the responsibility of a professional association in that the associations role is to promote desired behaviors and create an understanding of expectations for a profession (Kasar & Clark, 2000). In recreational therapy, early conversations regarding ethical practice led to the establishment of a COE by the National Therapeutic Recreation Society (NTRS) in 1972, later revised in 1990. Following this, the ATRA established a Code of Ethics in 1990 (six years after the start of the association), with the current revised version completed and adopted in 2009 (ATRA, 1998; 2009) (see Table 1). While these professional associations created a COE for the profession, each had little authority for enforcement. However, the NCTRC, the credentialing body for recreational therapists, did have authority to enforce compliance with the COE. In 1991, NCTRC created a Standards Hearing Committee, and developed an Ethics Board in 1998 to review allegations of unethical conduct (ATRA, 1998).

The ATRA COE. The ATRA COE "is to be used as guide for promoting and maintaining the highest standard of ethical behavior" (ATRA, 2009). It consists of 10 principles, commonly found in professional COEs, and applies to all individuals practicing in recreational therapy. The basic principles are as follows:

* Beneficence: promoting benefits and minimizing harm

* Non-Maleficence: protecting consumers from harm and respecting their decision-making

* Autonomy: preserving and protecting consumers' right to make their own choices

* Justice: serving consumers fairly and equitably

* Fidelity: being loyal and faithful to consumers, colleagues, and organizations

* Veracity: being honest and truthful

* Informed consent: providing information on interventions to consumers so that they can make informed choices

* Confidentiality and privacy: protecting consumer's information

* Competence: maintaining and continuing to improve one's knowledge about the profession, clients served and interventions provided

* Compliance with laws and regulations: complying with all levels of regulations and policies. (ATRA, 2009, para. 2-11)

These 10 principles provide the ethical framework for the practice of recreational therapy and are included in the ATRA Standards of Practice (2013). Standard of Practice #7: Ethical Conduct detailed the expectation of ethical conduct by recreational therapists and students to provide the most professional treatment to consumers (ATRA, 2013).

It has been over 17 years since the first ATRA ethics publication, Finding the Path: Ethics in Action (1998), was introduced as a training guide and reference designed to assist recreational therapists (RTs) in navigating ethical dilemmas that relate to the delivery of service to consumers. Even though there have been a significant number of changes in health care over that time, the topic of ethics, as it relates to recreational therapy practice, remains relatively unaddressed. Therefore, the purpose of this study was to examine the influence of various characteristics of RTs on ethical aspects of their job. Specifically, the research questions guiding this study included: 1) Is there a mean difference in years as a CTRS among recreational therapists on their knowledge of ethical practices, attitude toward ethical practices, and behavior on ethical practice?; and 2) Is there a mean difference of role on their knowledge of ethical practices, attitude toward ethical practices, and behavior on ethical practice?

Methods

This project resulted from the work of the ATRA Ethics Committee as it developed an ethics training tool entitled Guidelines for the Ethical Practice of Recreational Therapy (under review). Recognizing that not enough emphasis had been placed on ethics within the recreational therapy profession, the authors/editors concluded it would be beneficial to collect baseline data on RTs' knowledge and understanding of the COE to develop appropriate educational opportunities and promotion of ethical conduct. For this reason, a survey for RTs was developed to identify current perceptions of knowledge, attitudes and behaviors related to ethics. Prior to the start of the study, Institutional Review Board approval was obtained from Virginia Wesleyan College.

Participant description

Members of the ATRA were invited to participate in this study through email communication. An email was sent in July 2015 (N = 1,878), with a reminder published in the July 2015 newsletter sent to members (N - 1,925). In response to these two solicitations, 296 individuals completed the survey, with 27 of those being incomplete. This resulted in 269 usable responses (n = 269), indicating a response rate of 14%. Table 2 provides demographic information on the respondents.

Instrument

Development of survey content occurred over a two-year period and involved one author, the ATRA Research Committee, and the ATRA Board of Directors. It was recommended that Qualtrics be used for data collection. The survey was approved by the ATRA Board of Directors in 2014, and piloted through the ATRA National Office. In 2015, the ATRA members completed the survey, using a direct web link to the survey, during a three-week period. Responses were tabulated through Qualtrics and statistical analysis was conducted by a member of the ATRA Research Committee.

Each of the concepts of knowledge, behaviors, and attitudes was assessed through a series of statements related to the ATRA COE. Responses were based on self-perception of the respondents indicating their understanding, possible behaviors, and feelings about ethical practice. To assess the area of ethical knowledge, survey respondents were asked to indicate their understanding of each of the 10 principles within the ATRA COE such as justice and fidelity. Responses were based on a 5-point Likert scale, ranging from 5 strongly agree to 1 strongly disagree. The area of ethical behaviors was evaluated by participants selecting a response that most accurately reflected their thoughts on ethical behaviors. For example, respondents were asked about their agreement (5 strongly agree to 1 strongly disagree) if it is ethical to take progress notes home to complete documentation in a timely manner. Respondents were asked to indicate how well the statement reflected their attitude toward ethical practice. Examples of statements included: "Compliance with the ATRA Code of Ethics impacts my professional status" or "I have a professional obligation to my colleagues and to the field of recreational therapy."

Analysis

This study examined if there were differences among RTs in their knowledge of ethical practices, behavior on ethical practices, and attitude toward ethical practices based on their years as a CTRS[TM] and professional role. The dependent variables were: a) knowledge of ethical practices, b) ethical behavior scores, and c) attitude toward ethical practices. The independent variables were: a) years as a CTRS[TM], and b) job role.

The dependent variables consisted of 27 questions --10 related to knowledge of ethics, eight related to ethical behaviors, and nine about attitudes toward ethics. Understanding of the principles of the ATRA COE encompassed the first variable of "knowledge," and was based on responses to the 10 questions in this section of the survey. For the eight questions related to behaviors, respondents indicated their degree of agreement with statements asking if a particular behavior or situation was ethical; this formed the second variable of "behavior." In the last dependent variable of "attitude" respondents noted how accurate a statement reflected their personal attitude about ethical practice.

The independent variables focused on two components: years of practice as a CTRS[TM] with a range of less than one year to 10+ years or status as a student, and current role/position. Professional roles included recreational therapist, recreational therapist/supervisor, recreational therapist/administrator, recreation leader/programmer, administrator, educator, student, or not currently employed in recreational therapy. These variables were selected for convenience and potential contribution to understanding recreational therapists' knowledge, behaviors, and attitudes about ethics.

Data were analyzed using the Statistical Package for the Social Sciences (SPSS) for Windows, Version 23 (IBM, 2015). To create the three dependent variables of knowledge, behavior, and attitudes, the survey questions under each were collapsed using the SPSS compute function and then each were divided to obtain a mean score; thus, creating each of the dependent variables. Following this, one-way Analysis of Variances (ANOVA) was conducted for each research question. Both normality and homogeneity of variance were examined using histograms and Levene's test, with both tests being met for normality and homogeneity.

As previously mentioned, under the sections of knowledge, behaviors, and attitudes, respondents had the opportunity to provide written comments to explain their responses or provide additional information. These comments were reduced to themes and included in this study.

Results

Quantitative Analysis

Due to the limited capability of the Qualtrics package used, limited data at varying levels were obtained, thus, limiting the types of analyses that could be conducted. Data analysis revealed that there was no statistically significant differences in the mean scores of ethical knowledge by years as a CTRS[TM] [F(5,263) = 1.252, p = .285 ], ethical behavior by years as a CTRS'" [F(5, 263) = .699, p = .625], and ethical attitude by years as a CTRS[TM] [F(5,263) = 1.036, p - .397]. In addition, there were no statistically significant mean differences in ethical knowledge [F(7,261) = 1.107, p = .163] and ethical behavior by professional role [F(7,261) = .843,p = .553]. However, statistically significant mean differences existed on ethical attitude by professional role [F(7,261) = .237, p = .03]. Post hoc comparisons using the Tukey HSD test indicated that the mean score for the recreational therapist role (M = 3.33) was significantly different than the education role (M = 3.40), p = 0.03.

Under each of the questions, responses and percentages were calculated, as well as range, mean, variance, and standard deviation. Responses were predominately in agreement to the statement "I understand the ethical principles as identified in the ATRA Code of Ethics" (n = 269, SD = .697), 141 (52.4%) strongly agreed and 111 (41.3%) agreed, with only 17 (6.3%) indicating any type of disagreement. In response to the statement "I have sufficient understanding of the ATRA Code of Ethics as it applies to situations regarding my works as a CTRS," the majority of people were in agreement (94%; n = 269, SD = .704) (See Table 3).

Respondent comments that focused on ethical behavior indicated agreement to the statements. However, there were two statements that warrant further analysis. The statement that "It is ethical to forego a treatment team meeting in order to adhere to impending assessment deadline" in which 55 respondents agreed in some way indicating they are potentially putting a meeting ahead of a client's assessment, they are potentially violating ethical standards on fidelity (loyalty to the client first) and compliance (by not meeting a regulatory timeline) (see Figure 1).

The other response was to the statement "It is ethical to use a self-designed and/or non-standardized assessment tool "validity or reliability undetermined" (n = 269, SD = .981). Strong agreement was expressed by one respondent (0.4%), while agreement was indicated by 60 (22.3%). A total of 123 people (45.7%) indicated that it is unethical to use a non-standardized assessment, and 85 (31.6%) were neither agreed nor disagreed (see Figure 2).

Upon visual inspection of the data and bar graphs, there was agreement with almost all of the statements related to ethical attitudes (see Table 3). The only statement with ambiguity was the statement, "I have heard of instances where a CTRS may have violated the ATRA Code of Ethics" which was relatively split with 38% (n = 102) who agreed and 38% (n = 101) who disagreed.

Analysis of Themes and Comments

The option to provide additional written comments was offered after each statement. Through these comments, several common themes were identified in the areas of ethical knowledge, ethical behavior, and ethical attitude.

Within the "Knowledge of ATRA Code of Ethics" section, two common themes were identified among the six submitted comments. The first theme was that of relevance and understanding of the COE terms, which was mentioned four times. One respondent wrote, "The titles are what makes the ethics misleading and can be difficult to understand if you do not know what the titles themselves mean." Another commented, "The ATRA code is antiquated using terms such as 'non-maleficience' and has no distinctive language to inspire virtuous behavior as an aspiration." The second theme was that of the need for more and/or the lack of ethics education (n = 3). Respondents stated that there was not enough education on ethics, and one even suggested making it a regular requirement (once per year, or at least once per five-year certification cycle).

In the ethical behavior section, 101 comments were submitted about the various statements. In many instances, respondents attempted to explain their response and provide justification for their answer. Despite this, several themes emerged--one across multiple questions. The primary theme identified is that of variations in practice related to setting, population served, agency policy (e.g., permission to access an Internet portal from home to complete documentation), position flexibility (e.g., can another therapist cover the meeting for me), and specific job requirements. This theme was found in statements related to ethical behavior in the area of taking documentation home, missing a treatment meeting to complete an assessment on time, competency, and training. One respondent stated, "the CTRSs should advocate for themselves. Interdisciplinary team meetings are an integral part of the job of a CTRS. However, there are times, when it may be necessary to skip a meeting in order to aid a client in need." In the statement about the use of non-standardized/self-developed assessments, another theme emerged which was that of a lack of comprehensive and appropriate assessments to meet the needs of the diverse populations served in a variety of settings. Multiple respondents commented that leisure interests and preferences are rarely included in standardized tools; others reported that the cost of standardized recreational therapy assessments is prohibitive for their agencies. One person put it this way: "While in an ideal world we should be using standardized tools, reality is that we don't have enough tools to meet all the needs and sometimes using a non-standardized tool is better than no tool at all."

The final area for thematic analysis was in the area of attitudes about the COE. Eight comments were submitted here with the theme of lack of required ethical education appearing. The other theme identified in this section was that of a lack of professional recognition of the COE and of recreational therapy as a profession. Three respondents specifically commented about this: "You would be surprised when I come on a unit and run 'recreation therapy' how many patients will tell me, "That's not recreation therapy. Recreation therapy's supposed to be fun and games. That's what the last person did before you'."

Discussion

The COE survey was developed to establish a baseline understanding of the knowledge, behaviors, and attitudes regarding ethical practice within recreational therapy to guide the development of ethics training. Even though most of the results do not indicate significant differences in knowledge, behaviors, and attitudes, responses do provide insights into ethics for the practice of recreational therapy.

Nisbett, Brown-Welty, and O'Keefe (2002) wrote that professional ethics guide the behavior of the profession and that "professional ethics are more than just the written code; they are the moral obligation that can be understood from the activity of the profession" (p. 283). The results of this study indicated that respondents generally have similar knowledge, behaviors, and attitudes regarding ethical practice and moral obligation as a recreational therapist regardless of how long they have been certified, which is what we would hope for the recreational therapy profession.

The one area of significant differences in means was between the reported roles. Educators had a higher mean in the attitude section of the survey than those identifying as a practicing recreational therapist, indicating the educators had less agreement with the statements on the survey. This may have attributed to the fact that several of the questions were written toward the practicing recreational therapist (e.g., "other CTRSs I associate with utilize the ATRA Standards of Practice [including the Code of Ethics]," "All persons I serve (or their representative) are given the opportunity to determine their own treatment"). Another potential explanation is that educators practice as educators, not as therapists. Even though they are within the recreational therapy profession, the practice of being an educator is different than that of practice as a therapist.

Implications

Several implications were identified from this study. These were: the need for ethics education, the terms used within the COE, the gray areas of practice created by job requirements but not directly covered by the COE, attitudes and consistency of practice, and the need for more standardized comprehensive assessment tools specific to recreational therapy.

The need for ethics education. Historically, the importance of ethics education in recreational therapy is well documented. Some of the earliest articles discussing ethics appeared in the Therapeutic Recreation Journal (TRJ) 30 years ago. As the profession was growing, standards of practice and ethical principles were discussed. Fain (1985) encouraged the profession to look at what needed to be done to advance ethical knowledge. During 1985, an entire TRJ issue was devoted to the topic of ethics. In that issue, Sylvester (1985) noted that students and professionals should receive "proper and adequate training" (p. 19) in ethical behavior. Additionally, in his article about the NTRS Code of Ethics, Patterson (1985) contended that a professional code of ethics would "provide guidance in resolving issues" that a RT might encounter in the work environment. Yet, in 2002 Sylvester contented that little was offered in the way of ethics training for RTs even though it was acknowledged that "ethics guide professional practice" (Sylvester, 2002, p.315). Sylvester (1985) recommended that "a far greater effort be given to the ethical development" of students and professionals (p. 8).

Responses to this survey indicate that the majority of RTs are receiving ethics training. The demographic information found that 217 (81%) respondents had received previous ethics training whether that be from college therapeutic recreation (TR) course(s), another college course outside of TR, TR conference, or from their agency. What is unclear is the extent of the training and if that training included the values presented in the ATRA COE. It may be of interest to explore the topics covered and the extent of coverage. A 50-minute lecture on the ATRA COE one time during a persons education would be different than a 50-minute presentation provided through the persons agency.

Also related to ethics education is that 243 respondents (89%) agreed that there is a need for ethics education in recreational therapy. The survey did not explore whether respondents believed that this should be continued once an individual is practicing as a RT, or if training during higher education was adequate. However, one respondent commented that they believed it was important that recreational therapists receive regular ethics training, whether that occur annually or one time during each CTRS[TM] recertification cycle.

COE terminology. Historically, principles such as respecting privacy, using best judgment, and working to the best of ones' ability are embodied in the original Hippocratic Oath. Today, although in more modern language, these same principles are found in ATRA COE. However, it appears that the COE principles that are common terminology found in society (e.g., informed consent, confidentiality and privacy, justice, and competence) had high levels of agreement with the majority of responses in strongly agree or agree; whereas, less familiar terms, such as non-maleficence, beneficence, veracity, and fidelity, had lower levels of strongly agree and agree responses. Comments offered by respondents regarding the wording of the COE included the terms "misleading," "difficult to understand," and "antiquated." Consideration to updating terminology should be explored. Suggestions for new terms might be: non-harm in place of non-maleficence, welfare for beneficence, truthfulness for veracity, and loyalty for fidelity.

The gray areas created by job requirements. Universally in health care, the prevailing principle when providing services is to be guided by moral wisdom (Veatch, 2011). Yet, while being guided by wisdom, circumstances arise creating gray areas-areas that are not clearly delineated within a COE. Shank and Coyle (2002) wrote, "situations may arise with competing ethical obligations" and RTs are "forced to choose between two equally unacceptable alternative actions" (p. 254). When this occurs, the RT must examine, interpret, and apply the guiding principles that are impacted by specific circumstances, which is not always an easy task.

Comments and responses provided by respondents indicated that RTs struggle with behavior in these situations. Examples related to skipping a treatment meeting to meet an assessment timeframe include respondent comments such as: "We should always attend treatment meetings so we can note progress or lack of"; or "I do not like it when my job requires I miss treatment (meetings) so I can get other work done including assessments." While treatment team meetings are important to practice, neglecting to complete an assessment by a required timeframe violates the principles of fidelity (e.g., loyalty first to the consumer) and compliance. Balancing job requirements, agency policies, and the COE can be challenging and create conflict.

This study did not address interpretation and application of guiding principles; however, several comments were offered that demonstrated ethical decision-making and reflection that occur on a daily basis. In response to having a sufficient understanding of the ATRA COE as it applies to their job, one respondent reported, "I think they [COE] are understood but change so often." Training on various issues an RT may experience in his/her job could potential clarify some of the gray areas where recreational therapists are unsure of how to behave. It may also be interesting to research if different professionals in different service settings view the COE differently and how they make ethical decisions specific to their jobs.

Attitudes and consistency in practice. While there is strong agreement that ethical conduct is a priority to respondents and that compliance with the COE impacts professional status, there were two attitude areas that have potential implications for recreational therapy professionals. In the attitude section, 174 (65%) of respondents agreed that the CTRSs[TM] they associate with utilize the ATRA Standards of Practice (including the Code of Ethics) as a minimum standard for the provision of their recreational therapy services; 23 (9%) indicated disagreement and 66 (25%) were unsure (see Figure 3). While this indicates a majority in agreement, this is alarming. The ATRA Standards of Practice and the ATRA Code of Ethics are the professional standards for the recreational therapy profession in the United States, regardless of ATRA membership.

This is supported by the NCTRC. In the NCTRC Job Analysis (2016c) and the Recertification and Reentry Information (2016b), code of ethics and standards of practice are mentioned in several areas. Under "Professional Relationships and Responsibilities," the NCTRC states that recreational therapists must follow professional standards of practice and codes of ethics; under Foundational Knowledge, both standards of practice and code of ethics are mentioned; and in the area of "Standards of knowledge, skills and abilities for the CTRS," it states that recreational therapists must be able to understand and explain ethical practice as a part of being a competent recreational therapist. Of greater significance is the inclusion of the code of ethics and standards of practice within the Certification Standards Information for New Applicants (2016a). Under the "Grounds for Issuing Sanctions," it states that the NCTRC can deny or revoke a CTRS's[TM] credential or issue other sanctions due to "gross or repeated negligence, malpractice or misconduct as evidenced by a clear violation of the ethical guidelines of the profession (as referenced in the NTRS or the ATRA publications)" (p. 5). Since the NTRS no longer exists, this leaves the ATRA Code of Ethics and Standards of Practice as the documents representing the profession--only 65% of survey respondents felt that their colleagues use these professional documents in their practice.

Need for more comprehensive assessments. A final implication of this survey is the perceived need for more comprehensive recreational therapy assessments. While the majority of respondents noted that they believe it is unethical to use self-designed/non-standardized assessment, this was only 45% of respondents. On the other side, 23% disagreed that it was unethical, leaving 32% of respondents who were unsure. Comments under this statement included: It depends on the facility, if used in conjunction with a standardized tool, varies with the purpose of the assessment, and that there is a lack of standardized assessment tools. People felt that the standardized assessments that are available do not fit all populations served, and that cost and availability of standardized tools becomes an issue for some facilities.

Delimitations

Delimitations of this study include the use of convenience sampling. Members of ATRA were solicited for participation in the study, but this reflects only a small number of the available RTs. Another delimitation centers on the analysis of years of practice and role as a recreational therapist. These choices were made for convenience and time factors, as well as the thought that these would give some level of baseline for knowledge, behaviors, and attitudes related to the COE.

Limitations

The primary purpose for administering the survey was to develop an impression of what professionals know, how they act, and what their attitude is regarding the ATRA COE to assist in the development of training and/or future revisions of the COE. With this purpose, there were several limitations identified that warrant consideration in the evaluation of findings.

The first limitation is that the results are gleaned from a small portion of those identifying as recreational therapists (n = 269 of 15,000 CTRSs, or 1.8% [NCTRC, 2016]); thus, the findings are not generalizable to all RTs. Additionally, students and those who were not specifically practicing within the field of recreational therapy were included, limiting the applicability to professional development and training.

Another limitation is that even though the ethics survey went through multiple iterations, no reliability or validity testing was conducted. When considering reliability of the data specific to the measurement of knowledge of ethics, behavior of ethical practice, and attitude of ethical practice, caution is warranted. This may impact the generalizability and validity of this data to specific behavior of knowledge and attitudes related to ethical practice. Future research should test the reliability and validity of the survey.

Another limitation is the terminology and wording of the knowledge area. In the survey, only the principle was listed and individuals responded based their level of understanding of that principle. No explanations of the principles were provided, therefore, potentially leading to misinterpretations or understanding of the specific principles.

A final limitation in this study is the use of the basic Qualtrics package. The basic package limited the level of data and responses that could be obtained to that at the nominal level; this significantly impeded the ability to conduct in-depth analysis of the data.

In spite of the limitations, the findings from our analysis and the open ended responses can help guide future ethics education and research. It appears evident that professionals responding to the survey have the knowledge, skills, and behaviors to not only adhere to ethical practice but to also guide their practice ethically. Recreational therapists should be proud of the fact that there is little difference between newly practicing and seasoned practitioners regarding their belief about ethical knowledge, skills, and behaviors.

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Acknowledgements

We would like to thank Nancy Montgomery with her work as co-chair of the ethics committee and her contribution to survey development. A special thank you to Angela Wozencroft and members from the research committee for providing ample reviews and suggestions in the construction of the survey.

Melissa L. Zahl, Ph.D., CTRS/L

Associate Professor

Kinesiology, Applied Health and Recreation Oklahoma State University

(405)744-3209 * melissa.zahl@okstate.edu

Dawn DeVries, DHA, CTRS

Assistant Professor

Department of Diagnositic and Treatment Sciences

Grand Valley State University

Wayne Pollock, Ph.D., CTRS, FDRT

Associate Professor

Department of Recreation and Leisure Studies

Virginia Wesleyan College

Mwarumba Mwavita, Ph.D.

Associate Professor

Department of Research, Evaluation, Measurement, and Statistics

Oklahoma State University
TABLE 1 ATRA CODE OF ETHICS

The American Therapeutic Recreation Association's Code of Ethics is to
be used as a guide for promoting and maintaining the highest standards
of ethical behavior. The Code applies to all Recreational Therapy
personnel. The term Recreational Therapy personnel includes Certified
Therapeutic Recreation Specialists (CTRS), recreational therapy
assistants and recreational therapy students. Acceptance of membership
in the American Therapeutic Recreation Association commits a member to
adherence to these principles.
PRINCIPLE 1: BENEFICENCE
Recreational Therapy personnel shall treat persons served in an ethical
manner by actively making efforts to provide for their wellbeing by
maximizing possible benefits and relieving, lessening, or minimizing
possible harm.
PRINCIPLE 2: NON-MALEFICENCE
Recreational Therapy personnel have an obligation to use their
knowledge, skills, abilities, and judgment to help persons while
respecting their decisions and protecting them from harm.
PRINCIPLE 3: AUTONOMY
Recreational Therapy personnel have a duty to preserve and protect the
right of each individual to make his/her own choices. Each individual
is to be given the opportunity to determine his/her own course of
action in accordance with a plan freely chosen. In the case of
individuals who are unable to exercise autonomy with regard to their
care, recreational therapy personnel have the duty to respect the
decisions of their qualified legal representative.
PRINCIPLE 4: JUSTICE
Recreational Therapy personnel are responsible for ensuring that
individuals are served fairly and that there is equity in the
distribution of services. Individuals should receive services without
regard to race, color, creed, gender, sexual orientation, age,
disease/disability, social and financial status.
PRINCIPLE 5: FIDELITY
Recreational Therapy personnel have an obligation, first and foremost,
to be loyal, faithful, and meet commitments made to persons receiving
services. In addition, Recreational Therapy personnel have a secondary
obligation to colleagues, agencies, and the profession.
PRINCIPLE 6: VERACITY
Recreational Therapy personnel shall be truthful and honest. Deception,
by being dishonest or omitting what is true, should always be avoided.
PRINCIPLE 7: INFORMED CONSENT
Recreational Therapy personnel should provide services characterized by
mutual respect and shared decision making. These personnel are
responsible for providing each individual receiving service with
information regarding the services, benefits, outcomes, length of
treatment, expected activities, risk and limitations, including the
professional's training and credentials. Informed consent is obtained
when information needed to make a reasoned decision is provided by the
professional to competent persons seeking services who then decide
whether or not to accept the treatment.
PRINCIPLE 8: CONFIDENTIALITY & PRIVACY
Recreational Therapy personnel have a duty to disclose all relevant
information to persons seeking services: they also have a corresponding
duty not to disclose private information to third parties. If a
situation arises that requires disclosure of confidential information
about an individual (ie: to protect the individual's welfare or the
interest of others) the professional has the responsibility to inform
the individual served of the circumstances.
PRINCIPLE 9: COMPETENCE
Recreational Therapy personnel have the responsibility to maintain and
improve their knowledge related to the profession and demonstrate
current, competent practice to persons served. In addition, personnel
have an obligation to maintain their credential.
PRINCIPLE 10: COMPLIANCE WITH LAWS AND REGULATIONS
Recreational Therapy personnel are responsible for complying with
local, state and federal laws, regulations and ATRA policies governing
the profession of Recreational Therapy.

TABLE 2 DEMOGRAPHIC INFORMATION OF ETHICS SURVEY (JV=269)

Characteristic                       Values (n)

Sex(M/F)                             43/226
Ethnicity
White (non-Hispanic)                    233
Black/African American                    9
Asian/Pacific Islander                    5
East Indian                               6
Multi-racial/Multi-ethnic                 3
I choose not to respond                  13
Years as a CTRS
Less than one year                        8
1-3 years                                26
4-6 years                                26
7-9 years                                18
10 or more years                        187
Current student; not a CTRS               4
Work Status
Full-time CTRS                          195
Part-time CTRS                            3
Not employed as a CTRS                   40
Role/Position
Recreation Therapist                    108
Recreation Therapist/Supervisor          56
Not currently employed in RT             28
Recreation Therapist/Administrator       16
Recreation Leader/Programmer              4
Administrator                             5
Educator                                 47
Student                                   5
Age Group
Adults/Older Adults                      98
Adults                                   66
Older Adults                             28
All age groups                           51
Adolescents                               8
Pediatrics/Adolescents                   12
Pediatrics                                6
Previous Training
Yes                                     217
No                                       52
College training course                 145
Another college course (outside TR)      36
TR Conference                           112
Agency                                  108

Note: Values are number of respondents marking that area. Abbreviations
F, female; M, male

TABLE 3 RESPONSES TO ETHICS SURVEY STATEMENTS

Knowledge: 1 understand       Level of          Level of
the principle of...           Agreement         Disagreement
                             (Strongly Agree   (Strongly disagree
                              or Agree)         or disagree)

Informed consent              260 (97%)          3 (1%)
Confidentiality and privacy   265 (99%)          3 (1%)
Justice                       246 (91%)          6 (2%)
Non-Maleficence               222 (83%)         19 (7%)
Beneficence                   226 (77%)         21 (8%)
Veracity                      183 (68%)         39 (14%)
Fidelity                      225 (83%)         17 (6%)
Competence                    263 (98%)          3 (1%)
I understand the ethical      252 (94%)          3 (1%)
principles as identified
in the ATRA Code of Ethics.
I have a sufficient           253 (94%)          4 (1%)
understanding of the ATRA
Code of Ethics as it
applies to situations
regarding my work as a CTRS

Behaviors: It Is ethical           Level of         Level of
for a CTRS...                      Agreement        Disagreement
                                  (Strongly Agree  (Strongly disagree
                                   or Agree)        or disagree)

To routinely state the             237 (89%)         12 (4%)
intervention goal prior to
beginning treatment.
To take progress notes              13 (5%)         225 (83%)
home to complete documentation
in a timely manner.
To forego a treatment team          56 (20%)        126 (47%)
meeting in order to adhere to
impending assessment deadline.
To use a self-designed and/or       61 (22%)        123 (46%)
non-standardized
assessment tool (validity or
reliability undetermined).
To ignore the fact that a            7 (3%)         262 (97%)
co-worker speaks rudely to
a difficulty patient/consumer.
To avoid patient/consumer            5 (2%)         226 (84%)
questioning on a treatment
decision because of the
sensitive nature of the subject.
To supervise student interns       189 (70%)         20 (7%)
while serving on agency
and professional committees.
To obtain related specialty        245 (91%)          6 (2%)
/competency certifications
and utilize them in practice.

Attitudes                         Level of         Level of
                                  Agreement        Disagreement
                                 (Strongly Agree  (Strongly disagree
                                  or Agree)        or disagree)

There is need for training in     239 (89%)         14 (5%)
ethical practice for CTRSs
I have heard of instances         102 (38%)        101 (38%)
where a CTRS may have
violated the ATRA Code
of Ethics.
Other CTRSs I associate with      174 (65%)         29 (11%)
utilize the ATRA Standards
of Practice (including the
Code of Ethics) as a minimum
standard for the provision
of their recreational
therapy services.
Compliance with the ATRA          225 (84%)          4 (1%)
Code of Ethics impacts
my professional status.
Ethical conduct is a top          265 (99%)          0
priority for me in my
role as a CTRS.
It is essential to improve        263 (98%)          1 (.4%)
my knowledge related to
the profession for
demonstrating current
competent practice.
All persons I serve (or           216 (80%)         11 (4%)
their representative) are
given the opportunity to
determine their own course
of action in accordance
with a plan free chosen.
I have a professional             266 (99%)          1 (.4%)
obligation to my colleagues
and to the field of
recreational therapy.
There is a positive               231 (86%)          7 (3%)
correlation between the
conduct described in the ATRA
Code of Ethics and the
perception of our profession.
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Author:Zahl, Melissa L.; DeVries, Dawn; Pollock, Wayne; Mwavita, Mwarumba
Publication:Annual in Therapeutic Recreation
Date:Jan 1, 2017
Words:7120
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