PD400 class 1, 2, 3, 4 Flashcards
palliative care
Palliative care is an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and often terminal illnesses.
thanatology
Thanatology is the scientific study of death and the losses brought about as a result. It investigates the mechanisms and forensic aspects of death, such as bodily changes that accompany death and the postmortem period, as well as wider psychological and social aspects related to death.
permits for setting up business
putting up walls for building permit
permit for setting up plumbing/sink
permit for setting up electricity
Before going for permits, you have set up municipal building plan
booking/schedule software?
..
janitor, receptionist, IT, other therapists, lawyer, banker/financial advisor, accountant, laundry/cleaner, realtor,
what about –> MPT, PT, nutritionist, etc.
(These should be included in “range of community resources for referral … for ongoing patient support”)
professional support team
external expertise to employ
pcpi
Practice Competencies and Performance Indicators
vision/mission statement
..
business model
..
technicians and entrepreneurs have different skill sets
..
vision statement
future focus
what you want to become
embrace envisoned “
–> meant to inspire
first step developing realistic vision
pen picture of business
could be 3-5 year
5-10 years
10-20 years (huge business)
vision statemnt of the CMTBC
innovative regulation that shapes the future of exemplary health care
mission statement
enduring statement of purpose that dinstinguishes one organization from other siimlar organizations
what is our business?
describes organization’s purpose, clientele, services, markets, philosophy, and basic technology
allows client to distinguish one business from another and decide which is more suitable for them?
Mission Statement CMTBC
Ensuring the public’s right to safe, ethical and competent massage therapy through excellence in regulation.
three basic legal structures
sole proprietorships
partnerships
corporations
sole proprietorship
You alone own it and are 100% responsible for its debts and liabilities. All earnings are taxed as your personal income. This is the most popular small business structure because it’s simple and straightforward.
partnerships
Two or more owners agree to share profits and losses according to their share in the firm. In a general partnership, all partners are liable for debts; in a limited partnership, one or more partners limit their liability by not actively managing the business.
corporations
The company earns revenue, incurs losses and pays taxes separately from its owners. Companies often pay tax at a lower rate than individuals. Owners’ liability is limited to what they invest in the company, and they have options as to when and how they take money out of the company.
sole proprietorship or partnership – are good for…
You will be the sole owner or own the business with just a few partners
You plan to start the business using only personal savings or investments from friends and family
You expect business revenues to support only you and your partners or family members
You plan to do most of the work yourself
You will borrow personally on behalf of the business
You are in a low personal income bracket
Your business is highly unlikely to face a lawsuit or get into debt
You have limited net worth (personal assets)
If you answered yes to most of these questions, you should operate your business as a sole proprietorship or partnership
corporation — good for…
Ownership will be divided among several shareholders
You expect significant start-up costs
You will be hiring employees and paying out wages and salaries
You will require additional financing beyond savings and investments from family and friends
You expect increasing revenues and a rising asset base
You will probably need to raise equity or issue debt, either now or later
You will put a full management and organizational structure in place
You expect to look into income-splitting and tax-deferral options
You want to protect your existing substantial net worth
If you answered yes to most of these questions, you should operate your business as a corporation
accountant
find a good accountant
the accountant that was responsible for Laurie’s debt to CRA was negligent, so find someone who is talented and who has experience with accounting for healthcare professionals
disability insurance
one case of someone who didn’t get disability insurance,
and they broke their scaphoid rock climbing
and afterwards they tried to get disability insurance
and they were refused disability insurance
but if they had gotten it previously it would have been fine (?)
note clause in insurance
have you had a claim in the last ___ months/years
—> premiums could go up
—> could get refused (?)
other expenses/insurance
professional liability insurance
general liability private
CMTBC dues (?)
continuing education (500/yr ?)
—> optional, but recommended
—> Tax write-off?
other sole proprietorship expenses
GST
taxes
rent (for studio space)
business license
CPR recertification
figure out the TAX WRITE OFFS
..
GST
investing GST and earning interest before paying it out to CRA
how to find good accountant?
someone who has experience with HCP
ask other RMTs –> ask them who they use as an accountant
ask for multiple opinions from multiple accountants (?)
note also CPP/ RRSP contributions
..
laundry expenses
laundry services
e.g.
3700/year (308/mo)
insurance
you have to read the contract carefully, because the contracts be very different, and price reflects differences
if employer supplies everything to “Contractor” CRA says that they are no longer “Contractors” but
Employees
to avoid this, employer can avoid supplying everything
E.g.
Oil
But supplies:
laundry, reception, billing, etc.
note independent contractor vs employee
(?)
employee gets to keep the entire charged fee
—> But they pay rent to clinic owner
—> owner may supply things like laundry, billing, reception, etc. – RMT brings oil
—> However, not all owners will provide all of this
—-> some owners will require RMT to do more
—> But in this case, clinic/reception will take care of providing clients/patients for RMT
VS. Employee
—> Employee receives a percentage of the charged fee –> But they don’t pay rent to owner
(E.g. 70/30, or 60/40 split)
—> Generally speaking everything is provided to the RMT
Class 2
..
what type of people does Commercial Real estate sales/leasing (possibly) typically attract?
Commercial Real Estate Sales and Leasing usually attracts the Type A personality,
often with Bachelor of Commerce Degree
and in the higher levels of Corporate Realty an MBA is a requirement.
how do agents in commercial corporate firms begin their career?
Agents in Commercial Corporate Firms are mentored for a long time and start as assistants to more experienced agents,
often given the grunt work and will do the bulk of the showings, enquiries and weeding out of leads.
how do residential real estate agents start their careers?
Residential Realtors often start careers with minimum educational requirements, usually 6 month course with 6 month post-licensing training as required by the BCFSA.
The personality types most often attracted to residential are much more the “Touchy Feely” people,
most are focused only on residential sales helping buyers and sellers.
commercial
Work in teams, at a larger Corporate Brokerage with Jr. Agent qualifying all prospects
May or may not be a Member of a Real Estate Board
Are Licensed and Bound by the Standards of Practice of the British Columbia Financial Services Authority (BCFSA)
(commercial real estate members/agents) Expect prospects to be organized and already know the following:
Location – why that location
Budget - with financing in place
Business Plan
Partnership or Incorporation Docs Avail
Understanding of physical requirements
Understanding of leasing jargon
Other professionals engaged such as Lawyers & Accountants
residential re agent
Usually works independently, under the umbrella of a brokerage ( ie Oakwyn)
Usually focuses on a specific geographic area or neighbourhood
Can be a specialist for types of properties, such as Condos, Detached homes
Could work for a Developer on a Sales team at a pre-sale showroom, instead of in Re-Sale property
Majority of Re-Sale agents are members of the Real Estate Board in their area.
Are Licensed and Bound by the Standards of Practice of British Columbia Financial Services Authority (BCFSA)
commercial…
Commercial Tenancy is only governed by Contract Law – there is no consumer advocate !
It is highly suggested you engage a commercial real estate lawyer to review any leases prior to signing
There is a somewhat standard offer to lease, they can run 20-50 pages.
if issue with commercial realtor?
If you have an issue with conduct of a Commercial Realtor you can lodge a complaint with BCFSA
residential…
Residential Tenancies are governed under the Residential Tenancy Act of BC under the Ministry of Municipal Affairs & Housing
If a property is managed by a Licensee you have recourse with both the BCFSA and Residential Tenancy Branch
If you have issue with Landlord, can deal with RTB directly
Must use the standard forms to be enforceable – RT lease is 6 pages plus any addendums for included items or terms outside of the standard terms.
what is interest in land?
..
register a lease
One of the fundamental aspects of a commercial lease is the ability to register a lease of 5 years or more against the Title of the property.
property id
All properties are identified by a unique 9 digit number called the Property Identification Number (PID) at the Land Title Registry of BC.
title
Title – shows who is the Registered Owner of the Property and any Charges which may affect dealings in the property such as Mortgages, Liens, Judgments, Easements or Statutory Rights of Way and Leases of more than 5 years !
ending lease early?
sold w/o knowledge?
This is important as it means the building you establish your business in can not be sold without your knowledge and your lease should have provisions for compensation for breaking the lease early or assumption of lease and notice to existing tenants of a change of ownership of the building.
how are comercial rental rates often calculated?
Commercial Rental Rates are often calculated and expressed based on the Total Area of the property
such as $28/sqft.
sq ft of property is convention
but most legal documents will refer to ….?
The Sq Ft of the property is the convention but most legal documents such as site surveys and architectural drawings will refer to Square meters
components of rent (formula)
base rent (E.g. $28/Sqft – annual rate)
leasable area (e.g. 1000 sqft)
common area costs (e.g. $12/Sqft)
property tax ($12,000)
—> $4,333.00
triple net lease define
A triple net lease (NNN) assigns sole responsibility to the tenant for all costs relating to the asset being leased, in addition to rent.
“Triple net refers to leases where a tenant rents an entire freestanding commercial building and pays for all property expenses.”
escalating lease
lower lease rate in first years,
get higher in later years
(incentive to business owner to have less burden in initial years of business?)
(alternatively, just to keep up with inflation)
commercial real estate terminology
An excellent website for easy to understand Commercial Real Estate information is at https://www.bdc.ca
incidental expenses
Your costs on top of base rent. These can include property tax, insurance, utilities, maintenance,common area costsand repairs.
common area maintenance
Anincidental expensein some commercial real estate leases. All tenants generally share common area costs. Examples include fees for snow removal, janitorial services, landscaping, grass cutting and property management.
gross rent lease
A type of commercial real estate lease under which you pay a single amount to the landlord that covers base rent and allincidental expenses.
modified gross lease
A type of a commercial real estate lease under which you and the landlord share certainincidental expenses.
net lease
A type of commercial real estate lease under which you typically pay for one incidental expense directly. In a single net lease, you usually pay the base rent plus property taxes (though in some cases, you might pay for insurance or utilities instead). The landlord pays all other expenses.
double net lease
A type of commercial real estate lease under which you usually pay the base rent plus two incidentals—for example, property taxes and insurance. The landlord covers all other expenses
triple net lease
A type of commercial real estate lease under which you typically pay the base rent, plus property taxes, building insurance and utilities, as well as other operating and maintenance costs. The landlord assumes no costs, other than those for structural repairs.
percentage rent lease
A type of commercial real estate lease under which you pay a base rent plus a percentage of gross sales over a certain minimum. These are usually used in malls and other multi-tenant retail locations.
tenant improvement allowance
A cash amount offered by a landlord to help you pay for renovations to a leased space. The allowance is usually a certain amount of money per square foot of rented space. It is sometimes offered as atenant inducement.
tenant inducements
Incentives offered by a landlord to encourage you to rent a space. Examples include several months rent free or help with paying forleasehold improvements.
trade fixtures
Items in a leased space that you can take with you when you move out.
A trade fixture can generally be easily removed without damaging the property.
Examples include furniture, inventory and computers.
Get advice from a commercial real estate lawyer before signing a lease to clearly define trade fixtures and to seek exclusions for assets you want to take with you when you leave.
turnkey improvements (aka turnkey buildouts)
Renovations that a landlord carries out at your request when you sign a lease. A landlord may agree to these as a tenant inducement.
Leasehold improvements (also known as tenant improvements)
Renovations to a leased commercial real estate space to make it suitable for your business. Unless otherwise specified in the lease, any improvement that is attached to the building usually becomes the property of the landlord—meaning you can’t take it with you when you move out.
E.g.
Examples can include machinery, flooring and built-in shelving. Get advice from a commercial real estate lawyer when negotiating a lease to seek exclusions for assets that you want to take with you when you leave.
leasehold improvement loan
If necessary, you can always apply for a leasehold improvement loan, a short-term loan (often amortized over five or six years) that you can use to pay for renovations to a leased space.
You can sometimes negotiate a principal holiday for the first six to 12 months of the loan.
Depending on the value of the improvement, a bank may accept the improvement as collateral for the loan, which could result in a lower interest rate than that for an unsecured loan.
principal payment holiday
The principal payment holiday concerns principal instalments only of amortising loans or leases granted to performing borrowers, and is granted for a period no longer than 12 months depending on the product type. Any principal instalments that fall due during the payment holiday are paid at a future date.
collateral define
something pledged as security for repayment of a loan, to be forfeited in the event of a default.
money speak
..
amortizaiton
Amortization – A stream of Payments over time - ie: mortgage with an interest rate for the “Use of the Money” for a specified time period
fully amortized
after the stream of payments the debt is zero
term mortgage
after the stream of payments there is an outstanding balance owning (sp.??? owing?)
principle
the amount lent
interest rate
the user fee for the $$ – I.e. 3.4% per annum, compounded quarterly
principle and interest
annual, monthly, bi-monthly
collateral
what secures the loan — what creditors can take from you if you Default on your payments
personal guarantee
could put a lien on your house — Best to “incorporate” your business – may not absolve you from being personally liable for the debts of the Business
unsecured debt
no collateral for loan
depreciation
the decrease in Value of an Asset over Time.
Buildings are considered fully depreciated at 40 years, even if they have a long economic life left in them
Capital Cost Allowance
(the amount of depreciation you can claim on your taxes for an asset is less and less over time until fully depreciated)
types of property
..
Live-Work Strata Titled Space to Purchase or Lease
These types of spaces are typically loft type condos that are specifically zoned to be able to have a business license associated with address.
Each municipality has specific zoning requirements.
Many sole practitioners find this a dual investment as they can live and operate the business out of the same location while building equity in real estate that they own.
Many investors have bought into these types of developments and rent out these spaces as well.
Strata Titled Office Spaces for Purchase
This type of space has become more popular in the last 20 years. These are located in office buildings in many of the commercial districts of the lower mainland.
The advantages are also that you can build equity in real estate, have more control over your improvements and the long term stability of growing a business knowing what your overhead is going to be based on a mortgage and not a lease.
You can sometimes find these spaces for lease from the owner.
Storefront – Retail
The costs for this type of location are quite high in established commercial districts.
In the suburbs you may still find a reasonable rental rate in an older strip mall or shopping center.
You may be governed by specific hours of operation and tenant improvement fees for changing signage, this is often negotiated.
Professional Buildings – Medical-Dental
The obvious choice – rents vary greatly and the vacancy rates in most of these buildings are currently low – with average rates being $50-$75 sq. ft.
Packaged Offices
This might be a good choice if you want to start small and have the ability to expand – or if you want to have a full service facility without the overhead.
They usually have a reception area, a receptionist that will answer a phone with your specific business name.
Often there is a lunch room, washrooms, conference room, and opportunity to have cross promotions with other businesses.
May be more suitable for a consultative practice as these spaces are often small.
Monthly rates range from $500-$1500 depending on the size of the office and services chosen.
A. Employee
Simplest/Easiest arrangements. You work for someone else. You are classified as an employee and are protected and supported by BC labor laws
pros employee
Simple. You have set hours, set days, holidays. You show up to work, you are paid an hourly wage, and bonuses if any
You get vacation pay, taxes deducted, CPP, EI
You may/may not get health benefits, Life, Critical Illness (CI), Travel medical
(Usually) You don’t worry about marketing, promotions, costs of business cards, uniforms, oils, supplies, etc.
You are protected by the terms of a contract that govern your employment (ie. Employer can’t change things on you that are contrary to the terms of the contract)
You work, you go home, you get your weekends/days off. Pretty sweet.
When the toilet paper runs out, it’s not your problem. It’s someone else’s.
Cons (employee)
You don’t make very much. Not even close to RMT’s that work for self or run a practice. You are often paid a sub-standard rate with very little room to move up or improve.
You are bound by a contract and must adhere to owner’s/business’s work policies (holidays, dress code, etc). Ie, if you don’t like something or don’t agree with something, you don’t really have a choice
You have to get vacation and holidays approved ahead of time (ie. You can’t just go away for 3 weeks if you wanted to)
You can’t just ad hoc change things regarding your employment.
–> Days worked
–> Pay
–> Vacation
No tax write offs. That dinner you had, that trip you took? That seminar…. nada
If you miss too many days, you can be terminated
If you underperform, you can be terminated
If they don’t like you, feel threatened by you, or have a change in heart, you can be terminated.
B. Business for Self
Also known as sole proprietor or independent contractor
You are basically running a business within a business.
e.g.
For example. Mr. RMT is renting a space at Columbia Integrated Health Centre. (CIHC)
Mr. RMT pays a flat rate rent for usage of the room or a percentage of billings which represents that rent. Patients perceive Mr. RMT as a therapist at CIHC. Mr. RMT generates income, collects GST, remits GST, pays himself, incurs expenses, has tax write offs etc.,. All of this is under the company name of ”Massages “R” Us”. (owned by Mr. RMT)
Mr. RMT is an independent contractor/sole proprietor that is running a massage therapy business called Massages R us located at CIHC.
Business for self (pros)
Therapists potentially make way more money than employees
The harder you work, the more $ you make
You make more per hour
Therapists have more say and input into their practice
Therapists have more freedom to dictate their holidays, days and hours
Therapists now have multiple tax write off opportunities
Less chance of being terminated
You are an entrepreneur and officially a business person
Business for self (cons)
Work more hours that don’t generate income. Ie, paperwork, marketing, meetings, errands, supply runs, etc..
If you don’t work, you don’t get paid. That holiday you take for 4 weeks… well, you’re not making any money
You need to spend time and money on lawyers, accountants, book-keepers, Insurance, to support your business. Meetings, phone calls, etc…
You need to spend money on supplies, seminars, insurance,
Extra level of stress. Guaranteed!
C. corporation
Very similar in structure to a sole proprietor and independent contractor however YOU are the boss, and YOU wear all the hats.
Comes with all the benefits of the Independent contractor
There is no personal liability. Ie you are protected from being sued personally
You have the benefit of a lower tax rate for corporations than sole proprietors
You have access to professional support systems such as:
—> CFIB
—> Chambers of commerce
—> BBB
You have recognition as a legitimate legal business entity.
You are responsible for EVERYTHING!!!! Toilet paper, photo copier, maintenance, security issues, hiring, firing, etc… everything.
You work way harder and way more hours that you don’t get paid for.
Some self reflection
How do you want to practice?
What are some of the pros vs cons of practicing by yourself vs being part of a team?
Pros (corporation)
The business lives and dies by you and you alone
You make all the decisions. You live with all the consequences
No drama.
You get have to hire/fire anyone
Great for people who have leadership tendencies
Cons (corporation)
The elevated and constant stress levels are immeasureable
The business lives and dies by you and you alone.
What if you get sick or injured? Go on holidays? Emergencies?
When is a good time to start my own business?
- Is it based on $$$ saved? Is it based on opportunity? Is it based on your support system?
- Location. Where do I don’t mind driving/commuting to everyday? Is it close to home? Where is there the most need with the least amount of saturation?
- What is the lease rate? How big of a space is it? What are the triple net costs?
- What is TRIPLE NET?
—> Utilities, insurance, and rent rolled into 1 rent. - Is it stratified? Can I purchase it vs leasing it? (in Vancouver, good luck with this one)
—> What are the pros and cons of renting vs buying?
—> You need to calculate how much a monthly lease is vs mortgage willl be? Amortize it over the next 20 years? Is it worth it? - Do you have partners, staff, or are you going to do it by yourself?
if you purchase/owned
It’s yours, no one can raise rent, kick you out, tell you what type of business to run
Most up front costs
—> Lawyers, taxes, bank costs, interest
Amortirize it over 25- 30 years, you own it.
You can build up equity that you can use for growth or expansion
More worth it to put more money into renovations
You are pretty set at that location forever..
if you lease/rent
Less up front costs
Ie lawyers, banks, taxes
You don’t own it so no equity
After 25-30 years, you still don’t own it
If you move, you lose the $ you put in for renovations.
Pro: you can move easier
ongoing costs of running a business
A. Measurable costs
Lease/Rent/Mortgage
Billing/scheduling software
Cleaners and cleaning supplies
Front desk/admin
Marketing/promotions (business cards, brochures, pamphlets, etc..)
Webpage/design/SEO/Google Ads/Social media
Admin related: Tables, chairs, desks, computers, printers, paper, stationary etc…
Clinic related: Massage tables, stools, pillows, sheets, bolsters, lotions, gels, laundry
Business license, general liability insurance, professional liability, CI, DI, LI, AD & D,
Utilities (internet, phone, hydro, cable, security monitoring etc…)
Banking charges, fees, accounts, overdraft protection
Interest on loans borrowed
B. Non-Measurable costs
Managing the team
–> Conflict resolution,
–>Mentoring /guiding/supporting
–> Training
Hiring/Firing staff, entry/exit interviews – all this takes lots of time/resources.
Day to day maintenance and up keep of the offices space
Trouble shooting – What happens when things break down?
Accounting, Accounts receivables, outstanding invoices
Payroll – takes time to do
Marketing - someone needs to do it
Team building – organization and carrying out
Developing and maintaining systems within the office -
Security/patient complaint resolution
So what are the benefits of owning your own clinic/corp?
You make more $ actively and cover your costs passively.
You can see the “potential” income that the business can make and that you yourself can make
–> Passively via income from the associate therapists.
–> Actively via keeping 100% of what you bill from your treatment
Better protection, tax bracket, and recognition.
You get to make all the decisions
No body can ever fire you or tell you what to do.
There is gratification and reward in being an entrepreneur and creating a business to help others succeed.
Less stress in your life? More stress. A business is like a child. You have to nurture and treat it as if it’s your life. It lives and dies with you.
Time with family? How important is that?
note working after 5pm
people with coverage generally work 9-5
note that if you start with Jane then decide to switch
you can access charts (records) and put them in your own personal storage to keep (for 16 years for patients)
Class 3
…
intro to loss grief and bereavement
..
“Nothing that grieves us can be called little; by the eternal laws of proportion a child’s loss of a doll and a king’s loss of a crown are events of the same size.”
(Mark Twain quote)
I.e. showing empathy towards the things that makes people grieve
ACute frief is
definite syndrome with boht psychoogical and physical symptoms
grief has both ___ and ___ Sx
physical and psychological
grief may occur immediaitely after a….
crisis
it could also be…
delayed
may be…
exagerated
may APPEAR to be…
absent
typical pattern of grief is
distorted
Distorted patterns of grief can be transformed into a
Distorted patterns of grief can be transformed into a normal grief reaction with appropriate clinical interventions.
loss
The experience of loss is universal.
Loss involves pain.
Losses that are significant produce emotional upheaval.
Loss requires change and adjustment to situations that are new, uncertain, and unchosen.
Loss can impact many lives.
other emotions related to grief
anger
situational depresison
irritability
annoyance
intolerance
frustration
—> all may be exacerbated by sleep deprivaiton, ongoing changes in lifesryle, burdens of caregiving, and/or fear of separation & unknown
bereavement
the state of deep grief or loss
mourning
the period of accepting loss
grief
generally thought to be an inward expression
sudden death vs expected death
If grief begins with a sudden death, there is no time to prepare.
Emotional forces and thought processes are scattered as the shock of loss overwhelms physical and mental defenses.
There is no time to gather the coping mechanisms that protect us from emotional overload.
This grief is frequently more acute than when a person has time to prepare for the loss and change in family dynamics.
Grief is just as heartfelt, but it may be easier to withstand by having the process spread over a manageable time period.
physical responses to grief
panic
difficulty swallowing
increaesd HR/BP
exhaustion
insomnia
mm pain
altered eating patterns
headaches
sinus headaches
Sinus headaches are headaches that may feel like an infection in the sinuses (sinusitis). You may feel pressure around the eyes, cheeks and forehead.
sadness and depression vs immune system
Sadness and depression significantly lower resistance to opportunistic diseases, which may lead to physical illness in addition to emotional stress.
grief passing vs IS
When the pain of loss is accepted, healing begins.
when massage therapist is asked to attend funeral
When life is done and there is nothing left but the process of dying, massage therapists are uniquely equipped to support the dying person and attending family or friends by addressing pain, nausea, anxiety, depression, anger, stress, and fatigue.
Because massage therapy is a generalist form of healthcare, it is possible and even likely that massage therapists will be invited to share in the process of death as clients or their family members die.”
—-> It is up to therapist to decide whether to attend
how often are statements told to grievers perceived as helpful
“According to one study, a person can expect to hear approximately 121 phrases in the three days following a death, of which only 19 are perceived as helpful by the grievers.”
platitude define
a remark or statement, especially one with a moral content, that has been used too often to be interesting or thoughtful.
plat = flat
—> dullness, banality
platitudes…
Platitudes are a form of communication that involve the use of trite, usually untrue statements in an attempt to alleviate emotional pain that we may feel helpless to “fix” in any other way.
Examples of platitudes are:
“Time heals all wounds” and
“this grief will pass”.
why do people struggle to say something helpful to someone grieving
Perhaps it ‘s because of our cultural death phobia, and the way it pathologies everything related to sadness.
If we’re not better at dealing with grief, then it’s because we have never been taught better.
Unfortunately, that leaves the majority of us with only one stock phrase in our repertoire, “I’m sorry for your loss.”
what not to say?
Grief is intensely personal so avoid saying
“ I know just how you feel” You don’t.
A simple “I’m sorry for your loss” can let survivors know that you care, or a good place to start if you are not sure what to say.
But, it can be a little like the cashier saying “Have a nice day “at the grocery store.
Never point out “It was for the best “
or “you can always get another job/pet/house
(this belittles the relationship that was lost by implying that it is easily replaceable.
what can you say? …?
“I don’t know how to help you , but I want to try.”
“I don’t know what to say”
“This must be hard for you”
“I don’t have an answer for that”
“ I am sorry you are suffering right now.”
“I am sorry for whatever challenges might lie ahead for you.”
“Please accept my deepest condolences, I can’t imagine what you are going through right now.”
“I am sorry to hear about______ . I am sure you are going to miss them terribly.”
protecting yourself during other people’s grief process
In health care we tend to protect ourselves from grief by
detaching when the pain of caring is overwhelming.
You must resolve your feelings about death and loss, or you
cannot give effective care.
The term “burnout ‘ implies that your fire to
help has gone out.
loss of enthusiasm in profession?
The loss of enthusiasm for your profession is a high price to
pay for caring.
what can you do to maintain enuthusiasm in profesison?
Develop outside interests that direct your mind away from health care.
Protect yourself by taking time for yourself. Do things you enjoy.
Rest, relax and eat right.
Read literature regarding grief and “letting go” (?)
Talk to your spiritual adviser about your doubts and fears.
Take comfort from your faith and your support groups of family and friends
burnout vs grief
Burnout looks a lot like grief.
When we fail to take care of ourselves, we risk losing ourselves, so BURNOUT ,may actually be an expression of the grief we feel about that loss.
Burnout and ICD (international classificaiton of diseases)
“Is recognised in the International Classification of Disease (ICD), sponsored by the World Health organization (WHO).
The ICD codes diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury and diseases.
The ICD recognises burnout as “problems related to life-management difficulties.”
caregiver fatigue
“Is a particular form of burnout resulting from increased caregiving in combination with ever decreasing energy reserves.”
caregiver fatigue vs apathy
“They may become disconnected to the point of not caring about the ill person because they have no energy left to give.”
caregivers and MT
“Massage therapy represents an excellent diversion from caregiving because it encourages caregivers to focus on themselves, which is opposite of what is usually demanded of caregivers.”
3 fundamental principles t remmeber when working with loss/grief
1) There is no right or wrong way to grieve.
2) Grief has no set timetable. It is like a river and sets its own course.
3) Normal grieving often involves extreme thoughts and roller coaster emotions.
“As you strive to be a compassionate listener these principles can be a touchstone in helping grieving individuals feel understood at a time when they often feel terribly alone.“
guidelines for comuniating with terminally ill patients
Avoid rote responses. Each person and family are unique and deserve to be treated as such.
Relate person to person. Show humour as well as sorrow.
Use your mind, eyes and ears to hear what is said as well as what is not said.
Respect the individual’s pattern of communication and ways of dealing with stress. This is not the time to promote change!
Humility and honesty are essential. Be willing to admit that you do not know the answer.
Maintain a sense of calm. This will help the client’s sense of control.
Never force the client to talk. Respect the client’s need for privacy and be sensitive to the client’s readiness to talk.
Let the client lead the discussion to the future. Be comfortable with focusing on the here and now.
Be willing to allow the client to see some fears and vulnerabilities. It is much easier to open up to someone who is “human and vulnerable” than to someone who appears to have all the answers.
special concerns for palliative care
..
primary goal of massage therapy
The primary goal of massage treatment in advanced cancers is comfort and enhancement of quality of life. The gentlest and simplest techniques are often the most effective.
what to do as condition progresses
Body systems are weakening and close observation is necessary to ensure treatment adaptions are made as needed.
pain medicaiton and illness
At this stage touch can sometimes increase the sensation of pain. Flexibility is required. Strong pain medication may significantly impair the patient’s ability to give reliable feedback.
what about rest of medical team of pt
Regular contact with the medical team will help keep you current about medication and health status changes.
bedsores / decubitus ulcers (pressure ulcers)
There is a susceptibility of decubitus ulcers. Maintaining good skin lubrication and circulation, especially over bony areas, can help prevent their formation. Massage is not advised once redness of bedsore begins as it can speed up the breakdown.
preparedness for conversations about death
You may need support if you are uncomfortable or unprepared for conversations about death.
investment in ongoing relationship (?)
Investment in ongoing relationships is slowly withdrawn and should not be taken personally.
palliative care boundaries
Therapeutic boundaries keep caregivers emotionally whole and healthy.
They help us to be available to clients when providing care and also to walk away when our work is done.
boundaries with dying patients
For individuals working with the dying, therapeutic boundaries may be more difficult to establish and maintain.
It takes considerable energy and training for caregivers to repeatedly care for patients in long term care and then let go of patients as they die.
This repetitive process can erode boundaries and affect the caregiver’s ability to provide objective care. But how do you know if boundaries are intact?
in what scenarios must extra measures be taken to maintain therapeutic boundaries?
(If someone answers yes to any of these questions, it may mean that they need help with maintaining their therapeutic boundaries.)
Do you feel like family to this patient?
Have you checked in with the patient’s status when I am not scheduled to work?
Do you feel that you are the only person who knows best what this patient needs?
what do dying patients need?
medicaitons
support (friends, family, emotional, practical, spiritual)
comfort
estate management (organizing belongings)
respect
choices
autonomy
patient-centered care
therapy
palliative care
any form of medical care or tx that concentrates on reducing the Sx of disease rather than curing disease
relieving painor easing problem without solving the cause
treatment approach is indiivdualizd and usually involves a health care team from sevreal/many disciplines
palliative
litearl definition:
means to cloak or disguise
the WHO defines palliative care as
an approach to care that provides relief from pain/SSx for people close to dying
difference b/w palliative care and hospice
Bothpalliative care and hospice careprovide comfort.
Butpalliative carecan begin at diagnosis, and at the same time as treatment.
Hospice carebegins after treatment of the disease is stopped and whenitis clear that the person is not going to survive the illness
grief theory
Elizabeth Kubler Ross
Elizabeth Kubler Ross book
“On Death and Dying”
5 stages of grief
the book “On Death and Dying” which introduced the world to the five stages of grief…the basis of the Kubler Ross model , a theory based on her experience and interviews with terminally ill patients.
Original application of 5 stages of grief
Originally this model was applied to those facing the reality of their own death but before long practitioners found the constructs of this neat and tidy model fit nicely with the analysis and treatment of grieving individuals.
Elizabeth Kubler Ross the 5 stages
Denial
Anger
Bargaining
Depression
Acceptance
Denial
Denial is a conscious or unconscious refusal to accept facts, information, reality, etc., relating to the situation concerned. It’s a defense mechanism and perfectly natural. Some people can become locked in this stage when dealing with a traumatic change that can be ignored. Death is not particularly easy to avoid or evade indefinitely.
Anger
Anger can manifest in different ways. People dealing with emotional upset can be angry with themselves, and/or with others, especially those close to them. Knowing this helps us stay detached and non-judgmental when experiencing the anger of someone who is very upset.
Bargaining
Traditionally the bargaining stage for people facing death can involve attempting to bargain with whatever God the person believes in. People facing less serious trauma can bargain or seek to negotiate a compromise. For example “Can we still be friends?…” when facing a break-up. Bargaining rarely provides a sustainable solution, especially if it’s a matter of life or death.
Depression
Also referred to as preparatory grieving. In a way it’s the dress rehearsal or the practice run for the ‘aftermath,’ although this stage means different things depending on whom it involves. It’s a sort of acceptance with emotional attachment. It’s natural to feel sadness and regret, fear, uncertainty, etc. It shows that the person has at least begun to accept the reality.
Acceptance
Again this stage definitely varies, according to the person’s situation. Broadly speaking, it’s an indication that there is some emotional detachment and objectivity. Dying people can enter this stage early, often a long time before the people they leave behind will enter this stage. note: others necessarily pass through their own individual stages of dealing with loss.
is 5 stages of grief model entirely accurate /effective ?
not adequate theory
–> narrow in focus
–> we experience more than that (5 stages)
however, EKR opened the converstation (or reopened?) –> got us paying attention to the matter
EKR model
It is just a theory
There are many theories
The 5 stages of grief are not an absolute truth.
Like all theory it is based on a hypothesis (an educated guess) There is research that which supports this theory and research to contradict the theory.
Do not expect grief to fall into a neat and easy pattern, formula, or timeline
- it is not linear
“Grief is not a one way tunnel, it’s more like a labyrinth”
They do not happen in a particular order, if at all.
The stages are just tools , based on the experiences of many grievers.
- stages may repeat
“It is common to feel that you are making progress one day only to get knocked on your derriere the next.”
- it is not all encompassing
Grief is really complex.
- there is no end point
The 5 stages leave you with a feeling that there is some finite end point to grieving.
The theory will reach its end point , but your experience with grief won’t.
did EKR ultimately agree with 5 stages theory
Elizabeth Kubler-Ross, pioneer of the conscious dying movement, lived to regret having described the common features of the grief journey in stages.
She came to see that everyone grieves differently and that science collapses in the face of the mysteries of the heart.
There is no map for the landscape of loss, no established itinerary, no cosmic checklist, where each item ticked off gets you closer to success.
You cannot succeed in mourning your loved ones. You cannot fail.
Nor is grief a malady, like the flu. You will not get over it.
You will only come to integrate your loss, like the girl who learned to surf after her arm was bitten off by a shark. The death of a loved one is an amputation.
You find a new center of gravity, but the limb does not grow back.
When someone you love very much dies, the sky falls. And so you walk around under a fallen sky.
life transitions, aging, loss
Death is a part of the cycle of life.
Therapists may be invited to share in client transitions.
pointsto ponder
What are your family’s attitudes about death and dying?
How might these personal beliefs contribute to your reaction if you are presented with a client who is dying?
How might you respond professionally, independent of personal beliefs?
Massage Therapy at End of Life
Speak plainly and avoid lies or games about death.
Actively listen.
Provide information and perspective within the capacity of professional role.
Offer supportive treatments with no promises of cure.
Palliative and Hospice Care
Provides relief from symptoms for people who are dying.
Death is a normal part of life.
No efforts are made to hasten or postpone death.
Emphasis on ensuring quality of life.
Palliative and Hospice Care ..
Care integrates psychological and spiritual aspects.
Employs a team approach including counseling.
Offers support for both patients and families.
When working with clients in palliative care:
Be present.
Offer choice.
Negotiate a stop signal.
Create an atmosphere of calm.
Massage Therapy
and Palliative Care
At the stable palliative stage:
Ask about client status and prognosis.
Employ careful infection control and adapt to site restrictions.
Seek client goals.
Establish informed consent.
Adapt treatment to fit client capacity and comfort.
At the transitional palliative stage:
Check in with client if conscious or able to respond.
Verify client status with caregivers.
Seek permission to massage.
Anticipate need for crisis management.
—> incontinence
—> vomiting
—> bleeding
At the transitional palliative stage… :
Strategize treatments to facilitate:
lymphatic drainage
limb movement
joint mobilization
optimal respiration
End of life stage
Check in with client if conscious and able to respond.
Verify status with caregivers.
Provide pain relieving techniques, gentle joint mobilization.
Observe client carefully for signs of distress.
Cease treatment if treatment unwanted or client in pain.
Caregiver Fatigue
Form of burnout occurring when caring for ill family or friends
Fatigue occurs as levels of care increase.
Reduced sleep and insomnia
Results in caregivers feeling:
—> Inadequate
—> Exhausted
—> Disconnected
Depression Increases When Ill Person Lives With Caregiver
Caregivers can never get away from responsibilities.
They must separate disease from impulse to help.
They have a low sense of personal accomplishment and sense of failure:
—> Emotionally exhausted
—> Hopeless and despairing
Responding to Caregiver Fatigue
Watch for signals of burnout or caregiver fatigue.
—> Clients may not know how to explain their situation.
Listen for the unspoken story.
—> If information appears to be missing, clarify.
Match client goals with therapist skills, not the other way around.
Employ empathic investigation
—> “What would I want a therapist to ask me right now if I were this client?”
In Summary
Don’t overlook massage therapy’s powerful medicine.
—> In the face of complex circumstances, massage therapists can offer respite, rest, recuperation.
—> Pay attention to client stories of secrets or scars.
Employ concise communication skills when working with clients who are cognitively challenged.
Be prepared to support clients through life transitions and even death.
Class 6 (PROFESSIONAL COMMUNICATION)
..
suicide
“Suicide is a difficult topic to discuss- and the biggest barrier to preventing suicide is the stigma around it.
biggest barrier to preventing/discussing suicide
and the biggest barrier to preventing suicide is the stigma around it.
how many Canadians died in 2020 as a result of suicide
In 2020, about 3800 Canadians died by suicide.
what can we do when we reach out to people who are thinking about suicide?
When we reach out to people who are thinking about suicide, we can help them see that there is hope, they’re not alone, and help is available.”
Who does suicide affect?
People with mental illness- 90%
Men- 75%
Trans people- 1 in 3 trans youth
LGBQ people- LGBQ youth are 7 times more like than straight youth
Indigenous People- risk varies
How to help someone in crisis
Talking honestly, responsibly and safely about suicide can help you determine if someone needs help.
if you want to help to help someone in crisis, try:
listening and showing concern.
talking with them and reassuring them that they’re not alone
letting them know you care
connecting them with help
listening and showing concern.
showing concern can be an immediate way to help someone
listening won’t increase the risk of suicide and it may save a life
connecting them with a:
crisis line
counsellor
trusted person ( neighbour, friend, family member or Elder
responding to a suicidal person
“Ask direct questions such as “Are you considering suicide?”
THE MORE SPECIFIC AND DEADLY THE PLAN, THE GREATER THE RISK.
Take answers seriously and don’t ignore the signals.
are we responsible for decisions others make?
We are not responsible for the decisions that someone else makes. However, we are often in the best position to recognize and initiate the first response to someone’s signals of suicide.
what percentage of suicides occur without warning?
Some suicides (20%) occur without any warning and others take place despite the very caring responses of friends, family and counsellors. Suicide is ultimately a personal choice- it is not our job to ‘save’ someone else’s life, only to offer them other options.”
basic terms associated with suicide
intent
means
plan
suicidality
suicidal
suicide attempt
intent
motive behind action
means
the way the person intends to …
plan
fully formed and clear idea of how to accomplish suicide
suicidality
the qualities of suicidal thinking or behaviour that a client may experience acutely or chronically
suicide attempt
self-initiated, potentially fatal action of taking one’s life
nonsuicidal self injury
cutting, burning, or harming oneself.
intent is to harm, not take one’s life
completed suicide
act of taking one’s life and is used to describe death by suicide
this term is explicitly to avoid using the phrase “successful/succeeded” suicide
–> b/c no suicide can be considered a “success”
what to do when clients are at risk of suicide?
learn risk factors, warning signs, and where to get help
talk openly about what you have observed, about suicide, and concerns regarding clients’ well-being
actively listen if client is expressing feelings
offer hope that alternatives are available (I.e. through professional help)
seek patient’s permission to contact doctor or mental health professional to inform him or her of your concerns
seek peer supervision to manage feelings associated with client’s crisis
What NOT to do when clients are at risk of suicide
offer reassurance that things will get better
judge the client for feeling suicidal
debate the morality of suicide
avoid asking the person why they feel suicidal
agree to keep a client’s thoughts or actions secret
Mental health first aid
Assess the risk of suicide and/or harm.
Listen non judgementally.
Give reassurance and information.
Encourage the person to get appropriate professional help.
Encourage other supports.
if it is clear that patient is suicidal, then therapist must
“If it is clear that clients feel acutely suicidal, then therapists have an urgent responsibility to act on their behalf.
acutely suicidal clients should not be…
Acutely suicidal clients should not be left alone or allowed to leave.
Call emergency services and do not leave them alone until help has arrived
It may be necessary to call a client’s physician, even if the client does not want the call to be made or to call the client’s emergency contact.”
questions to ask about non-suicidal self-injury
I notice that you have some scars, …
textbook says that you should ask “are you currently cutting?”
—> however, that seems like it is not the best question to ask, as only a professional would be able to potentially know just based on seeing the injury
THE ADULT GUARDIANSHIP ACT
definition of “abuse”
The Adult Guardianship Act (the “Act”), defines “abuse” as “the deliberate mistreatment of an adult that causes theadult
a. physical, mental or emotional harm,or
b. damage or loss in respect of the adult’s financialaffairs,
—> and includes intimidation, humiliation, physical assault, sexual assault, overmedication, withholding needed medication, censoring mail, invasion or denial of privacy or denial of access tovisitors.”
Under Part 3 of the Act
Under Part 3 of the Act, anyone who has information indicating that an adult is abused or neglected (including self-neglect), and is unable to seek support and assistance becauseof:
- physicalrestraint,
- a physical handicap that limits their ability to seek help,or
- an illness, disease, injury or other condition that affects their ability to make decisions about the abuse orneglect
may report this information to a designatedagency.
is there legal duty to report abuse?
While there is no legal duty to report under the Act, it is worth noting that anyone who makes such a report will be protected from subsequent legal action, so long as the report was not made falsely ormaliciously.
designated agencies to report abuse
Designated agencies include:
the five regional health authorities,
the Providence Health Care Society;
and Community Living BC (for adults with developmentaldisabilities).
For more information, including contact information for designated agencies, see …
Public Guardian and Trustee of British Columbia website
DUTY TO REPORT CHILD ABUSE AND NEGLECT UNDER CHILD, FAMILY AND COMMUNITY SERVICE ACT
As medical professionals, registered massage therapists have an important role to play in keeping children safe. That role is to be aware of, and alert to, the signs of child abuse and neglect. A “child” is a person under 19 years ofage.
legal definition of child
a person under 19 years of age
Anyone who has reason to believe that a child has been or is likely to be abused or neglected has a legal duty to …
Anyone who has reason to believe that a child has been or is likely to be abused or neglected has a legal duty under Part 3 of the Child, Family and Community Service Act to report the matter.
Reports may be made to a child protection social worker at either a Ministry of Children and Family Development office, or at a First Nations child welfare agency that provides child protectionservices.
3 agencies to report child abuse
See the
a) Ministry of Children and Family Development website
b) and the Reporting Child Abuse
c) and Keeping Kids Safepages
source to find helpful information about recognizing and responding to child abuse and neglect
The BC Handbook for Action on Child Abuse and Neglect for Service Providers also provides helpful information about recognizing and responding to child abuse andneglect.
adults vs children
adults, you may report
children, you MUST report legally if you suspect abuse
in communaiton with othe rHCP
use their terminology /lingo
–> E.g. if they say “client” – return message/email with “client” even if you prefer to use “patient”
communicating with patients
if you use specific terminoogy, explain what it means
E.g. U trapezius
–> “a muscle that shrugs your shoulders”
—> you could evne show them a picture
E.g. Strain
–> “an injury involving tearing of some/many muscle fibres”
good communicaiton
- Potentially helpful in care of client
- Affects your image and gives you credibility
- Affects image of your profession
referrals
Remember, their reputation is on the line if they refer a patient to you, so they want to be absolutely confident you will provide not only great results, but also stellar
service
key concepts
Confidentiality
Exclusionary zones
File disposition
Inter and intraprofessional dialogue
Legal consequences of documentation
Legal Standards of Healthcare
Legal standards of healthcare imply each of the following:
Accountability
Confidentiality and privacy
Safety and security
What Does It Mean To Be Professional?
Mutual values and commitment
Self-regulation
Shared body of knowledge and skills
Application of sound judgment and evidence
What Does It Mean To Be Professional?
Mutually agreed upon standards and ethics
Social and therapeutic contract
Respectful communication
(The Role of Documentation) The Role of Documentation
..
(The Role of Documentation) As a medical record to:
Document client condition
Measure outcomes
Reflect clinical decisions
As a legal record for:
Third party or insurance payer actions
Court proceedings
Guidelines for Creating Legal Documents
Record all information accurately and legibly, including:
–> Date of treatment, time, and billing date.
–> Employ accepted terminology and abbreviations.
Include all correspondence and referrals.
Keep client records secure and private.
Documentation Can Be Used As Evidence
Evidence demonstrates that something is true.
Good evidence depends on data.
All client records are considered evidence.
Evidence-Informed Practice
In order to support practice decisions, consider:
Available research.
Profession’s best practices.
Objective clinical findings.
Evidence-Informed Practice (2)
Evidence-informed practice is easiest to defend when called as a court witness.
Problems with records arise when therapists include the following:
Judgments about client attitudes.
Therapist intuition.
Unproven claims.
Potential sales pitches.
Imprecise professional jargon.
Documenting Emotional States
Include client words to describe emotional state in subjective findings:
—> For example, sad, mad, glad
Include client behaviors that confirm therapist impression in objective findings:
—> Include client behaviors that confirm therapist impression in objective findings:
Documenting Emotional States (2)
Avoid diagnostic words like “depressed”.
–> Unless client indicates diagnosis confirmed by MD
Current Record-Keeping Options
Electronic health records (EHR)
—> Core data from multiple sources
—> Submitted by different providers
—> Data available to all who have secure access
—> Commonly used in hospitals or institutions
Current Record-Keeping Options (2)
Electronic management records (EMR)
—> Office-based or cloud network systems
—> Electronic versions of paper records
—> Kept by healthcare professionals
Security and E-Records
In order to protect data from loss or theft, client records must be:
Password protected.
Securely and frequently backed up.
Progress Reports
Keep other healthcare professionals informed about a client condition.
Most common format is “SBAR”.
SBAR
SBAR, which stands for Situation, Background, Assessment, and Recommendation (or Request), is a structured communication framework that can help teams share information about the condition of a patient or team member or about another issue your team needs to address.
SBAR Reporting Framework
S = situation
B = background
A = assessment
R = recommendation
Discharge Reports
Sent at end of treatment series to:
- Summarize achievements.
- Comment about outcomes.
- Bring closure to client chart.
Useful in third-party files to indicate beginning and end of treatment
MEDICAL DOCTORS – what they want to know – what they don’t care about
Want to know:
1. Did you get their referral
2. How long and what results are expected?
Don’t really care about:
1. What techniques you are doing.
2. Your assessment if it is the same as theirs.
3. Your technical jargon.
Medical-Legal Reports
Requested when determining whether or not:
Client should receive an award as a result of a lawsuit.
Client insurance benefits should stop or continue.
Contracts
Contracts exist to protect both parties.
Usually arranged between clinic owners and associates
Both parties responsible to ensure that contract reflects their best interests.
Contracts Are Binding Whether or Not They Are Legal
??
verbal contract
No documented evidence of agreement
Difficult to enforce
No protection
written contract
Agreement is only as good as the terms of the contract
Essential to review carefully before signing
Two Ways That Contracts Affect
the Therapeutic Relationship
File disposition
Exclusionary zones
File Disposition
File disposition determines who owns the client file.
Client information
The information about a client is the property of the client.
Client file (paper or electronic version)
The recorded file of this information is considered a business asset.
Exclusionary Zones
Noncompetition clause
noncompetition clause
When a therapist leaves a clinic, this clause describes:
—> How closely a therapist may work to the previous location.
—> Period of time before a therapist may advertise new clinic location.
When Signing a Contract
Remember:
All contracts are binding.
Don’t sign unless you’ve understood the fine print.
Refuse contracts that don’t allow professional obligations.
Evaluate the opportunity based on the contract.
Inter and Intra professional Dialogue
Interprofessional
Between professions
Intraprofessional
Within a profession
Point to Ponder
Would you communicate differently with your peers than with nonmassage therapy professionals?
Interprofessional Networks Are Good for Business
Strong professional networks enrich client care:
1) Send thank-you notes for referrals.
2) Follow up with progress notes.
3) When care questions arise, consult with other professionals on the client’s healthcare team.
4) Finish treatment plans with discharge notes.
how many regulated health professions are there in BC?
how many of them are self regulated vs government regulated (/appointed)
–> which profession is that?
There are 26 regulated health professions in British Columbia, of which 25 are self-regulating professions governed by 22 regulatory colleges under the Health Professions Act.
One profession (emergency medical assisting) is regulated by a government-appointed licensing board under a separate statute.
22 REGULATORY COLLEGES
The colleges have been delegated the authority under provincial legislation to govern the practice of their members in the public interest.
Their mandate at all times is to serve and protect the public.
The primary function of the colleges is to ensure their members are qualified, competent and following clearly defined standards of practice and ethics.
all colleges
All colleges administer processes for responding to complaints from patients and the public and for taking action when it appears one of their members is practicing in a manner that is incompetent, unethical, illegal or impaired by alcohol, drugs or illness.
Professional – Professional Relationships
Health care professionals need to collaborate and cooperate with one another in order to help patients resolve health care problems.
Three problem areas:
1. Role stress
2. A lack of inter-professional understanding
3. Autonomy struggles
- Role stress
The nature of health care work contributes to job stress.
There are two types of role stress:
- role conflict
- role overload
1) role conflict
Relates to professionals that are socialized to fit one role, yet are expected to fit another role.
New graduates learn that their ideals and aspirations are seldom the same as the values that receive praise on the job.
The discrepancy between these two very different value systems creates role conflict. (Nurses and social workers often experience stress and burnout carrying out their professional responsibilities).
2) Role overload.
Workload and scheduling stressors.
Assuming that role stress (e.g., role conflict and role overload) is common among health professionals,
what effects does role stress have on interpersonal relationships among health care providers?
..Is often the underlying source of professional –professional tensions.
Role stress leaves the professional in a vulnerable position, more easily stressed by minor conflicts with co-workers.
The role overload of one professional may interfere with the role functioning of another.
Professionals may withdraw from one another as a means of coping or may be unwilling to invest energy in maintaining professional relationships.
- Lack of interprofessional understanding
Why do health professionals know so little about one another’s roles?
Why do health professionals know so little about one another’s roles?
Professional education that takes place in virtual isolation from other health disciplines is a major cause.
The greater the gap in understanding of one another’s roles, the more negative we are toward collaborative decision-making.
Limited amount of contact that exists between HCP on a daily basis.
Busy schedules.
territorial disputes
In recent years, HCP’s roles have expanded considerably, leading to confusion as to which professional has expertise in a particular area.
This increases territorial disputes.
When HCP roles overlap considerably, it is not unusual for one to think that the other is trying to take over power or responsibilities.
This can result in unproductive competition.
- Autonomy Struggles
Autonomy- the freedom to be self-governing or self-directing.
The degree of autonomy depends on:
1) The permissible scope of practice for that group contained in the provincial licensing laws.
2) The ability of that group to secure access to necessary health facilities, such as hospitals.
3) The ability of that group to obtain reimbursement from private and third-party payers.
How do discrepancies in professional autonomy affect professional relationships?
The dominant profession tends to underestimate the professionalism or competence of other professionals.
Interprofessional Bias
Stems from a lack of awareness
- Focus on the issue.
- Acknowledge what is true.
- Avoid blaming.
When Communicating With Other Professions
Put aside professional rivalries or defensiveness.
Focus on what is best for each client.
Educate other professions in an evidence-informed way.
When faced with interprofessional bias or conflict, use an “I” statement
..
In Summary
Professional practice and client-centered care is good for business.
Professional accountability ensures client-centered care.
Legal obligations require attention to documentation, confidentiality, and a predictable standard of evidence.
In Summary (2)
Contracts are legally binding and must be carefully considered before being accepted.
Interprofessional communication creates opportunities for networking, education, and dialogue.
role stress
conflicts related to different roles of HCP (?)
class 7
..
Body mechanics:
Mechanics is the analysis of the action of forces on matter or material systems. (American Heritage dictionary-1995)
body awareness
A more accurate term and tool for describing the endeavor to achieve efficiency in massage practices would be Body awareness.
Body awareness incorporates a fuller understanding of the action of forces on the human body.
massage therapists need to
Massage therapists need to listen to their bodies
The best way to maintain body mechanics and avoid injury is to pay close attention to how you feel as you work.
ergonomics
Is the use of tools in a way that helps the human body, as opposed to adapting the human body to fit the standard tools.
biggest investment in ergonomic tool
Our biggest investment and most important ergonomic tool (besides our bodies) is our table.
Buy a hydraulic table if you can afford it.
If not, invest in a small step stool and/or a pair of clogs that you can easily slip into and out of, in order to adjust your height.
—> Or, purchase an office chair with a hydraulic adjustment.
Self-care:
According to The American Heritage Dictionary, (1995), care means to be concerned or interested.
Self-care is turning our concern and interest to maintaining one’s own good health in order to work easily and well.
It is imperative to
to make preparations before a session (stretching and strengthening) and after (icing to relieve inflammation, and stretching to counteract curling of your upper back)
psychological self-care
Psychological self-care (finding social support, setting good and safe boundaries for yourself and your guests) is as important as a regimen of exercise, good nutrition and adequate rest.
we need to
(physical/psychological needs)
We need to learn to care for ourselves in body, mind, heart and spirit.
Learning to attend to our physical and psychological needs is at he heart of the issue and is the essence of self-care.
Tai chi chuan
Not a bodywork discipline per se, but has some strong influences.
Means “supreme ultimate martial art exercise”.
in Asia, Tai chi is regarded as
Throughout Asia. Tai chi is not regarded as a martial art, but rather as a part of therapeutic remedies prescribed by traditional Chinese medicine.
the movements of tai chi
The movements of Tai Chi percolate life force from the body’s center (hara) and send it circulating around the body.
Yoga
Means to join together or yoke.
Is intricately intertwined with ayurvedic medicine.
Is an example of static unassisted stretching
Taking Self-Care Seriously
..
Therapists who work with emotionally challenged clients are at risk for:
Burnout.
Vicarious traumatization. (a term used to describe what happens when helpers such as healthcare professionals feel traumatized by the experiences of their clients.)
who is most at risk for burnout / vicarious trauma?
Highly Motivated and Caring Therapists Most at Risk
Signs and symptoms of burnout and vicarious traumatization include:
A lack of work and home life balance.
A feeling of disconnection from the world and others.
Withdrawal from friends and social activities.
Cynicism, despair, anger, fear, and a lack of motivation.
Diminished capacity to manage day-to- day activities.
Nightmares and intrusive imagery.
Finding Solutions to Burnout and Vicarious Traumatization
Observe personal responses to clients carefully.
Establish work, play, and rest balance.
Maintain connections with others.
Peer Supervision
..
a peer acts as
A peer acts as professional sounding board.
Discussions help therapists:
—> Understand responses to client situations.
—> Learn how their responses put them and clients at risk.
—> Clarifying boundaries.
who can work as peer supervisors?
psychotherapists
counselors
massage therapists experienced in psychological dynamics of patient relationsihp
types of peer supervision
formal, contractual
informal mentoring occasion
correspondence, phone
group supervision
peer support groups
problems that indicate peer supervision
confusion about a therapeutic relationship
feeling ineffective and unable to establish boundaries
encoutners with high-risk or vulnreable clients
feeling bored/angry with clients
surprising responses to clinical situations
feeling burned out and exhausted
how peer supervision works?
reflection and problem solving
identifying blind-spots and weaknesses of care
consideration of transference and counter-transference
helping to establish healthy boundaries
providing time with experienced mentor
in summary
Working with emotionally challenged clients means:
—> Adhering to a predictable framework.
—> Knowing how to ask questions.
—> Ensuring that clients are safe to receive treatment.
—> Responding empathically if clients become triggered.
—> Committing to therapist self-care, peer support or supervision.
