Presents The Jimmy A Young Memorial Lecture

1. PresentsThe Jimmy A Young Memorial Lecture Wednesday, July 20, 2011 8:00 to 9:30 AM Vail, CO

2. Jimmy Albert Young, MS, RRT1935 –1975 The NBRC has sponsored this lecture series in honor of Jimmy A. Young since 1978. The NBRC honors his memory and many contributions he made to respiratory care through this annual program.

3. Jimmy Albert Young, MS, RRT was one of the profession’s most outstanding and dedicated leaders • 1935 – born in South Carolina • 1960 – 1966 – served as Chief Inhalation Therapist at the Peter Bent Brigham Hospital in Boston • 1965 – earned the RRT credential, Registry #263 • 1966 – 1970 – served in many roles including Director of the Program in Respiratory Therapy at Northeastern University in Boston • 1970 – became Director of the Respiratory Therapy Department at Massachusetts General Hospital • 1973 – became the 22nd President of the American Association of Respiratory Care • 1975 – was serving as an NBRC Trustee and Member-at-Large of the Executive Committee when he passed away unexpectedly

4. Ethics in Testing and Candidate Preparation

5. Presenters • Robert C Shaw Jr PhD RRT FAARC • NBRC Assistant Executive Director and Psychometrician • Kerry E George MEd RRT FAARC • NBRC Treasurer • Chairman of the Therapist Multiple-Choice Examination Committee • Vice Chairman of the Judicial and Ethics Committee

6. Conflict of Interest We have no real or perceived conflicts of interest that relate to this presentation. Any use of brand names is not meant to endorse a specific product, but to merely illustrate a point of emphasis. Summer Meetings 2011

7. Objectives Learning objectives for this presentation: • Describe the integration of ethics scenarios into two NBRC specialty certification tests • Articulate principles of ethics that could be incorporated into these tests • Illustrate ways in which candidates or others could cross the line while taking or preparing for a test • Explain the activities of the NBRC’s Judicial & Ethics Committee Summer Meetings 2011

8. Ethics and Testing

9. Ethics Defined • Resolution of conflicts between principles that would be desirable alone • When there is no conflict, the way forward is clear • When there is conflict, the way forward requires careful thought • At what point is the line crossed by no longer serving one of the principles?

10. Principles that can Conflictfor the Psychometrician and the NBRC • Inform stakeholders about constructs that will be assessed • Maximize the validity of credentialing outcomes • Keep the content of the credentialing test secure

11. Principles that can Conflictfor the Healthcare Team • Non-maleficence • Avoid needless harm • Beneficence • Act to the benefit of the patient • Autonomy • The patient chooses what may be done to his or her body • Justice • Goods & services are fairly distributed

12. Non-maleficence Critical Questions Potential Conflicts • Is the potential benefit worth the risk? • Was care provided to a standard that avoids or minimizes risk?

13. Beneficence Critical Questions Potential Conflicts • Is the activity of the healthcare provider a benefit to the patient? • Non-maleficence • a constant duty • Beneficence • a limited duty

14. Autonomy • Is the patient or surrogate capable of making decisions that are free from coercion? • Duty of the physician1 to assess by asking a patient or surrogate • to rephrase information given to him or her • what is the most important to him or her • a question that was already asked to verify a consistent response 1. John Davenport, MD, JD (1997) Ethical principles in clinical practice. The Permanente Journal. Vol 1, No 1, pp 21-24.

15. Autonomy (cont.) Critical Questions Potential Conflicts • Has a capable patient or surrogate been informed of potential treatments and the risks of those treatments? • A recommendation from the physician is expected

16. Autonomy (cont.) • Patients or surrogates can refuse care that medical experts recommend to them • Evidence that justifies withholding care also justifies withdrawing care • Fear about starting treatment in one patient that may result in death when withdrawn could encourage withholding treatment from everyone in the population • Withdrawing care does not require stronger criteria than does withholding care • President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1983)

17. Justice Critical Questions Potential Conflicts • Are goods and services fairly distributed? • Do peers receive equal treatment? • Typically an issue for a therapist in extreme circumstances • natural disasters, attacks, triage

18. Other principles in healthcare that can conflict with one of the four common principles • Honesty • Healthcare team members deserve an objective assessment of therapeutic effectiveness • Fidelity • A patient should have enough confidence to trust that a physician will carry out his or her promises

19. Implementation of ethics assessmentS

20. Example from NPS Ethics Recall Application Analysis

21. Example from ACC Ethics Recall Application Analysis

22. No Pure Ethics Items • An item that involves an ethics scenario also will link to a competency, a level of cognition, and often knowledge of a disease or condition • Items with an ethics scenario will be a small subset of two certification tests for specialists • NPS: 3 of 120 items • ACCS: 5 of 150 items

23. Examples of Scenarios • A patient may not survive transport for a diagnostic test • Start treatment in spite of a risk for negative side effects • A gravely ill infant with congenital defects has an arrest • A patient (or surrogate) refuses care that could be therapeutic • A patient who would be difficult to wean suffers a life-threatening decline in health

24. Examples of Scenarios (cont.) • Transition from maximum support to comfort care • Withdraw mechanical ventilation • A patient can sustain blood pressure and ventilation, but has inoperable cancer • Evaluate a patient for brain death • Care of an organ donor before transport to surgery • Explain a treatment or test to a patient or guardian that is likely to cause discomfort

25. Examples of Scenarios (cont.) • Respond to a patient’s complaint of pain when the patient has a history of abusing prescription analgesics • Prioritize allocation of scarce resources while planning for a disaster • Care for patients with orders for “no blood products,” “DNI,” or “DNR”

26. NPS Study Guide Exam • A newborn has been admitted to the PICU with a complex congenital heart lesion and Trisomy 13. The patient is receiving mechanical ventilation and vasopressor therapy. The parents have declined surgical intervention. Which of the following should a neonatal/pediatric specialist anticipate? • A. continuous monitoring and pharmacologic support • B. placement of a tracheostomy and gastrostomy • C. comfort care and eventual withdrawal of life support • D. referral of the case to the hospital ethics committee

27. ACCS Study Guide Exam • An ICU committee is developing a disaster preparedness plan for an event featuring an extended electric grid power outage in a 10-mile radius under which power is supplied solely by emergency generators. Which of the following should be an element of the disaster preparedness plan for an event of this type? • A. Continue to accept emergency cardiac surgical cases. • B. Continue to accept patient transfers from lower levels of care. • C. Consider accelerating ventilator weaning protocols to liberate patients. • D. Consider transfer of patients on mechanical ventilation to other facilities.

28. Ethics and candidates

29. Principles that can Conflict for Faculty • Provide the opportunity for each graduate to achieve the credentials he or she desires • Achieve program credentialing success that exceeds the CoARC threshold • Ensure that the assessment of each candidate’s ability is valid • Assure public safety through graduating only those who are minimally competent

30. Crossing the line • Attempt to acquire specific examination content • Share acquired examination content with students

31. Principles that can Conflict for Students • Learn the knowledge and skills to become a respiratory therapist • Assist fellow students and friends to master the content as well • Obtain employment as a respiratory therapist • Ensure that assessment of each candidate’s ability, including one’s own, is valid so that the public will be protected

32. Crossing the line • Use of external aides while taking the test • Seeking or providing information to other candidates while taking the test • Acquiring specific examination content • Using acquired examination content while taking the test • Sharing acquired examination content with other students, program faculty, or test preparation companies

33. Testing Center Procedures • Each candidate • shows two forms of ID; one with a photo • signs the roster • removes hat, empties pockets, turns pockets out • stores personal belongings • takes his/her photo; printed to the score report

34. Testing Center Procedures (cont.) • Each supervisor • inspects for devices that could produce digital images • provides scratch paper; one sheet at a time • monitors candidates for behaviors associated with cheating

35. Video Monitoring Capabilities • Video 1 • We plan to display a video that starts by showing a 360-degree view of a testing center including each carrel • The image will zoom down to show one candidate seated at one carrel • The image will zoom further to show the monitor and keyboard used by the candidate

36. Video Surveillance Examples • Video 2 • We plan to show an actor who pulls notecards from beneath the keyboard, flips through a couple, studies one, slips the notecards under the keyboard, and selects a response to the item on screen

37. Video Surveillance Examples • Video 3 • We plan to show an actor who leans back from his/her carrel, turns toward the candidate next to him/her (or behind him/her), they speak briefly, then each returns to his/her carrel, and the first candidate selects a response to the item on screen

38. Video Surveillance Examples • Video 4 • We plan to show an actor who pulls a cell phone out of his/her shoe or boot and takes a picture of the screen

39. Principles that can Conflict for Examination Preparation Companies • Provide each client the best opportunity to pass a test • Attract more clients by success of those previously utilizing the services • Ensure that the ability of each test taker is validly assessed so that the public remains safe

40. Crossing the line • Seeking to acquire specific examination content • Debriefing clients after they have taken the examination • Sending persons to take the examination with the primary purpose of memorizing content • Providing other persons access to information that was obtained from persons who took the examination

41. Crossing the line (cont.) • Using illegally obtained intellectual property from an examination to • develop examination preparation curriculum • develop practice examinations

42. Judicial and ethics committee

43. Current Committee Composition • AARC – 4 • ASA – 2 • ACCP – 1 • ATS – 1 • Public member – 1

44. Annual Meeting Schedule • Face-to-face • April • December • Telephone conference • February • August

45. Agenda Items • A candidate or credential holder • obtained, attempted to obtain, or assisted an attempt to obtain credentialing by fraud, deception, or artifice • used a credential that he or she did not earn • used unauthorized or falsified NBRC documents • possessed or provided unauthorized NBRC examination content or materials

46. Agenda Items (cont.) Revocation, suspension, denial or voluntary surrender of a license to practice - a drug or alcohol-related offense • a job-related offense indicating the individual's intentional negligence or purposeful misconduct • an act of physical violence • any condition or impairment that interferes with the ability to practice safely or effectively

47. Procedure • Committee receives a complaint or information from an individual or state licensing agency • The committee determines whether there is a reasonable basis to believe that the charged offense has been committed • Committee votes to hold a hearing • Notify the complaining party, charged party, and any witnesses • If the charged party is provided opportunity to provide the committee any desired information

48. Procedure (cont.) • A hearing is conducted at the next meeting • if no additional information is provided, the committee decides based on information from complaint • if the charged party submits additional written information the committee considers this additional information to decide the case • the charged party, legal representative and any desired witnesses may appear in person at the hearing • witnesses may testify

49. Procedure (cont.) • The charged party (or legal counsel) may cross-examine witnesses and have access to evidence available to the committee • The NBRC records each hearing at its expense • The committee considers all information to reach a decision • Results of the decision are communicated to the complainant and charged party

50. Procedure (cont.) • Appeals • The charged party may appeal the committee decision to the Board of Trustees • Committee members are excused while appeals are considered • Decisions are made solely on the record of the hearing • The NBRC has a provision for emergency suspension of credentials and/or eligibility