Ethics: We all remember taking an ethics course in school, and we talk about it on a regular basis. Most of us who decided to become occupational therapists are intrinsically “good” people, so it’s really tough to think we may be faced with difficult situations that could blur our ethical boundaries.

Our field is seeming to become increasingly harder to keep to our Code of Ethics due to the profit-driven companies many of us are working for.

It seems to be harder and harder to get a job in an ethical placement, since the turnover at these jobs is much lower. As a new grad or fieldwork student, you may feel stuck taking a job in a less-than-ideal placement, and you will more than likely see these issues come up.

This post also works for physical therapists and speech therapists since we are all faced with these ethical dilemmas when working for the same companies.

Research on Ethics and Occupational Therapy

Surprisingly, there isn’t a lot of research on the topic of unethical practice in occupational therapy. I did locate one interesting article titled “Ethics, occupational therapy and discharge planning: Four broken principles” (Atwal & Caldwell, 2003).

In the article, the researchers state that common ethical issues include “ineffective treatment, unethical/incompetent colleagues, priorities in treatment, causing pain and discomfort, treating patients despite refusal, and misleading the patient and confidentiality.”

The researchers focused their article on how occupational therapists can complete discharge planning “following the four fundamental bioethical principles of respect for autonomy, beneficence, non-maleficence and justice.” It’s definitely worth the read.

Common Ethical Issues Clinicians Face

I did an informal poll in several of the Occupational Therapy and Geriatric Therapy Setting Facebook groups and asked for the member’s anonymous unethical practices they see on a consistent basis.

These were the most prevalent:

  • Treating patients that are inappropriate for therapy. This happens way too often much to the dismay of every practicing OT/COTA. Included in this is being forced to treat patients with ultra-high RUGs that cannot tolerate it. As the patient’s clinician, you have the right to confront your manager about this issue.
  • Seeing patients past the point of progress. If the patient has plateaued, is not making any more gains, or has met their prior level of function, it is time to discharge them from therapy regardless of what the “higher ups” are telling you.
  • Billing patients for documenting when you aren’t providing intervention. With crazy-high productivity requirements of SNF settings, this is sadly all too common in the field. 
  • Documenting and billing your services accurately. Completing your documentation in a timely manner (same day is best) so you don’t leave anything pertinent out that you may forget. This is super important to avoid failing audits conducted by Medicare or other insurance providers.

Not-So-Obvious Situations

You will also come across situations that may seem “fine” but are actually unethical. It can be harder to realize that you may be violating the Code of Ethics, so I wanted to include these as well to protect yourself.

Providing a treatment that you aren’t adequately trained to perform.

An example of this could be using a modality (like e-stim) without getting any training on proper use beforehand. Some states do require you to be modality certified, while others do not. If you’re in a state that does not require training, make sure you’ve had enough training to feel competent using the modality. The worst thing that could happen is that you unintentionally harm your patient.

Prolonging discharging the patient or discharging too early.

I’ve read multiple accounts of for-profit companies pushing their therapists to keep patients as long as possible, even after goals are met and patients have met their max potential. On the other hand, some patients are only approved for one week but need significantly more time in the rehab setting. If they are sent home because of payer source, this is sad but out of our control as therapists.

Billing for unskilled treatment.

This can be easy to do by accident if you’re new. If you’re billing for treatments where patients are independent in all ADLs, or you complete dependent dressing/bathing/self-feeding regularly for a dependent patient that a CNA could do, it technically isn’t skilled. Medicare or other insurance providers may deny their rehab services if this occurs. 

Blurring the lines of personal and professional relationships.

Becoming involved with patients, professors, clinical instructors, etc. happens and is of course frowned upon. You want to use good judgement avoiding a complicated situation.

For more on how to avoid crossing professional boundaries with patients, clinical instructors, professors, even your own friends/family in the treatment setting, check out this article from AOTA.

Companies Committing Unethical Practices

While the last section covered what you as a therapist can do to avoid committing unethical acts, oftentimes the company is the primary offender. This is because many companies are putting profits before patients and quality care.

You may be given unrealistic productivity standards, which forces many therapists to work off of the clock. This is more than just “not cool” but in fact illegal in many states.

It can become a slippery slope since documenting off the clock is the only way therapists are able to achieve the goals set out by the “higher ups” in rehab companies. The expectation is that 90%, 95%, or 100% productivity is possible and goals will continue to increase as long as the current goals appear to be met.

Other common practices of unethical settings include being urged to provide therapy to individuals that do not actually need therapy. This includes high level individuals that are independent with all basic and instrumental ADLs, as well as very sick, frail, or even dying people with ultra-high minutes that would not benefit from skilled therapy.


What Can You Do To Avoid Unethical Practices?

The best solution I can offer to this is to get out of there and find a different setting.

It’s definitely easier said than done for me to tell you to find a new job with more ethical practices. I totally get that it’s hard to find a good OT job. You can read more about it here.

But even so, I still want to encourage you to try to get to a place where you feel confident and comfortable as a clinician every day. You became an OT to love and enjoy your career, and I don’t want you to be miserable!

If your company is blatantly committing fraud or unethical practices, you can also become a whistle-blower. That may seem like a really scary task, but it is an important one to help keep companies honest.

For more in-depth information on becoming a whistle-blower, check out this article titled Blowing the Whistle on Fraud from Advance Healthcare Network for Occupational Therapists.

If you have any specific questions at your workplace that you aren’t sure about, it is never a bad idea to consult with your facility’s legal team (if you have one).

Most hospitals have lawyers on staff to help consult with you to prevent any issues. Your professors from OT school may also be willing to lend you words of advice if you’re concerned but hesitant to discuss with your employer (understandably).


At the end of the day, we all should be advocating for our profession, our patients, and our licenses. We have the right to stand up to the unethical behaviors of big corporations.

Do you have any tips you would share with new occupational therapists regarding how to advocate for themselves during unethical situations? Have you been faced with difficult situations in the past?

I also would love any positive comments on ethical settings you work in to encourage others that not every therapy setting is “bad,” and that quality patient care still does come first in most settings.

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  • Ashley December 29, 2017   Reply →

    Thank you for this article! As a new graduate, I am focused on what I am doing is ethically sound. I plan on reading the linked articles!

    • Sarah Stromsdorfer, OTR/L January 1, 2018   Reply →

      Thanks, Ashley! I’m glad the article was helpful for you 🙂 And congratulations on beginning your new OT career!

  • Dan February 1, 2019   Reply →

    Thank you for this article, it is super relevant to me at the moment. I appreciate you acknowledging these issues I don’t feel so alone and I have some ideas now, I am a new grad.

    • Sarah Stromsdorfer, OTR/L February 2, 2019   Reply →

      I’m so glad it was helpful for you! Ethical issues are one of the hardest parts about healthcare, and I know it’s hard to speak up or stand up your ground especially as a new grad. Just keep at it and you’ll find it does get easier to advocate for appropriate ethics as you keep doing it.

  • Alie April 16, 2019   Reply →

    I am a new student in fieldwork and wondering – what ethical steps should be taken for a patient who repeatedly refuses OT, but when planning to discharge the patient due to multiple refusals, the physician pushes the OT to continue services?

    • Sarah Stromsdorfer, OTR/L April 17, 2019   Reply →

      This is certainly a frustrating situation if you’re ever in it personally. At my facility, we typically discharge patients after three refusals (four at the most depending on the situation). If the doctor is adamant about keeping the refusing patient on caseload, you can remind them about the patient’s right to refusal.

      Here is a quick, helpful article that you can read and even print out for the doctor if you’re in this situation now at your FW: Do Patients Have the Right to Refuse Medical Treatment?

      An excerpt states, “It is unethical to physically force or coerce a patient into treatment against his will if he is of sound mind and is mentally capable of making an informed decision” and covers the patient’s right refusal in more detail.

      Every facility is a little different so I would also ask your CI what their policy is when the patients are continuously refusing. As a student and new grad it can be hard at first to stand up for yourself and your patients in these situations, but with time it does get easier!

  • Farrah September 3, 2020   Reply →

    Thank you for this post! New grad OT here! Nice to see I’m not alone, appreciate the articles and advice!

  • ERIN NICOL January 16, 2021   Reply →

    Two patients are supposed to receive OT 5x a week. Due to not being able to get coverage those patients were not seen. DOR wants me to put in for missed visits on a day I am not in the building working. Is this right?

    • Sarah Stromsdorfer, OTR/L January 17, 2021   Reply →

      No, I would not recommend documenting anything that you did not do as that is fraud and you don’t want to risk your license for that. The DOR needs to hire more therapists if the patients aren’t getting seen, that’s not your responsibility if you’re not working.

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