12Synergy and Challenges of Ethical Rural Interprofessional Collaborative Practice

Shelley L. Goodwin, Barry Wiser, Lisa MacNaughton-Doucet, Jaqi Allan, Judi L. Malone

Rural practice is a rewarding area of health care filled with clinical complexities that often are best approached from an interprofessional collaborative practice (ICP) perspective. However, rural ICP has the potential to create ethical challenges that require much attention and diligence. Our purpose in writing this chapter is to explore the ethical challenges encountered in rural ICP, as well as to examine how such a setting can be utilized to mitigate such challenges. Although ICP is a health care trend in Canada, and one with particular relevance for rural practice settings, there is a dearth of literature in the area. As such, we explore ethical best practices for ICP in rural settings based on our collective experiences. These are underscored with case examples and reflective queries. As will be illuminated, one can best practice with competence and integrity in the marginalized context of rural ICP practice when one establishes a solid grasp of the ethical obligations of one’s own profession, as well as an awareness of the ethical obligations of one’s ICP colleagues.

We, the authors, bring varied professional backgrounds to this shared examination. We have worked, lived, and thrived in rural settings across Canada, and have close to 100 years of collective experience in rural practice settings. We have known each other to varying degrees over a span of almost two decades. It has been a productive, yet informal and organic collaboration (Goodwin & Doucet, 2015, 2016; Goodwin et al., 2016). As a group, we have experience in clinical service, academia, and research. Like many rural practitioners, our backgrounds are rich and varied. Shelley is a doctoral-level psychologist who has a general independent practice involving participation in several ICP teams. She teaches at the graduate and undergraduate level in departments of education and psychology and is retired from law enforcement. Barry, also a doctoral-level psychologist, has a lengthy career as a psychologist in hospital-based mental health settings in direct service, management, and team leader roles, and has a special interest in ICP in behavioural health settings. Lisa is a masters-level registered nurse who has a background in home-health nursing, teaches at the undergraduate level in nursing, and is active in interprofessional education. Jaqi, a masters-level clinical social worker, has focused her career in mental health in both hospital and community settings, with particular attention to issues of relevance to the LGBTQ community. Judi is a doctoral-level psychologist with a 20-year rural generalist practice that includes academic and practical expertise in rural professional ethics and is currently a professional practice leader in a provincial association. As we all share a committed enthusiasm for living and practicing in rural Canada and have experienced the challenges and rewards of working collaboratively in such settings, we have chosen to write this chapter together.

Overview

Our group has frequently puzzled over perceptions of professional ethics as absolutes—black and white, and something to be dreaded. We have found that when discussions on ethical standards focus on consequences for misconduct, punishment for illegal acts, and sanctions for practice misdemeanours, practitioners tend to forget the positive aspirations, virtues, values, and principles that underpin ethics. In this chapter, we wish to shine a light on the stimulating and, dare we say, inspiring side of professional ethics from a rural perspective. We will provide an overview of ethical issues and guidelines in a rural and ICP context, particularly from the perspective of Principle III (Integrity in Relationships) of the fourth edition of the Canadian Code of Ethics for Psychologists (Canadian Psychological Association [CPA], 2017). We then will present four scenarios, suggesting practical and rural-friendly approaches for ethical decision making.

Rural ICP Practice and Integrity in Relationships

All relationships are built on trust and mutual expectations of integrity or, in other words, on Integrity in relationships (CPA, 2017, Principle III, Values Statement). This is magnified significantly in a rural environment where one’s decisions and actions can quite literally become everyone else’s business. Therefore, it is not only important for the psychologist to abide by the profession’s ethical principles, but it is also important for collaborating partners to perceive the psychologist as abiding by these principles. How well one is perceived as manoeuvring through ethical challenges is of critical importance with other professionals in the community, as well as with the community at large.

Peer-reviewed literature on ethical issues and dilemmas in small communities (e.g., in areas such as policing, military, rural, feminist, and cultural-ethnic communities) gained prominence in the psychology literature in the 1980s and 1990s. In particular, there was considerable focus on what was at first called “dual” relationships and then later “multiple” or “overlapping” relationships, which are inherent in small rural communities (Bagarozzi, 1982; Biaggio & Greene, 1995; Borys & Pope, 1989; Schank, 1989; Schank & Skovholt, 1997). The practice guidelines and codes of ethics at that time directed practitioners to avoid dual and multiple relationships. This created significant dilemmas for psychologists in rural settings, where such relationships were very hard, if not impossible, to avoid, insofar as such avoidance would result in a lack of engagement in their communities and, when not avoided, be very difficult to manage to the level implied as ethically needed by the guidelines and codes of the day. Simply stated, in the 1980s and 1990s, ethical codes, practice guidelines, and standards did not reflect the reality of rural practice. One respondent in a national study on rural ethical practices suggested that unless you were willing to live like a hermit, multiple relationships in small communities are a fact of life (Helbok et al., 2006).

The third edition of the Canadian Code of Ethics for Psychologists (CPA, 2000) softened this hard-line approach and suggested that although practitioners should avoid multiple or overlapping relationships, there were exceptions which must be carefully considered, managed, and ethically resolved. Although this was a positive transition for rural practitioners, it still could be (and often was) interpreted to mean that multiple relationships were exceptions, rather than the common practice context, of so many rural practitioners. In the 2000s, the literature began to differentiate between boundary crossings and boundary violations, highlighting the notion that relationships which overlap are not always harmful (Ebert, 1997; Zur, 2000a; 2000b; 2006). For instance, Truscott and Crook (2013) wrote:

The concept of dual relationships is generally considered to be outdated because avoiding having more than one relationship with a client is almost impossible, particularly in settings such as rural communities. It has now been superseded by the idea of harmful dual relationships. That is, we are not expected to avoid all dual relationships, only those that are harmful to our clients (p. 132).

The more recently released fourth edition of the Canadian Code of Ethics for Psychologists (CPA, 2017) offers a greater acknowledgement that small communities of practice require psychologists to be active community participants, stating that dual or multiple relationships may be “inevitable or culturally expected (e.g., rural, Indigenous, or immigrant communities) or could enhance the benefit of an activity” (CPA, Principle III, Values Statement, para 6). From our experience, we agree that in rural and small communities of practice the existence of multiple and overlapping relationships is the norm, not the exception.

In addition to the ethical value of Avoidance of conflicts of interest, under which the Canadian Code of Ethics for Psychologists addresses multiple relationships, Principle III (Integrity in Relationships) also addresses broader integrity issues of relevance to rural practitioners. The familial, generational, and/or lifelong loyalties and connections in rural settings includes both benefits and potential risks to integrity. Also included in Principle III are the ethical values of Accuracy/honesty, Objectivity/lack of bias, Straightforwardness/openness, Avoidance of incomplete disclosure and deception, Reliance on the discipline, and Extended responsibility. Even a cursory examination of the titles of these values suggests how easily ethical challenges might arise in an environment where overlapping, intertwined relationships prevail. The latest edition of the Canadian Code of Ethics for Psychologists provides a relevant guide to deal with these challenges to practicing ethically in a rural environment, acknowledging the geographical and cultural variations of practice necessary to thrive professionally and personally, as well as ethically, in the rural communities we serve.

History of ICP

As early as 1950, Macfarlane (1950) recognized the importance of professionals in the field of psychology engaging with other healthcare disciplines. Since the establishment of the Canadian Medical Care Act in the 1960’s and the subsequent Canada Health Act in 1984, the principles of universality and accessibility of publicly funded healthcare services to all Canadians have been fundamental. However, over the decades in Canada, offering equitable health care services within the constraints of an inequitable distribution of resources, particularly to those who are disadvantaged and living in remote settings such as rural communities, has proved challenging (Engel & Prentice, 2013). The Royal Commission on the Future of Health Care in Canada (Romanow, 2002), also known as the Romanow Report, continues to be an influential document. It highlights key issues and recommendations on how health care could streamline both human resources and infrastructure to secure an affordable health care system in Canada. One recommendation was to advance ICP in healthcare delivery—where health professionals from varied backgrounds, along with patients, families and/or communities, collaboratively deliver quality care to achieve health goals. Within this recommendation, developing and maintaining effective working ICP relationships is recognized as an important direction for health care.

ICP also is recognized globally as a necessity in providing effective, sustainable health care in complex environments. The World Health Organization (2010) endorses ICP as a core framework for healthcare services. According to the Canadian Interprofessional Health Collaborative (2010), the required competencies include: (a) knowing the roles of other professions; (b) understanding the commonalities and differences between different professions; and (c) sharing common goals. ICP is seen as a key driver for facilitating healthcare equity to rural Canadians, as it has the potential to improve access for individuals living in these regions (Donato, 2015; Goodwin et al., 2016). Today, ICP practices in Canada are embedded in our fiscally constrained health care system through sharing of professional expertise, ensuring person-centred practices, and maximizing scarce resources. Rural communities can greatly benefit from these practices as oftentimes they lack a full complement of professional healthcare teams, have limited resources, and/or experience geographical isolation. As such, ICP is an ideal practice for rural health services.

Introduction to Scenarios

Ethical issues in ICP can be ubiquitous, and we invite readers to transfer the experiences described in the following scenarios to their own actual or potential experiences in rural or small communities of practice. All the scenarios are a compilation of real-life situations drawn from the authors’ collective experiences and are modified and disguised for confidentiality. We believe the narratives that such scenarios provide can connect difficult or complex concepts in transferable ways. As explained above, we present our four scenarios primarily from the perspective of Principle III (Integrity in Relationships) of the Canadian Code of Ethics for Psychologists (CPA, 2017), while acknowledging that the three other ethical principles of the Code also may apply. In addition to relying on the Code, we also reflect on relevant ethical statements from some of the other professions we represent.

The Code is strongly aspirational in nature and emphasizes striving to meet the highest ideals of human awareness, intention, reasoning, and behaviour. Yet, this level of perfection is rarely, if ever, seen in real life, even when we strive and aspire to it (CPA, 2017; Truscott & Crook, 2013). In the spirit of striving towards these ideals, we invite the reader to ponder how these case examples may relate to and be addressed within their own current and/or future areas of practice.

Scenario #1

Our first scenario presents a common ethical challenge that confronts many rural and remote practitioners working on an ICP team. The primary ethical value highlighted is Reliance on the discipline (Ethical Standards III.33–III.35).

Marie is a psychologist practicing in a small town 300 kilometres from any other psychologist. She works in an ICP primary care setting with a physician, registered nurse, paramedic, nurse practitioner, occupational therapist, and a non-regulated counsellor from the local non-profit Women’s Centre. It is a close-knit ICP team where many members socialize with each other outside of the office. Some have children of a similar age. At dinner one evening, Marie learns that her 14-year-old daughter continues to be bullied at school by an ICP colleague’s child, despite Marie having addressed the issue with the school. The 15-year-old adolescent, who is the aggressor, experiences learning difficulties and impulsivity challenges. This adolescent had been referred to Marie by the school but instead, Marie recommended telepsychology with a professional outside the community due to Marie’s dual relationship with the child’s mother. However, the child refused to participate in any form of counselling. Marie now feels isolated. She is worried about her daughter, and worried about talking with her ICP colleague about the situation. If it goes poorly, the emotional fallout may impact their working relationship and, in turn, the team.

Marie remembers a graduate professor once saying to her, “You don’t need to know it all, you just need to know how to reach out and find it,” which she thought was very wise advice. Although Marie would prefer to obtain advice about her situation through face-to-face contact, she does not feel comfortable speaking with any other team member about the situation, as she believes this would put them in a very awkward position. However, finding a face-to-face alternative is not always possible in rural areas.

Marie reminds herself that she needs to remain isolated for advice only as far as the nearest phone or internet connection, and that she could contact her former registration supervisor, a past colleague, or her provincial association where, in her province, a list is maintained of psychologists willing to consult with fellow psychologists on ethical matters (III.35). In preparation, she familiarizes herself with her province’s consent and child protection legislation (III.33) and psychology’s standards of practice for telehealth services (III.34). She also reviews relevant sections in the Criminal Code of Canada related to bullying and social media harassment. Once prepared, she chooses to consult with her former registration supervisor who has good knowledge of her practice environment, with whom she had a positive supervisory relationship, and who she thinks could probably provide her with very workable suggestions. She follows through and is very happy with the advice she receives.

Discussion

The primary ethical value of the Canadian Code of Ethics for Psychologists (CPA, 2017) highlighted in this scenario is Reliance on the discipline. A number of professional codes of ethics promote or require their members to actively seek consultation within their discipline (e.g., nursing, social work, physicians, and psychology). This was true of most of the members of Marie’s ICP team. In rural ICP, however, non-regulated colleagues who are not governed by a code of ethics also might be team members. Although not part of Marie’s dilemma, psychologists on ICP teams sometimes can take on the added responsibility of educating and encouraging others to adhere to high ethical standards both in practice and in research, as appropriate (Ethical Standards III.36 and III.37).

Marie remembered that, similar to other regulated professionals (e.g., Canadian Nurses Association, 2017; Canadian Association of Occupational Therapists, 2007; Paramedic Association of Canada, 2016), psychologists are required to be familiar with their code of ethics, practice standards, and relevant provincial and federal statutes/acts. This was helpful to her in preparing to proceed with consultation. Considering that consultation between urban and rural colleagues can be beneficial (Malone & Stanley, 2011), she did not need to rule out an urban colleague for consideration. Furthermore, considering that consultation may usually be profession specific, but does not have to be province specific, Marie also could have considered calling a friend from graduate school living in another province, or a colleague on a national committee that she knows. Reflecting on the Canadian Code of Ethics for Psychologists and the Universal Declaration of Ethical Principles for Psychologists (International Union of Psychological Science, 2008), she even could have considered the relevance of stepping outside her own country for consultation.

Queries for Consideration

1. If the bullying situation did not exist, could Marie have started a therapeutic relationship with this client in this ICP/rural setting? If so, under what conditions?
2. Exercise: From your profession’s scope of practice, write out what you think your potential role could be in an ICP team with respect to a child of one of the team members in this scenario.
3. Exercise: Now imagine yourself to be a member of another discipline on an ICP team. Write out what you think your role might be. What are the similarities and/or differences to your role within your own profession’s scope of practice?

Scenario #2

This second scenario takes us into the complexities of balancing service provision with financial and administrative responsibilities in a rural private practice. The primary ethical values highlighted are Straightforwardness and openness (Ethical Standards III.13-III.22) and Extended responsibility (Ethical Standards III.36–III.37).

John is the only private practice psychologist in his rural area. Aki is the owner/practitioner of the only rehabilitation clinic in town, the Painfree Clinic. The nearest clinic like this is 400 kilometres away. Aki has invited John to join her clinic’s ICP insurance-related injury team. In addition to psychology, the clinic’s ICP team includes chiropractic medicine, general medicine, massage therapy, occupational therapy, physiotherapy, and social work. During negotiations, John is encouraged to streamline his assessment process, and feels pressured to allow other professionals (whose hourly rate is less expensive) to administer psychological inventories, and to lower his hourly rate (the provincially recommended rate) to match the insurance company’s allowable billing rate. John is excited by the opportunity to join the clinic as the opportunity to collaborate with other professionals in this way does not always happen when practicing in a small town. He also is aware that it will increase his revenue, which is a good thing, as he is still developing his business. One area of concern for John, however, that makes him apprehensive is that the collaboration would require him to work with professionals from whom he had personally received medical care, albeit six years ago. After contemplating the pros and cons and consulting with fellow psychologists, John decides to pursue this collaboration. Further details of his thinking appear in the discussion below.

Discussion

Money is often a difficult topic for people to address. In this case, a third party (the insurance company) is mandating an hourly rate that is below psychology’s provincially recommended rate. In many settings this is not unusual; some psychologists do not adhere to the provincially recommended rate, some charge more and some charge less. Discerning what he needs to charge to complete the assessment and what the Painfree Clinic can afford requires a respect for openness, a level of directness, and a degree of co-operation from all parties. Through open and respectful dialogue, these issues may be resolved while maintaining both integrity and harmony in the ICP relationship.

The Canadian Physiotherapy Association Code of Ethics (2016) emphasizes the importance of physiotherapists practicing to their full scope of practice. This opens the question of who can administer psychological tests. Although other professions can administer level A and B inventories, the standards followed by psychologists require that the more complex level C tests be used only by those with specific competencies and credentials (American Educational Research Association et al., 2014; Simner, 1994). Those companies that sell psychological tests and inventories, however, set their own criteria for who can administer them. Understanding this may help lessen the need for psychologists to defend the right to administer and interpret inventories by instead allowing the sellers of psychological assessment tools to confirm the user’s qualifications. In an ICP team, John needs to be aware of his colleagues’ abilities and scopes of practice, thus allowing him to promote a harmonious working relationship (Ethical Standard III.10). John reviews the test publisher requirements to determine if it may be appropriate for the ICP team member to administer the inventories. With this information, John decides to engage his ICP teammates to have their input, and then have the team evaluate what is best for the clients being served.

When John reviews confidentiality with his regular private practice clients, he informs them of the usual exceptions to confidentiality, namely: harm to self; harm to others; vulnerable persons in need of protection; and a judge ordering the information to be shared. John realizes that, when working with an ICP client for their insurance-related injury assessment, he also will have to advise each client that some information will be shared among team members (Ethical Standard III.13). However, not all client information should be shared with ICP team members if it is not relevant to the injury assessment. This will require sound judgement on John’s part and could impact the level of openness and engagement of the relationship of other ICP team members. Maintaining confidentiality also includes not sharing client information between his private practice office and the Painfree Clinic by email unless password protected, and most preferably by fax or personal delivery (Ethical Standard III.14). John knows that the other health professionals on the ICP team are bound to confidentiality through their own professional codes of ethics, but these may not be to the same ethical standard as John believes is required by his own code. The Canadian Code of Ethics for Psychologists (CPA, 2017) encourages John to engage in conversation with his team members to promote confidentiality to the same ethical standard, which reflects the value of Extended responsibility (Ethical Standard III.36). John is aware of this and engages Aki in a conversation about how to navigate these requirements.

As already noted, a number of scholarly publications exist that highlight the challenges of overlapping roles in rural community practice (Malone & Dyck, 2011; Schank, 1989; Schank et al., 2010; Schank & Skovholt, 1997, 2006; Truscott & Crook, 2013; Zur, 2006). John knows that he must also consider the issue of dual roles with the ICP team during negotiations. In the Canadian Association of Social Work Code of Ethics (2005), Principle 4 recommends the avoidance of multiple roles, and promotes the values of openness and transparency. However, John realizes there are ICP team members for whom overlapping relationships are not discussed in their code of ethics. This allows John an opportunity to inform and discuss with colleagues psychology’s Code and the issues that it raises with respect to overlapping relationships (Ethical Standard III.36).

Some psychology practitioners may read this and revert to the absolutist thinking mentioned in the introduction, and see overlapping roles as forbidden, to be avoided at all costs, or as inherently dangerous. Fortunately, John is aware of recent advances in the literature and changes in the fourth edition of the Canadian Code of Ethics for Psychologists (CPA, 2017) that counteract such interpretations of overlapping relationships. For instance, in the Code, under the ethical value Avoidance of conflict of interest (discussed in more detail later), Ethical Standard III.30 states that practitioners should “avoid dual or multiple relationships . . . that are not justified by the nature of the activity, by cultural or geographic factors, or where there is a lack of reasonably accessible alternatives” (CPA, 2017, Principle III). The wording of this standard supports the view that a linear way of thinking about overlapping relationships is too restrictive, particularly in rural settings. Having this knowledge allows John to open a dialogue while negotiating his role on the ICP team.

Aki, as a physiotherapist, will be guided by her own professional body’s Code of Ethics to “communicate effectively and respectfully, and practice cooperatively with colleagues, other health professionals and agencies for the benefit of patients/clients” (Canadian Physiotherapy Association, 2016, p. 3). Having read Aki’s code for his own knowledge, John takes comfort in this information as it allows him to engage in an open, straightforward dialogue on the best approach. Although John is mindful that this new ICP opportunity has ethical considerations, he does not feel that they are insurmountable; rather, he believes he can navigate them with openness and clarity. With this understanding, John and his ICP colleagues sign a contract (Ethical Standard III.13); in doing so, he is protecting his clients, himself, and his partners.

Queries for Consideration

1. John completes an insurance-related injury assessment and advises the client and his ICP team that there are no psychological barriers for the physically injured client to return to work. He does not reschedule with the client and advises the team there is no further reason for him to see the client. Two weeks later he receives an update on the client’s progress by fax. Does receiving a progress report when he has terminated his service to the client pose an ethical concern? Why or why not?
2. John is a distance runner and experiences an injury. What are the ethical implications if he receives services from the Painfree Clinic while he is in an ICP partnership with them?
3. A client advises you that he wishes to have his injury treated with Indigenous methods of care. How do you respond? How does this fit within the ICP model of care and within your code of ethics?

Scenario #3

This scenario underscores the opportunities for ICP research, while acknowledging the rewards of rural community engagement and the need to manage multiple roles in a rural setting. The primary ethical values highlighted are Avoidance of incomplete disclosure and deception (Ethical Standards III.23-III.27), and Avoidance of conflict of interest (Ethical Standards III.28-III.32).

Ben is a psychologist and equine enthusiast who lives in a small remote community. He is aware that he has gotten to know people in many ways through his work, family life, shared hobbies, and passions. He is also aware this is the way of small communities, where people get to know each other in many ways and on many levels. Included in such knowledge is who might contribute professionally to a project and who might volunteer their time when doing so. They know this through word of mouth, social media, community involvement, past work experience, or just because they are part of a local interest group. So, when he is asked to be the primary investigator leading a team conducting program evaluation in equine therapy, he appreciates the fit between his personal and professional life and is excited by the opportunity to engage in the project, albeit somewhat leery of the potential for role conflict and interprofessional challenges. He also sees the opportunity to use the data collected from the program evaluation for publication and wants to make sure that he obtains ethical approval for this data collection as he hopes to present and possibly publish the findings.

Ben learns about the project from Allison, who describes how a local rural-based parent support group, of which Allison is a member, has received a grant for a summer recreation day camp for children with a developmental disorder. The project would run on Saturdays over the summer at a local equestrian centre. Grant money would cover the project’s operational costs but not staff salaries or program evaluation/research expenses. The parent support group, however, hopes that the effectiveness of the program can still be evaluated, especially with respect to the effectiveness of the new type of equine therapy that will be part of the program. Allison and other parents approach acquaintances and professionals known to them through the support group, but also through community and shared social circles, about volunteering to participate. Ben sees and appreciates how the ICP participants are respectful of colleagues’ parenting obligations, work, and personal demands; for example, by being flexible in scheduling and being mindful of childcare constraints during summer vacation. With small-town community spirit, two teams are formed—a service provision team to run the program, and a program evaluation/research team to conduct a mixed method study on the effects of the program. The service provision team consists of three recreation therapists, an artist, nursing students, community volunteers, and a certified equine therapist. The program evaluation/research team consists of two psychologists, a registered nurse, a registered social worker, and a nursing student. One of Ben’s roles is to build team capacity by providing basic research education for inexperienced team members.

Having lived in this small community for many years, Ben is very aware how roles can become unintentionally and unavoidably blurred in a rural collaborative relationship compared to those in an urban setting where roles are better defined and easier to maintain. He is aware that ethical values and standards may not be applied easily. So, before accepting the opportunity, Ben wisely reflects on possible relationships that might come to bear on this new opportunity. These include his having taught some of the students in the past and the possible teaching of some in the future, riding horses with several of the volunteers and the pediatrician, and taking riding lessons from the certified equine therapist. As with many things rural, this ICP team was realized because of “who knew whom,” and he feels honoured to have been asked to work with his colleagues in this way.

Ben advises the teams that to ensure a more objective research approach, members of the ICP research team were not to be directly involved in the project’s service provision. Not only did this allow for research objectivity, it also allowed Ben to avoid overlapping roles, particularly where he had had a therapeutic relationship with some participants. Other members would be responsible for data collection, tabulation, and responding to research questions that arise. Some professions’ codes of ethics do not address research expectations or standards as clearly as psychology (e.g., recreation therapists). Aware of this, Ben asks his professional partners to follow the Code’s ethical values and standards for research (consistent with Ethical Standards III.36 and III.37 regarding the value of Extended responsibility). Ben is able to assume overall responsibility for the research activities of his collaborating partners (III.37) and, in doing so, he is mindful of the ethical standards for research laid out in the CASW Code of Ethics, Value 6.5 (CASW, 2005) and the Canadian Nurses Association Code of Ethics, Value C.1-4 (CNA, 2017).

In keeping with the Canadian Code of Ethics for Psychologists’ values and ethical standards regarding research, and the Canadian Medical Association’s (CMA) Code of Ethics (2004), Ben ensures that ethical approval of the research is obtained through the ethics board of the hospital with which he is affiliated. In addition, reflecting CPA’s Ethical Standard III.29, he also makes sure that rewards are not offered to motivate individuals or parents to participate in the recreation program or the research portion of the program. Furthermore, because of the financial limitations of the grant, remuneration and/or financial rewards are not offered to ICP research team members for their participation. They are asked to participate on a completely voluntary basis. Nina, the social worker, affectionately argues that her arm had been gently “twisted” to compile and tabulate the data, but she states that she is pleased to contribute as she recognizes the potential non-financial gains. As is common in rural settings, where a handshake and a person’s word are the way of doing business, no written contracts are signed as team members are pulled together for this project. Ben is surprised when one of the team members, Jordan, unexpectedly, after two planning meetings, submits a written request for payment of his proposed hours. Ben acknowledges Jordan’s valuable contribution as well as apologizes for the apparent lack of clarity in the initial verbal agreement. He then respectfully advises Jordan privately that there is inadequate grant money to pay the fee requested (Ethical Standards III.16 and III.19). Ben leaves it open for Jordan to remain as a volunteer or leave the project. All ICP members’ professional codes of ethics advise handling this type of situation with straightforwardness and respect, which reflects the Canadian Therapeutic Recreation Association’s (CTRA, n.d.) Code of Ethics Principle 4 of “Professionals practice mutual respect and work cooperatively for the benefit of those they serve,” while also adhering to the Canadian Code of Ethics for Psychologists’ Ethical Standards III.5 and III.13, CASW code’s Principles 1 and 4, and CNA’s code Values A and B.

Ben, recognizing the value for students to participate in an ICP activity, arranges for separate groups of undergraduate students to participate either in the research or in the service provision. Given the nature of the work, this was appropriate, yet required clarification of boundaries with the students both during and after the project concluded, particularly when all returned to the classroom in the fall. One student used this experience to present at a national conference, which was supported fully. Collaborating on an interesting local research project, while building research skills, provided an exciting professional growth opportunity. For this student and other ICP partners, these benefits help offset the time commitment and lack of compensation.

Discussion

Putting youth and families first, while also paying attention to collaborating partners’ well-being, allows ICP team members to feel respected and appreciated for their contributions. ICP involves developing and maintaining effective working relationships with professionals, paraprofessionals, mental health consumers and their families, students, and communities to ensure optimal health outcomes (Canadian Interprofessional Health Collaborative [CIHC], 2010). This scenario is an example of ICP at its best, weaving all the threads of an effective collaboration into a beautiful fabric where the threads of comradery within the team make it strong. CIHC states that effective collaboration can only occur when individual professionals move their approach from a traditional mindset of “I/we know best” to a holistic approach that allows all team members to feel welcome and respected (Canadian Collaborative Mental Health Initiative [CCMHI], 2006; Coffey & Anyinam, 2015). We believe this scenario highlights how it is possible for the grey areas of overlapping relationships to be managed ethically and with integrity. Notice we did not say it was easy, just that it is possible.

Queries for Consideration

1. If, because of interpersonal conflicts, not all of the current team members want to work together, but still want to work on Ben’s new equine therapy research project, how might Ben select his team members? How can Ben maintain the relevant ethical values of Principle III?
2. Xavier, a social worker, has been an enthusiastic part of the organizing committee from the start. Two weeks before the project starts, Xavier’s extended family unexpectedly decides to take a family vacation during week four to six of the eight-week project. They invite Xavier and his family to come. Xavier advises the team he would like to go with his family. He is not a lead on the project but is an important part of the project. Relevant to Principle III, how might Ben navigate this dilemma?

Scenario #4

For our final scenario, we introduce you to a more complex ethical dilemma which has ramifications for the psychologist not only professionally, but also on a personal and family basis. The primary values highlighted under Principle III are Accuracy/honesty (Ethical Standards III.1–III.8), and Objectivity/lack of bias (Ethical Standards III.9–III.12).

Pat is the administrative supervisor for both Jacob, an occupational therapist, and Emma, a psychologist. Emma witnessed Pat sexually assaulting Jacob and has just heard that the police are now investigating. They want a witness statement from Emma regarding what she observed on that day. Emma is torn between being truthful and supporting her colleague versus risking potential consequences from both her family and supervisor if she gives an accurate and complete factual statement. To complicate the dilemma even more, being in a small rural environment with its web of interconnecting and overlapping relationships, Pat is a relative of Emma. Emma is worried that possible subsequent court testimony for this case would be big news in her small town. Such news coverage or small-town gossip regarding her testimony could influence her current and future interprofessional collaborative relationships in her community, as well as her family relationships.

Several of Emma’s confidants have suggested to her that no one would blame her for having one or two passing thoughts of refusing to provide a statement, or perhaps giving a vague statement. Emma reflects on the difficult spot she finds herself in. She realizes that the idea of a vague statement, although it might preserve the stability and comfort of her ongoing family relationships and career path, would sacrifice the truth of what she witnessed as well as the trust of her ICP colleague, Jacob. Emma realizes providing an inaccurate or incomplete statement is not something she could do in good conscience, and she begins to seek guidance and answers. Her first resource is the set of ethical standards under Integrity in Relationships of the Canadian Code of Ethics for Psychologists.

The initial ethical standard under Principle III is particularly relevant to Emma’s deliberations, as it calls for psychologists to “not knowingly participate in, condone, or be associated with dishonesty, fraud, misappropriation, or misrepresentation.” How to handle this situation from an ethical standpoint seems straightforward in that Emma just needs to tell the truth, even though the personal costs of doing so could be quite high.

The Principle III value, Objectivity/lack of bias, encourages being “as objective and unbiased as possible,” and to “take care to communicate as completely and objectively as possible.” Furthermore, the Canadian Association of Occupational Therapists’ (CAOT) Code of Ethics encourages use of professional communication with colleagues, valuing and respecting those they work with, and working collaboratively through interdisciplinary collaboration (CAOT, 2007; Dick & Brockett, 2006). The CPA ethical value Straightforwardness/openness further clarifies how to approach this dilemma. Emma appreciates these guidelines as she develops a framework for not giving in to work and family pressures on her to provide a dishonest or biased statement. She also explores whether she would benefit from an awareness of other statutes and policies including the Criminal Code of Canada sections (e.g., obstruction of justice), provincial statutes forbidding harassment in the workplace (e.g., Department of Labour), and knowledge of a workplace anti-bullying/harassment policy.

Emma would be adhering to the ethical values and standards of Principle III if she is complete and truthful in her witness statement and in any subsequent subpoenaed court testimony. She finds that Principle III provides support and direction for her amongst the whirl of competing thoughts, pressures, and feelings. She also realizes that she can rely on colleagues for support during this time, including consulting another psychologist.

Discussion

Professional relationships in rural environments are built on trust and respect, or in other words, on Integrity in Relationships. Emma’s situation illustrates the importance of having a professional code of ethics to guide her through a difficult situation that could impact her career, family, and work relationships. Standards and other legal statutes can provide important external guidance to help her ethically manoeuvre through the competing pressures of the situation. This scenario illustrates that it is not only important for the psychologist to abide by the ethical principles, but it is also important for present and future collaborating partners to perceive the psychologist as abiding by these principles. Thus, how well one is perceived in manoeuvring through ethical challenges is of critical importance in the community at large, as well as with other professionals in the community. As noted earlier in this chapter, this is significantly magnified in a rural environment where one’s decisions and actions, quite literally, can become everyone else’s business.

Query for Consideration

1. Keeping in mind the importance of Integrity in Relationships, what situations might you if your friendship and/or loyalty to a colleague conflicts with the values of Principle III? Such a situation could extend anywhere from the colleague who likes to take home office supplies to the friend who admits to you that they biased their instructions to some of their research subjects in hopes of getting “better” results for their honours research project. What are your professional and ethical obligations? What steps might you take?

Summary and Future Directions

We are fully aware of the challenges and embrace the opportunities of ethical rural ICP (Goodwin et al., 2016; Malone & Stanley, 2013). We recognize the importance of helping our peers and peers-in-training to be better prepared for this type of vibrant practice. To this end, there are now greater opportunities for rural practice, internship placements, and increased ICP interaction/training in the classroom and graduate programs. We hope that by having shared some of the ethical challenges we have faced in our own endeavours that our current and future colleagues can be more aware, better prepared, and more enthused by this approach. In rural collaborative practice, our daily interactions are entwined with those around us. It is not just on our professional lives that collaboration will have an impact, but on our daily personal lives as well. We can best influence the fabric of our rural cultural experience by ethically weaving the collaborative threads of our schools, hospitals, non-governmental organizations, communities, and skilled individuals of all disciplines.

As noted at the beginning, our intent in writing this chapter is to raise awareness and interest for this area of practice and its amazing possibilities for: personal, professional and collegial growth; enhanced service to clients; and a richer and more rewarding engagement in one’s community. We hope we have demonstrated that ethical ICP rural psychological practice and research can be dynamic, rewarding, and energizing. We have found that, when we collaborate ethically, we benefit from the richness that we invite into our professional and personal lives, and we strengthen our communities. Becoming comfortable with engagement in ICP in our communities can spread to collaboration provincially, territorially, nationally, and even on a global scale. This synergy creates exciting opportunities to practice locally with global influence (McDaniel, 2016).

Questions for Reflection

1. As a psychologist moving to and opening a practice in a rural community, what ethical challenges do you think you might need to prepare for?
2. What practice area(s) do you think you might need consultation about from a colleague to help you navigate challenges related to Principle III (Integrity in Relationships)?
3. A research team from a city-based university approaches you to ask for your help with a research project to be carried out in your rural community. In familiarizing yourself with the project, you find you have ethical concerns. Community members hear about the project and ask your opinion. How do you respond?
4. Six months after moving to the rural community, your child crashes your family’s all-terrain vehicle into a neighbour’s fence. Your child is unharmed, but the neighbours are upset. In addition to being neighbours, they also are your clients. How do you respond?

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