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S
p eech
P
athology
A
ustralia
MULTICULTURALISM AND DYSPHAGIA
to another service, if indeed one exists. Clinicians and clients
jointly must decide whether any service is better than no
service, if geography or client immobility or social isolation
preclude access to other more skilled clinicians.
Increasing client complexity has also coincided with
increasing costs associated with professional indemnity
insurance and with increasing rates of professional litigation.
Practitioners, while acknowledging the right of all clients to
receive the best care available, may be reluctant to engage in
clinical practices that have the potential to pose an “increased
risk” to the client. Not only does such a decision, based upon
fear of litigation, restrict client autonomy in relation to their
treatment, it also curbs aspects of speech pathology practice.
The increasing complexity of clients also raises the issue of
caseload prioritisation. Nowhere is this more evident than in
the profession’s increased focus on the management of clients
with dysphagia. The emphasis upon reduced length of hospital
stay and community-based rehabilitation has seen those
clients with dysphagia prioritised over those with communication
problems. This surely poses an ethical dilemma when the
maximisation of both communication and swallowing functions
is (and must remain) a joint priority of the profession. Such
situations are premised on the need for clients to be “safe”
enough to discharge. Safe swallowing is undoubtedly needed,
but so too is “safe” communication which will allow a client
to maintain some level of social interaction with family and
community to preserve mental health, and for example, to
call for help in emergencies.
Increased emphasis upon evidence
based practice
The need for speech pathologists to inform their practice
through the best available evidence was addressed in the first
of the “Ethics Conversations” columns (Eadie & Atherton,
2008). As noted in that article, “best evidence needs to be
integrated with clinical reasoning in order to make ethical
decisions around service delivery for each of our clients” (p.
94). Undoubtedly, it is an ethical responsibility for individual
clinicians to know what the literature says and what the
available evidence is.
It is also critically important that speech pathologists stay
abreast of developments in clinical knowledge and practice
by engaging in continuing professional development (CPD) –
this is an ethical responsibility, as reiterated in the
Association’s
Code of Ethics
(2000): “We strive to continually
update and extend our professional knowledge and skills…
and work towards the best possible standards of service to
our clients” (p. 3).
Ethical concerns may arise, however, when due to caseload
and other demands, time is not available to undertake CPD
and/or access to relevant facilities and technology, such as the
Internet, is restricted. This may be particularly the case for
those services limited by budget and for those clinicians in
rural and remote areas where access is not reliable. Such
situations raise questions of “whose responsibility is it to
ensure competence and fitness for practice: the employer’s or
the speech pathologist’s?” Where employers decline or are
unable to support CPD, our ethical duties to clients and
colleagues and the profession mean individual speech
pathologists must assume responsibility (and cost, in dollars
and time) for their own CPD. The means by which a practitioner
ensures currency of knowledge and ongoing fitness to practice
may require creative and lateral thinking. A willingness to
access mentoring, to engage the assistance and expertise of
colleagues, as well as devote time to ongoing education may
conflict with long waiting lists and organisational targets.
quantify if they are made over extended periods of time as is
often the case with chronic disease and disability.
Chronic shortage of health workers
The chronic shortage of health workers in Australia has been
recognised by both state and federal governments, and a suite
of initiatives have been proposed to address the inherent
problems of inadequate service provision (Australian Govern
ment Productivity Commission, 2005). For the speech pathologist,
as with all health workers, a number of ethical considerations
arise in relation to this, apart from those addressed earlier in
relation to caseload prioritisation.
Speech pathologists may, on the one hand, consider that
any service is better than no service. However, when armed
with the knowledge and evidence that outcomes are maximised
by certain types of interventions provided over certain
timeframes, speech pathologists face a dilemma as to how
and what to provide. Cost-driven decisions based on ever
increasing waiting lists and caseloads may force clinicians to
terminate client treatment even though the potential for
ongoing client gains is very real.
The increasing profile of allied health assistants and
support workers reflects the unmet demand for health
services. Suitably qualified allied health assistants offer an
opportunity for allied health practitioners not only to increase
the level of service provision to clients, but also to expand the
profession’s scope of practice. The concern for the speech
pathologist, however, may be in understanding the role of the
allied health assistant and the adequacy of their prior training,
and in determining what type of work should be delegated.
While guidance is provided to the profession through the
Parameters of Practice
document (Speech Pathology Australia,
2007b), this document reflects the position of the membership
only and as such may hold only limited weight with other
key stakeholders. Given that legal and professional
responsibility rests ultimately with the clinician, the speech
pathologist may grapple with questions related to the type
and quality of services to be provided by allied health
assistants, the degree of supervision that should be provided,
and the mechanisms that must be in place to ensure client
outcomes and safety are maximised. The issue of protectionism
and its potential to limit the development of the allied
assistant role will need to be addressed by the profession, as
will the standards of allied health assistant training,
supervision and monitoring.
Increased complexity of clients and settings
Speech pathologists are providing services to clients who are
sicker, and who present with more complex conditions, in
more complex medical and community settings than ever
before. Practitioners rightly express concern regarding the
acquisition of skills and competencies to meet the demands
associated with working effectively and safely with such
clients. Unless a clinician is working in an organisation which
has a well-developed competency attainment program, the
individual clinician may be left to determine whether they
possess the skills and knowledge that is required. As stated in
the Association’s
Code of Ethics
(2000), as practitioners we
must “recognise the limits of our competence” (p. 2). This
issue may be further compounded when an organisation does
not acknowledge the benefit or need to support the clinician
in attaining the necessary skills. A situation may then arise
where the clinician must decide whether to refuse to see the
client, see the client and engage in practice outside their level
of expertise (hopefully while simultaneously engaging in
professional development and mentoring to achieve com
petence in management of such clients), or refer the client on