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ACQ
uiring knowledge
in
sp eech
,
language and hearing
, Volume 11, Number 1 2009
33
MULTICULTURALISM AND DYSPHAGIA
These developments raise a number of ethical and legal
concerns including maintaining privacy, confidentiality and
security of information transmitted and held in electronic
health records (Stanberry, 2000); ensuring standards for
providing legally and professionally recognised services
(Reed, McLaughlin & Milholland, 2000); and issues of
reimbursement for services delivered by telehealth (Chetney,
2002). A growing ethical concern about telehealth in any form
(via video-teleconference suites or webcam) is the impact it
may have on what Stanberry (2000) refers to as the
“traditional clinician–patient relationships” (p. 615). Cornford
and Klecun-Dabrowska (2001) caution against “substitution
of care with treatment” (p. 161). Speech pathologists do not
yet have enough experience with telehealth to know how it
impacts on consumer satisfaction with services.
The views of Australian speech
pathologists regarding emerging
ethical risks to practice
The authors ran a workshop at the National Conference of
Speech Pathology Australia in Sydney in May 2006 to
ascertain what Australian speech pathologists perceived as
emerging ethical risks to practice. After a brief presentation
summarising some of the above trends, some 50 speech
pathologists were asked to discuss in small groups and then
summarise emerging ethical issues. These are presented in
table 1. The emerging ethical issues identified by workshop
participants fell into 10 categories of concern. By far the
largest category of concerns were those related to resource
allocation. These categories are discussed below.
Discussion
The emerging ethical issues identified in the workshop align
well to the trends presented in the first part of this paper,
particularising these to our professional practice, as well as
raising some new concerns. Of interest in the discussions at
this workshop was the focus on ethical issues at the systemic
level rather than at the individual client–practitioner level.
Inevitably, system level pressures will impact on services to
clients but the discussion in the workshop was primarily
around the larger contexts in which ethical practice must be
ensured. Speech pathologists at the workshop spoke of the
ethics of a medical emphasis on “saving lives at all costs”,
especially when the costs to quality of life are high. As a
result, allied health professionals increasingly work with
clients with complex disabilities who have care needs across
the lifespan. This in turn impacts on resource allocation and
prioritisation of services, which are already under strain with
population ageing, fiscal constraints and a shrinking health
care workforce.
Workshop participants identified several worrying trends
in resource allocation and prioritisation, including the cutting
of services to some client groups (e.g., those with fluency or
voice disorders, children with speech and/or language
impairments in the absence of concurrent behavioural
problems) and some age groups. For example, in some states
without school-based therapy services, school-aged children
are not a high priority at health services. Further, service
management policies sometimes limit the number of
occasions of service to clients in ways which are not consistent
with evidence based practice or which may lead to discharge
before an episode of care has achieved the established goals.
As a result, practitioners often experience tension and conflict
between the values of the profession and the values under
pinning management policies (Cross, Leitão & McAllister,
Extended scope of practice
The ongoing development of our profession together with
workforce re-engineering precipitated by the health workforce
shortage will lead to changes in our scope of practice. At one
end of the continuum, scope of practice will extend to include
roles and tasks not currently part of our practice, and at the
other end our scope of practice may retract as more tasks are
delegated to assistants or other professionals. Considerations
in relation to changed scope of practice highlight a number of
key professional issues: identifying the scope of speech
pathology practice, determining the role of governance and
risk management frameworks, specifying responsibilities for
supervision of those to whom tasks are delegated, and
determining the boundaries of legal liability.
Speech pathology practice in Australia is informed by key
Association documents such as
Scope of Practice in Speech
Pathology
(Speech Pathology Australia, 2003) and
Parameters of
Practice
(Speech Pathology Australia, 2007a). Association
position papers further inform specific areas of specialist
clinical practice – for example,
Dysphagia: Modified Barium
Swallow; Tracheostomy Position Paper; Fiberoptic Endoscopic
Evaluation of Swallowing
(Speech Pathology Australia, 2005a,
2005b, 2007a). However, a speech pathologist’s involvement
in particular clinical practices will always be dependent upon
a number of key factors including the preferred model of
service delivery of an employing organisation, the support
and explicit authorisation of an employing organisation for
speech pathologists to perform particular tasks, access to
training and demonstration of competence, and consideration
of clinical governance issues. The challenge for the practitioner
will be to ensure that service delivery models in which they
work meet the requirements of minimising risk and harm,
while at the same time facilitating new skill development and
ongoing expansion of the profession.
Community expectations
Through access to the Internet and other forms of media,
consumers are now better informed about health care services.
They have a greater expectation that services provided will
reflect best practice and will provide value for money. This
expectation requires practitioners to remain abreast of current
knowledge and practice, and the information gleaned will
arm consumers with the confidence to question practices
which may be inappropriate or outdated. In addition, consumers
may request services they have read or heard about which
our profession considers to be unsupported by evidence.
Speech pathologists will therefore need to be aware of the
evidence across the range of their practice and be able to
explain and defend their recommendations for management.
Increased consumer expectations will also inevitably lead
to demand for more convenient location of services, including
services closer to home and actually in the home. Practitioners
therefore will need to consider new models of service
delivery. As services increasingly move from secondary and
tertiary medical settings to primary care (community-based)
settings, practitioners may need to extend their repertoire of
skills in needs assessment, training of others, delegation of
tasks and supervision and mentoring of assistants, volunteers
and carers.
Telehealth offers considerable promise for more flexible
community-based and domiciliary service delivery. Elspeth
pathology using high-end video-teleconference suites is
already in use across Australia, enabling practitioners in
major centres to provide services to rural and remote clients.
Elspeth pathology using web-based delivery into clients’
homes is rapidly becoming an option (Theodoros, 2008).