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JCPSLP
Volume 17, Supplement 1, 2015 – Ethical practice in speech pathology
Journal of Clinical Practice in Speech-Language Pathology
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 competence in
management of such clients), or refer the client on 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
on community-based models of service delivery. Some of
these issues will be discussed later in this article.
Increased prevalence of chronic disease
and disability
Advances in the medical and surgical management of a
range of conditions, diseases and injuries have reduced
mortality, but increased morbidity and life expectancy.
Examples include the improved survival rate of very
premature infants and the survival of persons with severe
head injuries. Life-prolonging procedures and technologies
result in survivors now presenting with significant long-term
disabilities that extend to communication and swallowing.
As is likely the case with all health professionals, speech
pathologists may hold concerns about the quality of life that
ensues for people living with severe and complex
disabilities.
Concerns may exist in relation to service provision for
persons with chronic disease and disability; specifically,
where this service should sit as part of a larger caseload,
and how the speech pathologist should maximise the
potential of clients with chronic disease and disability
within the limited available resources. Ongoing limitations
in the health budget will continue to place pressure upon
clinicians to demonstrate the benefits of intervention with
this group of clients, as with all clients; however, such gains
may be more difficult to 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 Government 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