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JCPSLP Volume 17, Supplement 1, 2015 – Ethical practice in speech pathology 61
management/administration team. Chiarella (2013)
suggested that successful stakeholders worked to
complete the problem stream and policy stream so if and
when the political stream aligned they could “surf the policy
wave” and have the momentum to implement change.
People affected by potentially life limiting or chronic
illnesses and their families and the health care professionals
who care for them are important stakeholders in the
consultation and development of policy and practice that
supports individuals and allows them the quality of life
they choose to enjoy. For many health professionals, there
is uncertainty and ambiguity in the legal frameworks that
may affect treatment and support, and in the frameworks
and protections regarding treatment decisions (particularly
if substitute decision-makers are involved). The lack
of uniformity among health professionals can lead to
challenging experiences for vulnerable patients and their
families.
Clearly, ethical policy development and implementation
is a time-intensive, collaborative process. Knowledge
of Speech Pathology Australia’s Code of Ethics can
inform ethical analysis of policies and can be used by
speech pathologists as a reference when working on
policy development. Speech pathologists, through their
application of the Code of Ethics and clinical knowledge,
have a unique perspective to bring to the consideration
and development of policies and procedures that will affect
patients with disorders of swallowing who are compromised
in their ability to enjoy a normal range of foods and fluids.
Speech pathologists involved in policy development are
encouraged to include ethical deliberation as an integral
part of the process.
5. the local community that relies on the hospital/health
network for care;
6. related agencies such as social services.
It is important to acknowledge that each of these groups
may hold differing opinions regarding a new policy or policy
change. Ideally, the processes involved in developing a new
policy around a sensitive topic with many divergent views
would occur through exploration and discussion of values
and desired outcomes from patients, family, relevant health
care professionals and decision-makers in the organisation.
Hospitals are institutions and it is important to
acknowledge that health care in hospitals is practised by
(multidisciplinary) teams and not individual practitioners
(Winkler, 2005) and this has implications for ethical policy
development. Winkler argues that when formulating
hospital-wide policies, consensus-building processes
including all stakeholders will ultimately result in fair and
efficient (and we would suggest may facilitate ethical)
clinical decision-making at the bedside. Thus, for an
ethical policy approach to our case, we need to consult
with key stakeholders to build an ethical, acceptable and
implementable response.
Formulating an ethical policy
So how do we begin to reflect ethically on policy
development? Mintrom (2010) suggests it starts with those
involved in policy work upholding ethical principles. This is a
fundamental concept in using underlying principles to drive
the translation into policy and procedure. Mintrom’s ethical
principles correlate well with the SPA Code of Ethics (SPA,
2010) values of integrity, professionalism, respect and care,
quality standards and continuing competence. Integral to
ethical policy construction according to Mintrom are
concerns for others and a deep understanding of the
community that may be affected by the policy. Frolic et al.
(2012) suggest using an “ISSUES” guideline to facilitate
organisational policy review. This is a 6-step framework:
1. Identify the ethical issues raised by the policy
2. Study the facts
3. Select the potential recommendations
4. Understand the values and duties
5. Evaluate and justify options
6. Sustain and review the policy
The successful implementation
of policy
New policies or changes to policy generally arise from
identified problems. Kingdom (1995) delineated three
streams in systems that need to coalesce to form a policy
window, which then maximises the uptake of new policies.
Initially problems may be identified that appear to be
addressed by a policy. In Kingdom’s model this is known as
the problem stream. Objective reports of the size and
extent of the problem, a crisis or feedback may help
highlight a problem. Once the problem has been delineated
a policy stream is commenced in which ideas and ways of
managing the problem are gathered. Some ideas are trialled
and if successful may lead to attempts to achieve broader
implementation. For the new policy to be enshrined,
however, there needs to be political will or the political
stream needs to be in play. This might occur because of
organisational mood, pressure groups or a new
Text box D. How Kingdom’s model assisted uptake
of our case’s new policy
1. The problems stream
The problem had been clearly identified through
risk assessment and analysis plus review of critical
incidents in the hospital system related to choking.
The investigation into the matter included a
literature review of relevant laws and acts as well as
information from the coroner’s office and data about
dysphagia management.
Key stakeholders were engaged in the
development process, including the consumers’
voice, health professionals, quality improvement and
risk personnel and hospital decision-makers.
2. The policy stream
A new policy was written after many options were
evaluated, including drafts for circulation and
comment.
3. The political stream
With a change in the hospital catering services
management and a new hospital coming on line,
hospital administrators were keen to have clear
policies around the provision of modified food and
fluids for all patients.
The policy developers met with clinicians,
management and the quality and safety committee
to ensure executive sign off and commitment. They
valued the work that had been done and endorsed
the new policy.