54 / 64
164
JCPSLP
Volume 17, Number 3 2015
Journal of Clinical Practice in Speech-Language Pathology
me how to recognise an ethical problem, which is
something that may come naturally for someone who
has worked clinically for years. While I don’t map it out
step by step, a general understanding of the Brown
and Lamont (2002) ethical decision-making protocol
(reprinted in the Leitão et al., 2014) has allowed me to
recognise the issue and take the first steps to resolving
it when something doesn’t feel quite right.
The ethical problems I have encountered since
graduating have not been huge dilemmas. However on
reflection, I make decisions containing ethical issues
very often, and rely on my theoretical learning to do
so. An example of these has included [deciding] what
to do when a family openly reports that they are not
doing home practice, and constantly miss sessions.
Another example was when a client’s mother wanted
to trial her daughter on a high-tech AAC device she
had purchased after reading about it on the Internet
(her daughter continues to astound me with her ability
to use this machine).
The most comforting thing for me as a new
graduate, and therefore at least somewhat unsure on
every decision I make, is that I am not making them
alone. Referring to the SPA Code of Ethics allows me
to use it as a bit of a moral compass that covers areas
my gut feelings don’t cover, and justifies the areas it
did. I am also fortunate to work in a very supportive
environment where I can access wonderful advice
from a number of experienced speech pathologists.
The explicit inclusion of ethical practice in my course
has very much impacted the speech pathologist I am,
and the speech pathologist I hope to still become.
Suze Leitão and Trish Johnson – ethical
reflections
On reading this reflection we were struck by the fact that
the newly graduated speech pathologist identified that she
was still building up her “case-based” experience. In other
words, JC is describing the idea that as we gain
experience, we learn from the cases we have managed:
both the ones that work out well but also those that don’t.
In the SPA Ethics Training Package (Leitão et al., 2014), this
relates to the chapter on “casuistry” – a perspective where
clinicians draw on their own experience or documented
cases to help solve current ethical problems or dilemmas.
By considering the most important issues in a current
scenario (e.g., not doing home practice and missing
sessions), the clinician can try to flesh out what the current
dilemma might be (e.g., not adhering to evidence-based
guidelines for treatment, the client failing to make progress,
another client missing out on access to appointments). The
clinician can also consider if she or he has managed a
similar case before and reflect on what the outcome was at
that time. The approach taken, the evidence drawn upon,
the outcome and – of course – the similarity to the current
case, may be helpful in making a plan for this scenario. If,
as is often the case with new graduates, a similar case is
not yet in their repertoire, turning to the published literature
or a more experienced colleague, may also be of help. In
this scenario, the graduate clinician may then draw on a
previous case perhaps leading to a phone call at a
convenient time to listen to the mother’s story, explore
barriers to attendance and home practice, and perhaps put
in place other strategies, such as a different time for the
session or training an older sibling to carry out some of the
home practice.
supported problem-solving, decisions, and outcomes.
These elements describe the phases of ethical reasoning
frequently used by speech pathologists with less than 18
months experience, in an interactive reasoning process
rather than stages of discrete steps
The initial stage of awareness was gradual – GG became
gradually more aware of the ethical issues involved in the
case, rather than a critical incident being the trigger. From
this point she moved between the elements of independent
and supported problem-solving. Her initial reaction was that
the situation was “unjust”. This was followed by GG drawing on
her clinical reasoning based on documenting communication
information about the client’s performance, and her beliefs
and values drawing on the SPA Code of Ethics. As a student
on placement, she had a clinical educator who was in the
position to support her problem-solving through discussion
and creation of a plan to document the abilities that were
not easily demonstrated. Supported problem-solving drew
on the checking and discussing features of this element of
the model (Kenny et al. 2007). This stage of supported
problem-solving and encouragement may not always be in
place for new graduates and can be crucial in developing
the skills and confidence for independent ethical problem-
solving in the future. The decision-making element in this
case was the acceptance of the client for rehabilitation as a
result of the advocacy by the student clinician and her
clinical educator. Her evaluation of the final outcome
allowed her to reflect back on the process involved and the
role she played as an advocate for her client.
In this clinical ethical reflection, it is clear how GG has
learned skills in client management beyond a narrow
“clinical” view. A further exploration of this scenario could
also draw on the “ethics of care” approach documented
in the SPA Ethics Training Package (Leitão et al., 2014).
An ethics of care approach may be adopted by following
guiding questions that prompt us to carefully consider key
relationships involved in a dilemma. The following broad
questions are suggested to support the process of analysis
of a case with more focused questions underlying each:
What are the needs of the individual and family
affected by this dilemma?
What are the roles and responsibilities of the health
care team in providing care?
Are there any barriers to effective care?
What resources are required to provide competent
health care?
How are clients responding to care?
How can I improve the care offered to clients?
(Leitão
et al., 2014, p.75)
In this case, the ethics of care framework may support
consideration of the needs of the client who is disempowered
by the current situation and hence the advocacy role taken
by the student clinician and her clinical educator.
A newly graduated speech
pathologist
JC
As a new grad speech pathologist, I am currently more
reliant on my theoretical knowledge than my clinical
experiences when making decisions. I was lucky
enough that my theoretical education included a unit
devoted purely to ethics. The content of these classes
and the discussions about ethics that they generated
is something that has directly impacted my day-to-
day practice. This education in ethics has taught