Students entering the field of speech-language pathology or audiology recognize the rigorous academic coursework required to complete the degree. They are aware of the time, effort and dedication it will take to become certified professionals. Clinical practicum requirements, internship placements and comprehensive exams are at the forefront of their concerns. Conversely, professional issues including ethics and workplace dilemmas seem to be the least of their worries. Beginning clinicians may enter the workforce assuming all professionals adhere to ethical standards. They may think "workplace dilemmas" are simply fabricated scenarios they will never encounter. Unfortunately, the dynamic and evolving scope of the professions of speech-language pathology and audiology can present unforeseen challenges in the workplace, especially for beginning clinicians. However, with the proper education and training, students can enter the workforce prepared to handle any conflict that may compromise their ethicality. In order to demonstrate how to resolve ethical dilemmas occurring in the workplace, two scenarios involving support personnel, prescription and misrepresentation will be discussed in further detail.
The first scenario involves the administrator of an outpatient rehabilitation clinic. She is requiring a certified speech-language pathologist (SLP) to supervise a speech-language pathology assistant (SLPA). While supervising a session, the SLP notices the SLPA performing a diagnostic evaluation, a service that exceeds her competency level and clearly goes beyond the American Speech-Language-Hearing Association's (ASHA) guidelines for support personnel. The administrator told the SLP she cannot afford to hire an additional certified professional and stated supervision was part of his duties. The SLP was recently hired at the facility and feels he must comply with the administrator's demands. This scenario leads to the following ethical dilemma: Should the SLP continue to supervise the SLPA performing duties beyond her competency level or not supervise the SLPA and face reprimands from his superior?
If the SLP continues to supervise the SLPA, he will violate multiple aspects of ASHA's Code of Ethics, the most significant being Principle I, Rule E. The rule explains, "Individuals who hold the Certificate of Clinical Competence shall not delegate tasks that require the unique skills, knowledge, and judgment that are within the scope of their profession to assistants, technicians, support personnel, or any nonprofessional over whom they have supervisory responsibility" (2010a). Similarly, the SLP must consider Principle II, Rule D, "Individuals shall not require or permit their professional staff to provide services or conduct research activities that exceed their staff member's competence, level of education, training, and experience" (2010a). In this case, the SLP will intentionally violate both rules if he continues to supervise the SLPA and needs to take action immediately.
Knowing his duty to remain ethical as a professional, what steps should the SLP take to resolve the situation? First, he must meet with the administrator again; explain the ASHA Code of Ethics, relevant Issues in Ethics Statements and the ethical dilemma he faces. Referencing ASHA's Guidelines for the Training, Use, and Supervision of Speech-Language Pathology Assistants, the SLP needs to inform the administrator of the duties the SLPA can and cannot perform. Lastly, the SLP should explain the true purpose of a speech-language pathology- assistant as someone who helps manage the current caseload of a certified speech-language pathologist (ASHA, 2004). Hopefully, the administrator will recognize her error in delegating skilled services to a nonprofessional and the ethical dilemma she has created.
Ideally, the SLPA will be allowed to perform only those duties within her scope of practice without compromising the supervising speech-language pathologist's ability to provide appropriate care to the client's on his caseload. If the administrator is uncooperative, the SLP must meet with the SLPA and discuss what tasks she may perform. Any task exceeding the speech-language pathology assistant's competency level must be executed by the certified speech-language pathologist.
The second scenario involves prescription and misrepresentation. The administrator of a large contracting agency is prescribing an SLP to bill a set number of patients per day, despite low census numbers in the nursing homes the SLP services. Because many of the patients have limited restorative potential, it would be unethical for the SLP to assess or treat them. Furthermore, the SLP feels the need to misrepresent diagnostic information to qualify these patients for services. The administrator has created the following workplace dilemma: Should the SLP evaluate and treat patients who are not suitable candidates for services or should she abstain from servicing these patients and face reprimand from her superior?
If the SLP chooses to evaluate and treat patients with little restorative potential, she would be in clear violation the Code of Ethics. Most pertinently, Principle I, Rule I applies: "Individuals shall evaluate the effectiveness of services rendered and of products dispensed, and they shall provide services or dispense products only when benefit can be reasonably expected" (2010a). Furthermore, because the SLP feels pressured to falsify clinical documentation, she must consider Principle III, Rule D: "Individuals shall not misrepresent research, diagnostic information, services rendered, results of services rendered, products dispensed, or the effects of products dispensed" (2010a). Lastly, the SLP must utilize her professional judgment in all situations as outlined by Principle IV, Rule J: "Individuals shall not provide professional services without exercising independent professional judgment, regardless of referral source or prescription" (2010a).
Similar to the first scenario, the SLP should meet with the administrator and discuss the ethical dilemma at hand. The SLP must explain the ASHA Code of Ethics, relevant Issues in Ethics Statements and her duty to remain ethical as a professional. The SLP may refer to ASHA's statement on Representation of Services for Insurance Reimbursement, Funding, or Private Payment. It states, "...a professional who identifies specific persons in a nursing home as not likely to have significant communication benefit from speech or language therapy may not ethically provide therapy to those persons, even if the services may be reimbursed by Medicare" (2010b). Likewise, professionals cannot falsify progress in order to continue receiving reimbursement (ASHA, 2010b).
Ideally, the administrator would understand the ethical dilemma the SLP is facing and adjust the required billing quotas. However, if the administrator is noncompliant, the SLP should only provide services to patients who can make reasonable progress. Then, the contracting agency would be responsible for taking action, if any, in the situation.
It is clear the outcomes for each workplace dilemma may not be ideal, but the speech-language pathologists in both scenarios have more than enough supporting documentation to justify their actions. These professionals were educated on ethical decision making and are aware of the available resources needed to handle the complex situations. Thus, with adequate instruction regarding the ASHA Code of Ethics, Issues in Ethics Statements and guidance from clinical educators during their undergraduate or graduate coursework, beginning clinicians can enter the workforce prepared to avoid ethical dilemmas altogether or resolve unavoidable conflicts when they arise.