A Model for Ethics Education for SpeechLanguage Pathologists and Audiologists

1
A Model for Ethics Education for Speech-Language
Pathologists and Audiologists

• Mary Pannbacker, Ph.D. CCC-SLP, Professor, LSU
  Health Sciences Center (LSUHSC)-Shreveport
• David L. Irwin, Ph.D., CCC-SLP, Professor and
  Dept. Head, LSUHSC-Shreveport
• Norman J. Lass, Ph.D., Professor,
• West Virginia University
• Thomas D. Miller, Ph.D., J.D., CCC-SLP,
  Professor,
• Nazareth College of Rochester, NY
• Glenn Waguespack, M.S., CCC-A, Audiologist,
• Private Practice Shreveport, LA

2
Learner Outcomes Agenda

• After completing this session, you will
• Describe components of an ethics curriculum
• Explain factors students and professionals
  consider when making ethical decisions
• Describe application of case scenarios pertaining
  to students and professionals

3
Agenda

• 330-400 Objectives of Ethics Education Results
  of Ethics Research Justification for Ethics
  Education Curriculum
• 400-430 Reporting Ethical Misconduct Laws
  Ethics Preventing and Minimizing Ethical Risks
• 430-445 A Model for Ethical Decision Making by
  Students and Faculty
• 445-510 Panel Discussion of Case Scenarios
  Submitted by Audience
• 510-520 Technology Resources for Ethics
  Education
• 520-530 Summary/ Q A

4
Disclaimer

• All case scenarios are fictitious and do not
  depict any specific individual or situation. Any
  resemblance to an actual situation or person is
  purely coincidental.
• Nothing during this presentation should be
  construed as legal advice.
• Our interpretation of ethical codes or standards
  should not be viewed as reflecting the official
  opinion of any specific professional association.

5
Objectives of Ethics EducationDavid Irwin, Ph.D.
Mary Pannbacker, Ph.D. LSUHSC-Shreveport

• Goals include
• To effect an understanding of basic ethical
  principles
• To recognize the relationship between law
  ethics
• To develop professional values
• To recognize ethical issues
• To identify and resolve ethical problems (Gross
  2001, Li, 2000 Singer, 2004).

6
Three Parts of Ethics Curriculum

• Part One-Knowledge
• Important to understand standards of ethical
  conduct in the American Academy of Audiology
  (AAA) 2003 and American Speech-Language-Hearing
  Association Code of Ethics (ASHA) 2003.
• Knowledge about current rules, regulations and
  laws that change the Code of Ethics for
  organizations/associations (national, state,
  licensure).
• Business Code of Conduct-employers require
  employees to sign a code of conduct that
  encompasses ethics.

7
Three Parts of Ethics Curriculum

• Part Two-Development
• Model and nurture moral maturity for students and
  practicing professionals.
• Others are watching and monitoring your behavior.
  
• Moral character is formed and it needs
  reinforcement and application to professional
  activities.
• Discuss and monitor ethical behavior with
  students so they will be more equipped to
  identify and resolve ethical dilemmas
• Educate them about sanctions and enforcement

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Three Parts of Ethics Curriculum

• Part Three-Skills
• Students and practicing professionals need
  practice identifying ethical issues
• Make use of case-based scenarios
• Scenarios can be hypothetical or based on
  real-life dilemmas
• Utilize a model for ethical decision making.
  There is a process.
• Faculty should facilitate discussions about
  ethics and ethical dilemmas (Seymour, 1994).

9
Content Areas for Ethics in SLP and Audiology
Curriculum

• Ethical theories and Ethical Decision Making
• Consequentialism
• Deontologism
• Virtue
• Autonomy
• Beneficence
• Nonmalficence
• Justice

10
Ethics Curriculum (continued)

• Professional Ethics
• ASHA Code of Ethics
• AAA Code of Ethics
• Scope of Practice
• Business Code of Conduct
• Issues in ethics specific to SLP and AUD

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Ethics Curriculum (continued)

• Applied Ethics
• Allocation of scarce resources
• Competence
• Conflict resolution
• Consent (informed consent)
• Controversial procedures
• Ethics related to students

• Applied Ethics (cont.)
• Ethics related to SLP Assistants
• Misrepresentation
• Quality of Life
• Reporting ethical misconduct
• Telepractice
• Truth Telling

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Ethics Curriculum (continued)

• Research Ethics
• Authorship
• Institutional Review Boards (IRB)
• Plagiarism
• Scientific misconduct and fraud
• Sources Lehman, L.S., Kasoff, W.S., Koch, P.
  Federman, D.P. (2004). A survey of medical
  ethics education at U.S. Candian medical
  schools. Academic Medicine,79, (7), 182-189.
• Pannbacker, M., Middleton, G.F., Lass, N.J.
  (1994), Ethics Education for speech-language
  pathologists and audiologists. ASHA, 40-43.
• Roff, S. Preece, P. (2004). Helping medical
  students to find their moral compasses Ethics
  teaching for second and third year
  undergraduates. Journal of Medical Ethics, 30,
  487-489.

13
Examples of Ethical Concerns in Clinical
Supervision

• Failure to education students about
  confidentiality
• Failure to provide the appropriate amount of
  supervision
• Failure to assure that students have needed
  competency before delegating tasks
• Failure to evaluate client outcomes to
  demonstrate benefit to client
• Failure to provide appropriate tools for
  self-assessment
• Failure to inform the client that services are
  being provided by a student
• Source King, D. (2003). Supervision of student
  clinicians. ASHA Leader, 26, 26.

14
Ethical Issues Experienced by Speech-Language
Pathologists, Audiologists, Students

• Norman Lass, Ph.D.
• West Virginia University

15
Respondents

• Survey administered to
• Speech-language pathologists
• Students
• Audiologists
• Total number of participants
• 159 SLPs
• 20 Students
• 18 Audiologists

16
Demographic Categories

• Demographic data included the following
  information
• Education of participant
• Certification of participant
• Setting in which participant practices

17
Demographics for SLPs
18
Demographics for SLPs
19
Demographics for Audiologists
20
Demographics for Audiologists
21
Questionnaire

• What 2 or 3 situations involving professional
  practice have caused you the most conflict about
  the right thing to do?

22
Category List for All Respondents

• Discharge
• Confidentiality
• Referral
• Compliance
• Academic
• Other

• Evaluation/Treatment
• Family Caregiver
• Coworker/Supervisor
• Pay Source/Funding
• Caseload
• Disorder

23
Participants Response Categories

• Evaluation/Treatment
• Includes issues surrounding evaluation,
  development of treatment plan, and completion of
  treatment

24
Evaluation/Treatment

• Examples
• SLP
• Conflicting reports on evidence for the
  effectiveness of oral motor treatment
• Quality of life/comfort issues vs. safety/long
  term effects
• Assessment language test appears limited to
  target observed deficits

25
Evaluation/Treatment

• Examples
• Student
• Controversial treatment procedures (methods)
• In the school-sometimes what treatment was done
  was questionable if it related to IEP goals
• Having to change goals because they are either
  too easy or too hard

26
Evaluation/Treatment

• Examples
• Audiologist
• Workmens compensation cases-judging whether
  hearing loss is work related or not and whether
  to give the patient benefit of-a-doubt
• Patients that get minimal benefit from
  amplification but are happy with their hearing
  aids

27
Response Categories

• Family/Caregiver
• Includes issues regarding families and caregivers
  of clients

28
Family/Caregiver

• Examples
• SLP
• Parents not agreeing to certain services
• Dealing with difficult (assertive/aggressive)
  parents
• How to handle a family who still introduces food
  into their family members mouth when they have a
  G-tube and they know this is dangerous

29
Family/Caregiver

• Examples
• Student
• Parental involvement-parents in low
  socioeconomic standing do not participate in
  childrens education
• Conflict between parents over goals for therapy

30
Family/Caregiver

• Examples
• Audiologist
• Parent will not believe test results that verify
  their child has a severe sensorineural hearing
  loss-thus will not accept amplification
• Family member, who is not the legal guardian,
  brings child to all/most appointments

31
Participants Response Categories

• Coworker/Supervisor
• Includes issues related to conflict or
  disagreement with coworkers, supervisors, or
  other professionals

32
Coworker/Supervisor

• Examples
• SLP
• The push to pick-up patients although they are
  not appropriate for speech therapy
• Disagreements with employers about provision of
  services (type, length of therapy, issues
  with/related to compensation of third party
  payer
• Physicians not supporting recommendations that
  you know would benefit the client

33
Coworker/Supervisor

• Examples
• Student
• Conflict between supervisor and student
  clinician supervisor being unethical
• What do we do if, in clinical practice, we are
  asked to do
• Given the opportunity by supervisor to give
  treatment that requires certification although I
  wasnt certified

34
Coworker/Supervisor

• Examples
• Audiologist
• Being honest with patients when physicians have
  provided them with less then professional care
• Reporting inadequate care reported by other
  professionals (HI teachers complain to me about
  SLPs)
• When a colleague micromanaged my caseload
  denying me opportunity to exercise appropriate
  clinical judgment

35
Participants Response Categories

• Pay Source/Funding
• Includes issues concerning payment of services
  and funding for services

36
Pay Source/Funding

• Examples
• SLP
• Billing services guidelines
• It often gets easy to get worried more about
  spending the minimum amount of time with patients
  in order to bill more in a day. The focus can be
  taken off of quality patient care and more on
  quantity of billable units

37
Pay Source/Funding

• Examples
• Student
  Lack of funding

38
Pay Source/Funding

• Examples
• Audiologist
• Reimbursement issue with insurance companies.
  Receiving preauthorization for services and then
  having the claims either denied or reimbursed at
  a much lower level
• Deciding whether to provide audiologic services
  to a needy patient with no means of paying for
  services
• Necessary to make profit on hearing aids yet it
  still feels odd

39
Participants Response Categories

• Caseload
• Includes issues regarding too high or too low
  number of clients in caseload

40
Caseload

• Examples
• SLP
• Handling pressure in LTC facilities to keep
  productivity with lack of patients
• Basing the amount of services a child receives
  on my schedule, rather than the childs needs
• Continually being told to group children and
  not feeling that they should be grouped-not
  having that control over caseload

41
Caseload

• Examples
• Student
• 50 students on a caseload in a school system if
  you are the only SLP and cannot service them all
  with 100

42
Caseload

• Examples
• Audiologist
• No responses falling into this category from
  audiologists

43
Participants Response Categories

• Disorder
• Includes issues related to specific disorders and
  their severity

44
Disorder

• Examples
• SLP
• Diagnosing autism spectrum disorder or being
  asked to
• Cognitive impairments-lack of understanding
• Treating adults with cognitive deficits with
  underlying dementia

45
Disorder

• Examples
• Student
• What to do with oral motor therapy and apraxia

46
Disorder

• Examples
• Audiologist
• Mentally disabled patients that are physically
  aggressive

47
Participants Response Categories

• Discharge
• Includes issues surrounding the discharge and
  completion of treatment

48
Discharge

• Examples
• SLP
• Feeling pressure to continue treatments when I
  felt maximum benefit was achieved
• Decisions regarding discharge when the client
  continues to have errors
• When to discharge patients and how to determine
  when those patients have reached max potential in
  nursing home settings

49
Discharge

• Examples
• Student
• Do I continue with therapy to the end of the
  semester even though the child may not need it
• Discharge when making slow progress
• Discharge when a child performs at an
  inconsistent level

50
Discharge

• Examples
• Audiologist
• No responses falling into this category from
  audiologists

51
Participants Response Categories

• Confidentiality
• Includes issues regarding the confidentiality of
  client matters

52
Confidentiality

• Examples
• SLP
• Share confidential information with colleagues
  not directly involved with case
• Patient confidentiality rights being breached
  due to lack of space resulting in interruptions,
  etc. (hallway waiting room)

53
Confidentiality

• Examples
• Student
• Being approached by persons claiming to be
  relatives of clients and not knowing if I should
  share information with them concerning the
  clients

54
Confidentiality

• Examples
• Audiologist
• No responses falling into this category from
  audiologists

55
Participants Response Categories

• Referral
• Includes issues concerning referral of clients to
  other professionals and practitioners

56
Referral

• Examples
• SLP
• When to refer a parent for further testing
• Determining when to refer to developmental
  pediatrician
• Sometimes a referral comes in and the therapist
  assigned is not the best fit for the family
• Psychological referrals for toddlers who have
  exhibitory behaviors/test scores which might
  suggest disabilities (autism, delay, etc) and
  relating that information to the parents

57
Referral

• Examples
• Student
• No responses falling into this category from
  audiologists

58
Referral

• Examples
• Audiologist
• No responses falling into this category from
  audiologists

59
Participants Response Categories

• Compliance
• Includes issues concerning the compliance to
  ASHA, state, and Federal regulations

60
Compliance

• Examples
• SLP
• Following all HIPAA guidelines is a challenge
• One of my students is using facilitated
  communication with an OT privately-outside of
  school and wanted it done in school too-school
  districts said no based on ASHA and other
  position statements

61
Compliance

• Examples
• Student
• No responses falling into this category from
  audiologists

62
Compliance

• Examples
• Audiologist
• No responses falling into this category from
  audiologists

63
Participants Response Categories

• Academic
• Includes issues regarding students, grades, and
  graduation requirements

64
Academic

• Examples
• SLP
• University pressure to inflate grades and let
  poor performance slide
• Passing graduate students because I was told to
  do so, even though they were incapable of the
  academic demands of grad. school

65
Academic

• Examples
• Student
• No responses falling into this category from
  audiologists

66
Academic

• Examples
• Audiologist
• No responses falling into this category from
  audiologists

67
Participants Response Categories

• Other
• Includes special and specific issues that did not
  meet criteria for other categories

68
Other

• Examples
• SLP
• Threat of lawsuit
• Proper procedures reporting abuse/neglect to DHR
  in school settings
• Clients wanting to continue working with me
  after leaving the practice/provider group with
  whom I had been working for

69
Other

• Examples
• Student
• Which test to use when the child is
  developmentally low but whose age does not fall
  in the test norms
• Inexperience

70
Other

• Examples
• Audiologist
• Receiving products/rewards, etc from HA mfrs-how
  much is okay? Free pens, trips?
• There are times when the patients expectation
  are their hearing abilities with their hearing
  aids may not be met-even though realistic
  expectations were discussed prior to hearing aid
  purchase-handling these situations to mutual
  benefit is difficult

71
Distribution of SLP Responses
72
Distribution of Student Responses
73
Distribution of Audiologist Responses
74
Reporting Ethical MisconductThomas Miller,
Ph.D., J.D. Nazareth College of Rochester, NY

• How do I know if a practice constitutes ethical
  misconduct?
• Who should report it? Do I have to?
• When should it be reported?
• To whom do I report it?
• What happens if...

75
Whats Unethical? Whats Illegal? Whats the
Difference?

• Sources of Ethical Conduct
• Codes of Ethics
• Preferred Practice Patterns

• Sources of Legal Conduct
• Constitutional law
• Case law
• Statutes
• Administrative law/
• Regulations

76

• Established by
• Members of regional/state/national professional
  associations
• Employers
• Established for
• Members of the
• profession
• Employees

• Established by
• State/Federal legislators
• Courts/Judges
• Appointed government administrators
• State license boards
• Established for
• Protection of the public

77

• Alleged ethical violations
• Investigated and adjudicated by ethical practice
  committees and boards

• Alleged legal
• violations
• Investigated and adjudicated by administrative
  government and the courts

78

• How are ethical standards and legal standards
  alike?
• How are ethical standards and legal standards
  different?

79
Prevention Minimizing Ethical Risks

• Be aware of ethical dilemmas and problems other
  SLP/As have had.
• Know professional sanctions for unethical
  practice.
• Be familiar with codes of ethics.
• Consider competence and scope of practice.

80
Ethical Decision MakingDavid Irwin, Ph.D.,
LSUHSC-Shreveport

• Process involves a multitude of factors and
  experiences.
• Each person involved in an ethical dilemma has
  personal beliefs, moral values, experiences, and
  usually some knowledge of laws and regulations.
• ASHA now requires all candidates for CCC to have
  documented ethical education.

81
Ethical Decision Making Model for Students and/or
Faculty

• Beginning The Process

Student
Faculty

• Background
• Education
• Experiences
• Personal Values Beliefs

82
Ethical Issue Identified

• First Step for Decision Making Process

• Prevention Options
• Refuse to
• participate or
• conceal unethical
• practices
• Discuss standards
• values supporting
• ethical decision
• Determine if
• changes are needed
• Be an advocate
• for ethics education

Ethical Issue

• Documentation
• Nature of Problem
• Facts
• Person(s) Involved

Ethical Dilemma Identified Proceed
83
Evaluation Process

• Second Step for Decision Making Process

Ethical Dilemma is Identified

• Consider
• Ethical principles
• 2. Consult code of
• ethics
• 3. Facility guidelines

Evaluation by Interested Parties
Proceed to Options for Resolution
84
Options for Resolution

• Third Step for Decision Making Process

Options for Resolution
Report Violation to Proper Authority (ies)
Ignore
Internal Resolution
No Resolution
Monitor Outcome
2 Possible Outcomes
85
Internal Resolution

• Possible Outcomes for Internal Resolution

Resolution Unsuccessful
Resolution Successful
Confirmed violation
Review
Periodic Follow-Up
Determine cause of Failure
Consider options
Consider Ethical Consultant
Reconsider Course of Action
86
PROFESSIONAL CODES OF ETHICSGlenn Waguespack,
M.A., Private Practice, Shreveport, LA

• Developed by professional associations
• Incorporated into licensure laws
• Serve dual functions
• Regulate the behavior of professionals
• Protect the public

87
SANCTIONS FOR VIOLATIONS

• Association Licensure Board
• Reprimand Reprimand
• Censure Monetary fine
• Revoke membership Restrictions on practice
• Revoke certification License suspension
• License revocation

88
APPLICATIONS FOR STUDENTS INTERPRETATION OF
CODES OF ETHICS

• Recognize whether a given situation represents a
  violation of the code of ethics
• When violations are present, develop a plan for
  resolution through ethical decision making

89
ETHICAL SITUATION

• I am in a private audiology practice with Paula
  Robinson. Dr. Robinson, who owns the practice,
  has been an audiologist for over 20 years and is
  a respected member of the professional community.
  While at a CE activity at the Intercontinental
  Hotel, I saw her kissing a tall handsome stranger
  (who was not her husband) prior to entering the
  hotel room with him. I feel Dr. Robinsons
  behavior reflects negatively both on our
  profession and on our private practice.
• Is this a violation of the Code of Ethics for an
  association and/or a regulatory board? If so,
  which principle(s) does it violate?

90
ETHICAL SITUATION

• I am in a private audiology practice with Paula
  Robinson. Dr. Robinson, who owns the practice,
  has been an audiologist for over 20 years and is
  a respected member of the professional community.
  While at a CE activity at the Intercontinental
  Hotel, I saw her kissing a patient (who had
  purchased hearing aids from us last week) prior
  to entering the hotel room with him. I feel Dr.
  Robinsons behavior reflects negatively both on
  our profession and on our private practice.
• Is this a violation of the Code of Ethics for an
  association and/or a regulatory board? If so,
  which principle(s) does it violate?

91
ETHICAL DILEMMA

• As a graduate student, you are assigned to an
  off-campus site with two supervisors. One of
  your supervisors often lets you dismiss therapy
  early and go home, but still lets you claim the
  full amount of practicum hours.
• Is this a violation of the Code of Ethics for a
  professional association and/or a regulatory
  board? If so, which principle(s) does it violate?

92
ETHICAL DECISION MAKING

• Develop a plan for resolution of the problem.
• Describe potential harm to the student.
• Describe potential harm to the faculty.
• Describe potential harm to the university.

93
Audience Participation

• Case scenario submitted by audience

94
ETHICAL DILEMMA

• A graduate student, working with a client with
  ADHD and a severe language impairment at an
  off-campus practicum site, complains to her
  supervisor because she feels she needs help in
  dealing with the students behavioral problems as
  well as the language disorder. She feels as if
  she is not getting enough supervision, but the
  supervisor states that she is too busy to give
  more time to the graduate student. The
  supervisor tells her she should have already
  learned in her coursework what to do with clients
  like this one.

95
ETHICAL DECISION MAKING

• What should be the students first course of
  action?
• How should the supervisor be disciplined if
  discipline is indicated?
• Develop a plan for resolution of the problem.

96
ETHICAL DILEMMA

• An audiology graduate student goes into the
  speech/language therapy room to make an earmold
  impression for a hearing impaired student who is
  in a speech therapy session. Upon entering the
  room, the audiology student discovers the child
  coloring pictures while the SLP is asleep in a
  chair. After being awakened, the SLP complains
  of having a migraine headache and asks the grad
  student not to mention anything to the supervisor.

97
ETHICAL DECISION MAKING

• Develop a plan for resolution of the problem.
• Should the graduate student report the incident
  to a supervisor?
• What ethical issues/violations exist in this
  dilemma?

98
Technology/Resources for Ethics EducationDavid
Irwin, Ph.D.

• Ethics Roundtable
• Goal To respond to the ethics questions and
  educational needs of ASHA members.
• Uses commentaries on a case to illustrate many
  ways to approach ethical issues
• Examples
• When Supervisors and Supervisees Disagree
• When a Student Fails to Make the Grade
• Are Sales Quotas Appropriate for a Clinical
  Setting?
• www.asha.org/about/ethics/roundtable/ Retrieved
  October 2, 2006.

99
Technology/Resources for Ethics Education

• Issues in Ethics Statements
• ASHA Board of Ethics determines that members can
  benefit from analysis and instruction about
  ethical conduct
• Examples
• Conflicts of Professional Interest
• Fees for Clinical Service Provided by Students
  and Clinical Fellows
• Supervision of Student Clinicians
• www.asha.org/about/ethics/ethics_issues_.htm
• Retrieved October 2, 2006

100
Technology/Resources for Ethics Education

• Scott (1998) described a multimedia software
  program of ethical instruction for students and
  clinicians
• Developed by Elizabeth Sakarakis-Doyle, SLP at
  University of Western Ontario.
• Program addresses allocation of resources,
  private practice, conflict of interest,
  confidentiality, etc.
• Scott, A. (November 23, 1998). Ethical
  Instruction. Advance for Speech-Language
  Pathology and Audiology. Retrieved on October 2,
  2006 at http//speech-languagepathology-audiology.
  advance.web.com/common/EditorialSearch/printer

101
Technology/Resources for Ethics Education

• Virtual Mentor
• Prepared by the American Medical Association
• Web-based, interactive forum for students and
  residents about ethics and professional issues
• Examples of Topics Available
• Parental influence on level of functioning in a
  child with Down Syndrome
• The desperate parent and the lure of experimental
  research
• http//www.amaassn.org/ama/pub/category/3040.html

102
Technology/Resources for Ethics Education

• Ethical Decision Making for the Allied Health
  Curriculum
• Loma Linda University has designed an
  interdisciplinary one-year portfolio ethics
  course
• Students accumulate information about ethical
  behavior and professionalism including community
  service, role-playing, etc.
• In workshops students introduce a problem,
  present facts, and choose and justify their
  actions.
• Gibbons, M. (November 23, 1998). Whats your EQ?
  Adding ethical decision-making to the allied
  health curriculum. Retrieved on October 2, 2006.
  httpspeech-language-pathology/audiology.advancew
  eb.com

103
Technology/Resources and Ethics Education

• ASHA sponsored teleseminars
• Ethics for SLP and Audiology (Pannbacker Irwin,
  2003).
• Business Ethics (Shinn, 2004)
• Working with English Language Learning Students
  (Crowley, 2005).
• SLP Services in End-of-Life Care Ethical and
  Legal Considerations ( Sharp, Wagmann, Bolstor,
  Wagner, 2005).
• AAA (2005) published Ethics of audiology
  Guidelines for Ethical Conduct in Clinical,
  Educational, and Research Settings. More
  information available at www.audiology.org

104
Resource

• Ethical Decision Making for Speech-Language
  Pathologists and Audiologists An Illustrative
  Casebook by Irwin, D. Pannbacker, M., Powell, T.,
  and Vekovius, G. (2007). www.delmarhealthcare.com
  
• All royalties paid to authors support
  scholarships for graduate students in
  speech-language at LSUHSC-Shreveport.
• Contact David Irwin dirwin_at_lsuhsc.edu or Mary
  Pannbacker at mpannb_at_lsuhsc.edu.