A Model for Ethics Education of Speech Language Pathologists Audiologists

A Model for Ethics Education for Speech-Language Pathologists and Audiologists oMary Pannbacker, Ph.D. CCC-SLP, Professor, LSU Health Sciences Center (LSUHSC)-Shreveport oDavid L. Irwin, Ph.D., CCC-SLP, Professor and Dept. Head, LSUHSC-Shreveport oNorman J. Lass, Ph.D., Professor, West Virginia University oThomas D. Miller, Ph.D., J.D., CCC-SLP, Professor, Nazareth College of Rochester, NY oGlenn Waguespack, M.S., CCC-A, Audiologist, Private Practice Shreveport, LA 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 Agenda 3:30-4:00 Objectives of Ethics Education; Results of Ethics Research; Justification for Ethics Education Curriculum 4:00-4:30 Reporting Ethical Misconduct; Laws & Ethics; Preventing and Minimizing Ethical Risks 4:30-4:45 A Model for Ethical Decision Making by Students and Faculty 4:45-5:10 Panel Discussion of Case Scenarios Submitted by Audience 5:10-5:20 Technology Resources for Ethics Education 5:20-5:30 Summary/ Q & A 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. Objectives of Ethics Education David 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). 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-LanguageHearing 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. 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 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). Content Areas for Ethics in SLP and Audiology Curriculum Ethical theories and Ethical Decision Making – Consequentialism – Deontologism – Virtue – Autonomy – Beneficence – Nonmalficence – Justice 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 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 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. 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. Ethical Issues Experienced by Speech-Language Pathologists, Audiologists, & Students Norman Lass, Ph.D. West Virginia University Respondents   Survey administered to:  Speech-language pathologists  Students  Audiologists Total number of participants:  159 SLPs  20 Students  18 Audiologists Demographic Categories  Demographic data included the following information:  Education of participant  Certification of participant  Setting in which participant practices Demographics for SLPs Education 5% MA/MS Doctorate 95% Certification 6% 1% CCC CFY NONE 93% Demographics for SLPs Setting 1% 1% 4% 2% 1% 1% 1% 8% 24% School SNF Private Practice College/Univ. Hospital 7% Early Inter. Clinic NonProf it 9% 21% 12% 7% Assisted Liv. Home Health Rehab Nursing Home LTC Private School N/A 1% Demographics for Audiologists Education 0% BA/BS MA/MS 44% 56% DR Certification 6% CCC NONE 94% Demographics for Audiologists Setting 6% School College 17% 22% 33% Clinic PP Hospital ENT 11% 11% Questionnaire “What 2 or 3 situations involving professional practice have caused you the most conflict about the right thing to do?” Category List for All Respondents       Evaluation/Treatment Family Caregiver Coworker/Supervisor Pay Source/Funding Caseload Disorder       Discharge Confidentiality Referral Compliance Academic Other Participants‟ Response Categories  Evaluation/Treatment  Includes issues surrounding evaluation, development of treatment plan, and completion of treatment 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 “ 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” Evaluation/Treatment  Examples:  Audiologist  “Workmen‟s compensation cases-judging whether hearing loss is work related or not and whether to give the patient benefit ofa-doubt”  “Patients that get minimal benefit from amplification but are happy with their hearing aids” Response Categories  Family/Caregiver  Includes issues regarding families and caregivers of clients 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 member‟s mouth when they have a G-tube and they know this is dangerous” Family/Caregiver  Examples:  Student  “Parental involvement-parents in low socioeconomic standing do not participate in children‟s education”  “Conflict between parents over goals for therapy” 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” Participants‟ Response Categories  Coworker/Supervisor  Includes issues related to conflict or disagreement with coworkers, supervisors, or other professionals 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” 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 wasn‟t certified” 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”   Participants‟ Response Categories  Pay Source/Funding  Includes issues concerning payment of services and funding for services 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” Pay Source/Funding  Examples: Student “Lack of funding” 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” Participants‟ Response Categories  Caseload  Includes issues regarding too high or too low number of clients in caseload 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 child‟s needs”  “Continually being told to “group children” and not feeling that they should be grouped-not having that control over caseload” 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%” Caseload  Examples: Audiologist No responses falling into this category from audiologists Participants‟ Response Categories  Disorder  Includes issues related to specific disorders and their severity Disorder  Examples:  SLP  “‟Diagnosing‟ autism spectrum disorder or being asked to”  “Cognitive impairments-lack of understanding“  “Treating adults with cognitive deficits with underlying dementia” Disorder  Examples: Student “What to do with oral motor therapy and apraxia” Disorder  Examples: Audiologist “Mentally disabled patients that are physically aggressive” Participants‟ Response Categories  Discharge  Includes issues surrounding the discharge and completion of treatment 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” 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” Discharge  Examples: Audiologist No responses falling into this category from audiologists Participants‟ Response Categories  Confidentiality  Includes issues regarding the confidentiality of client matters 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)” 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” Confidentiality  Examples:  Audiologist  No responses falling into this category from audiologists Participants‟ Response Categories  Referral  Includes issues concerning referral of clients to other professionals and practitioners 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” Referral  Examples:  Student No responses falling into this category from audiologists Referral  Examples:  Audiologist No responses falling into this category from audiologists Participants‟ Response Categories  Compliance  Includes issues concerning the compliance to ASHA, state, and Federal regulations 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” Compliance  Examples:  Student No responses falling into this category from audiologists Compliance  Examples:  Audiologist No responses falling into this category from audiologists Participants‟ Response Categories Academic  Includes issues regarding students, grades, and graduation requirements  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” Academic Examples:  Student: No responses falling into this category from audiologists  Academic  Examples:  Audiologist No responses falling into this category from audiologists Participants‟ Response Categories  Other  Includes special and specific issues that did not meet criteria for other categories 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” Other  Examples:  Student  “Which test to use when the child is developmentally low but whose age does not fall in the test norms”  “Inexperience”  Examples:  Audiologist  “Receiving products/rewards, etc from HA mfrs-how much is okay? Free pens, trips?”  “There are times when the patient‟s expectation are their hearing abilities with their hearing aids may not be met-even though realistic expectations were discussed prior to hearing aid purchasehandling these situations to mutual benefit is difficult” Other Distribution of SLP Responses SLP Responses 1% 10% 2% 1% 2% 3% 4% 7% 10% 24% 12% 24% Evaluation/Treatment Family/Cargiver Coworker/Supervisor Pay Source/Funding Caseload Disorder Discharge Confidentiality Referral Compliance Academic Other Distribution of Student Responses SLP Student Responses Evaluation/Treatment Family/Cargiver Coworker/Supervisor 22% 24% Pay Source/Funding Caseload 13% 5% 3% 3% 5% 15% Discharge Other 10% Disorder Confidentiality Distribution of Audiologist Responses Audiology Responses 13% 9% 44% 9% 22% Evaluation/Treatment Family/Cargiver Coworker/Supervisor Pay Source/Funding Disorder Other 3% Reporting Ethical Misconduct Thomas 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... What’s Unethical? What’s Illegal? What’s the Difference? Sources of Ethical Conduct Codes of Ethics Preferred Practice Patterns Sources of Legal Conduct Constitutional law Case law Statutes Administrative law/ Regulations 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 Alleged ethical violations Investigated and adjudicated by ethical practice committees and boards Alleged legal violations Investigated and adjudicated by administrative government and the courts How are ethical standards and legal standards alike? How are ethical standards and legal standards different? Prevention: Minimizing Ethical Risks Be aware of ethical dilemmas and problems other SLP/A’s have had. Know professional sanctions for unethical practice. Be familiar with codes of ethics. Consider competence and scope of practice. 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. Ethical Decision Making David Irwin, Ph.D., LSUHSCShreveport Ethical Decision Making Model for Students and/or Faculty Beginning The Process Student Faculty •Background •Education •Experiences •Personal Values & Beliefs Ethical Issue Identified First Step for Decision Making Process Ethical Issue Prevention Options: 1. Refuse to participate or conceal unethical practices 2. Discuss standards & values supporting ethical decision 3. Determine if changes are needed 4. Be an advocate for ethics education Documentation •Nature of Problem •Facts •Person(s) Involved Ethical Dilemma Identified Proceed Evaluation Process Second Step for Decision Making Process Ethical Dilemma is Identified Evaluation by Interested Parties Consider: 1. Ethical principles 2. Consult code of ethics 3. Facility guidelines Proceed to Options for Resolution Options for Resolution Third Step for Decision Making Process Options for Resolution Ignore Internal Resolution Report Violation to Proper Authority (ies) No Resolution 2 Possible Outcomes Monitor Outcome Internal Resolution Possible Outcomes for Internal Resolution Resolution Unsuccessful Resolution Successful Confirmed violation Review Periodic Follow-Up Determine cause of Failure Consider Ethical Consultant Reconsider Course of Action Consider options PROFESSIONAL CODES OF ETHICS Glenn 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 SANCTIONS FOR VIOLATIONS Association     Licensure Board Reprimand Monetary fine Restrictions on practice License suspension License revocation Reprimand Censure Revoke membership Revoke certification 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 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. Robinson’s 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?  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. Robinson’s 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?  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? 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. Audience Participation  Case scenario submitted by audience ETHICAL DILEMMA  A graduate student, working with a client with ADHD and a severe language impairment at an offcampus practicum site, complains to her supervisor because she feels she needs help in dealing with the student’s 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. ETHICAL DECISION MAKING    What should be the student’s first course of action? How should the supervisor be disciplined if discipline is indicated? Develop a plan for resolution of the problem. 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. 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? Technology/Resources for Ethics Education David 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. 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 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-languagepathologyaudiology.advance.web.com/common/EditorialS earch/printer 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.ht ml Technology/Resources for Ethics Education Ethical Decision Making for the Allied Health Curriculum – Loma Linda University has designed an interdisciplinary oneyear 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). What’s your EQ? Adding ethical decision-making to the allied health curriculum. Retrieved on October 2, 2006. http:speech-languagepathology/audiology.advanceweb.com 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 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@lsuhsc.edu or Mary Pannbacker at mpannb@lsuhsc.edu.