ACQ Vol 11 No 1 2009

MULTICULTURALISM AND DYSPHAGIA

quantify if they are made over extended periods of time as is often the case with chronic disease and disability. Chronic shortage of health workers The chronic shortage of health workers in Australia has been recognised by both state and federal governments, and a suite of initiatives have been proposed to address the inherent problems of inadequate service provision (Australian Govern­ ment Productivity Commission, 2005). For the speech pathologist, as with all health workers, a number of ethical considerations arise in relation to this, apart from those addressed earlier in relation to caseload prioritisation. Speech pathologists may, on the one hand, consider that any service is better than no service. However, when armed with the knowledge and evidence that outcomes are maximised by certain types of interventions provided over certain timeframes, speech pathologists face a dilemma as to how and what to provide. Cost-driven decisions based on ever increasing waiting lists and caseloads may force clinicians to terminate client treatment even though the potential for ongoing client gains is very real. The increasing profile of allied health assistants and support workers reflects the unmet demand for health services. Suitably qualified allied health assistants offer an opportunity for allied health practitioners not only to increase the level of service provision to clients, but also to expand the profession’s scope of practice. The concern for the speech pathologist, however, may be in understanding the role of the allied health assistant and the adequacy of their prior training, and in determining what type of work should be delegated. While guidance is provided to the profession through the Parameters of Practice document (Speech Pathology Australia, 2007b), this document reflects the position of the membership only and as such may hold only limited weight with other key stakeholders. Given that legal and professional responsibility rests ultimately with the clinician, the speech pathologist may grapple with questions related to the type and quality of services to be provided by allied health assistants, the degree of supervision that should be provided, and the mechanisms that must be in place to ensure client outcomes and safety are maximised. The issue of protectionism and its potential to limit the development of the allied assistant role will need to be addressed by the profession, as will the standards of allied health assistant training, supervision and monitoring. Increased complexity of clients and settings Speech pathologists are providing services to clients who are sicker, and who present with more complex conditions, in more complex medical and community settings than ever before. Practitioners rightly express concern regarding the acquisition of skills and competencies to meet the demands associated with working effectively and safely with such clients. Unless a clinician is working in an organisation which has a well-developed competency attainment program, the individual clinician may be left to determine whether they possess the skills and knowledge that is required. As stated in the Association’s Code of Ethics (2000), as practitioners we must “recognise the limits of our competence” (p. 2). This issue may be further compounded when an organisation does not acknowledge the benefit or need to support the clinician in attaining the necessary skills. A situation may then arise where the clinician must decide whether to refuse to see the client, see the client and engage in practice outside their level of expertise (hopefully while simultaneously engaging in professional development and mentoring to achieve com­ petence in management of such clients), or refer the client on

to another service, if indeed one exists. Clinicians and clients jointly must decide whether any service is better than no service, if geography or client immobility or social isolation preclude access to other more skilled clinicians. Increasing client complexity has also coincided with increasing costs associated with professional indemnity insurance and with increasing rates of professional litigation. Practitioners, while acknowledging the right of all clients to receive the best care available, may be reluctant to engage in clinical practices that have the potential to pose an “increased risk” to the client. Not only does such a decision, based upon fear of litigation, restrict client autonomy in relation to their treatment, it also curbs aspects of speech pathology practice. The increasing complexity of clients also raises the issue of caseload prioritisation. Nowhere is this more evident than in the profession’s increased focus on the management of clients with dysphagia. The emphasis upon reduced length of hospital stay and community-based rehabilitation has seen those clients with dysphagia prioritised over those with communication problems. This surely poses an ethical dilemma when the maximisation of both communication and swallowing functions is (and must remain) a joint priority of the profession. Such situations are premised on the need for clients to be “safe” enough to discharge. Safe swallowing is undoubtedly needed, but so too is “safe” communication which will allow a client to maintain some level of social interaction with family and community to preserve mental health, and for example, to call for help in emergencies. Increased emphasis upon evidence based practice The need for speech pathologists to inform their practice through the best available evidence was addressed in the first of the “Ethics Conversations” columns (Eadie & Atherton, 2008). As noted in that article, “best evidence needs to be integrated with clinical reasoning in order to make ethical decisions around service delivery for each of our clients” (p. 94). Undoubtedly, it is an ethical responsibility for individual clinicians to know what the literature says and what the available evidence is. It is also critically important that speech pathologists stay abreast of developments in clinical knowledge and practice by engaging in continuing professional development (CPD) – this is an ethical responsibility, as reiterated in the Association’s Code of Ethics (2000): “We strive to continually update and extend our professional knowledge and skills… and work towards the best possible standards of service to our clients” (p. 3). Ethical concerns may arise, however, when due to caseload and other demands, time is not available to undertake CPD and/or access to relevant facilities and technology, such as the Internet, is restricted. This may be particularly the case for those services limited by budget and for those clinicians in rural and remote areas where access is not reliable. Such situations raise questions of “whose responsibility is it to ensure competence and fitness for practice: the employer’s or the speech pathologist’s?” Where employers decline or are unable to support CPD, our ethical duties to clients and colleagues and the profession mean individual speech pathologists must assume responsibility (and cost, in dollars and time) for their own CPD. The means by which a practitioner ensures currency of knowledge and ongoing fitness to practice may require creative and lateral thinking. A willingness to access mentoring, to engage the assistance and expertise of colleagues, as well as devote time to ongoing education may conflict with long waiting lists and organisational targets.

S p eech P athology A ustralia

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