ACQ Vol 11 No 1 2009

MULTICULTURALISM AND DYSPHAGIA

These developments raise a number of ethical and legal concerns including maintaining privacy, confidentiality and security of information transmitted and held in electronic health records (Stanberry, 2000); ensuring standards for providing legally and professionally recognised services (Reed, McLaughlin & Milholland, 2000); and issues of reimbursement for services delivered by telehealth (Chetney, 2002). A growing ethical concern about telehealth in any form (via video-teleconference suites or webcam) is the impact it may have on what Stanberry (2000) refers to as the “traditional clinician–patient relationships” (p. 615). Cornford and Klecun-Dabrowska (2001) caution against “substitution of care with treatment” (p. 161). Speech pathologists do not yet have enough experience with telehealth to know how it impacts on consumer satisfaction with services. The views of Australian speech pathologists regarding emerging ethical risks to practice The authors ran a workshop at the National Conference of Speech Pathology Australia in Sydney in May 2006 to ascertain what Australian speech pathologists perceived as emerging ethical risks to practice. After a brief presentation summarising some of the above trends, some 50 speech pathologists were asked to discuss in small groups and then summarise emerging ethical issues. These are presented in table 1. The emerging ethical issues identified by workshop participants fell into 10 categories of concern. By far the largest category of concerns were those related to resource allocation. These categories are discussed below. Discussion The emerging ethical issues identified in the workshop align well to the trends presented in the first part of this paper, particularising these to our professional practice, as well as raising some new concerns. Of interest in the discussions at this workshop was the focus on ethical issues at the systemic level rather than at the individual client–practitioner level. Inevitably, system level pressures will impact on services to clients but the discussion in the workshop was primarily around the larger contexts in which ethical practice must be ensured. Speech pathologists at the workshop spoke of the ethics of a medical emphasis on “saving lives at all costs”, especially when the costs to quality of life are high. As a result, allied health professionals increasingly work with clients with complex disabilities who have care needs across the lifespan. This in turn impacts on resource allocation and prioritisation of services, which are already under strain with population ageing, fiscal constraints and a shrinking health care workforce. Workshop participants identified several worrying trends in resource allocation and prioritisation, including the cutting of services to some client groups (e.g., those with fluency or voice disorders, children with speech and/or language impairments in the absence of concurrent behavioural problems) and some age groups. For example, in some states without school-based therapy services, school-aged children are not a high priority at health services. Further, service management policies sometimes limit the number of occasions of service to clients in ways which are not consistent with evidence based practice or which may lead to discharge before an episode of care has achieved the established goals. As a result, practitioners often experience tension and conflict between the values of the profession and the values under­ pinning management policies (Cross, Leitão & McAllister,

Extended scope of practice The ongoing development of our profession together with workforce re-engineering precipitated by the health workforce shortage will lead to changes in our scope of practice. At one end of the continuum, scope of practice will extend to include roles and tasks not currently part of our practice, and at the other end our scope of practice may retract as more tasks are delegated to assistants or other professionals. Considerations in relation to changed scope of practice highlight a number of key professional issues: identifying the scope of speech pathology practice, determining the role of governance and risk management frameworks, specifying responsibilities for supervision of those to whom tasks are delegated, and determining the boundaries of legal liability. Speech pathology practice in Australia is informed by key Association documents such as Scope of Practice in Speech Pathology (Speech Pathology Australia, 2003) and Parameters of Practice (Speech Pathology Australia, 2007a). Association position papers further inform specific areas of specialist clinical practice – for example, Dysphagia: Modified Barium Swallow; Tracheostomy Position Paper; Fiberoptic Endoscopic Evaluation of Swallowing (Speech Pathology Australia, 2005a, 2005b, 2007a). However, a speech pathologist’s involvement in particular clinical practices will always be dependent upon a number of key factors including the preferred model of service delivery of an employing organisation, the support and explicit authorisation of an employing organisation for speech pathologists to perform particular tasks, access to training and demonstration of competence, and consideration of clinical governance issues. The challenge for the practitioner will be to ensure that service delivery models in which they work meet the requirements of minimising risk and harm, while at the same time facilitating new skill development and Through access to the Internet and other forms of media, consumers are now better informed about health care services. They have a greater expectation that services provided will reflect best practice and will provide value for money. This expectation requires practitioners to remain abreast of current knowledge and practice, and the information gleaned will arm consumers with the confidence to question practices which may be inappropriate or outdated. In addition, consumers may request services they have read or heard about which our profession considers to be unsupported by evidence. Speech pathologists will therefore need to be aware of the evidence across the range of their practice and be able to explain and defend their recommendations for management. Increased consumer expectations will also inevitably lead to demand for more convenient location of services, including services closer to home and actually in the home. Practitioners therefore will need to consider new models of service delivery. As services increasingly move from secondary and tertiary medical settings to primary care (community-based) settings, practitioners may need to extend their repertoire of skills in needs assessment, training of others, delegation of tasks and supervision and mentoring of assistants, volunteers and carers. Telehealth offers considerable promise for more flexible community-based and domiciliary service delivery. Elspeth pathology using high-end video-teleconference suites is already in use across Australia, enabling practitioners in major centres to provide services to rural and remote clients. Elspeth pathology using web-based delivery into clients’ homes is rapidly becoming an option (Theodoros, 2008). ongoing expansion of the profession. Community expectations

ACQ uiring knowledge in sp eech , language and hearing , Volume 11, Number 1 2009

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