JCPSLP Vol 17 Supplement 1 2015_lores

5. the local community that relies on the hospital/health network for care; 6. related agencies such as social services. It is important to acknowledge that each of these groups may hold differing opinions regarding a new policy or policy change. Ideally, the processes involved in developing a new policy around a sensitive topic with many divergent views would occur through exploration and discussion of values and desired outcomes from patients, family, relevant health care professionals and decision-makers in the organisation. Hospitals are institutions and it is important to acknowledge that health care in hospitals is practised by (multidisciplinary) teams and not individual practitioners (Winkler, 2005) and this has implications for ethical policy development. Winkler argues that when formulating hospital-wide policies, consensus-building processes including all stakeholders will ultimately result in fair and efficient (and we would suggest may facilitate ethical ) clinical decision-making at the bedside. Thus, for an ethical policy approach to our case, we need to consult with key stakeholders to build an ethical, acceptable and implementable response. Formulating an ethical policy So how do we begin to reflect ethically on policy development? Mintrom (2010) suggests it starts with those involved in policy work upholding ethical principles. This is a fundamental concept in using underlying principles to drive the translation into policy and procedure. Mintrom’s ethical principles correlate well with the SPA Code of Ethics (SPA, 2010) values of integrity, professionalism, respect and care, quality standards and continuing competence. Integral to ethical policy construction according to Mintrom are concerns for others and a deep understanding of the community that may be affected by the policy. Frolic et al. (2012) suggest using an “ISSUES” guideline to facilitate organisational policy review. This is a 6-step framework: 1. I dentify the ethical issues raised by the policy 2. S tudy the facts 3. S elect the potential recommendations 4. U nderstand the values and duties 5. E valuate and justify options 6. S ustain and review the policy The successful implementation of policy New policies or changes to policy generally arise from identified problems. Kingdom (1995) delineated three streams in systems that need to coalesce to form a policy window, which then maximises the uptake of new policies. Initially problems may be identified that appear to be addressed by a policy. In Kingdom’s model this is known as the problem stream . Objective reports of the size and extent of the problem, a crisis or feedback may help highlight a problem. Once the problem has been delineated a policy stream is commenced in which ideas and ways of managing the problem are gathered. Some ideas are trialled and if successful may lead to attempts to achieve broader implementation. For the new policy to be enshrined, however, there needs to be political will or the political stream needs to be in play. This might occur because of organisational mood, pressure groups or a new

management/administration team. Chiarella (2013) suggested that successful stakeholders worked to complete the problem stream and policy stream so if and when the political stream aligned they could “surf the policy wave” and have the momentum to implement change. People affected by potentially life limiting or chronic illnesses and their families and the health care professionals who care for them are important stakeholders in the consultation and development of policy and practice that supports individuals and allows them the quality of life they choose to enjoy. For many health professionals, there is uncertainty and ambiguity in the legal frameworks that may affect treatment and support, and in the frameworks and protections regarding treatment decisions (particularly if substitute decision-makers are involved). The lack of uniformity among health professionals can lead to challenging experiences for vulnerable patients and their families. Clearly, ethical policy development and implementation is a time-intensive, collaborative process. Knowledge of Speech Pathology Australia’s Code of Ethics can inform ethical analysis of policies and can be used by speech pathologists as a reference when working on policy development. Speech pathologists, through their application of the Code of Ethics and clinical knowledge, have a unique perspective to bring to the consideration and development of policies and procedures that will affect patients with disorders of swallowing who are compromised in their ability to enjoy a normal range of foods and fluids. Speech pathologists involved in policy development are encouraged to include ethical deliberation as an integral part of the process. management and the quality and safety committee to ensure executive sign off and commitment. They valued the work that had been done and endorsed the new policy. Text box D. How Kingdom’s model assisted uptake of our case’s new policy 1. The problems stream The problem had been clearly identified through risk assessment and analysis plus review of critical incidents in the hospital system related to choking. The investigation into the matter included a literature review of relevant laws and acts as well as information from the coroner’s office and data about dysphagia management. Key stakeholders were engaged in the development process, including the consumers’ voice, health professionals, quality improvement and risk personnel and hospital decision-makers. 2. The policy stream A new policy was written after many options were evaluated, including drafts for circulation and comment. 3. The political stream With a change in the hospital catering services management and a new hospital coming on line, hospital administrators were keen to have clear policies around the provision of modified food and fluids for all patients. The policy developers met with clinicians,

61

JCPSLP Volume 17, Supplement 1, 2015 – Ethical practice in speech pathology

www.speechpathologyaustralia.org.au