Ethics Across the Curriculum 2013 Ethics and Speech-Language Pathology Assistants (SLPAs): Consensus building in real-world applications Ethics Across the Curriculum 2013 Jennifer A. Ostergren, PhD, CCC-SLP Department of Communicative Disorders California State University, Long Beach

Lecture Phase II: Lecture Presentation In Phase II, the instructor presents the content contained in the lecture slides. Instructor notes within these slides discuss areas of emphasis and discussion. Approximate Time: 60 minutes

Integrity Adherence to high moral standards (Horner, 2003) A person with professional integrity is someone who adheres to ethical principles in the execution of their professional duties.

Ethics “The discipline dealing with what is good and bad and with moral duty and obligation” (http://www.merriam-webster.com/dictionary/ethic) The study of the morality, or what is good/bad and right/wrong (Horner, 2003)

Laws versus Morals Laws dictate what we must do. Morals (and thereby ethics) address what we should do.

Why Study Ethics? “Ethics is really about helping one to make good decisions” (Carbon and Morris, 2004, para. 2) Ethical principles can serve as a compass in performing your duties as an SLPA.

American Speech-Language-Hearing Association (ASHA) Code of Ethics “Preservation of the highest standards of integrity and ethical principles is vital to the responsible discharge of obligations by speech-language pathologists, audiologists, and speech, language, and hearing scientists. This Code of Ethics sets forth the fundamental principles and rules considered essential to this purpose.” (ASHA, 2010, para 1) Not directly applicable to SLPAs (ASHA, 2013) Applicable to: A member of ASHA, whether certified or not A nonmember holding the ASHA Certificate of Clinical Competence An applicant for membership or certification A Clinical Fellow seeking to fulfill standards for certification. “Although some SLPAs may choose to affiliate with ASHA as associates, the Code of Ethics does not directly apply to associates. However, any individual who is working in a support role (technician, aide, assistant) under the supervision of an SLP or speech scientist must be knowledgeable about the provisions of the code. It is imperative that the supervising professional and the assistant behave in a manner that is consistent with the principles and rules outlined in the ASHA Code of Ethics. Since the ethical responsibility for patient care or for subjects in research studies cannot be delegated, the SLP or speech scientist takes overall responsibility for the actions of the assistants when they are performing assigned duties. If the assistant engages in activities that violate the Code of Ethics, the supervising professional may be found in violation of the code if adequate oversight has not been provided.” (ASHA, 2013, para 21). Explain the difference between a Principle and a Rule. American Speech-Language-Hearing Association. (2010). Code of ethics [Ethics]. Available from www.asha.org/policy

ASHA Code of Ethics (2010) Four Basic Principles Principle 1 (Responsibility to Clients Served and Research Participants) Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or who are participants in research and scholarly activities, and they shall treat animals involved in research in a humane manner. Principle 2 (Responsibility for Maintaining Professional Competence) Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence and performance. Principle 3 (Responsibility to the Public) Individuals shall honor their responsibility to the public by promoting public understanding of the professions, by supporting the development of services designed to fulfill the unmet needs of the public, and by providing accurate information in all communications involving any aspect of the professions, including the dissemination of research findings and scholarly activities, and the promotion, marketing, and advertising of products and services.  Principle 4 (Responsibility to Other Members, Students, and Other Profession and Disciplines) Individuals shall honor their responsibilities to the professions and their relationships with colleagues, students, and members of other professions and disciplines.

Principle I- Guidance for SLPA Supervisors Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or who are participants in research and scholarly activities, and they shall treat animals involved in research in a humane manner. Guidance (ASHA, 2013): The supervising SLP remains responsible for the care and well-being of the client or research subject. If the supervisor fails to intervene when the assistant's behavior puts the client or subject at risk or when services or procedures are implemented inappropriately, the supervisor could be in violation of the Code of Ethics. Explain that discussion will begin with ASHA’s recommendation for those who supervise SLPAs as ASHA’s Code is directly applicable to these individuals. This information sheds light on the relationship between the SLPA and their supervisor. After this discussion, ASHA’s Code of Ethics will be discussed in further detail as a “compass” for SLPAs in navigating their own conduct. Principles and Rules (as per ASHA Code of Ethics) Guidance (as per ASHA SLPA Scope of Practice)

Principle I, Rule A – Guidance for SLPA Supervisors Individuals shall provide all services competently. Guidance (ASHA, 2013): The supervising SLP must ensure that all services, including those provided directly by the assistant, meet practice standards and are administered competently. If the supervisor fails to intervene or correct the actions of the assistant as needed, this could be a violation of the Code of Ethics.

Principle I, Rule D – Guidance for SLPA Supervisors Individuals shall not misrepresent the credentials of assistants, technicians, support personnel, students, Clinical Fellows, or any others under their supervision, and they shall inform those they serve professionally of the name and professional credentials of persons providing services. Guidance (ASHA, 2013): The supervising SLP must ensure that clients and subjects are informed of the title and qualifications of the assistant. This is not a passive responsibility; that is, the supervisor must make this information easily available and understandable to the clients or subjects and not rely on the individual to inquire about or ask directly for this information. Any misrepresentation of the assistant's qualifications or role could result in a violation of the Code of Ethics by the supervisor.

Principle I, Rule F – Guidance for SLPA Supervisors Individuals who hold the Certificate of Clinical Competence may delegate tasks related to provision of clinical services to assistants, technicians, support personnel, or any other persons only if those services are appropriately supervised, realizing that the responsibility for client welfare remains with the certified individual. Guidance (ASHA, 2013): The supervising SLP is responsible for providing appropriate and adequate direct and indirect supervision to ensure that the services provided are appropriate and meet practice standards. The SLP should document supervisory activities and adjust the amount and type of supervision to ensure that the Code of Ethics is not violated.

Applicable Principle I Rules – Compass for SLPAs A. Individuals shall provide all services competently. C. Individuals shall not discriminate in the delivery of professional services or the conduct of research and scholarly activities on the basis of race or ethnicity, gender, gender identity/gender expression, age, religion, national origin, sexual orientation, or disability. M. Individuals shall adequately maintain and appropriately secure records of professional services rendered, research and scholarly activities conducted, and products dispensed, and they shall allow access to these records only when authorized or when required by law. N. Individuals shall not reveal, without authorization, any professional or personal information about identified persons served professionally or identified participants involved in research and scholarly activities unless doing so is necessary to protect the welfare of the person or of the community or is otherwise required by law. O. Individuals shall not charge for services not rendered, nor shall they misrepresent services rendered, products dispensed, or research and scholarly activities conducted. Q. Individuals whose professional services are adversely affected by substance abuse or other health-related conditions shall seek professional assistance and, where appropriate, withdraw from the affected areas of practice. Be sure to explain that these are NOT all “rules” listed under Principle I, but examples of some rules potentially applicable to SLPAs. Explains that as the symbol on the slide suggests, even though ASHA does not consider non-certified SLPA Associates as beholden to ASHA’s Code of Ethics, SLPAs can use these rules as a “compass” in navigating for their OWN ethical conduct. Note: Labels for the rules above correspond to numbering within ASHA’s Code of Ethics. Because only those rules applicable to SLPAs are listed, the lettering is not sequential (e.g., A, B, C, D, etc.).

Principle II, Rule B – Guidance for SLPA Supervisors Individuals shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their level of education, training, and experience. Guidance (ASHA, 2013): The supervising SLP is responsible for ensuring that he or she has the skills and competencies needed in order to provide appropriate supervision. This may include seeking continuing education in the area of supervision practice.

Principle II, Rule D – Guidance for SLPA Supervisors Individuals shall not require or permit their professional staff to provide services or conduct research activities that exceed the staff member's competence, level of education, training, and experience. Guidance (ASHA, 2013): The supervising SLP must ensure that the assistant only performs those activities and duties that are defined as appropriate for the level of training and experience and in accordance with applicable licensure laws. If the assistant exceeds the practice role that has been defined for him or her, and the supervisor fails to correct this, the supervisor could be found in violation of the Code of Ethics.

Applicable Principle II Rules – Compass for SLPAs B. Individuals shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their level of education, training, and experience. C. Individuals shall engage in lifelong learning to maintain and enhance professional competence and performance. E. Individuals shall ensure that all equipment used to provide services or to conduct research and scholarly activities is in proper working order and is properly calibrated. Be sure to explain that these are NOT all “rules” listed under Principle II, but examples of some rules potentially applicable to SLPAs. Explains that as the symbol on the slide suggests, even though ASHA does not consider non-certified SLPA Associates as beholden to ASHA’s Code of Ethics, SLPAs can use these rules as a “compass” in navigating for their OWN ethical conduct. Note: Labels for the rules above correspond to numbering within ASHA’s Code of Ethics. Because only those rules applicable to SLPAs are listed, the lettering is not sequential (e.g., A, B, C, D, etc.).

Applicable Principle III Rules – Compass for SLPAs A. Individuals shall not misrepresent their credentials, competence, education, training, experience, or scholarly or research contributions. B. Individuals shall not participate in professional activities that constitute a conflict of interest. D. Individuals shall not misrepresent research, diagnostic information, services rendered, results of services rendered, products dispensed, or the effects of products dispensed. E. Individuals shall not defraud or engage in any scheme to defraud in connection with obtaining payment, reimbursement, or grants for services rendered, research conducted, or products dispensed. F. Individuals' statements to the public shall provide accurate information about the nature and management of communication disorders, about the professions, about professional services, about products for sale, and about research and scholarly activities. G. Individuals' statements to the public when advertising, announcing, and marketing their professional services; reporting research results; and promoting products shall adhere to professional standards and shall not contain misrepresentations. Be sure to explain that these are NOT all “rules” listed under Principle III, but examples of some rules potentially applicable to SLPAs. Explains that as the symbol on the slide suggests, even though ASHA does not consider non-certified SLPA Associates as beholden to ASHA’s Code of Ethics, SLPAs can use these rules as a “compass” in navigating for their OWN ethical conduct. Note: Labels for the rules above correspond to numbering within ASHA’s Code of Ethics. Because only those rules applicable to SLPAs are listed, the lettering is not sequential (e.g., A, B, C, D, etc.). In addition, you will note there is not a slide labeled “Guidance for SLPA Supervisors” for Principle III as none were listed within ASHA’s SLPA Scope of Practice document for this specific principle.

Principle IV, Rule B – Guidance for SLPA Supervisors Individuals shall prohibit anyone under their supervision from engaging in any practice that violates the Code of Ethics. Guidance (ASHA, 2013): Because the assistant provides services as “an extension” of those provided by the professional, the SLP is responsible for informing the assistant about the Code of Ethics and monitoring the performance of the assistant. Failure to do so could result in the SLP's being found in violation of the Code.

Applicable Principle IV Rules – Compass for SLPAs A. Individuals shall uphold the dignity and autonomy of the professions, maintain harmonious interprofessional and intraprofessional relationships, and accept the professions' self-imposed standards. C. Individuals shall not engage in dishonesty, fraud, deceit, or misrepresentation. D. Individuals shall not engage in any form of unlawful harassment, including sexual harassment or power abuse. E. Individuals shall not engage in any other form of conduct that adversely reflects on the professions or on the individual's fitness to serve persons professionally. I. Individuals' statements to colleagues about professional services, research results, and products shall adhere to prevailing professional standards and shall contain no misrepresentations. K. Individuals shall not discriminate in their relationships with colleagues, students, and members of other professions and disciplines on the basis of race or ethnicity, gender, gender identity/gender expression, age, religion, national origin, sexual orientation, or disability. Be sure to explain that these are NOT all “rules” listed under Principle III, but examples of some rules potentially applicable to SLPAs. Explains that as the symbol on the slide suggests, even though ASHA does not consider non-certified SLPA Associates as beholden to ASHA’s Code of Ethics, SLPAs can use these rules as a “compass” in navigating for their OWN ethical conduct. Note: Labels for the rules above correspond to numbering within ASHA’s Code of Ethics. Because only those rules applicable to SLPAs are listed, the lettering is not sequential (e.g., A, B, C, D, etc.).

Ethical Decision-Making Worksheet Step 1: Gather/Clarify Facts Who is involved in this situation? Who is impacted by this situation? What are the motives and roles of those involved in this situation? List applicable ASHA Ethical Principles and Rules of Ethics (if any). Step 2: Action Analysis Possible Courses of Action? Benefits? Risks? Ethical Resolution? Yes or No Step 3: Action Implementation What action was implemented? What was the outcome of that action?

Class discussion: ethical worksheet applied/sample case Phase III: Group Discussion (Decision-Making Worksheet Explanation/Application) In Phase III, the instructor reviews the Ethical Decision-Making Worksheet (Ostergren, in press; Appendix C), including a sample case. Appendix D contains a sample case and completed worksheet for this purpose. This information is also available on lecture slides for display during discussion of this information. Approximate Time: 15 minutes

Worksheet Applied: Case Example Julie is an SLPA employed in a large, urban high school setting. Julie is bilingual and frequently assists her supervisor as an interpreter during assessment. Julie has worked in this setting for more than a year. She is currently supervised by an experienced SLP with her ASHA CCCs. Julie’s supervisor has one of the highest caseloads in their district. Next week, her supervisor has several Individualized Educational Plan (IEP) meetings scheduled. She has expressed to Julie that she is behind schedule in writing documentation for these meetings and in performing follow-up assessments. Julie’s supervisor asked her to perform an assessment on a bilingual client in preparation for an upcoming IEP meeting. Julie is concerned because performing diagnostic assessment is outside the scope of her practice, as per both ASHA recommendation and state licensing standards.

STEP 1: Gather/Clarify Facts Who is involved in this situation? Who is impacted by this situation? What are the motives and roles of those involved in this situation? List applicable ASHA Ethical Principles and Rules of Ethics (if any). Using the sample case, engage students in a problem solving exercise, encouraging them to generate answers to Step 1 questions. See Appendix A for sample answers.

Step 2: Action Analysis Possible Courses of Action? Benefits? Risks? Ethical Resolution? Yes or No Using the sample case, engage students in a problem solving exercise, encouraging them to generate answers to Step 2 questions. See Appendix A for sample answers.

Step 3: Action Implementation What action was implemented? What was the outcome of that action? ----- If ethical dilemma has not resolved, start again Using the sample case, engage students in a problem solving exercise, encouraging them to generate answers to Step 3 questions. See Appendix A for sample answers.

Small Group discussion (Case Analysis) Phase IV: Small Group Discussion (Case Analysis) In Phase IV, module participants should be assigned to groups of 4-5 students each. Each group should be provided with a different case scenario (Appendix E), a copy of the Ethical Decision-Making Worksheet (Appendix C), and a copy of ASHA’s Code of Ethics (2010). This portion of the module is separated into small group discussion and small group presentation, as follows: Small Group Discussion: Using the Ethical Decision-Making Worksheet, each group is tasked with collectively completing a worksheet on the case scenario provided. A member of the group should be assigned to write responses for the group on this worksheet. Groups should be instructed to first read aloud the case scenario and then to spend 5-10 minutes discussing this case informally. Following informal discussion, group members are tasked with completing the Ethical Decision-Making Worksheet. The instructor should move between the groups and encourage thoughtful reflection on the case scenario and full participation by all group members in collectively completing the Ethical Decision-Making Worksheet.  Group Presentation: Following small group discussion, the class should reconvene as a group, when the results of their small group case analysis can be presented. The case scenarios for this exercise are incorporated into lecture slides so that they can be displayed while each small group presents their findings. During this presentation, group members are asked to describe the following outcomes from their Ethical Decision-Making Worksheet: -Are there any potential conflicts with ASHA’s Code of Ethics? -Which ethical principles are involved? Why? -What is a potential resolution to this situation? The instructor can facilitate class participation by reiterating that there is not one right answer, and by encouraging participants to expand upon their rationale or resolution. The instructor can also present an alternate interpretation for class discussion. Approximate Time: 80 minutes. This includes approximately 20 minutes of small group discussion and 60 minutes of small group presentation. This is based on approximately 10 minutes of discussion time per group, for a total of 6 groups. If you are presenting to a larger class with more than 6 groups, this portion of the module may take longer to present the results of the case analyses.

Group Presentations (Case Analyses) Engage in group presentation (see notes on previous slide). 

SLPA Ethics Case #1 Jonathan is a newly hired SLPA, working in an elementary school setting. This is his first SLPA position and his first job in a public school. His supervisor trained him for approximately 1 week, consisting of showing him paperwork and having him observe her providing services to students. She then became seriously ill and has taken an extended medical leave. The district supervisor has asked Jonathan to work until they can find a replacement supervisor for him, including providing treatment services to the students on the supervisor’s caseload. __________ Are there any potential conflicts with ASHA’s Code of Ethics? Which ethical principles are involved? Why? What is a potential resolution to this situation? Display during group presentation of applicable case.

SLPA Ethics Case #2 Susan is an SLPA working in a private practice setting while attending graduate school to become an SLP. She has been employed as an SLPA for approximately 2 years, under the supervision of an ASHA certified SLP. There is an opening for a SLP position at the site where she works. The owner of this site told her they would like to hire Susan for this position. The owner indicated that Susan could be begin working in this position immediately because she is in school to become an SLP. Further, the owner states that they would list her title on official records as an SLP, because clients prefer to be seen by an SLP.   __________ Are there any potential conflicts with ASHA’s Code of Ethics? Which ethical principles are involved? Why? What is a potential resolution to this situation? Display during group presentation of applicable case.

SLPA Ethics Case #3 Edith is an SLPA working in a medical setting that bills Medicare for services provided to patients. During Edith’s initial training, her supervisor mentioned that SLPA services are not “billable” under Medicare, unless the paperwork indicates that the SLP provided the services. Because of this, Edith’s supervisor instructed Edith that she is not to record anything in official records. Her supervisor instructed Edith to tell her verbally the outcome of the treatment so that she can enter that information into the billing system as if an SLP provided the services. _______ Are there any potential conflicts with ASHA’s Code of Ethics? Which ethical principles are involved? Why? What is a potential resolution to this situation? Display during group presentation of applicable case.

SLPA Ethics Case #4 Leena is an SLPA working in a private practice. Her supervisor has trained her to work with individuals in this setting and she feels competent in doing so with the supervision. She is assigned a new client to work on treatment goals addressing memory and attention. When Leena reads the client’s chart, she sees that the client is HIV positive. Leena is concerned that she will contract HIV/AIDs so she tells her supervisor that she does not want to provide services to this client. _______ Are there any potential conflicts with ASHA’s Code of Ethics? Which ethical principles are involved? Why? What is a potential resolution to this situation? Display during group presentation of applicable case.

SLPA Ethics Case #5 Bill is an SLPA working in a public school setting. He has been working in this setting for 6 months. Thus far, he has received excellent training. There is a particular student’s mother that does not get along with his supervising SLP. As a result, the student’s mom asks Bill questions about the student’s goals, progress, results of assessment, and future recommendations for services. She tells Bill, “I trust you” and as such she wants to know his opinion about her daughter’s disorder and treatment. __________ Are there any potential conflicts with ASHA’s Code of Ethics? Which ethical principles are involved? Why? What is a potential resolution to this situation? Display during group presentation of applicable case.

Case Creation and Presentation Phase V: Small Group Discussion (Case Creation and Presentation) In Phase V, students return to their small groups to create a new ethical case scenario applicable to an SLPA or SLPA in training. For this portion of the module, a group member should be tasked with writing down this case scenario. Module participants should be instructed to create a case, addressing a core ethical conflict, from a different/unique perspective. The instructor should encourage module participants to think realistically in creating an ethical scenario that may actually occur and in creating a conflict that contains the subtleties common in real world ethical dilemmas. These cases can be collected for use in future models. If time permits, group members can share their case with the class. Approximately: 15 minutes

LESSONS LEARNED Phase VI: Wrap-Up and Lessons Learned In this Phase VI, the class reconvenes to summarize lessons learned. This can be a collective exercise that is facilitated first by asking the participants to describe one (1) thing they learned from this module. The instructor can list these items on the board. After this, the instructor can ask the participants to take on the role of an ethical advisor and share one (1) message/concept they would convey to an SLPA new to the topic of ethics. These comments can also be summarized in list fashion on the board. At the completion of this exercise, participants can complete the Post-Module Questionnaire (Appendix B). Approximately: 15 minutes