Ethical considerations for allied health assistants in speech pathology

Keywords::

• Allied Health Assistants
• Ethical Practice
• Allied Health Assistant Program

This is an adaptation of the winning essay submitted by Mackayla for the inaugural presentation of the student award for an essay on the topic of ethics. The award is for an ethics essay and is presented by the members of the Ethics Board of Speech Pathology Australia. Input for this adaptation was provided by Associate Professor Susan Block who was a senior member of the Ethics Board.

As waitlists grow and demand rises for speech-language pathology services across Australia, an increasing number of practices are offering additional services using the support of allied health assistants (AHAs). O’Brien et al. (2013) described the primary responsibility of AHAs as providing clinical and administrative support to allied health professionals. Wylie et al. (2013) described the growth of the use of AHAs internationally as a response to address workforce shortages and better respond to the needs of clients. However, in many cases, AHAs are students studying speech-language pathology degrees. Students and others may choose to pursue these roles in part seeking an opportunity to gain clinical experience and build professional relationships during their studies. While the benefits of using AHAs are clear, especially in rural and remote areas where there is a need for increased access to and frequency of speech-language pathology services, there are ethical challenges that can arise in this partnership that need to be considered. Bradd et al. (2022) confirmed the importance of being professionally and ethically responsible. Clinical leaders and AHAs must be aware of the ethical boundaries of their professional collaborations and the limits associated with service delivery by allied health professionals to provide services that align with the ethical standards of the profession.

Clinical practices that incorporate AHAs into their service delivery model must observe the highest standards of ethical practice in order to provide quality, efficient, and effective services. Speech-language pathologists (SLPs) in Australia are expected to provide services in alignment with the Code of Ethics published by Speech Pathology Australia (2020). AHAs working within the field of speech-language pathology are encouraged to ensure they meet these ethical standards; however, as they are not certified practising SLPs, there are limits to the services and support they are able to provide. They also require careful instruction and supervision to ensure they are providing an ethical service.

AHAs, and the SLPs they work alongside, need to be aware of the limitations and ethical considerations at play in this dynamic working relationship. The impacts of an oversight in this area can be detrimental not only to client outcomes, but also to the professional relationships between the SLP, AHA, and client. AHAs who operate outside their scope of practice risk their own reputations, the reputations of their employing SLPs, and those of the clinics they are operating within. Clinical practices and individual SLPs who encourage or enable AHAs to operate outside their scope of practice, either due to oversight or for intentional financial gain, not only risk their reputation but also act in a way that directly opposes the ethical standards of the speech pathology profession.

AHAs in the speech pathology field are typically involved in supporting the delivery of speech pathology interventions (delegated care) and creating resources for clients (indirect care) (Speech Pathology Australia, 2022). In a professional setting, a treating SLP will perform an assessment and create session plans to support their client in achieving their goals. AHAs will then implement and facilitate speech pathology sessions in accordance with the SLP’s plan during a face-to-face or telehealth session and report back to the treating clinician with the session outcomes. AHAs may also be involved in the setup and facilitation of group therapy sessions.

As AHAs are not qualified SLPs, there are limitations to the level of support they can provide from a practical and ethical standpoint. AHAs cannot carry out assessments, diagnose communication or swallowing difficulties, and develop or make changes to therapy goals or plans (Speech Pathology Australia, 2022). It is important that these professional boundaries are maintained and upheld by all members of the speech pathology field to ensure adherence to the Speech Pathology Australia Professional Standards (2021) and the Code of Ethics (2020).

Speech pathologists who allow AHAs to administer or score assessments, update therapy goals or plans, and assist in the diagnostic process put their clients at risk and directly oppose the ethical principles of the profession (Speech Pathology Australia, 2020). Under the principle of nonmaleficence, SLPs are required to prevent harm and to not knowingly cause harm. As AHAs are not qualified at the level of SLPs, their involvement in assessment, diagnosis, and intervention planning is unethical. Ensuring clear professional boundaries between what tasks can be completed by an SLP and what AHAs can support with is an essential component of successful professional collaboration.

Professional practice: ethical considerations

Professionalism is one of the core ethical values that underpins the Speech Pathology Australia Code of Ethics. Both professional competence and professional conduct need to be considered by the treating SLP and AHA engaging in a professional collaboration to ensure ethical, fair, and responsible outcomes for all involved.

AHAs should be aware of their levels of competency (scope of education, training, and experience) and not practise beyond these limits when supporting SLPs and their clients (Speech Pathology Australia, 2020). While most individuals practising as AHAs have some clinical experience and education in the field of speech pathology, particularly university students, they are not yet qualified to provide services at the level of an SLP. AHAs are therefore bound by the clinical judgement and subsequent recommendations of the certified practising SLP (Speech Pathology Australia, 2022).

An example of a violation of this Code of Ethics would be an AHA making changes to a therapy plan, such as changing session goals, without the knowledge of the treating SLP (Speech Pathology Australia, 2020). This would be an ethical violation as the AHA does not have the competency and responsibility to make these changes. The AHA may have appropriate clinical reasoning for their suggestion, but this is not enough to justify making adjustments that are beyond their scope of practice without consultation with their supervising SLP.

Further, it is critical that AHAs are aware of the way in which their qualifications and level of experience are communicated to clients they support. Portraying an AHA’s level of knowledge accurately and fairly is crucial in creating a trusting relationship with clients, as well as avoiding any ethical dilemmas. For example, if an AHA’s relationship is established without clear communication, a client may assume they are working directly with a qualified SLP: which is inaccurate, inappropriate, and could be interpreted as misleading for the client. This can lead to difficult conversations, frustration, and potentially the loss of a client or loss of an effective client-clinician relationship (Speech Pathology Australia, 2020).

To provide collaborative services between SLPs and AHAs, professional boundaries and ethical portrayal of services must be upheld. This commitment to professionalism and ethical practice ensures delivery of high-quality, appropriate services and supports positive client-clinician relationships.

Quality service: ethical considerations

For the reputation of the speech-language pathology profession to remain in good standing, clinicians across the country must be able to consistently provide a high standard of services that are accurate, safe, and free of conflict of interest. Quality service delivery relies on ethical practice being upheld, particularly in the provision of AHA services.

When a treating SLP works alongside an AHA to provide ongoing therapeutic support to a client, it is critical that the Code of Ethics is adhered to. In particular, protecting the wellbeing of clients when delegating the delivery and administration of speech pathology services. This should be a priority for all SLPs participating in this type of service provision (Speech Pathology Australia, 2020). Clients who have been assessed and had their therapy intervention delivered by an SLP initially should be actively involved in the transition from SLP-directed care to AHA-directed care. It should be a transition that is agreed to by the client, with all efforts made to clearly communicate how the AHA will deliver services as well as the level of involvement of the AHA. It is imperative that client preferences, external evidence, and clinician experience are considered before a client is determined to be suitable for this service delivery model (Speech Pathology Australia, 2020).

Another key ethical consideration when providing speech therapy services via an AHA is ensuring they are not guaranteeing the results of a therapeutic procedure, prescribed device, or intervention (Speech Pathology Australia, 2020). This aligns with the Code of Ethics and is an important reminder for all who provide speech therapy services. However, for students and AHAs, it is important to keep this guideline in mind and to always seek the support of an experienced clinician to provide guidance to clients with particular concerns around treatment outcome, efficacy, and reliability. AHAs do not have the clinical expertise or formal qualifications required to inform clients of the efficacy of their treatment and its potential outcome. This level of insight should only be provided alongside the treating SLP to ensure the requirements of the Code of Ethics are upheld and to mitigate any professional liability (Speech Pathology Australia, 2020).

For SLPs and AHAs to provide high-quality collaborative services, the wellbeing of the client, open communication, and evidence-based selection of clients suitable for the service delivery model must be prioritised. This commitment to quality service delivery and ethical practice ensures that treatment is delivered in a way that is client centred and builds trust between the client and their care team.

Knowledge: ethical considerations

Regardless of the individual delivering speech therapy, all elements of speech-language pathology professional practice should be underpinned by the best available and accepted evidence (Speech Pathology Australia, 2020). To provide speech therapy services that are effective in helping clients to achieve their goals, evidence-based practice must be maintained.

For certified practising SLPs, this means combining high-quality research findings with the best available evidence from clinical practice experience with a client’s preferences to create a well-informed treatment plan. By using evidence-based practice to inform the development of individual session plans, SLPs and AHAs can work together to deliver highly effective speech treatment. SLPs are responsible for ensuring that all assessments and subsequent session plans are valid, reliable, and evidence based. For the services of AHAs to be effective, they need to be guided by the clinical judgement and best practice approaches implemented by the treating SLP, and the AHAs need to understand the rationale for the approaches they are using.

AHAs can provide value and support to both speech pathology clinical teams and the clients with whom they work. Their willingness to learn from and adhere to the clinical guidance of treating SLPs enables AHAs to provide high-quality clinical administration support and client-centred therapy intervention. University

students undertaking the role of AHA can learn valuable administrative and clinical skills that will serve them well upon stepping into new graduate roles following graduation. Their greater understanding of the role of AHA in the provision of speech-language pathology services may also inform future improvements to this professional collaboration in a variety of clinical settings.

Ethical practice in every clinical setting

Speech-language pathology practices will continue to incorporate, and hopefully increase, AHAs into their service delivery model. However, in their study of SLPs in New South Wales, O’Brien et al. (2013) reported concerns from SLPs who wanted further training to work with AHAs. It is a professional collaboration that can be seen as a necessity to address the wait times for services, so education for the speech-language pathology profession is vital. AHAs who are supported by treating SLPs with clear and accurate therapy plans, professional support, and effective client handover can provide immense value to the speech pathology profession. Clear communication, professionalism, and adherence to the Speech Pathology Australia Code of Ethics is essential for this working relationship to thrive.

Improving the collaborative efforts between SLPs and AHAs can and should involve all levels of leadership within the profession. University educators, clinical educators, and employers can all play a role in building students’ ethical awareness for them to become ethical practitioners (Bourne et al., 2013). To enable the profession to move forward on a united front, committed to high-quality and ethical service delivery across all settings, leaders must review and improve current processes. Implementation of and adherence to the Code of Ethics in all aspects of service delivery will ensure that all ethical considerations have been made when implementing allied health assistance in a clinical setting.

Relevant links for this article

Collaborative: Delegated care – speech pathology students working as AHA’s.	https://bit.ly/SPAethicslink11
Ethics collaborative: How can I ethically work with AHA’s or other delegated care models?	https://bit.ly/SPAethicslink12
Working with Allied Health Assistants Homepage.	https://bit.ly/SPAethicslink13

Additional information

Notes on contributors

Paul Mackayla

Mackayla Paul is a 2nd-year speech pathology student at the Australian Catholic University, Brisbane.