Issues in Ethics: Ethical Issues Related to Clinical Services Provided by Audiology and Speech-Language Pathology Students
About This Document
Published 2013. This Issues in Ethics statement is a revision of Fees for Clinical Service Provided by Students and Clinical Fellows (2004), which revised Clinical Service Provided by Students and Clinical Fellows (2003). The Board of Ethics reviews Issues in Ethics statements periodically to ensure that they meet the needs of the professions and are consistent with ASHA policies.
Issues in Ethics Statements: Definition
From time to time, the Board of Ethics determines that members and certificate holders can benefit from additional analysis and instruction concerning a specific issue of ethical conduct. Issues in Ethics statements are intended to heighten sensitivity and increase awareness. They are illustrative of the Code of Ethics and intended to promote thoughtful consideration of ethical issues. They may assist members and certificate holders in engaging in self-guided ethical decision making. These statements do not absolutely prohibit or require specified activity. The facts and circumstances surrounding a matter of concern will determine whether the activity is ethical. This statement replaces an earlier version (2003), titled Fees for Clinical Service Provided by Students.
The ASHA Code of Ethics provides members and certificate holders with guidance regarding the ethical issues that may arise when professional service is provided by students. Principle of Ethics I, Rule G recognizes the professional acceptability of appropriately supervised clinical practice by students.
Individuals who hold the Certificate of Clinical Competence may delegate tasks related to provision of clinical services that require the unique skills, knowledge, and judgment that are within the scope of practice of their profession to students only if those services are appropriately supervised. The responsibility for client welfare remains with the certified individual.
Nevertheless, ethical questions may arise as ASHA certificate holders supervise the clinical practice of students. This Issues in Ethics statement addresses six such questions:
- Must clients be informed of the qualifications of those providing the clinical service?
- What level of supervision should be provided to the students and clinical fellows?
- Is it legitimate to charge for services provided by individuals who are not fully trained or certified?
- Must students complete all related course work before being assigned to a particular case?
- Can students be paid for practicum?
- Can a graduate student work as a speech-language pathology or audiology assistant while in graduate school?
Discussion and Guidance
Question 1: Must clients be informed of the qualifications of those providing the clinical service?
The Code of Ethics speaks directly to the issue of accurately representing the credentials of students in Principle of Ethics III, Rule A, which states:
Individuals shall not misrepresent their credentials, competence, education, training, experience, or scholarly or research contributions.
It is always the client's right to be fully informed of the professional qualifications of the service provider. Students must be appropriately identified to those they serve. Name tags should clearly indicate the status of students, and it is always good practice for a clinician to fully introduce himself or herself, including professional status, when beginning service. Supervisors and students should invite any questions that clients or patients may have regarding the qualifications of the individuals providing professional service. By describing the background and education of students and certificate holders fully and accurately, professionals are promoting a fuller understanding of the profession.
Question 2: What level of supervision must be provided to students?
The Code of Ethics provides guidance to certificate holders who are responsible for the supervision of students. Principle of Ethics I, Rule G states:
Individuals who hold the Certificates of Clinical Competence may delegate tasks related to the provision of clinical services that require the unique skills, knowledge, and judgment that are within the scope of practice of their profession to students only if those services are appropriately supervised. The responsibility of the welfare of the client remains with the certified individual.
Supervisors must base the nature and intensity of supervision on the stage of clinical development of each student in light of the complexity of the clinical case. Supervisors must bear in mind that the ultimate responsibility for client welfare remains with the certified individual.
Supervisors must also know and follow the supervision requirements of the Council on Academic Accreditation in Audiology and Speech-Language Pathology (CAA) and the Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC), the setting where the services are delivered, and the third-party payer. Although supervision standards and regulations provide guidance regarding minimum supervision requirements, supervision may need to exceed the minimum requirements so that the supervising clinician is confident regarding client outcomes. It is the supervisor's responsibility to intervene if there is any question regarding the quality of the care being provided.
Question 3: Is it legitimate to charge fees for services provided by individuals who are not yet fully trained or certified?
The ASHA Code of Ethics recognizes the professional acceptability of appropriately supervised clinical practice by students; hence, there is no basis for suggesting or requiring that fees charged for services delivered by students differ in any way from the fees typically charged for services provided by certified audiologists or speech-language pathologists. As described above, when students are involved in the provision of clinical services, client welfare and the quality of service remains the responsibility of the certified supervisor. If appropriate supervision is provided, the fees charged are justified; if not, something is fundamentally wrong with the service offered, and the fee is immaterial in view of Principle of Ethics I of the Code, which obligates members and certificate holders to “honor their responsibility to hold paramount the welfare of persons they serve professionally.”
Third-party payers are often very specific about the supervision required in order to receive reimbursement for services provided by students; therefore, it is imperative that supervisors be knowledgeable regarding these specific requirements and meet them. Because the rules and regulations regarding reimbursement by federal, state, and private health plans are constantly changing, supervisors must keep abreast of all reimbursement policies, rules, and regulations.
Question 4: Must students complete all related course work before being assigned to a particular case?
Ideally, the sequencing of a student's graduate program would provide all necessary course work before clinical practice in a particular area; however, in real-world clinical settings, occasionally students are assigned to a case or client before the completion of related courses. The Code of Ethics indicates that supervisors must determine the nature and intensity of supervision based on the stage of clinical development of the student and the complexity of the case. If a student is faced with a case in an area where course work has not been completed, the student and supervisor should develop a plan so that the student can appropriately prepare (e.g., examine previous case notes and reports, read supervisor-assigned texts and journal articles, familiarize himself or herself with test manuals and procedures, etc.). The supervisor must provide a level of supervision that will ensure the welfare of the person served.
Question 5: Can students be paid for practicum?
The ASHA Code of Ethics recognizes the professional acceptability of appropriately supervised clinical practice by students. As noted in Question 3, it is acceptable to charge for services provided by students, so it follows that it is acceptable to pay students in practicum settings. Many examples of students being paid for practicum exist. For example, the U.S. Department of Veterans Affairs (VA) has long offered stipends to students completing clinical training in VA facilities. In some settings, payment is offered to audiology students completing their 4th-year externship.
Payment should not influence the level of supervision or services provided.
Question 6: Can a graduate student work as a speech-language pathology or audiology assistant while in graduate school?
The roles and responsibilities of a graduate student in a practicum assignment and as an assistant in the work setting must not be confused. Audiology and speech-language pathology assistants have a limited scope of practice and must not provide clinical services that require the unique knowledge, skills, and judgment of an audiologist or speech-language pathologist. Graduate students, on the other hand, can provide such services when appropriately supervised. Graduate students who are also working as assistants, as well as their supervisors, must exercise caution so that the roles are not confused. This can be especially difficult if the student is given a practicum assignment in his or her work setting. Because of the potential for confusion of roles, the student should work closely with the academic program, his or her employer, and his or her supervisor to clearly delineate when the individual is working as an assistant and when the individual is accruing clock hours as a graduate student. Only then can appropriate assignments and supervision be determined.