February 12, 2008 Features

Triangulated Ethics

The Patient-Student-Supervisor Relationship

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The roles and responsibilities of speech-language pathologists and audiologists have increased in scope and complexity. In the face of dwindling resources and growing demands for accountability and productivity, we must be diligent in bringing ethical issues to the attention of future professionals. Certainly, the ability to anticipate and respond to ethical challenges is essential for our professional success and our professions' survival. New generations of SLPs and audiologists require the knowledge, attitudes, and skills to identify potential ethical conflicts and to critically evaluate their professional decisions and the underlying theories, facts, and beliefs that inform them. SLPs and audiologists agree to the overarching ethical principle of holding patients' welfare paramount.

Every day, clinical educators must answer the question: How do we preserve the integrity and quality of clinical services and engender confidence and competence in students simultaneously? Consider the following five scenarios:

  1. A speech-language pathology student administers a language test to a young child but does not use standardized testing procedures. 
  2. An audiology student fails to appropriately employ masking when giving a hearing test. 
  3. A speech-language pathology student, while obtaining a measure of client progress in treatment, fails to correctly record two disfluencies during a conversational sample. 
  4. An audiology student administers basic audiometric testing correctly but the test time is much longer than that for an experienced clinician. 
  5. In preliminary discussion with the supervisor, a student in training suggests findings that are incorrect; when the supervisor explains a more accurate recommendation, the student understands and then delivers the correct recommendation to the client.

Which of these examples are to be expected as part of clinical education? Which result in compromised patient welfare? Who is ultimately responsible when an ethical dilemma arises? And, finally, if preventing a problem is better than solving one, how can prevention be achieved?

Relationship Paradigm

Several relationships can be identified in the student-supervisor-client paradigm. These relationships include student/patient issues, supervisor/patient issues, and supervisor/student issues. Additionally, the role of the university training program is important in delineating these relationships and roles, thereby enhancing ethical decision-making and minimizing ethical dilemmas.

Student/Patient Issues

Academic program accreditation standards (ASHA, 1999) and clinical certification standards for audiology (ASHA, 2007) and speech-language pathology (ASHA, 2005) require training programs to assign students to patients with disorders for which they have theoretical and practical knowledge. The supervisor often is primarily responsible for helping students to make the connection between what they know and how they practice.

Patients always have the right to know that they are being treated by a student. In fact, students have a duty to inform patients that they are students, even if they are assisting credentialed professionals. When patients are informed, they also have the right to refuse services provided by students, particularly in facilities that do not have a published mission of student education.

Within the student-patient relationship, patients expect confidentiality and professionalism. Issues such as punctuality and dress may affect clients' perceptions about the quality of services rendered. Students should not perform procedures beyond their level of knowledge and expertise and should request guidance from their supervisors when necessary or appropriate. Ethical principles, which guide the responsibility to the profession and to the public, also guide students in these arenas.

In the first two scenarios above, the student-patient relationship has been compromised, and the supervisor must help correct the problems to preserve patient welfare. In the final three scenarios, patient welfare may be maintained through the diligence of the supervisor.

Supervisor/Patient Issues

Whether or not they serve as clinical supervisors, SLPs and audiologists are ethically bound to have sufficient expertise and experience to provide appropriate and effective services. Patients have the right to expect that a credentialed professional is directing their care and must be informed by the supervisor when students are participating in clinical service delivery. Patients should also be confident that their service providers are committed to ensuring that their best interests are always held paramount. Given the nature of clinical rotations, which often last 8-15 weeks, it is the supervisor who is ultimately responsible for the patient's continuity of care and the appropriate appraisal, treatment, follow-up, and referral across the course of intervention.

Although students may participate in the process of documenting the services provided to patients, it is the supervisor who is charged with maintaining appropriate records for all aspects of service delivery. The supervisor must review and, if needed, correct any student documentation before entering it into the permanent patient record. Some settings have strict confidentiality guidelines governing electronic record systems, such as whether and when a student may view a record being accessed with a supervisor's code. Supervisors must be familiar with the rules for viewing, sharing, and entering data and must model adherence to the rules while protecting patients' rights to privacy. The responsibility for documentation also encompasses aspects of billing and reimbursement, which are governed by ethical and, more often than not, legal requirements.

In the first two scenarios described above, the supervisor must correct the errors made by the student—or assist the student in doing so—to ensure patient welfare. In the fourth scenario, the supervisor may need to discuss with the patient that the expanded testing time is necessary to assist the student in learning, but that the supervisor will ensure testing procedures are completed appropriately. In the third and fifth scenarios, the supervisor can protect patient welfare by providing appropriate instruction to the student.

Supervisor/Student Issues

Supervisors are ethically obligated to oversee the training of students at levels commensurate with their expertise and in compliance with certification standards for audiology (ASHA, 2007) and speech-language pathology (ASHA, 2005). When professionals accept the responsibility for supervising students, they also are required to possess knowledge of the current literature on supervision. The ethical responsibility of the supervisor includes accepting teaching and mentoring roles relevant to the patient's disorder as well as to the larger clinical milieu. Appropriate supervisory support encourages patient comfort and progress and facilitates student learning. A focus on basic issues related to professionalism, ethical decision-making, and evidence-based procedures may encourage patients' progress, students' professional commitment, and supervisors' satisfaction.

In the first two scenarios above in which students made identifiable clinical errors, it is the supervisor's responsibility to teach the student appropriate procedures and to assess student progress in mastering those skills. In the third scenario, the student error probably did not adversely affect patient assessment; however, the supervisor should continue to monitor skill development in this area. In the final scenario, the supervisor necessarily corrected the student before patient counseling occurred; however, the supervisor must work with the student to ensure appropriate clinical decision-making with future patients.

Role of the University

The university program's role is to educate students. Programs in communication sciences and disorders must adhere to standards for student preparation that protect and promote patient welfare while encouraging students to develop knowledge and skills across the depth and breadth of the scope of professional practice. Orientation sessions, handbooks, case-based learning problems, clinical case conferences, grand rounds, and course work in professional and ethical issues help students gain higher levels of clinical proficiency and understanding. Clinical simulations can be helpful learning tools if used prior to placement in the actual clinical setting. Clinical internships provide students important opportunities to learn by observing and working with their clinical supervisors in a safe, selective environment. When students fail to make adequate clinical progress, remediation plans that do not compromise patient well-being should be implemented. University programs are obligated to provide adequate resources to support both student and supervisor education.

The Ethical Context

Patient, supervisor, and student relationships should always be viewed in the over-arching context of ethics. Clarification of roles and responsibilities may help to minimize confusion, anxiety, and vulnerability, and maximize the effective and ethical interaction of the participants in the patient/student/supervisor triad. In addition to the clinical expertise required to manage patients' needs, ethical imperatives ensure that the responsibilities to all parties are met. 

Shelly S. Chabon, former member and chair of ASHA's Board of Ethics, is the executive director of Children's Therapeutic Learning Center in Kansas City, Missouri. 

Sue T. Hale, 2008 ASHA president-elect, is director of clinical education and assistant professor of hearing and speech sciences at Vanderbilt University. Contact her at sue.t.hale@vanderbilt.edu. 

David J. Wark, a member of the ASHA Board of Ethics, is an associate professor of audiology at the University of Memphis, where he serves as director of graduate studies and director of the audiological rehabilitation laboratory. Contact him at dwark@memphis.edu. 

cite as: Chabon, S. S. , Hale, S. T.  & Wark, D. J. (2008, February 12). Triangulated Ethics : The Patient-Student-Supervisor Relationship. The ASHA Leader.


American Speech-Language-Hearing Association. (2003). Code of Ethics [Ethics].

American Speech-Language-Hearing Association. (2004). Supervision of Student Clinicians [Issues in Ethics]. 

American Speech-Language-Hearing Association. (2007). Standards and Implementations for the Certificate of Clinical Competence in Audiology.

American Speech-Language-Hearing Association. (2005). Background Information and Standards and Implementation for the Certificate of Clinical Competence in Speech-Language Pathology [Standards/Quality Indicators]. 


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