by the Coordinating Committee of the Vice President for Speech-Language Pathology Practice
As the scope of practice for speech-language pathology has grown, clinicians in all practice settings have redefined their roles and expanded their knowledge to provide high-quality services to a growing population of persons with communication and swallowing disorders. A key component of these changes has been the increased use of collaborative models of care that require speech-language pathologists to learn new skills related to team dynamics and conflict resolution. During this period of rapid change, questions and concerns have been raised by some ASHA members about professional boundaries and ambiguous situations in which there is overlap in scope of practice with other professions. The term "encroachment" has been used by some ASHA members to describe these situations.
Factors Affecting Scope of Practice
In the schools, changes in laws and regulations (including the Individuals with Disabilities Education Act and the No Child Left Behind Act) have affected clinical best practices and collaborative interactions between SLPs and other professions. These mandates coincide with changes in the profession, including SLPs' expanded role in reading and writing/literacy, and a gradual but steady growth in caseload and demand for more specialized knowledge and skills.
In health care settings, SLPs are responding to increased demands to provide services for severely ill patients across the lifespan, many of whom require specialized knowledge and skills that go beyond those required for "generalist" practice. Increased productivity demands and decreased reimbursement rates create tensions that compel clinicians to do more with less. Further, changes in facilities' organizational structures and other cost-containment measures have resulted in the increased use of template or protocol-based practices and multi-skilled personnel (e.g., aides and assistants) and have generated greater demands for fast and efficient outcome-oriented care.
Two other factors complicate service delivery. First, the shortage of qualified personnel has resulted in the hiring of individuals without previously accepted qualifications to perform the work of SLPs. Additionally, the gap between research and clinical practice challenges SLPs who attempt to use evidence-based practices and demonstrate the measurable impact of speech-language services on communication and swallowing outcomes.
In response to concerns of a gradual blurring of boundaries and the perceived loss of professional identity raised by ASHA members, Brian Shulman, then vice president for professional practices in speech-language pathology, convened a committee in October 2006 to examine the issues and make recommendations to the ASHA Board of Directors. Committee members included Anastasia Antoniadis, Suzanne Ducharme, Maureen A. Lefton-Greif, Sherry Sancibrian, and Lemmietta McNeilly (ex officio). Genncis Rosado joined the committee in 2008 following Antoniadis' departure.
"Encroachment" is a term that has been used by SLPs and ASHA in various contexts. Initial discussion focused on that term and its negative connotation. The committee sought to reframe "encroachment" by referring to the issue as "scope of practice" or "role ambiguity" to reflect more accurately the prevailing emphasis on team-driven models.
To determine the extent and scope of encroachment perception, the committee developed and disseminated an electronic survey to 50,335 members in May 2007. Responses were obtained from 4,708 members (ASHA, 2007), yielding a response rate of 9.4% (see Figure 1 [PDF]).
Survey highlights are listed in the sidebar on p. 15 (the complete report is available online).
Briefly, survey responses revealed:
- SLPs were evenly divided about the appropriateness of the term "encroachment" and how to define it.
- SLPs who have and have not experienced encroachment reported concern about this issue.
- SLPs were most likely to identify encroachment from professions with the greatest degree of overlap in scope of practice.
- Disorders/populations that require the highest level of teaming and collaboration were most susceptible to the perception of encroachment.
- SLPs' perceptions and experiences of encroachment were related to internal factors (i.e., institutional patterns of practice and service delivery) and external factors (i.e,, reimbursement issues and patterns).
- ASHA cannot mandate the scope of practice for another discipline, but might be an agent to facilitate change.
- Many of the suggestions about steps to improve the situation are already in place or underway through ASHA programs.
- Many respondents reported concerns or ambivalence about the expanding scope of practice in the field. Some clinicians reported being asked to perform tasks or work in areas they deemed inappropriate given their training and comfort levels. Others indicated disapproval of SLPs' involvement in specific areas of practice, including swallowing, literacy, and cognition. Survey results underscored some sharp contrasts within the field and the need for more discussion and debate.
The negative connotation of the term "encroachment" expressed by survey respondents has spurred an interest in adopting terminology that reflects a more accurate—and neutral—view of professions' overlapping scopes of practice. A more appropriate term may be "role ambiguity," as professional boundaries stretch as SLPs expand their roles to meet client needs.
Team-Oriented Service Delivery
It is ASHA's position that SLPs do not "own" any aspect of their scope of practice, nor can they dictate what another profession can or cannot do. Clearly, speech-language pathology shares professional boundaries with related professions, and SLPs need to understand other team members' expertise while articulating the value of their own unique knowledge and skills.
A potential response to environmental changes in education and health care is to increase collaboration and teaming to enhance functional outcomes. "Teaming" emphasizes an individual-by-individual approach that focuses on the "whole" client as he or she functions within the environment, rather than a profession-by-profession approach. Each team must determine how to define and execute best practices for each client in that specific setting. Team-building and decisions for each client are affected by the individuals who make up the team and the professions they represent. Each professional brings a unique scope of practice, professional identity, skill set, and personal opinions about how to interact with other team members.
Team Practice Models
Teams are traditionally classified as multidisciplinary, interdisciplinary, and transdisciplinary. Boon, Verhoef, O'Hara, and Findlay (2004) propose an expanded conceptual framework with seven models on a continuum from parallel to integrative practice (see Table 1 [PDF]). Boon et al. emphasize that there is no single "best" model; different types and stages of care require different practice models. A child with a mild articulation disorder may be well-served by the parallel practice model, but an interdisciplinary or integrative approach might better meet the multi-faceted needs of a child with autism or an adult in rehabilitation after a stroke. A more intensive, integrative model may be preferable in initial stages of care, with a gradual shift to less integrative models as intervention goals are achieved.
Teamwork has obvious advantages if one assumes that many perspectives yield better outcomes than fewer perspectives. Team members share knowledge and resources and provide integrated intervention rather than perform isolated tasks; teamwork may reduce redundancy and fragmentation of service and improve quality and cost-efficiency.
Implementation of a team model may, however, be challenging. Barriers to effective team building and teamwork include:
- Lack of time. In an era of cost containment, increased productivity demands, and personnel shortages, time for team meetings is dwindling. This problem has been exacerbated by the inability to bill for team conferencing time (see Table 2 [PDF]), although it may change as new billing codes for team services are implemented.
- Lack of information. A survey of students in physical and occupational therapy and speech-language pathology found that although students were aware of the teamwork concept they had little teamwork experience (Insalaco, Ozkurt, & Santiago, 2007) and limited knowledge of other professions' training and expertise.
- Lack of harmony. Friction among team members may arise from many sources, including differences in generation, gender, culture, stage of career development, hierarchical status, commitment to the team approach, personality, and work styles. Perhaps the most common source of tension comes from ambiguity over team members' roles. Shared practice areas offer numerous opportunities for collaboration, but concern over protecting professional turf can destroy the trust and mutual respect required to function as a team.
Teaming requires SLPs to develop skills to establish team relationships, navigate conflict, solve problems, deal with divergent thinking, and incorporate new paradigms for analyzing situations and implementing solutions. Recognizing these requirements, ASHA (2001) has identified workplace skills that graduate students need, including team-building, conflict management, "organizational agility," and interpersonal skills.
Opportunities for New Skills
Teaming provides new opportunities for SLPs. Nancarrow and Borthwick (2005) reviewed how team members can develop and deliver skills within and across professional boundaries:
- Diversification: development of new treatment methods or techniques not previously practiced by any particular professional group, resulting in an expansion of the professional boundaries.
- Specialization: development of an increased level of expertise in an area adopted by a profession.
- Vertical substitution: adoption of tasks across professions with different levels of training or expertise (for example, changing the role of nursing to include the prescribing of medication).
- Horizontal substitution: providers undertake roles normally within the scope of another profession, not because of a desire for increased professional or financial status, but because of factors including staff shortages, work settings, and treatment populations.
Resolution of Role Ambiguity
The path to resolving role ambiguity may be blocked by structural or organizational obstacles (see Table 3 [PDF]). The management style of an organization may not allow a clinician to challenge the administration with questions of role ambiguity. Communication among providers and between providers and administration may not be open and bidirectional. Expectations of managers who have no direct contact with clients may differ from the practitioner's view of quality of care. Practitioners may disagree on the primary roles of their own and other professions.
There is a lack of models to help SLPs clarify issues stemming from role ambiguity and resolution of associated conflicts. A candidate model must be sufficiently fluid to allow for the integration of relevant facts (e.g., evidence-based methodologies) with judgments (e.g., perceived or desired roles of individual team members), regardless of work setting and specific populations served. Adaptation of a model that addresses ethical quandaries proposed by Lefton-Greif and Arvedson (1997) may provide a framework for managing the complex issues evolving from role ambiguity. The model includes:
- Identifying pertinent organizational systems and acquiring relevant facts about each of the systems.
- Defining potential actions and their consequences.
- Implementing "best" actions.
Finally, individual SLPs face personal decisions regarding the need to balance the cultures of institutional and team systems with their professional scope and practices. For example, role expectations for SLPs differ across settings for a variety of reasons including, but not limited to, history (the way things have always been done), personnel shortages (past or current), and personal decisions.
Current trends suggest that SLPs and other allied health professionals will face even greater role diversification—and therefore issues of role ambiguity—in the future.
Beyond role ambiguity, two related critical areas need to be addressed within the profession. First, personnel shortages demand recruitment of new SLPs educated in the current and anticipated needs of the populations served. Second, research is needed to establish the evidence base for speech-language pathology practice.
Strategies are needed to improve recognition of the SLP's role and ensure the highest quality of services. The profession must:
- Increase awareness of speech-language pathology among college undergraduates to encourage more students to consider the field.
- Develop graduate curricula with interdisciplinary training and information about the roles of SLPs on teams.
- Create post-graduate opportunities for mentoring and training that promote advanced levels of clinical practice and research.
- Conduct research that demonstrates the impact of the SLP's expertise on outcomes.
- Advocate for changes in educational and health care policies that enhance the delivery of speech-language treatment and help establish appropriate salary and reimbursement levels.
- Educate consumers about SLPs' services.
- Increase communication among professional organizations in allied health fields to enhance understanding of each profession's knowledge base and develop models that promote interdisciplinary collaboration.
- Encourage use of current mechanisms—such as reimbursement codes—that support interdisciplinary models.
Scope-of-practice issues are viewed both negatively and positively by SLPs and other professionals who serve on various patient management teams; these views are determined by a variety of factors that affect scope of practice. SLPs should value and respect one another's roles and validate the specific roles of each individual team member in effective management of patients with communication disorders. It is also critical for SLPs to openly discuss specific roles with other team members so that the expertise of each professional can be maximized effectively to deliver services designed to meet the individual needs of each patient.
The 2007-2009 Vice President for Speech-Language Pathology Practice Coordinating Committee included Brian Shulman, PhD, CCC-SLP (chair); Suzanne Ducharme, MS, CCC-SLP; Maureen A. Lefton-Greif, PhD, CCC-SLP; Genncis Rosado, MA, CCC-SLP; Sherry Sancibrian, MS, CCC-SLP; and Lemmietta McNeilly, PhD, CCC-SLP (ex officio).