Revised Scope of Practice in Audiology Reflects Evolving Profession

November 2018

Julie Honaker

By the year 2050, the Unites states will experience a significant growth in persons over the age of 65, projected at close to 90 million, with an increase in the overall population of close to 400 million (Ortman, Velkoff, & Hogan, 2014). Our aging population will have a significant impact on hearing health care, with more individuals experiencing hearing loss, dizziness, and other related concerns such as tinnitus. Indeed, it is time for us to ask whether we are keeping up with the changes in our profession and working at the top of our license to meet the needs of this demand. Simply stated, are we engaging in patient care activities consistent with our skill set and knowledge? Are we keeping with best practice recommendations?

It is often said that the only thing constant is change. Thus, it is time to reflect on the changing and evolving practice of audiology to pave the way for the future of our profession. The last update to ASHA’s Scope of Practice (SOP) in Audiology was in 2004. During the past 14 years, we have seen significant technological advances in assessment and intervention for hearing, balance, and other related conditions (e.g., tinnitus). These changes in the profession, along with new trends in related disciplines, were the impetus for this revision to our SOP. Through the work of the ASHA Ad Hoc Committee on the Scope of Practice in Audiology, a revised Scope of Practice in Audiology was created (ASHA, 2018). The information provided in the updated SOP was carefully selected based on best practice guidelines, an extensive search of the literature, and clinical experience and expertise. 

Timeline of the Scope of Practice in Audiology

The initial document was completed in 1990 as a joint Scope of Practice for Speech-Language Pathology and Audiology. A position statement titled Scope of Practice in Audiology was approved in 1995, which then led to the initial version of the Scope of Practice in Audiology in 1996 (Bergen, 2003). In 2004, a revised scope of practice was accepted that was substantially longer and more comprehensive than previous versions, with emphasis on our expanding clinical duties and role within the framework of the World Health Organization’s International Classification of Functioning, Disability and Health (ICF; WHO, 2014). In 2017, a group of eight audiologists with diverse audiology subspecialties, an ASHA board liaison, and an ex officio member met to review and revise the 2004 SOP. Their charge was to design a clear, concise document outlining the current and evolving practice areas, nonmedical treatment, and (re)habilitation services. Through face-to-face meetings and conference calls, a revised version of the document was submitted for peer review in March 2018—initially to targeted groups and then to the ASHA members at large. The Ad Hoc Committee then reviewed all received comments and addressed the action items in a final draft, which was submitted to the ASHA Board of Directors in early August 2018. It reached final approval on August 20, 2018.

New in This Version

Prior to the discussion of the specific changes in practice, the updated SOP provides an introduction with 13 definitions, including a revised definition of audiologist, a statement of purpose, and the goals of the SOP. It emphasizes that this SOP should not replace existing state licensure laws but should serve as a model for development or modifications to these laws. The revision outlines the growing trend of specialization within our field, whereas our training programs cover all areas. The document format clearly defines audiology service delivery areas, including all areas of hearing, balance, and other related disorders such as tinnitus, cognition, and auditory processing; it also provides guidance on the additional areas of audiology practice. The document continues to incorporate use of the ICF (WHO, 2014), but less emphasis is placed on outlining the specifics of the ICF domains. Key updates to the SOP are highlighted below in bold, italic font. 

Role of diagnostics for hearing, balance, and related disorders was expanded to include administration of clinical case history; behavioral, electroacoustic, and electrophysiologic measures; and diagnostic screening, with additional screening for cognitive impairment and mental health—all to aid in assessment, intervention, and referrals. The language is still broad so as not to limit our scope based on emerging trends, but it now outlines the use of quantitative and qualitative tools, explains modifications to our diagnostic measures based on patient factors, and details the discussion of looking beyond our diagnostic measures to include informational counseling, interpretation of results, and intervention.

Although a large part our professional practice focuses on diagnostic care, increased emphasis on treatment for hearing, balance, and other related disorders is provided in the updated SOP. In particular, it highlights the comprehensive (re)habilitation services that audiologists provide to individuals and families across the lifespan—services such as auditory training; counseling; manual communication; strategies to address tinnitus, misophonia, and vestibular disorders; and technology interventions.

Hearing amplification needs are still a focus of (re)habilitation programs, but the updated scope is inclusive of the diverse services that we may provide beyond selecting, fitting, verifying, and validating hearing technology performance. As audiologists, we work with a variety of interventions not only for hearing but also for balance and other related disorders. The updated scope outlines advances in medicine and our role with other emerging technologies such as auditory brainstem implants, balance-related devices, classroom audio distribution systems, cochlear implants, middle ear implants, osseointegrated devices, tinnitus devices, hearing assistive technology, and even over-the-counter (OTC) hearing aids. Additional importance is placed on collaboration with other professionals in the delivery of these interventions for improved quality of care.

Additional changes to the document include distinct sections related to treatment for children, with descriptions of developmental and educational interventions (e.g., Individualized Education Program [IEP], Individualized Family Service Plan [IFSP]) for school-age children and for children birth to 36 months, participation in a 504 plan, and role in the classroom for sound measurement and noise reduction modifications. Specific sections are now dedicated to Early Hearing Detection and Intervention (EHDI) as well as educational audiology, with details of the full spectrum of hearing services provided for academic support, early screening, assessment, and treatment services.

The updated scope classifies the role of the audiologist in hearing conservation and preservation programs for occupational and nonoccupational settings to help prevent hearing loss from occurring in individuals. It outlines our charge to adhere to and monitor current Occupational Safety and Health (OSHA) regulations for hearing protection and monitoring risk. In addition, this section outlines the capacity at which we serve in these programs through sound measurement, assessing risk of noise-induced hearing loss, and determining functional hearing abilities. It also specifically indicates that audiologists implement and manage all aspects of hearing conservation activities, including educating the public and other professionals on the prevention of noise-induced hearing loss.

Finally, this section of the SOP describes the audiologist’s role in telehealth for both diagnostics and intervention services, to meet the audiologic needs of underserved communities and to expand our service delivery model. Under the direction of the American Telemedicine Association (Richmond et al., 2017), audiologists should comply with appropriate regulatory and accrediting agencies. Areas of care may include aural/auditory (re)habilitation, auditory evoked potentials, hearing aid and cochlear implant fitting/programming, supervision of electrophysiology services, and supervision of hearing and balance services—including vestibular rehabilitation.

The updated SOP also recognizes our distinct role in counseling for education, guidance, and support to individuals and their families. These counseling strategies include informational counseling regarding interpretation of findings, with expansion of our role for empowering individuals and their families by providing support and the tools to become self-advocates to make informed decisions related to plan of care.

Much of the above discussion outlines our role in clinical practice. However, many audiologists have duties and responsibilities outside the clinical realm, including work in academic, government, and educational settings. Thus, the updated SOP should reflect the ever-expanding profession of audiology and the positions that audiologists hold. The section titled "Additional Areas of Audiology Practice" stresses interdisciplinary education and interprofessional practice (IPE/IPP) and the work of audiologists inside and outside the clinic to help advance the care for individuals with hearing, balance, and other related disorders. Activities that are described in addition to IPE/IPP include research, administration and leadership, education, advocacy and outreach, cultural competency, clinical supervision/precepting, business management, and legal/professional consulting.

Indeed, it is an exciting time to be an audiologist, and we should continue to make every effort to address the needs of the individuals and families we serve. Audiologists are encouraged to read the updated SOP and think deeply about how they are using—or how they plan to implement—high-quality, evidence-based services and work at the top of their license within their practice setting. This document will also articulate to other professionals the current and emerging roles and responsibilities of the audiologist—and how audiologists can better align their services for the care of individuals with hearing and balance concerns across the lifespan.

About the Author and Acknowledgements

Julie A. Honaker, PhD, CCC-A, is director of the Vestibular and Balance Disorders Laboratories of the Head and Neck Institute at Cleveland Clinic. She served as chair of the ASHA Ad Hoc Committee on the Scope of Practice in Audiology, but this document could not have come to fruition without the help of the other committee members: Robert Beiter, Kathleen Cienkowski, Gregory Mannarelli, Maryrose McInerney, Tena McNamara, Jessica Sullivan, Julie Verhoff, Robert Fifer (board liaison), and Pam Mason (ex officio). On behalf of the committee, we sincerely thank everyone who provided feedback and guidance to update the Scope of Practice in Audiology.

References

American Speech-Language-Hearing Association. (2018). ASHA scope of practice in audiology. Retrieved from https://www.asha.org/policy/SP2018-00353/.

Bergen, M. (2003). Audiology scope of practice expands as profession grows. The ASHA Leader,8, 1–25. Retrieved from https://leader.pubs.asha.org/article.aspx?articleid=2292408.

Ortman, J. M., Velkoff, V. A., & Hogan, H. (2014). An aging nation: The older population in the United States. [U.S. Department of Commerce Economics and Statistics Administration, U.S. Census Bureau, Pub. No. P25-1140]. Retrieved from https://www.census.gov/content/dam/Census/library/publications/2014/demo/p25-1140.pdf [PDF].

Richmond, T., Peterson, C., Cason, J., Billings, M., Abrahante, T., Chong, W., ...Brennan, D. (2017). American Telemedicine Association's principles for delivering telerehabilitation services. International Journal of Telerehabilitation, 9(2), 63–68. Retrieved from http://telerehab.pitt.edu/ojs/index.php/Telerehab/article/view/6232.

World Health Organization. (2014). International classification of functioning, disability and health. Geneva, Switzerland: Author. Retrieved from http://www.who.int/classifications/icf/icf_more/en/.

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