Scope of Practice in Audiology

Statement of Purpose

The purpose of this document is to define the scope of practice in audiology in order to (a) describe the services offered by qualified audiologists as primary service providers, case managers, and/or members of multidisciplinary and interdisciplinary teams; (b) serve as a reference for health care, education, and other professionals, and for consumers, members of the general public, and policy makers concerned with legislation, regulation, licensure, and third party reimbursement; and (c) inform members of ASHA, certificate holders, and students of the activities for which certification in audiology is required in accordance with the ASHA Code of Ethics.

Audiologists provide comprehensive diagnostic and treatment/rehabilitative services for auditory, vestibular, and related impairments. These services are provided to individuals across the entire age span from birth through adulthood; to individuals from diverse language, ethnic, cultural, and socioeconomic backgrounds; and to individuals who have multiple disabilities. This position statement is not intended to be exhaustive; however, the activities described reflect current practice within the profession. Practice activities related to emerging clinical, technological, and scientific developments are not precluded from consideration as part of the scope of practice of an audiologist. Such innovations and advances will result in the periodic revision and updating of this document. It is also recognized that specialty areas identified within the scope of practice will vary among the individual providers. ASHA also recognizes that credentialed professionals in related fields may have knowledge, skills, and experience that could be applied to some areas within the scope of audiology practice. Defining the scope of practice of audiologists is not meant to exclude other appropriately credentialed postgraduate professionals from rendering services in common practice areas.

Audiologists serve diverse populations. The patient/client population includes persons of different race, age, gender, religion, national origin, and sexual orientation. Audiologists' caseloads include individuals from diverse ethnic, cultural, or linguistic backgrounds, and persons with disabilities. Although audiologists are prohibited from discriminating in the provision of professional services based on these factors, in some cases such factors may be relevant to the development of an appropriate treatment plan. These factors may be considered in treatment plans only when firmly grounded in scientific and professional knowledge.

This scope of practice does not supersede existing state licensure laws or affect the interpretation or implementation of such laws. It may serve, however, as a model for the development or modification of licensure laws.

The schema in Figure 1 depicts the relationship of the scope of practice to ASHA's policy documents that address current and emerging audiology practice areas; that is, preferred practice patterns, guidelines, and position statements. ASHA members and ASHA-certified professionals are bound by the ASHA Code of Ethics to provide services that are consistent with the scope of their competence, education, and experience (ASHA, 2003). There are other existing legislative and regulatory bodies that govern the practice of audiology.

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Framework for Practice

The practice of audiology includes both the prevention of and assessment of auditory, vestibular, and related impairments as well as the habilitation/rehabilitation and maintenance of persons with these impairments. The overall goal of the provision of audiology services should be to optimize and enhance the ability of an individual to hear, as well as to communicate in his/her everyday or natural environment. In addition, audiologists provide comprehensive services to individuals with normal hearing who interact with persons with a hearing impairment. The overall goal of audiologic services is to improve the quality of life for all of these individuals.

The World Health Organization (WHO) has developed a multipurpose health classification system known as the International Classification of Functioning, Disability, and Health (ICF) (WHO, 2001). The purpose of this classification system is to provide a standard language and framework for the description of functioning and health. The ICF framework is useful in describing the role of audiologists in the prevention, assessment, and habilitation/rehabilitation of auditory, vestibular, and other related impairments and restrictions or limitations of functioning.

The ICF is organized into two parts. The first part deals with Functioning and Disability while the second part deals with Contextual Factors. Each part has two components. The components of Functioning and Disability are:

• Body Functions and Structures: Body Functions are the physiological functions of body systems and Body Structures are the anatomical parts of the body and their components. Impairments are limitations or variations in Body Function or Structure such as a deviation or loss. An example of a Body Function that might be evaluated by an audiologist would be hearing sensitivity. The use of typanometry to access the mobility of the tympanic membrane is an example of a Body Structure that might be evaluated by an audiologist.

• Activity/Participation: In the ICF, Activity and Participation are realized as one list. Activity refers to the execution of a task or action by an individual. Participation is the involvement in a life situation. Activity limitations are difficulties an individual may experience while executing a given activity. Participation restrictions are difficulties that may limit an individual's involvement in life situations. The Activity/Participation construct thus represents the effects that hearing, vestibular, and related impairments could have on the life of an individual. These effects could include the ability to hold conversations, participate in sports, attend religious services, understand a teacher in a classroom, and walk up and down stairs.

The components of Contextual Factors are:

• Environmental Factors: Environmental Factors make up the physical, social, and attitudinal environment in which people live and conduct their lives. Examples of Environmental Factors, as they relate to audiology, include the acoustical properties of a given space and any type of hearing assistive technology.

• Personal Factors: Personal Factors are the internal influences on an individual's functioning and disability and are not a part of the health condition. These factors may include but are not limited to age, gender, social background, and profession.

Functioning and Disability are interactive and evolutionary processes. Figure 2 illustrates the interaction of the various components of the ICF. Each component of the ICF can be expressed on a continuum of function. On one end of the continuum is intact functioning. At the opposite end of the continuum is completely compromised functioning. Contextual Factors (Environmental and Personal Factors) may interact with any of the components of functioning and disability. Environmental and Personal Factors may act as facilitators or barriers to functioning.

The scope of practice in audiology encompasses all of the components of the ICF. During the assessment phase, audiologists perform tests of Body Function and Structure. Examples of these types of tests include otoscopic examination, pure-tone audiometry, tympanometry, otoacoustic emissions measurements, and speech audiometry. Activity/Participation limitations and restrictions are sometimes addressed by audiologists through case history, interview, questionnaire, and counseling. For example, a question such as “Do you have trouble understanding while on the telephone?” or “Can you describe the difficulties you experience when you participate in a conversation with someone who is not familiar to you?” would be considered an assessment of Activity/Participation limitation or restriction. Questionnaires that require clients to report the magnitude of difficulty that they experience in certain specified settings can sometimes be used to measure aspects of Activity/Participation. For example: “Because of my hearing problems, I have difficulty conversing with others in a restaurant.” In addition, Environmental and Personal Factors also need to be taken into consideration by audiologists as they treat individuals with auditory, vestibular, and other related impairments. In the above question regarding conversation in a restaurant, if the factor of “noise” (i.e., a noisy restaurant) is added to the question, this represents an Environmental Factor. Examples of Personal Factors might include a person's background or culture that influences his or her reaction to the use of a hearing aid or cochlear implant. The use of the ICF framework (WHO, 2001) may help audiologists broaden their perspective concerning their role in evaluating a client's needs or when designing and providing comprehensive services to their clients. Overall, audiologists work to improve quality of life by reducing impairments of body functions and structures, Activity limitations/Participation restrictions and Environmental barriers of the individuals they serve.

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Definition of an Audiologist

Audiologists are professionals engaged in autonomous practice to promote healthy hearing, communication competency, and quality of life for persons of all ages through the prevention, identification, assessment, and rehabilitation of hearing, auditory function, balance, and other related systems. They facilitate prevention through the fitting of hearing protective devices, education programs for industry and the public, hearing screening/conservation programs, and research. The audiologist is the professional responsible for the identification of impairments and dysfunction of the auditory, balance, and other related systems. Their unique education and training provides them with the skills to assess and diagnose dysfunction in hearing, auditory function, balance, and related disorders. The delivery of audiologic (re)habilitation services includes not only the selecting, fitting, and dispensing of hearing aids and other hearing assistive devices, but also the assessment and follow-up services for persons with cochlear implants. The audiologist providing audiologic (re)habilitation does so through a comprehensive program of therapeutic services, devices, counseling, and other management strategies. Functional diagnosis of vestibular disorders and management of balance rehabilitation is another aspect of the professional responsibilities of the audiologist. Audiologists engage in research pertinent to all of these domains.

Audiologists currently hold a master's or doctoral degree in audiology from a program accredited by the Council on Academic Accreditation in Audiology and Speech-Language Pathology (CAA) of the American Speech-Language-Hearing Association. ASHA-certified audiologists complete a supervised postgraduate professional experience or a similar supervised professional experience during the completion of the doctoral degree as described in the ASHA certification standards. Beginning January 1, 2012, all applicants for the Certificate of Clinical Competence in Audiology must have a doctoral degree from a CAA-accredited university program. Demonstration of continued professional development is mandated for the maintenance of the Certificate of Clinical Competence in Audiology. Where required, audiologists are licensed or registered by the state in which they practice.

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Professional Roles and Activities

Audiologists serve a diverse population and may function in one or more of a variety of activities. The practice of audiology includes:

1. Prevention

   1. Promotion of hearing wellness, as well as the prevention of hearing loss and protection of hearing function by designing, implementing, and coordinating occupational, school, and community hearing conservation and identification programs;

   2. Participation in noise measurements of the acoustic environment to improve accessibility and to promote hearing wellness.

2. Identification

   1. Activities that identify dysfunction in hearing, balance, and other auditory-related systems;

   2. Supervision, implementation, and follow-up of newborn and school hearing screening programs;

   3. Screening for speech, orofacial myofunctional disorders, language, cognitive communication disorders, and/or preferred communication modalities that may affect education, health, development or communication and may result in recommendations for rescreening or comprehensive speech-language pathology assessment or in referral for other examinations or services;

   4. Identification of populations and individuals with or at risk for hearing loss and other auditory dysfunction, balance impairments, tinnitus, and associated communication impairments as well as of those with normal hearing;

   5. In collaboration with speech-language pathologists, identification of populations and individuals at risk for developing speech-language impairments.

3. Assessment

   1. The conduct and interpretation of behavioral, electroacoustic, and/or electrophysiologic methods to assess hearing, auditory function, balance, and related systems;

   2. Measurement and interpretation of sensory and motor evoked potentials, electromyography, and other electrodiagnostic tests for purposes of neurophysiologic intraoperative monitoring and cranial nerve assessment;

   3. Evaluation and management of children and adults with auditory-related processing disorders;

   4. Performance of otoscopy for appropriate audiological management or to provide a basis for medical referral;

   5. Cerumen management to prevent obstruction of the external ear canal and of amplification devices;

   6. Preparation of a report including interpreting data, summarizing findings, generating recommendations and developing an audiologic treatment/management plan;

   7. Referrals to other professions, agencies, and/ or consumer organizations.

4. Rehabilitation

   1. As part of the comprehensive audiologic (re)habilitation program, evaluates, selects, fits and dispenses hearing assistive technology devices to include hearing aids;

   2. Assessment of candidacy of persons with hearing loss for cochlear implants and provision of fitting, mapping, and audiologic rehabilitation to optimize device use;

   3. Development of a culturally appropriate, audiologic rehabilitative management plan including, when appropriate:

      1. Recommendations for fitting and dispensing, and educating the consumer and family/caregivers in the use of and adjustment to sensory aids, hearing assistive devices, alerting systems, and captioning devices;

      2. Availability of counseling relating to psycho social aspects of hearing loss, and other auditory dysfunction, and processes to enhance communication competence;

      3. Skills training and consultation concerning environmental modifications to facilitate development of receptive and expressive communication;

      4. Evaluation and modification of the audiologic management plan.

   4. Provision of comprehensive audiologic rehabilitation services, including management procedures for speech and language habilitation and/or rehabilitation for persons with hearing loss or other auditory dysfunction, including but not exclusive to speechreading, auditory training, communication strategies, manual communication and counseling for psychosocial adjustment for persons with hearing loss or other auditory dysfunction and their families/caregivers;

   5. Consultation and provision of vestibular and balance rehabilitation therapy to persons with vestibular and balance impairments;

   6. Assessment and non-medical management of tinnitus using biofeedback, behavioral management, masking, hearing aids, education, and counseling;

   7. Provision of training for professionals of related and/or allied services when needed;

   8. Participation in the development of an Individual Education Program (IEP) for school-age children or an Individual Family Service Plan (IFSP) for children from birth to 36 months old;

   9. Provision of in-service programs for school personnel, and advising school districts in planning educational programs and accessibility for students with hearing loss and other auditory dysfunction;

   10. Measurement of noise levels and provision of recommendations for environmental modifications in order to reduce the noise level;

   11. Management of the selection, purchase, installation, and evaluation of large-area amplification systems.

5. Advocacy/ Consultation

   1. Advocacy for communication needs of all individuals that may include advocating for the rights/funding of services for those with hearing loss, auditory, or vestibular disorders;

   2. Advocacy for issues (i.e., acoustic accessibility) that affect the rights of individuals with normal hearing;

   3. Consultation with professionals of related and/or allied services when needed;

   4. Consultation in development of an Individual Education Program (IEP) for school-age children or an Individual Family Service Plan (IFSP) for children from birth to 36 months old;

   5. Consultation to educators as members of interdisciplinary teams about communication management, educational implications of hearing loss and other auditory dysfunction, educational programming, classroom acoustics, and large-area amplification systems for children with hearing loss and other auditory dysfunction;

   6. Consultation about accessibility for persons with hearing loss and other auditory dysfunction in public and private buildings, programs, and services;

   7. Consultation to individuals, public and private agencies, and governmental bodies, or as an expert witness regarding legal interpretations of audiology findings, effects of hearing loss and other auditory dysfunction, balance system impairments, and relevant noise-related considerations;

   8. Case management and service as a liaison for the consumer, family, and agencies in order to monitor audiologic status and management and to make recommendations about educational and vocational programming;

   9. Consultation to industry on the development of products and instrumentation related to the measurement and management of auditory or balance function.

6. Education/ Research/Administration

   1. Education, supervision, and administration for audiology graduate and other professional education programs;

   2. Measurement of functional outcomes, consumer satisfaction, efficacy, effectiveness, and efficiency of practices and programs to maintain and improve the quality of audiologic services;

   3. Design and conduct of basic and applied audiologic research to increase the knowledge base, to develop new methods and programs, and to determine the efficacy, effectiveness, and efficiency of assessment and treatment paradigms; disseminate research findings to other professionals and to the public;

   4. Participation in the development of professional and technical standards;

   5. Participation in quality improvement programs;

   6. Program administration and supervision of professionals as well as support personnel.

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Practice Settings

Audiologists provide services in private practice; medical settings such as hospitals and physicians' offices; community and university hearing and speech centers; managed care systems; industry; the military; various state agencies; home health, subacute rehabilitation, long-term care, and intermediate-care facilities; and school systems. Audiologists provide academic education to students and practitioners in universities, to medical and surgical students and residents, and to other related professionals. Such education pertains to the identification, functional diagnosis/assessment, and non-medical treatment/management of auditory, vestibular, balance, and related impairments.