Published 2017. This Issues in Ethics statement is a revision of Ethical Issues Related to Clinical Services Provided by Audiology and Speech-Language Pathology Students (2013), which revised Fees for Clinical Service Provided by Students and Clinical Fellows (2004) and Clinical Service Provided by Students and Clinical Fellows (2003). It has been updated to make any references to the Code of Ethics consistent with the Code of Ethics (2016). 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.
From time to time, the Board of Ethics (hereinafter, the "Board") 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 (2016) (hereinafter, the "Code") and are 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.
The Code provides guidance regarding the ethical issues that may arise when professional service is provided by students. Although the Board does not have jurisdiction over students, the Code does apply to their supervisors, clinic directors, and mentors. Specifically, Principle of Ethics I, Rule G recognizes the professional acceptability of appropriately supervised clinical practice by students by stating, "Individuals who hold the Certificate of Clinical Competence may delegate to students 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 only if those students are adequately prepared and are appropriately supervised. The responsibility for the welfare of those being served 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:
The Code 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, and scholarly 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.
The Code provides guidance to certificate holders who are responsible for the supervision of students in Principle of Ethics I, Rule G (full text above in Introduction). The main emphasis of Rule G is found in the last sentence, which states "the responsibility for the welfare of those being served 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 specifics and complexity of the clinical case. Supervisors must be mindful that at all times 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 in a timely manner if there is any question regarding the quality of the care being provided.
The Code 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. As a general rule, when more than one supervision requirement applies, the most stringent requirement should be followed.
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 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.
The Code 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.
The roles and responsibilities of a graduate student in a practicum assignment and 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.