Professional Issues in Speech-Language Pathology and Audiology [6 ed.] 1635506557, 9781635506556

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Students reading this book will appreciate how the professions have evolved over time while acquiring a sense of where they are right now as they prepare to enter the professional world. Each of the topics covered in the book will continue to play important roles in the future of speech-language pathology and audiology, providing early career professionals with the requisite knowledge to achieve success in any setting. New to the Sixth Edition: • New information on issues related to the COVID-19 pandemic • Coverage of recent changes in technology • Updates to ASHA certification requirements, the Assistants certification program, and the 2023 ASHA Code of Ethics • New contributors: Nicole E. Corbin, Sandra Liang Gillam, Erin E.G. Lundblom, Christine T. Matthews, Shari Robertson, Rachel A. Ritter, and Jennifer P. Taylor • Updated list of acronyms used in the book Key Features: • Chapters authored by recognized experts in communication sciences and disorders • Each chapter begins with an introduction and ends with a summary of key areas • Case studies related to child and elder abuse • Case studies related to advocacy From the Foreword: “The editors have been immersed for many years in undergraduate and graduate education as well as in the practice of audiology and speech-language pathology. Their varied experiences are illustrated in their selection of topics and authors. …Chapters on competency-based education and practice, leadership, and stress and conflict in the workplace offer valuable guidance for students as they prepare to shift to the next phase of their evolving careers. Ultimately, this is a resource for crafting a pathway to a vocation. The final chapter, Advocacy, by Dr. Tommie Robinson, serves as a coda to the abundance of resources contained in this text. He offers the “why” for what we do in the professions. According to Dr. Robinson, we all have the opportunity to promote our excellence, help those we serve to speak for themselves, and create access for others who need our services. The authors in this text craft the framework for this endeavor.” – Barbara H. Jacobson, PhD, CCC-SLP

www.pluralpublishing.com

Sixth Edition

PROFESSIONAL ISSUES in Speech-Language Pathology and Audiology

The book is divided into four major sections: Overview of the Professions, Employment Issues, Setting-Specific Issues, and Working Productively. The information presented in each section provides the reader with a better understanding and a new perspective on how professional issues have been affected by both internal and external influences in recent years including technological advances, demographic shifts, globalization, and economic factors. Chapter authors are recognized subject-matter experts, providing a blend of both foundational and cutting-edge information in areas such as evidence-based practice, ethics, job searching and employment issues, interprofessional practice, service delivery in health care and education, technology, cultural competence, supervision, and leadership.

Hudson DeRuiter

This sixth edition of Professional Issues in Speech-Language Pathology and Audiology is intended to be a primary text for students in speech-language pathology and audiology, as well as a resource for practitioners, providing a comprehensive introduction to contemporary issues that affect these professions and service delivery across settings. It aims to provide a better understanding that day-to-day clinical work, as well as personal professional growth and development are influenced by political, social, educational, health care, and economic concerns. By instilling a big-picture view of the profession, future clinicians will be more prepared to make informed decisions as they provide services, engage in advocacy efforts, and plan their careers as audiologists or speech-language pathologists.

PROFESSIONAL ISSUES in Speech-Language Pathology and Audiology Sixth

Edition

Melanie W. Hudson | Mark DeRuiter

PROFESSIONAL ISSUES in Speech-Language Pathology and Audiology Sixth Edition

PROFESSIONAL ISSUES in Speech-Language Pathology and Audiology Sixth Edition

Melanie W. Hudson, MA Mark DeRuiter, PhD, MBA

9177 Aero Drive, Suite B San Diego, CA 92123 Email: [email protected] Website: https://www.pluralpublishing.com

Copyright ©2025 by Plural Publishing, Inc. Typeset in 9/11 Adobe Garamond Pro by Flanagan’s Publishing Services, Inc. Printed in the United States of America by Bradford & Bigelow, Inc. All rights, including that of translation, reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording, or otherwise, including photocopying, recording, taping, web distribution, or information storage and retrieval systems without the prior written consent of the publisher. For permission to use material from this text, contact us by Telephone: (866) 758-7251 Fax: (888) 758-7255 Email: [email protected] Every attempt has been made to contact the copyright holders for material originally printed in another source. If any have been inadvertently overlooked, the publisher will gladly make the necessary arrangements at the first opportunity. Library of Congress Cataloging-in-Publication Data Names: Hudson, Melanie W., editor. | DeRuiter, Mark, editor. Title: Professional issues in speech-language pathology and audiology / [edited by] Melanie W. Hudson, Mark DeRuiter. Description: Sixth edition. | San Diego, CA : Plural Publishing, Inc., [2025] | Includes bibliographical references and index. Identifiers: LCCN 2023024925 (print) | LCCN 2023024926 (ebook) | ISBN 9781635506556 (paperback) | ISBN 1635506557 (paperback) | ISBN 9781635504569 (ebook) Subjects: MESH: Speech-Language Pathology | Audiology | Professional Practice Classification: LCC RC428.5 (print) | LCC RC428.5 (ebook) | NLM WL 21 | DDC 616.85/5--dc23/eng/20230824 LC record available at https://lccn.loc.gov/2023024925 LC ebook record available at https://lccn.loc.gov/2023024926

Contents

Foreword xv Preface xvii About the Editors

xix

Contributors xxi Acronyms xxv

Section I Overview of the Professions

1 Professions for the 21st Century 3 Melanie W. Hudson and Mark DeRuiter Introduction 3 Trends in Technology and the Digital Revolution

4

21st-Century Trends and Issues

5

Evidence-Based Practice (EBP)

7

Summary 7 References 7

2 Professional Issues and Organizations:   9 From the Past to the Present

Jaynee A. Handelsman Introduction 9 Practical Dilemmas and Affiliation

9

Organization of the Professions

10

Common Characteristics of Professional Associations

12

Historical Perspective on Scope and Practice Framework

12

Common Characteristics of Professional Associations Revisited

16

Related Professional Associations

20

State Associations and Impacts on Licensure

21

Student Organizations

22

International Professional Associations

22

v



vi CONTENTS

Focus on Recent History

23

Summary of the Evolution of the Professions

27

Summary 28 References 28

3 Establishing Our Competencies as Professionals:  33 Education, Certification, and Licensure

Lissa Power-deFur Introduction 33 How Do You Know You Are Competent?

34

Credentialing Programs

35

State Licensure

37

Professional Development and Certification Maintenance

38

Demonstrating Expertise in Particular Areas of Practice

39

Credentialing Graduate Programs

40

Next Steps:  After Graduation

41

Summary 43 References 43

4 Professional Ethics, Accountability, and Liability 45 Jaynee A. Handelsman Introduction 45 Standards of Professional Conduct

45

Conflicts of Interest

45

Role of Professional Associations

47

Ethical Issues in Practice Management

49

Ethical Issues in Supervision

52

Ethical Issues in Academia

53

Ethical Dilemmas

53

Unethical Complaint Process

53

Recent Changes and Future Directions

56

Summary of Professional Ethics

57

Introduction to Professional Accountability

57

Accountable Care

57

Managing Risks and Risk Intelligence for Accountable Clinicians and Organizations

57

Current Critical Risks Facing Health Care

58

Concept of Risk Intelligence

58

Raising the Bar on Accountability —The Value Equation

58

Learning Health Systems —An Opportunity to Shape the Future of Accountability

58

Professional Accountability Requires Relentless Reimagining

59

Conclusion and Summary of Professional Accountability

59

Introduction to Professional Liability

59

Summary 59 References 59

CONTENTS vii

5 International Alliances 63 Robert M. Augustine,Tina K.Veale, and Kelly M. Holland Introduction 63 Definitions:  Alliances, Partnerships, and Collaborations

64

International Alliances, Partnerships, and Collaborations Promoting Cultural Responsiveness for a Global Workforce Grounded in Standards of Practice

67

International Alliances and Access

69

International Alliances Through the American Speech-Language-Hearing Association

70

International Alliances Through Other Professional Organizations

71

International Alliances and Attributes of High-Quality Programs Offered Through Colleges and Universities

72

Alliances Promoting Macro International Experiences

81

International Alliances Promoting Global Research for Scholars

82

Summary 85 References 86 Appendix 5–A Definitions of Eight Transferrable Competencies Valued in the Workforce

91

Appendix 5–B Global Learning Value Rubric Glossary

92

Appendix 5–C Proposed Competencies for Global Engagement

96

Appendix 5–D An MOU Checklist for International Collaborations

99

6 Applying Evidence to Clinical Practice 101 Lizbeth H. Finestack and Stacy K. Betz Introduction 101 Evidence-Based Practice

102

Evaluating Assessment Evidence

104

Using Assessment Evidence

109

Evaluating Intervention Evidence

111

The Future of Evidence-Based Practice

117

Summary 118 References 118

Section II Employment Issues

7 Workforce Issues and Finding Employment 123 Mark DeRuiter and Cathy DeRuiter Introduction 123 The Current Workforce

123

ASHA Membership and Affiliation Data

124

Shortage of PhD Students and Faculty in CSD

126

The Future:  Factors Affecting Employment

127

Job Search

127

Resumé 128



viii CONTENTS

Completing Your Application

130

Interviewing Success

131

The Anatomy of an Interview

133

“Forbidden” Interview Questions

137

Postinterview Follow-Up

138

Considering the Benefits That Might Be Available to You

138

Salary and Benefits

138

Retirement and Other Incentives

140

Receiving the Offer

141

Making the Decision

142

Is This Where I Want to Work?

143

Red Flags

143

Getting Started

143

Summary 144 References 144 Resources 145 Appendix 7–A Sample Resumé

147

8 Building Your Career 149 Shari Robertson and Marva Mount Introduction 149 Getting Off to a Good Start

149

Professional Ethics

152

Creating a Career Path

152

Your First Mentor

153

Professional Skills That Foster Success

154

Impostor Syndrome

158

Professional Engagement and Responsibilities

160

Career Considerations

163

Summary 164 References 165

9 Assistants in Audiology and 167 Speech-Language Pathology

Diane Paul,Tricia Ashby-Scabis, and Lemmietta G. McNeilly Introduction 167 Rationale for Use of Assistants

168

Challenges of Using Assistants

170

Evolving Professional Policies and Practices

171

Chronology of Ethical and Professional Practice Policies Related to the Use of Assistants by Audiologists and Speech-Language Pathologists

173

Chronology of Professional Practice Policies

174

State Regulations

178

Supervisory Requirements

179

CONTENTS ix

Assistant Employment Trends

179

Training for Assistants

180

Credentialing Assistants

183

Supervision of Assistants

183

Supervision of Assistants in Speech-Language Pathology

184

Job Responsibilities of Audiology Assistants

185

Job Responsibilities of Assistants in Speech-Language Pathology

185

Payment of Services Provided by Assistants

185

Research Related to Assistants

186

Future Research Issues

190

Summary 191 References 191 Appendix 9–A Assistants in Audiology and Speech-Language Pathology: Key Word Definitions

200

Section III Setting-Specific Issues

10 Health Care Legislation, Regulation, and Financing 203 Jeffrey P. Regan Introduction 203 Medicare 203 Medicaid 205 Private Health Insurance

205

Coding Systems

205

Key Health Care Legislative and Regulatory Issues

206

Summary 210 References and Resources

210

11 Service Delivery in Health Care Settings 213 Jeffrey P. Johnson, Christine T. Matthews, and Alex F. Johnson Scope of Chapter

213

Health Care Settings and Key Responsibilities

213

Routine Considerations for Speech-Language Pathologists and Audiologists in Health Care

219

Dynamic Considerations for Speech-Language Pathologists and Audiologists in Health Care

228

Summary 231 References 232

12 Knowledge and Skills for Providing 237 Evidence-Based Services in School-Based Settings Sandra Laing Gillam Introduction 237 Population in U.S. Schools

238



x CONTENTS

Federal Legislation, Landmark Court Cases, and the Provision of Special 239 Education Services in Schools 242 Due Process Identification, Assessment, and Intervention in Schools 242 Service Delivery Options 247 Scheduling in the Schools 248 Working With Support Personnel 248 Professional Practice in the Schools 248 Outreach 249 Supervision 250 Research 250 Administration and Leadership 250 Summary 250 References 251

13 Service Delivery in Early Intervention 255 Corey Herd Cassidy Introduction 255 What Is Early Intervention? 256 Roles and Responsibilities of Speech-Language Pathologists and Audiologists 257 in Early Intervention 258 Guiding Principles of Early Intervention Comprehensive, Coordinated, and Team-Based Services 266 Services Based on the Highest Quality of Evidence 274 Other Considerations for Early Intervention Services in Natural Environments 275 Challenges and Evidence-Based Practices for Remote Service Delivery 277 Summary 278 References 279

14 Service Delivery Issues in Private Practice 285 Robin L. Edge Introduction 285 Advantages and Disadvantages of a Private Practice 286 Private Practice Options 286 Business Plan 289 Marketing Strategy 291 Location of Private Practice 291 Private Practice Credentials and Qualifications 292 Ethics 292 Cultural Competence 293 Resources Needed for Private Practice 293 Payment for Services 294 Rates for Services 296 Billing 297 297 Outcomes Data for Private Practices

CONTENTS xi

Networking 298 Summary 298 References 299 Resources 302

Section IV Working Productively

15 Strategically Promoting Access to Speech-Language 307 Pathology and Audiology Services

Brooke Hallowell Introduction 307 Identifying Barriers to Access 307 Ensuring Others Understand the Need for Our Services 309 Optimizing Reimbursement for Clinical Services 310 Advancing Legislation to Improve Access 313 Advocating for Our Professions 313 Actions for Advocacy and Professional Assertiveness 314 Care Extenders 317 Expanding Access Through Technology 318 Educating the Public 319 Adjusting Service-Providing Environments 319 Summary 320 References 320

16 Documentation 323 Nicole E. Corbin and Erin E. G. Lundblom Introduction 323 Purposes of Clinical Documentation for Consumers 323 General Principles of Clinical Documentation for Practitioners 324 326 Types of Clinical Documentation Influences on Clinical Documentation 330 Summary 340 References 340

17 Developing Leadership Skills 343 Gail J. Richard Introduction 343 Roles of a Leader 343 Effective Leadership Skills 345 Fiduciary Responsibilities 348 Strategies for Conflict in Leadership 349 Pathways to Leadership 351 Summary 354 References 355



xii CONTENTS

18 Safety in the Workplace 357 Cynthia McCormick Richburg and Donna Fisher Smiley Introduction 357 358 Regulatory Agencies 359 Accrediting Agencies Policies, Procedures, and Trainings 360 362 Personal and Environmental Hazards 364 Infection Control in Clinical and Educational Settings 366 Confidentiality of Client and Research Participant Information Summary 369 References 370 Appendix 18–A Acronyms 372

19 Overview of Interprofessional Practice and 373 Interprofessional Education

Alex F. Johnson Introduction 373 374 Interprofessional Practice Interprofessional Education 379 381 National and International Organizations and Resources for IPE and IPCP Summary 381 References 382

20 Child Abuse and Elder Mistreatment/Abuse 385 Carolyn Wiles Higdon Introduction 385 386 Child Abuse and Neglect: How to Identify Elder Mistreatment and Neglect 396 407 Palliative Care and Hospice Summary 409 References 410 Resources 413 Other Websites 414 415 Videos Related to Palliative Care and Hospice Appendix 20–A Case 1:  Joshua 416 Appendix 20–B Case 2:  Sam 417 418 Appendix 20–C Case 3:  Miriam Appendix 20–D Common Reactions in the Grief Process 419

21 Working With Culturally and Linguistically 421 Diverse Populations

Shirley Huang and Pui Fong Kan Introduction 421

CONTENTS xiii

Demographic Landscape in the United States

422

Speech, Language, and Hearing Clinicians and Scientists: Demographic Profiles

424

Defining Cultural and Linguistic Diversity

426

“An Inconvenient Truth”

429

Cultural Competence, Responsiveness, and Humility

429

Service Delivery for Children and Adults

430

Systems-Level Inequities

432

Action Is Long Overdue: Moving the Field Forward

434

Summary 436 References 436

22 Supervision and Mentoring 445 Melanie W. Hudson and Mary Sue Fino-Szumski Introduction 445 A Brief History of Supervision and Mentoring

445

The Supervisory Process

447

Key Elements of the Supervisory Process

449

CORE Model of Supervision and Mentoring

451

Supervisory Style and Communication Skills

451

Transition:  Supervisor to Mentor/Preceptor

453

Regulations, Standards, and Guidelines

454

Clinical Fellowship Experience and Audiology Externship

454

Speech-Language Pathology Clinical Fellowship (SLPCF)

454

Supervision Postcertification

456

Supervision of Students and Support Personnel

456

Ethical Issues

457

Cultural, Linguistic, and Generational Issues

458

Supervision of Challenging Supervisees

459

Technology and Supervision

459

Training in Supervision

460

Supervisor Accountability

461

Future Needs in Supervision and Mentoring

462

Summary 462 References 462 Resources 466

23 Technology for Service Delivery, Professional 469 Practice, and Student Training Carol C. Dudding and Rachel A. Ritter Scope of Chapter

469

The Digital Revolution

469

Technology for Service Delivery

470

Professional Practice Settings

480



xiv CONTENTS

Education and Training

482

Ethical Considerations

485

Summary 486 References 486

24 Managing Stress and Conflict in the Workplace 491 Mark DeRuiter and Jennifer P.Taylor Introduction 491 What Is Stress?

491

Burnout and Compassion Fatigue

493

What Are the Risks for Experiencing Burnout?

494

Workplace Conflict

496

Workplace Violence

499

Coping With Stress:  The Importance of Self-Care

500

Talking With Others

502

Employee Assistance Programs

503

Mindfulness Practices for Stress Reduction

503

Summary 504 References 504 Resources 507

25 Advocacy 509 Tommie L. Robinson, Jr. Introduction 509 Definitions 510 Recognizing the Benefits of Being an Advocate

510

Advocacy Case Examples

511

Developing a Game Plan for Advocacy

512

Legislative Advocacy

513

Resources 514 Summary 514 References 514 Index 517

Foreword

As a clinician and educator, I am honored to write this Foreword to the sixth edition of Professional Issues in Speech-Language Pathology and Audiology. Previous editions provided a foundation for teaching graduate courses and afforded helpful guidance in clinical practice. The editors have been immersed for many years in undergraduate and graduate education as well as in the practice of audiology and speech-language pathology. Their varied experiences are illustrated in their selection of topics and authors. While the focus of this book is on themes that are most critical for emerging clinicians, it is also designed to serve as a resource for more experienced practitioners who might want to seek another career path, understand the fundamentals of health care policy, refine their skills as clinical supervisors, or expand the scope of their clinical specialty internationally. While there are many online resources for topics covered in this text, Melanie Hudson and Mark DeRuiter have coalesced the context that frames our professions in one comprehensive text. In graduate school, students are focused on acquiring knowledge about the science underlying communication and swallowing disorders, the evidence that supports clinical practice, and the clinical methods that help students, clients, and patients (and their families and caregivers) achieve successful participation in their respective worlds. Yet other critical content is necessary for navigating clinical practice. Chapters on competency-based education and practice, leadership, and stress and conflict in the workplace offer valuable guidance for students as they prepare to shift to the next phase of their evolving careers. Ultimately, this is a resource for crafting a pathway to a vocation. The final chapter, Advocacy, by Dr. Tommie Robinson, serves as a coda to the abundance of resources contained in this text. He offers the “why” for what we do in the professions. According to Dr. Robinson, we all have the opportunity to promote our excellence, help those we serve to speak for themselves, and create access for others who need our services. The authors in this text craft the framework for this endeavor. Barbara H. Jacobson, PhD, CCC-SLP Barbara H. Jacobson, PhD, CCC-SLP, is retired faculty from the Department of Hearing and Speech Sciences at the Vanderbilt Bill Wilkerson Center in the Vanderbilt University Medical Center. In addition to clinical practice in adult acute care and in voice disorders, she has taught courses in professional issues, dysphagia, voice disorders, and medical speech-language pathology. She is a former ASHA vice president for standards and ethics in speech-language pathology and is an ASHA fellow.

xv

Preface

Welcome to the sixth edition of Professional Issues in Speech-Language Pathology and Audiology! Since the publication of the first edition more than 25 years ago, the professions of audiology and speechlanguage pathology have continued to evolve. Our scopes of practice are regularly updated to reflect the dynamic growth and increasing complexity of our roles and responsibilities within our varied work settings. Our caseloads are more diverse than ever, and we must keep abreast of evidence-supported knowledge and skills that define best practices in our professions. Audiologists and speech-language pathologists continue to remain challenged and motivated to meet the demands of their professional environment. This sixth edition of Professional Issues in Speech-Language Pathology and Audiology is intended to be a primary text for students and a resource for faculty and practicing clinicians seeking a comprehensive introduction to contemporary issues that affect our professions and our service delivery across settings. We aim to provide our readers with a better understanding that both day-to-day clinical work and personal professional growth and development are influenced by political, social, educational, health care, and economic concerns. Your professional identity is enhanced when you understand the range of factors that define what you do, with whom, for how long, and at what cost. With this big-picture view of your profession, you will be more prepared to make informed decisions as you provide services, engage in advocacy efforts, and plan your career as an audiologist or speech-language pathologist.

How to Use This Text This text is widely used in CSD programs, typically in professional-issues courses or capstone seminars, but also as a general reference tool for faculty and practitioners. It should continue to serve as an excellent desk reference even after you complete your graduate education. Important topics such as the job search (and keeping your job!), ethical practice, accountability and documentation, leadership, cultural competence, economic issues, technology, research, and setting-specific issues will continue to be relevant as you grow professionally.

New to the Sixth Edition The success of the first five editions of this text is attributed to the insightful and cutting-edge contributions made by each of the chapter authors, recognized experts in their respective topic areas. This sixth edition continues that tradition by including both previous and new contributors who have made timely updates and revisions to reflect new issues and trends in audiology and speech-language pathology within their topic areas. Our new contributors include (in order of how they appear in the text) Shari Robertson, Christine T. Matthews, Sandra Gillam, Erin Lundblom, Nicole Corbin, Rachel Ritter, and Jennifer Taylor. You will note in particular that the updates include issues related to the 2020 pandemic, changes in technology, how the changing political landscape has affected the xvii



xviii PREFACE

professions, ASHA certification requirements and the assistants certification program, and the 2023 ASHA Code of Ethics. We have also updated the list of acronyms to include those that are referred to throughout this edition. This list is provided at the front of the book to use as a quick reference. Professional issues always provide the basis for lively discussions among students and practitioners alike. We have included Critical Thinking on the companion website to encourage discussion and reflection on the topics covered in each chapter.

Online Ancillary Materials The sixth edition of Professional Issues in Speech-Language Pathology and Audiology comes with ancillary materials

on a PluralPlus companion website. Instructors can access PowerPoint slides for each chapter, and students can download Critical Thinking questions. Instructors should send an email to [email protected] to request access to the slides. Students, please see the inside front cover of the printed book for the website address and access code. Students using the ebook via the Plural eReader will find the questions embedded in the ebook.

A Final Thought We hope that by reading this text, participating in class discussions, and engaging in critical reflection, you will be motivated and inspired to explore more learning opportunities, become involved in your professional associations, and advocate for your professions and those you serve.

About the Editors

Melanie W. Hudson received her BS from James Madison University and her MA from George Washington University, with postgraduate studies at George Washington University and the University of Virginia. She is an ASHA Fellow and a Distinguished Fellow of National Academies of Practice (NAP). She served on ASHA’s Board of Directors as chair of the Speech-Language Pathology Advisory Council (2016–2018), the Board of Ethics, and the Board of Special Interest Group Coordinators. She currently serves as a trustee on the board of the ASHFoundation. Melanie’s publications include Professional Issues in Speech-Language Pathology and Audiology (4th ed.) (Lubinski & Hudson; Delmar, Cengage Learning, 2013; Plural Publishing, 2018), and chapter author for The Clinical Education and Supervisory Process in Speech-Language Pathology and Audiology (McCrea & Brasseur, Slack, Inc., 2019). She served as president of the Georgia Speech-Language and Hearing Association and on the Georgia Board of Examiners for Speech-Language Pathology and Audiology. She worked as an SLP in Arlington (VA) Public Schools, in private practice, and as adjunct faculty. Recently retired from full-time work, she was the national director at EBS Healthcare from 2003–2022 and continues to be an invited speaker at universities and professional conferences. Mark DeRuiter is professor and vice chair for academic affairs in the department of Communication Science and Disorders at the University of Pittsburgh. He received his BA and MA degrees from Michigan State University, his PhD from the University of Minnesota, and his MBA from Augsburg University. He teaches coursework in aural rehabilitation, practice management, and professional issues, He has research interests in speech perception as well as clinical practice within the professions. He is certified by the American Speech-Language-Hearing Association (ASHA) as both an audiologist and a speech-language pathologist, and he is a fellow of ASHA and the American Academy of Audiology (AAA). Mark has a history of service on ASHA’s Council for Clinical Certification and Special Interest Group 11 (Administration and Supervision), as well as extensive service with the Council of Academic Programs in Communication Sciences and Disorders.

xix

Contributors

Department of Communication Science and Disorders University of Pittsburgh Pittsburgh, Pennsylvania Chapter 1, Chapter 7, and Chapter 24

Tricia Ashby-Scabis, AuD, CCC-A Senior Director, Audiology Practices American Speech-Language-Hearing Association Rockville, Maryland Chapter 9

Carol C. Dudding, PhD, CCC-A, ASHA Fellow Professor and Online Program Director Department of Communication Sciences and Disorders James Madison University Harrisonburg, Virginia Chapter 23

Robert M. Augustine, PhD, CCC-SLP Senior Vice President Council of Graduate Schools Washington, District of Columbia Chapter 5 Stacy K. Betz, PhD Associate Professor and Graduate Program Director Department of Communication Sciences and Disorders Purdue University Fort Wayne Fort Wayne, Indiana Chapter 6

Robin L. Edge, PhD, CCC-SLP Chief Clinical Operations Officer Neurodevelopment of Words The Morris Center Ponte Vedra Beach, Florida Chapter 14

Corey Herd Cassidy, PhD, CCC-SLP Professor Department of Communication Sciences and Disorders Radford University Radford, Virginia Chapter 13

Lizbeth H. Finestack, PhD, CCC-SLP Associate Professor and Director of Graduate Studies Department of Speech-Language-Hearing Sciences University of Minnesota Minneapolis, Minnesota Chapter 6

Nicole E. Corbin, PhD, CCC-A Assistant Professor Department of Communication Science and Disorders University of Pittsburgh Pittsburgh, Pennsylvania Chapter 16

Mary Sue Fino-Szumski, PhD, MBA, CCC-A Associate Professor and Director of Clinical Education Department of Hearing and Speech Sciences Vanderbilt University Medical Center Nashville, Tennessee Chapter 22

Cathy DeRuiter, MA, CCC-SLP DeRuiter, LLC Pittsburgh, Pennsylvania Chapter 7

Sandra Laing Gillam, PhD, CCC-SLP Professor Department of Communication Disorders and Deaf Education Utah State University Logan, Utah Chapter 12

Mark DeRuiter, PhD, MBA, CCC-A, CCC-SLP, ASHA Fellow Professor and Vice Chair for Academic Affairs xxi



xxii

CONTRIBUTORS

Brooke Hallowell, PhD, CCC-SLP, FNAP, ASHA Fellow Dean, School of Health Sciences Springfield College Springfield, Massachusetts Chapter 15 Jaynee A. Handelsman, PhD, CCC-A, FNAP, ASHA Fellow Assistant Professor (retired) Department of Otolarynology–Head and Neck Surgery Michigan Medicine Ann Arbor, Michigan Chapter 2 and Chapter 4 Carolyn Wiles Higdon, EdD, CCC-SLP, FNAP, ASHA Fellow Professor Department of Communication Sciences and Disorders University of Mississippi CEO, Wiles Higdon and Associates, LLC Oxford, Mississippi Chapter 20 Kelly M. Holland, MEd Vice President Institutional Partnerships AIFS Abroad Annapolis, Maryland Chapter 5 Shirley Huang, PhD, CCC-SLP Child Development and Behavior Branch The National Institutes of Health Eunice Kennedy Shriver National Institute of Child Health and Human Development Bethesda, Maryland Chapter 21 Melanie W. Hudson, MA, CCC-SLP, ASHA Fellow Distinguished Fellow National Academies of Practice Board Certified Specialist, Child Language and Disorders National Director at EBS Healthcare (retired) Atlanta, Georgia Chapter 1 and Chapter 22 Alex F. Johnson, PhD, CCC-SLP Provost Emeritus MGH Institute of Health Professions Boston, Massachusetts Chapter 11 and Chapter 19 Jeffrey P. Johnson, PhD, CCC-SLP Research Speech-Language Pathologist Geriatric Research, Education and Clinical Center

Audiology and Speech Pathology VA Pittsburgh Healthcare System Pittsburgh, Pennsylvania Chapter 11 Pui Fong Kan, PhD, CCC-SLP Associate Professor Department of Speech, Language, and Hearing Sciences University of Colorado Boulder Boulder, Colorado Chapter 21 Erin E. G. Lundblom, PhD, CCC-SLP Associate Professor; Director Clinical Education Speech-Language Pathology Department of Communication Science and Disorders University of Pittsburgh Pittsburgh, Pennsylvania Chapter 16 Christine T. Matthews, CScD, CCC-SLP, BCS-S Audiology and Speech Pathology Service Chief Board Certified Specialist — Swallowing and Swallowing Disorders VA Pittsburgh Healthcare System Pittsburgh, Pennsylvania Chapter 11 Lemmietta G. McNeilly, PhD, CCC-SLP, FASAE, CAE, FNAP Chief Staff Officer for Speech-Language Pathology American Speech-Language-Hearing Association Rockville, Maryland Chapter 9 Marva Mount, MA, CCC-SLP, FNAP Related Services Director Instructional Services Imagine Learning Scottsdale, Arizona Chapter 8 Diane Paul, PhD, CCC-SLP, CAE, ASHA Fellow Senior Director Clinical Issues in Speech-Language Pathology American Speech-Language-Hearing Association Rockville, Maryland Chapter 9 Lissa Power-deFur, PhD, CCC-SLP, BCS-CL, ASHA Fellow Professor Emeritus Department of Communication Sciences and Disorders Longwood University Farmville, Virginia Chapter 3



Jeffrey P. Regan, MA Senior Vice President Actum LLC West Springfield, Virginia Chapter 10 Gail J. Richard, PhD, CCC-SLP, ASHA Fellow, ASHA Honors Professor Emerita Department of Communication Disorders and Sciences Eastern Illinois University Charleston, Illinois Chapter 17 Shari Robertson, PhD, CCC-SLP, ASHA Fellow Professor Emerita Department of Communication Sciences and Disorders Indiana University of Pennsylvania Indiana, Pennsylvania Chapter 8 Cynthia McCormick Richburg, PhD, CCC-A Professor and AuD Program Coordinator Department of Communication Sciences and Disorders Wichita State University Wichita, Kansas Chapter 18 Rachel A. Ritter, MS, CCC-SLP Clinical Educator Department of Communication Sciences and Disorders

CONTRIBUTORS

James Madison University Harrisonburg, Virginia Chapter 23 Tommie L. Robinson, Jr., PhD Chief, Division of Hearing and Speech Director, Scottish Rite Center for Communication Disorders Children’s National Hospital Professor of Pediatrics George Washington University School of Medicine and Health Sciences Washington, District of Columbia Chapter 25 Donna Fisher Smiley, PhD, CCC-A Chief Staff Officer for Audiology American Speech-Language-Hearing Association Rockville, Maryland Chapter 18 Jennifer P. Taylor, AuD, CCC-A Director of Clinical Education in Audiology; Clinical Associate Professor School of Communication Sciences and Disorders University of Memphis Memphis, Tennessee Chapter 24 Tina K. Veale, PhD, CCC-SLP Professor and Administrative Director Department of Speech-Language Pathology Lewis University Romeoville, Illinois Chapter 5

xxiii

Acronyms

AAA:  American Academy of Audiology

ACO:  Accountable care organization

AAC:  Augmentative and alternative communication

ACT:  American College Testing Program

AAC&U:  American Association of Colleges and Universities

ADA:  Academy of Doctors of Audiology

AAO-HNS:  American Academy of Otolaryngology– Head and Neck Surgery

ADEA:  Age Discrimination in Employment Act of 1967

AAPM:  Advanced alternative payment method AAPPSLPA:  American Academy of Private Practice in Speech-Language Pathology and Audiology AAS:  American Auditory Society AAVE:  African American Vernacular English ABA:  American Board of Audiology ABA:  Applied behavior analyst ABC System:  A (high priority), B (medium priority), C (low priority) ABER:  Auditory brainstem evoked response ABESPA:  American Board of Examiners for SpeechLanguage Pathology and Audiology ABIM:  American Board of Internal Medicine ABO-HNS:  American Board of Otolaryngology– Head and Neck Surgery ABR:  Auditory brainstem response AC:  Advisory Council ACA:  Patient Protection and Affordable Care Act

ADA:  Americans With Disabilities Act

ADL:  Activity of daily living AGREE:  Appraisal of Guidelines for Research and Evaluation AHRQ:  Agency for Healthcare Research and Quality AI:  Artificial intelligence AIDS:  Acquired immune deficiency syndrome AIHC:  American Interprofessional Health Collaboration ALICE:  Alert, lockdown, inform, counter, evacuate ALS:  Amyotrophic lateral sclerosis AMA:  American Medical Association ANCDS:  Academy of Neurologic Communication Disorders and Sciences APA:  American Psychological Association APD:  Auditory processing disorders APM:  Alternative payment model APR:  Annual performance report

ACAE:  Accreditation Commission for Audiology Education

APS:  Adult Protective Services

ACE:  American Council on Education

ARC:  Association for Retarded Citizens

ACE:  Award for Continuing Education

ARRA:  American Recovery and Reinvestment Act of 2009

ACEBP:  Advisory Committee on Evidence-Based Practice ACGME:  Accreditation Council for Graduate and Medical Examination ACLU:  American Civil Liberties Union

AR:  Augmented reality

ASD:  Autism spectrum disorder ASE:  American Society of Echocardiography ASHA:  American Speech-Language-Hearing Association xxv



xxvi

ACRONYMS

ASLP-IC:  Audiology and Speech-Language Pathology Interstate Compact

CCC-SLP:  Certificate of Clinical Competence in Speech-Language Pathology

AT:  Assistive technology

CCHP:  Center for Connected Health Policy

ATA:  American Telemedicine Association

CCI:  Center for Cultural Interchange

ATC:  Assistive Technology for Cognition

CCI:  Correct Coding Initiative

AuD:  Doctor of Audiology (audiologist) AUD: Audiology

CCSPA:  Council of University Supervisors in Speech-Language Pathology and Audiology

AYP:  Adequate yearly progress

CCSS:  Common Core State Standards

BAA:  British Academy of Audiology BAAS:  British Association of Audiological Scientists BAAT:  British Association of Audiologists BASE:  Brief Abuse Screen for the Elderly BBA:  Balanced Budget Act BBP:  Bureau of Business Practice BBRA:  Balanced Budget Refinement Act BCBSA:  Blue Cross Blue Shield Association BICS:  Basic interpersonal communication skills BIPA:  Benefits Improvement and Protection Act BLS:  Bureau of Labor Statistics BOD:  Board of Directors BOE:  Board of Ethics BSHAA:  British Society of Hearing Aid Audiologists BSHT:  British Society of Hearing Therapists BYOD:  Bring your own device CAA:  Council on Academic Accreditation C-AA:  Certified Audiology Assistant CACS:  Cultural Awareness and Competence Scales CAE:  Certified association executive CALP:  Cognitive academic language proficiency CAOHC:  Council for Accreditation in Occupational Hearing Conservation CAP:  Computerized Accreditation Program CAPCSD:  Council of Academic Programs in Communication Sciences and Disorders CAPD:  Central auditory processing disorders CAPTA:  Child Abuse Prevention and Treatment Act CARF:  Commission on Accreditation of Rehabilitation Facilities CASE:  Caregiver Abuse Screen CASLPA:  Canadian Association of Speech-Language Pathologists and Audiologists

CCSSO:  Council of Chief State School Officers CDAL:  Certified Director of Assisted Living CDC:  Centers for Disease Control and Prevention CDCHU:  Center on the Developing Child at Harvard University CD-ROM:  Compact disc-read-only memory CDS:  Communication disorders and sciences CDSS:  Clinical decision support system CE:  Continuing education CEC:  Council for Exceptional Children CEO:  Chief executive officer CETI:  Communication Effectiveness Index CF:  Clinical fellowship or clinical fellow CFCC:  Council for Clinical Certification in Audiology and Speech-Language Pathology CFP:  Certified financial planner CFR:  Code of Federal Regulations CFSI:  Clinical Fellowship Skills Inventory CFY:  Clinical fellowship year CGC:  Certified genetic counselor CHEA:  Council on Higher Education Accreditation CHIP:  Children’s Health Insurance Program CHW:  Community health worker CI:  Cochlear implant CI:  Confidence interval CIC:  Completely in canal CIRRIE:  Center for International Rehabilitation Research Information and Exchange CISA:  Cybersecurity and Infrastructure Security Agency CISC:  Cochlear Implant Specialty Certification CLD:  Cultural and linguistic diversity CMHs:  Certification maintenance hours

CCC:  Certificate of Clinical Competence

CMS:  Centers for Medicare and Medicaid Services

CCC-A:  Certificate of Clinical Competence in Audiology

COA:  Council of Accreditation

CMV: Cytomegalovirus



ACRONYMS

COBRA:  Consolidated Omnibus Budget Reconciliation Act

DRA:  Deficit Reduction Act

COE:  Code of Ethics

DSW:  Doctor of Social Work

COIL:  Collaborative online international learning COPs:  Conditions of participation CORE:  Collaboration, observation, reflection, and evaluation CORF:  Comprehensive Outpatient Rehabilitation Facility CoSN:  Consortium for School Networking COVID-19:  Coronavirus disease–2019 CP:  Cerebral palsy CPLOL:  Comité Permanent de Liaison des Orthophonistes/Logopèdes de l’Union Européenne CPOP:  Certificate Program for Otolaryngology Personnel CPR:  Cardiopulmonary resuscitation CPS:  Child Protective Services CPT:  Current procedural terminology CSC:  Computer Sciences Corporation CSD:  Communication sciences and disorders CSDCAS:  Communication Sciences and Disorders Centralized Application Service for Clinical Education in Audiology and Speech-Language Pathology

DRG:  Diagnosis-related group DTI:  Diffusion Tensor Imaging DVD:  Digital versatile/video disc EADSS:  Elder Abuse Decision Support System EAI:  Elder Assessment Instrument EARAE:  Elder Abuse Risk Assessment and Evaluation Tool EASI:  Elder Abuse Suspicion Index EBHC:  Evidence-based health care EBP:  Evidence-based practice EBSR:  Evidence-based systematic review ED:  Department of education EdD:  Doctor of Education ED-EMATS:  Emergency Department Elder Mistreatment Assessment Tool for Social Workers EDI:  Electronic data interchange EEG: Electroencephalography EEO:  Equal employment opportunity EEOC:  Equal Employment Opportunity Commission EHA:  Education for All Handicapped Children Act

CSEP:  Center for the Study of Ethics in the Professions

EHB:  Essential health benefits

C-SLPA:  Certified Speech-Language Pathology Assistant

EHR:  Electronic health record

CSSPA:  Council of University Supervisors in Speech-Language Pathology and Audiology

EIN:  Employee identification number

CV:  Curriculum vitae

EMG: Electromyography

CWD:  Child with a disability DDS:  Doctor of Dental Surgery DETECT:  Detection of elder abuse through emergency care technicians

EHDI:  Early hearing detection and intervention EI:  Early intervention ELL:  English language learner EMR:  Electronic medical record EMTALA:  Emergency Medical Treatment and Labor Act

DEU:  Dedicated (Collaborative) Education Unit

EM-SART:  Elder Mistreatment Screening and Response Tool

DHS:  Department of Homeland Security

ENG: Electronystagmography

DMD:  Doctor of Dental Medicine

ENT:  Ear, nose, and throat

DNP:  Doctor of Nursing Practice

EPA:  Environmental Protection Agency

DO:  Doctor of Osteopathic Medicine

EPC:  Ethical Practices Committee

DOE:  U.S. Department of Education

EPHI:  Electronic protected health information

DOTPA:  Developing outpatient therapy payment alternatives

EPO:  Exclusive Provider Organization

DPH:  Doctor of Public Health

EPSDT:  Early periodic screening, diagnosis, and treatment

DPT:  Doctor of Physical Therapy

EQ:  Emotional intelligence

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xxviii

ACRONYMS

ERISA:  Employee Retirement Income Security Act of 1974

HHA:  Home health agency

ESEA:  Elementary and Secondary Education Act

HIE:  Health information exchange

ESL:  English as a second language ESLA:  European Speech Language Therapy Association ESSA:  Every Student Succeeds Act ETB:  Educational Testing Board ETS:  Educational Testing Service E-IOA:  Expanded Indicator of Abuse FAAP:  Fellow of the American Academy of Pediatrics

HHS:  Health and Human Services HIPAA:  Health Insurance Portability and Accountability Act of 1996 HIT:  Health information technology HIV:  Human immunodeficiency virus HMO:  Health maintenance organization HPSO:  Healthcare Providers Service Association HR:  Human resources HSV:  Herpes simplex virus

FACS:  Functional Assessment of Communication Skills for Adults

IACET:  International Association for Continuing Education and Training

FAPE:  Free appropriate public education

IALP:  International Association of Logopedics and Phoniatrics

FCM:  Functional Communication Measure FD&C Act:  Federal Food, Drug, and Cosmetic Act

IASLT:  Irish Association of Speech and Language Therapists

FEES:  Fiberoptic endoscopic evaluation of swallowing

ICC:  Infection Control Committee ICC:  Interagency Coordinating Council

FERPA:  Family Educational Rights and Privacy Act

ICD:  International Classification of Diseases

FIM:  Functional Independence Measure

ICE:  Institute for Credentialing Excellence

FLSA:  Fair Labor Standards Act

ICF:  International Classification of Functioning, Disability, and Health

FDA:  Food and Drug Administration

FM:  Frequency modulated fMRI:  Functional magnetic resonance imaging FPCO:  Family Policy Compliance Office FRL:  Free and reduced lunch GAO:  Government Accountability Office GDP:  Gross domestic product

ICRA:  International Collegium of Rehabilitative Audiology IDDSI:  International Dysphagia Diet Standardization Initiative IDEA:  Individuals With Disabilities Education Act

GERD:  Gastroesophageal reflux disease

IDEIA:  Individuals With Disabilities Education Improvement Act

GHE:  Global health experience

IEP:  Individualized education program

GMS:  Geriatrics Mistreatment Scale GPA:  Grade point average

IERASG:  International Evoked Response Audiometry Study Group

GRE:  Graduate Record Examination

IFSP:  Individualized family service plan

HATS:  Hearing Assistive Technology Systems

IHE:  Institution of higher education

HBCU:  Historically Black College and University

IHS:  International Hearing Society

HBV:  Hepatitis B virus

IIB:  International Issues Board

HCA:  Hearing Conservation Amendment

IMEHD:  Implantable middle ear hearing device

HCEC:  Health Care Economics Committee

IOM:  Institute of Medicine

HCFA:  Health Care Financing Administration

IOM:  Internet-only manual

HCPCS:  Healthcare Common Procedures Coding System

IP:  Internet protocol IPA:  Independent Practice Association

HEO:  Higher education organization

IPCP:  Interprofessional collaborative practice

HEP:  Home exercise program

IPE:  Interprofessional education

HES:  Higher education data system

IPEC:  Interprofessional Education Collaboration



ACRONYMS

IPEC:  Interprofessional Care Collaborative

MCO:  Managed care organization

IRB:  Institutional Review Board

MD:  Doctor of medicine

IRF-PAI:  Inpatient Rehabilitation Facility-Patient Assessment Instrument

MDAT:  Multidisciplinary assessment team

IRS:  Internal Revenue Service

MedPAC:  Medicare Payment Advisory Committee

MDS:  Minimum data set

ISA:  International Society of Audiology

MIPS:  Merit-based incentive payment model

ISA:  Irish Society of Audiology

MIPPA:  Medicare Improvements for Patients and Providers Act

IST:  Instructional support team ITPA:  Illinois Test of Psycholinguistic Abilities

MMA:  Medicare Prescription Drug, Improvement, and Modernization Act

JAAA:  Journal of the American Academy of Audiology

MOA:  Memorandum of agreement MOOCS:  Massive Open Online Courses

JD:  Juris Doctorate (law degree)

MOSAIC:  Multiplying Opportunities for Services and Access to Immigrant Children

IT:  Information technology

KASA:  Knowledge and skills assessment KSA:  Kingdom of Saudi Arabia KT:  Knowledge translation LAN:  Local area network LAST:  Liberal Arts and Sciences Test LCD:  Local coverage determination LCSW:  Licensed Clinical Social Worker LEA:  Local education agency LEP:  Limited English proficient LFEP:  Learn from every patient LGBTQIA+:  Lesbian, gay, bisexual, transgender, queer, intersex, asexual LLC:  Limited Liability Company LLD:  Language learning disability LLP:  Limited Liability Partnership LMS:  Learning management system LOE:  Levels of evidence LPAA:  Life Participation Approach to Aphasia LPC:  Licensed Professional Counselor

MOU:  Memorandum of understanding MPFS:  Medicare Physician Fee Schedule MPH:  Master of Public Health MPPR:  Multiple Procedure Payment Reduction MRI:  Magnetic resonance imaging MRSA:  Methicillin-Resistant Staphylococcus Aureus MSDS:  Material Safety Data Sheet MSHA:  Mine Safety and Health Administration MTSS:  Multitiered systems of support MUE:  Medically unlikely edits NACE:  National Association of Colleges and Employers NAEP:  National Assessment of Educational Progress NAFDA:  National Association of Future Doctors of Audiology NAFTA:  North American Free Trade Agreement NARF:  National Association of Rehabilitation Facilities

LR:  Likelihood ratio

NASEM:  National Academies of Sciences, Engineering, and Medicine

LRE:  Least restrictive environment

NATS:  National Association of Teachers of Speech

LTACH:  Long-term acute care hospital

NBTS:  National Board for Professional Teaching Standards

LTC:  Long-term care LTCF:  Long-term care facility MAC:  Medicare Administrative Contractor MACRA:  Medicare Access and CHIP Reauthorization MARC:  Mentoring for Academic-Research Careers MAT:  Miller Analogies Test MBP:  Munchausen by proxy MC:  Managed care

NCAA:  National Commission for Credentialing Agencies NCANDS:  National Child Abuse and Neglect Data System NCATE:  National Council for Accreditation of Teacher Education NCCP:  National Center for Children in Poverty NCELA:  National Clearing House for English Language Acquisition

xxix



xxx

ACRONYMS

N-CEP:  ASHA’s National Center for Evidence-Based Practice in Communication Disorders

OBRA:  Omnibus Reconciliation Act

NCHS:  National Center for Health Statistics

OECD:  Organization for Economic Cooperation and Development

NCLB:  No Child Left Behind Act

OGET:  Oklahoma General Education Test

NCSB:  National Council of State Boards of Examiners

OIG:  Office of Inspector General

NCQA:  National Council of Quality Assurance

OPTE:  Oklahoma Professional Teaching Exam

ND:  No date NEA:  National Education Association

OPIM:  Other potentially infectious material OSAT:  Oklahoma Subject Area Test OSEP:  Office of Special Education Programs

NEXUS:  National Center for Interprofessional Practice and Education

OSERS:  Office of Special Education and Rehabilitative Services

NGA:  National Governors Association Center for Best Practices

OSHA:  Occupational Safety and Health Administration

NGO:  Nongovernmental organization

OT:  Occupational therapy(ist)

NGS:  National Governmental Services

OTD:  Doctor of Occupational Therapy

NHPO:  National Hospice and Palliative Care Organization

OTO:  Otologic technician

NHS:  National Health Service NICHD:  National Institute of Child Health & Human Development NICU:  Neonatal Intensive Care Unit NIDCD:  National Institute on Deafness and Other Communication Disorders NIH:  National Institutes of Health

OTR:  Registered occupational therapist PAHO:  Pan-American Health Organization P&P:  Policy and procedure P2P:  Peer-to-peer file sharing program PA:  Physician assistant PAC:  Postacute care PASC:  Pediatric Audiology Specialty Certification

NIHL:  Noise-induced hearing loss

PCP:  Primary care physician

NIOSH:  National Institute for Occupational Safety and Health

PCMH:  Patient-centered medical home model PDH:  Professional development hour

NIRS:  Near-Infrared Spectroscopy

PDPM:  Patient-driven payment model

NOMS:  National Outcomes Measurement System

PEP:  Personalized education plan

NPI:  National Provider Identifier

PharmD:  Doctor of Pharmacy

NPO:  Nothing by mouth

PhD:  Doctor of Philosophy

NPV:  Negative Predictive Value

PHE:  Public health emergency

NRH:  National rehabilitation hospital

PHI:  Protected health information

NSA:  Nonstate actor

PHR:  Personal health record

NSC:  National Safety Council

PI:  Performance improvement

NSOME:  Nonspeech oral-motor exercises

PICO:  Patient, intervention/index measure, comparison, outcome

NSSE:  National Survey of Student Engagement NSSLHA:  National Student Speech Language Hearing Association

PL:  Public law PLOP:  Present level of performance

NZAS:  New Zealand Audiological Society

PMPM:  Per member, per month premium

NZSTA:  New Zealand Speech-Language Therapists’ Association

PPACA:  Patient Protection and Affordable Care Act PPD:  Purified Protein Derivative

OAA:  Older Americans Act

PPE:  Personal protective equipment

OAE:  Otoacoustic emission

PPO:  Preferred Provider Organization

OASIS:  Outcome and assessment information set

PPS:  Prospective payment system



ACRONYMS

PQRI:  Physician Quality Reporting Initiative

SD:  Standard deviation

PQRS:  Physician Quality Reporting System

SEA:  State education agency

PRI:  Protected research information

SED:  Survey of Earned Doctorates

PRN:  Pro re nata — as the circumstances arise

SERTOMA:  Service to Mankind

PSAP:  Personal sound amplification product

SGD:  Speech Generating Device

PSLF:  Public service loan forgiveness

SHRM:  Society of Human Resources Management

PsyD:  Doctor of Psychology

SIE:  Society for International Education

PT:  Physical therapy(ist)

SIG:  Special interest group

PTA:  Parent-teacher association

SIGN:  Scottish Intercollegiate Guideline Network

PTO:  Paid time off

SIO:  Senior Internationalization Office

PV:  Predictive value

SITE:  Society for Information Technology and Teacher Education

PVA:  Paralyzed Veterans of America QCL:  Quality of communication life R01:  Research project grant RAC:  Recovery audit contractor RAI:  Resident Assessment Instrument RBRVS:  Resource-Based Relative Value Scale RCCP:  Registration Council for Clinical Physiologists RCR:  Responsible conduct of research RCSLT:  Royal College of Speech and Language Therapists RCT:  Randomized controlled trial RDN:  Registered dietician nutritionist RFA:  Request for applications RN:  Registered nurse RPO:  Related professional organization

SLP:  Speech-language pathologist SLPA:  Speech-language pathology assistant SLPCF:  Speech-language pathology clinical fellowship SLPD:  Speech-language pathology doctorate SLT:  Speech language therapist SMART:  Specific, measurable, achievable, realistic, timely SNF:  Skilled nursing facility SNHL:  Sensorineural hearing loss SnNout:  Sensitivity high, negative result — rule out SOAP:  Subjective, objective, assessment, plan SP:  Standardized patient SPA:  Speech Pathology Australia SPAI:  Supervisee Performance Assessment Instrument

RRT:  Registered respiratory therapist

SPP:  State performance plan

RSAC:  ASHA Research and Scientific Affairs Committee

SpPin:  Specificity high, positive result — rule in SR:  Systematic review

RtI or RTI:  Response to instruction/intervention

SSR:  Single-subject research

RUC HCPAC:  Resource Update Health Care Professionals Advisory Committee

SSW:  Staggered spondaic word

RUG:  Resource Utilization Group

STATS:  Short-term alternatives for therapy services

RUG-IV:  Resource Utilization Group, Version IV

STEP:  Student to empowered professional

RVU:  Relative value unit

STLD:  Short-term limited-duration plan

SAA:  Student Academy of Audiology

SWOT:  Strength, weakness, opportunity, threat

SALT:  Systematic analysis of language transcripts

TB: Tuberculosis

SASLHA:  South African Speech-Language-Hearing Association

TCP/IP:  Transfer Control Protocol/International Protocol

SAT:  Scholastic Aptitude Test

TCT:  Teleaudiology Clinical Technician

ScD:  Doctor of Science

tDCS:  Transcranial Direct Current Stimulation

SCHIP:  State Children’s Health Insurance Program

TEFRA:  Tax Equity and Fiscal Responsibility Act

SD:  Spasmodic dysphonia

TJC:  The Joint Commission

STAR:  State Advocates for Reimbursement

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xxxii

ACRONYMS

TMS:  Transcranial magnetic stimulation

VA:  Veterans Administration

TN:  Trade NAFTA

VEMP:  Vestibular Evoked Myogenic Potential

TRHCA:  Tax Relief and Health Care Act

VFSS:  Videofluoroscopic swallowing study

TTY/TDD:  Text telephone/telecommunications device for the Deaf

VHS:  Veterans Healthcare System

UEP:  Union of European Phoneticians

VNG: Videonystagmography

UK:  United Kingdom UNESCO:  United Nations Educational Scientific and Cultural Organization URAC:  Utilization Review Accreditation Commission USC:  U.S. Code USDE:  U.S. Department of Education

VIA:  Values in action VR/AR:  Virtual reality/augmented reality WASP:  Waveforms Annotations Spectograms and Pitch WC-RAPS:  Weinberg Center Risk and Abuse Prevention Screen WHO:  World Health Organization ZIKV:  Zika virus

This text is dedicated to our chapter contributors who have shared their expertise and their wisdom with future audiologists and speech-language pathologists.

SECTION I

Overview of the Professions

1 Professions for the 21st Century Melanie W. Hudson and Mark DeRuiter

Introduction You have chosen a dynamic profession, with substantial growth expected to continue in the coming years. According to the U.S. Bureau of Labor Statistics, the need for services provided by audiologists is expected to increase by 10% from 2021 to 2031, while the need for speech-language pathologists (SLPs) is expected to increase by 21% during the same period (U.S. Bureau of Labor Statistics, n.d.). Even as we are writing this introductory chapter, changes are occurring and more professionals are being trained, which will significantly impact the professions of audiology and speech-language pathology. As the demand for our services continues to grow, what are some of the major trends and issues impacting our professions? Many factors have come into play in recent years that are transforming how we plan and carry out our work. Rapidly advancing technology, legislation in health care and education, demographic shifts that include an aging population and an increase in diversity, global economic changes, the COVID-19 pandemic, and new research are influencing how we deliver services. Even the effects of climate change are playing a role in how audiologists and SLPs make career decisions. Faced with these and other changes, how do we ensure that our clinical skills are state of the art and incorporate the latest technological advances? How do we provide services that are of the highest quality, yet cost effective? What are the ripple effects of global economic changes and demographic shifts on our professional practice? What have we learned from a global pandemic? And finally, what role does evidence play in our clinical decision making? This chapter provides an overview of some of the most important trends and issues that are likely to affect your professional practice in the coming years: technology, trends in health care and education, economic influences, demographic shifts and globalization, and evidence-based practice. Each of these areas is addressed more fully in chapters specific to the topic and within the appropriate context throughout the rest of the book. Additionally, chapter authors will include information relative to the global pandemic where appropriate. The information in this chapter will set the stage for advanced critical thinking and constructive dialogue. In this rapidly evolving professional climate, it is not enough to be performing only competently as a clinician. Today’s audiologists and SLPs also need to engage in analytical thinking and critical reflection when making decisions that affect the lives of others. 3



4

SECTION I   Overview of the Professions

As you read this chapter, consider the scopes of practice in audiology and speech-language pathology (ASHA, 2016, 2018). Remember that each of these practices is well defined and dynamic. Take time to reflect on how the trends and issues presented in this chapter influence your own decisions and plans for the future as we complete the first quarter of the 21st century.

Trends in Technology and the Digital Revolution The future is an inevitable reality . . . which we either adapt to or resist, but that we have the power to “envisage and take action to build alternative and desirable futures.”  (Facer & Sandford, 2010) We are living in what is known as the digital revolution, also known as the third industrial revolution, the change from mechanical and electronic technology to digital technology. Analogous to the agricultural revolution and industrial revolution, the digital revolution marked the beginning of the Information Age (Digital Revolution, 2019). Those born during the 21st century would not be able to imagine a world without computers, the internet, and personal electronic devices such as smartphones that enable instant communication with anyone, anywhere, anytime. By 2022, the internet penetration rate was 69% worldwide (Internet World Stats, 2023), and mobile internet use and access is expected to eclipse desktop use in the next few years (Bouchrika, 2022). These digital advances have made globalization possible, allowing businesses to operate more efficiently with increased opportunities to find and share information. We hold virtual meetings instead of traveling to conduct face-to-face business, and more of us work from home as telecommuters, especially after the COVID-19 global pandemic. These advances have also had a significant impact on our individual lifestyles and daily routines. Instead of going to the shopping mall or even the grocery store, we buy our goods from online retail merchants and order services from a company’s website. As a student reading this text, you may even have taken some, if not all, of your courses through an online university program. Advanced classroom technologies have enhanced learning opportunities for all students. Where digital technology saves us time and helps us stay connected, many people find it increasingly difficult to keep their personal and professional lives separate. This can lead to digital overload, causing stress and job burnout. The advancing technological contributions to science are continually growing, notably in the areas of artificial intelligence (AI) and robot design. The evolution of three-dimensional (3D) printing and ongoing

developments in computer design, such as Digital Twin (Venkatesh et al., 2022), where providers and manufacturers can test the impact of potential change on the performance of a health care procedure by experimenting on a virtual version of the system (i.e., a person or device), continue to change the landscape of the industrial sector. AI continues to play a major role in the health care industry due to the availability of big data and the drive to lower health care costs. Research firm Grand View Research predicts that AI in health care will have a compound growth rate of 37.5% between 2023 and 2030, starting at $15.4 billion in 2022 (Grand View Research, n.d.). Implications for practicing SLPs and audiologists include chat-based digital services in which users have a conversation with a chatbot, software designed to understand and respond to natural language inputs. Through the use of coaching conversations, clinicians can apply their knowledge and skills with AI resources to engage patients in meaningful conversations about their health. The medical industry has also been impacted by the digital revolution. Genomic medicine, the use of genetic information for personalized treatment plans, will have long-lasting implications in the provision of health care. The use of simulated patients and virtual reality and augmented reality (VR/AR) formats, the delivery of health care services through telepractice, and securing sensitive information will certainly play important roles in the training of future health care providers. New devices for hearing amplification and augmentative communication will be of special interest to SLPs and audiologists. Currently, audiologists are expressing concern regarding the future of the discipline as more hearing technologies are available to the public through smartphone retail outlets and as over-the-counter devices. Although our patients may have increased access to better communication, there is a general concern that some patients may be at risk without the advice of a trained professional, making professional collaboration more critical (Berenbrock et al., 2022). The same is true for augmentative and alternative communication options that are readily available to patients and families on smartphones and tablets. What expertise is needed to guide these families? How can we be assured these technologies are being optimally used? What responsibility do we have as a profession to shape these various technologies and their availability? These are challenging times, with many opportunities! The positive and negative aspects of the impact of the digital revolution on human lives will continue to be discussed, explored, and analyzed as we move into the future. As audiologists and SLPs facing such challenges, we need to be well prepared to engage in critical



thinking that supports our decision-making ability in a world of rapid technological advancement. Technology is discussed in more depth in Chapter 23.

21st-Century Trends and Issues Trends in Health Care Health care in the United States is undergoing rapid transformation due to several reasons — political, demographic, and technological being among the key drivers. Health care legislation and regulation have created a shift in reimbursement policy, moving away from providercentered payment models toward patient-centered models, with Medicare, Medicaid, and private health insurance being most relevant to practicing SLPs and audiologists. In addition, provider shortages; increasing costs paired with a lack of affordability, even for those with good insurance; and an aging population are changing the face of health care as we know it. The costs associated with health care continue to increase while both public and private insurance reimbursement rates for providers fall below the actual cost of providing services. Many physicians and payers may view audiology and speech-language pathology as lowpriority services as they attempt to conserve limited financial resources. As a result, referrals and authorizations for evaluations and treatment are decreasing and jobs in physicians’ offices and other health care facilities may be eliminated or reduced to an as-needed basis. See Chapter 15 for further discussion of access to services. Another factor influencing reimbursement for health care services is that the age-old concept that “more care means better care” is no longer an accepted tenet in the evolving health care industry. The trend is moving in the direction of value-based reimbursement where quality of service is favored versus fees for services, which only reward volume. Patient satisfaction surveys have more and more influence on insurance reimbursement, and this has important implications for practitioners. The number of health professionals working in home health care will continue to grow as the demand for treatment outside the traditional doctor’s office is on the rise. A recent survey conducted by the PricewaterhouseCoopers Health Research Institute showed that consumers increasingly sought care outside of their doctor’s office during the pandemic. Additionally, patients desired to engage with more digital tools to support their health during the pandemic, and the overall utilization of health care services increased after the pandemic (PricewaterhouseCoopers, n.d.). Health information technologies (HITs) and electronic health records (EHRs) are other changes in health

CHAPTER 1   Professions for the 21st Century

care that continue to shape what we do as audiologists and SLPs. Currently, there is a proliferation of different EHR and HIT options. Even though these systems are designed to increase reliability of access to records and clinician productivity, they can pose barriers as well. One challenge is the way we serve our patients. Many of us have experienced a health care provider who has spent more time looking at a computer screen than interacting with the patient. Additionally, records are not easily transferred across different EHR platforms, posing roadblocks to patients as they seek care, particularly from specialty providers. One of our most important tasks as SLPs and audiologists is to ensure our services are mandated and maintained at reasonable rates. As the population ages, we also need to ensure our practices enable and prolong independent living, support access to needed services, support our patients’ participation in decision making regarding their lives and care, and help them maintain a positive quality of life for as long as possible. We need to be not only skilled and knowledgeable clinicians but also ready to employ our skills as advocates on behalf of our patients. Chapters 11 and 14 provide further discussion of services in health care.

Trends in Education The educational landscape continues to transform, with political influences, demographic shifts, and nearly immediate requirements for distance education as a result of the COVID-19 pandemic as major drivers. Federal, state, and local funding for schools influences the quantity and quality of services provided by schoolbased SLPs and audiologists. Government-mandated accountability with an emphasis on standardized testing to measure student achievement has provided data for important decision making, including systems used for teacher evaluations. The paperwork burden and the demands that come with ever-increasing caseloads and responsibilities assigned to school-based service providers continue to be hot-button issues and are the focus of advocacy efforts by professional organizations such as the American Speech-Language-Hearing Association (ASHA, n.d.-a). The use of multitiered systems of supports such as Response to Intervention (RTI), the importance of using a variety of service delivery models including distance education, incorporating evidence-based practice (EBP), and engaging in interprofessional collaboration in the diagnosis and treatment of school-aged children have been noteworthy initiatives in the evolution of school-based services. Many school districts have increased the hiring and use of paraprofessionals to ease the caseload burden and to support the work of school-based service providers.

5



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SECTION I   Overview of the Professions

SLPs and audiologists will need to develop their knowledge and skills in supervision, particularly in the area of ethical accountability as they work with support personnel. You will find further discussion of support personnel in Chapter 9. As in health care, technology continues to play a major role in education for SLPs and audiologists working in schools. Software programs designed specifically for special education documentation and recordkeeping have become the norm. Technology tools that support oral, audio, and written skills allow students of all ages to express themselves beyond the capacity of their writing abilities. Much work with critical thinking can also be done in this manner when tools such as Seesaw blogs (https://web.seesaw.me/blogs) are used to support learning. Finally, with the global pandemic, more children were seen with internet-based technologies for both assessment and treatment sessions. These children learned to deal with technology very quickly as they engaged with services from SLPs and audiologists. Issues related to school safety and information and training on trauma-informed practices will continue to increase as education professionals seek resources for responding to traumatic events that affect children of all ages. Postpandemic mental health concerns in children are on the rise and teachers and clinicians will be required to adapt classroom management strategies, instructional supports, and school climate to support children who have experienced trauma to help them achieve success. Chapter 18 explores these issues more fully. Audiologists and SLPs in the schools continue to play a major role in helping educators adopt more inclusive practices in education. Such practices are designed to enable special education students at all grade levels and with a wide range of needs to be involved in and make progress in the least restrictive environment (LRE). To that end, service delivery models that place an emphasis on working with students in their natural environment, in addition to interprofessional collaboration, are appropriately taking the place of the more traditional medical (pull-out) model. As educational trends continue to evolve, SLPs and audiologists will need evidence-based studies that demonstrate the quantitative and qualitative differences we make in students’ lives. Practices that help students improve their ability to participate productively in education and employment will continue to be the focus of school-based service providers in the coming years. See Chapter 12 for further discussion of policy and service delivery in education.

Economic Trends The United States is a highly developed nation, with the world’s biggest economy in gross domestic product

(GDP), representing around one-fourth of the global GDP. At the time of this writing, economic indicators show that U.S. GDP will grow 2.8% in 2022, 2.2% in 2023, and 2% in 2024. Challenges in predicting growth relate to both current inflationary and interest rate issues (Amadeo, 2022). The United States experienced a gradual economic recovery at the time the fifth edtion of this book was published. However, the COVID-19 pandemic created significant economic challenges. In the second quarter of 2020, unemployment moved to a high of 13%. The jobless rate has steadily declined to 3.5% in 2023 (Edwards et al., 2022). Although there may be a perception that many people retired early due to the pandemic, the statistics have not necessarily supported this assertion (Thompson, 2022). Inflation has been a major concern following the COVID-19 pandemic. The inflation rate was 7.1% between November 2021 and November 2022. The annual inflation rate in December 2022 was 6.5% (U.S. Inflation Calculator, 2023). With rising inflation comes concerns about the erosion of real income, which may impact any services viewed as elective from SLPs and audiologists. Additionally, concerns regarding a subsequent recession typically follow high inflation, which has caused many to view the economic landscape very carefully. Employment prospects for SLPs and audiologists in all settings are excellent. As mentioned at the beginning of this chapter, speech-language pathology and audiology are both expected to grow significantly over the next seven years. In 2021, the median pay for SLPs was $79,060 per year, or $38.01 per hour. For audiologists, it was $78,950 per year, or $37.96 per hour (U.S. Bureau of Labor Statistics, n.d.). Chapters 7 and 8 provide more detail on issues related to employment for audiologists and SLPs.

Demographic Trends and Globalization The world’s population is more than 8 billion, with the largest populations in China and India (Worldometer, n.d.). The United States ranks third and its population continues to grow, in large part due to immigration. With an increase of more than 10 million people between 2016 and 2020, the 2020 estimated population of the United States is 331,002,651 million. According to a 2020 report, the pace at which the worldwide population is aging is faster than ever. It is anticipated that the proportion of people over 60 years old will nearly double between 2015 and 2050 (World Health Organization [WHO], 2022). Population aging, while due primarily to lower fertility rates, has created many new challenges, particularly in the health care arena. How many years can older people expect to live in good health? What are the chronic diseases they may have to deal with? How long can they live



independently? How many of them are still working? Will they have sufficient economic resources to last their lifetimes? Can they afford health care costs? The World Health Organization (WHO) is dedicated to reducing health inequities for this aging population with a focus on person-centered care (WHO, 2022). Audiologists and SLPs working with this growing population will need to be prepared to face these challenges as they apply to practice settings. As with all populations, providing the highest quality services that support hearing, communication, and swallowing will need to be the focus of continuing education as trends in best practices continue to evolve with this aging group. Finally, new graduates will need to be mindful of these same challenges as they contemplate their own retirement years and as they plan their career paths. The COVID-19 pandemic had an impact on the U.S. population, with a slower rate of growth between 2020 and 2021. However, the rate of growth has recovered in 2022. Migration patterns into the U.S. had also slowed during the pandemic but are now near normal prepandemic levels (U.S. Census Bureau, 2022). According to the American Community Survey of the U.S. Census Bureau, English is the most commonly spoken language (78.5%), while 13.2% of the population speak Spanish and 1.1% speak Chinese (U.S. Census Bureau, n.d.). As our population becomes increasingly diverse in age, spoken languages, race, ethnicity, religion, education, gender, sexual orientation, gender identity, and socioeconomic factors, it is imperative that we demonstrate cultural competence in meeting the needs of those we serve. See Chapter 21 for further discussion.

Evidence-Based Practice (EBP) The foundations of best practices in audiology and speech-language pathology are rooted in evidence. EBP is the integration of (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/ caregiver perspectives (ASHA, n.d.-b). What does this mean to the new clinician who wants to ensure the highest quality of services, yet lives in a world where “facts” are questioned and empirical data is politicized? The policymakers in both the insurance industry and government have implemented EBP requirements for reimbursement, making research in communication sciences and disorders (CSD) all the more important. Audiologists and SLPs can access sources for EBP guidance including bibliographies, evidence maps, and summaries of treatment efficacy in a wide range of clinical areas from ASHA (https://www.asha.org), the American Academy of Audiology (https://www.audiology.org), and the Academy of Neurologic Communication Disorders and Sciences (ANCDS; ancds.org), among others. ASHA

CHAPTER 1   Professions for the 21st Century

and other organizations continue to build resources for professionals as the demand evolves for accountability and quality. See Chapter 6 for more discussion of EBP.

Summary The professions of speech-language pathology and audiology are dynamic and diverse, much like the patients we work with. This chapter discussed some of the most dynamic changes, trends, and issues that are likely to affect your practices. Included in this discussion was information on technology and the digital revolution, trends in health care and education, economic influences, demographic shifts and globalization warranting cultural sensitivity and competency, and evidence-based practice needs. Knowledge of these topics is essential for applying analytical and critical reflection when making decisions that affect the lives of those we serve. It is the intention of this chapter and book, much like the overall goal of SLPs and audiologists, to optimally communicate the present and projected practices that will shape our expertise and professional necessity long into the future.

References Amadeo, K. (2022, July 27). U.S. economic outlook for 2022 and beyond. The Balance. https://www​ .thebalance.com/us-economic-outlook-3305669 American Speech-Language-Hearing Association. (n.d.-a). Caseload and workload. https://www .asha.org/practice-portal/professional-issues/ caseload-and-workload/ American Speech-Language-Hearing Association. (n.d.-b). Evidence-based practice (EBP). https:// www.asha.org/research/ebp/ American Speech-Language-Hearing Association. (2016). Scope of practice in speech-language pathology. https://www.asha.org/policy/sp201600343/ American Speech-Language-Hearing Association. (2018). Scope of practice in audiology. https://www​ .asha.org/policy/sp2018-00353/ Berenbrok, L. A., DeRuiter, M., & Mormer, E. (2022). OTC hearing aids: An opportunity for collaborative working relationships between pharmacists and audiologists. Journal of the American Pharmacists Association (JAPhA), 62(6), 1765–1768. Bouchrika, I. (2023, April 6). Mobile vs desktop usage statistics for 2023. Research.com. https://research​ .com/software/mobile-vs-desktop-usage

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Digital revolution. (2019, May 1). In Wikipedia. https://en.wikipedia.org/wiki/Digital_Revolution Edwards, R., Essien, L. S., & Levinstein, M. D. (2022). U.S. labor market shows improvement in 2021, but the COVID-19 pandemic continues to weigh on the economy. Monthly Labor Review, U.S. Bureau of Labor Statistics. https://doi.org/10.219​ 16/mlr.2022.16 Facer, K., & Sandford, R. (2010, January 12). The next 25 years?: Future scenarios and future directions for education and technology. https://doi.org/10.1111/​ j.1365-2729.2009.00337.x Grand View Research. (n.d.). Artificial intelligence in healthcare market size, share, and trends analysis report by component (software solutions, hardware, services), by application (virtual assistants, connected machines), by region, and segment forecasts, 2023–2030. https:// www.grandviewresearch.com/industry-analysis/ artificial-intelligence-ai-health​care-market Internet World Stats (IWS). (2023). World internet usage and population statistics: 2023 year estimates. https://www.internetworldstats.com/stats.htm

on retirement timing. U.S. Census Bureau. https:// www.census.gov/library/stories/2022/09/did-covid19-change-retirement-timing.html U.S. Bureau of Labor Statistics. (n.d.). https://www​ .bls.gov/ U.S. Census Bureau. (2022, December 27). Growth in U.S. population shows early indication of recovery amid Covid-19 pandemic. Census.gov. https://www​ .census.gov/newsroom/press-releases/2022/2022population-estimates.html U.S. Census Bureau. (n.d.). Language spoken at home by ability to speak English for the population 5 years and over. U.S. Inflation Calculator. (2023, January 12). Current U.S. inflation rates: 2000-2023. https:// www.usinflationcalculator.com/inflation/ current-inflation-rates/ Venkatesh, K. P., Raza, M. M., & Kvedar, J. C. Health digital twins as tools for precision medicine: Considerations for computation, implementation, and regulation. NPJ Digital Medicine, 5, 150. https://doi.org/10.1038/s41746-022-00694-7

PricewaterhouseCoopers. (n.d.). Medical cost trend: Behind the numbers 2022. https://www.pwc.com/ us/en/industries/health-industries/library/behindthe-numbers.html

World Health Organization. (2022). Ageing and health. https://www.who.int/news-room/fact-sheets/detail/ ageing-and-health

Thompson, D. (2022, September 19). Pandemic disrupted labor markets but had modest impact

Worldometer. (n.d.). Current world population. https:// www.worldometers.info/world-population/

2 Professional Issues and Organizations:  From the Past to the Present Jaynee A. Handelsman

Introduction This chapter provides information about professional associations, including some of the benefits of affiliation both for seasoned professionals and for individuals in training to become audiologists or speech-language pathologists (SLPs). We will take a brief journey through the history of the professions as well as some of the important factors that have shaped the discipline over time. In discussing common characteristics of professional associations, the American Academy of Audiology (AAA) and the American Speech-Language-Hearing Association (ASHA) will serve as examples. In addition to these two national professional associations, we will discuss related groups with which audiologists, SLPs, and speech and hearing scientists choose to affiliate, both within the United States and abroad. Of course, this journey would not be complete without a focus on recent history and current trends within the professions. Finally, some critical thinking questions will be posed to help readers think about how the topics discussed pertain to their individual situations.

Practical Dilemmas and Affiliation Audiologists, SLPs, and speech and hearing scientists have a variety of reasons for wanting to affiliate with one or more professional associations. We are each faced with practical issues in the workplace for which we may need guidance to come up with an appropriate resolution. The next sections highlight some examples of practical issues needing a solution.

Workload Issues Imagine you are an SLP working in a rural area with a caseload that includes children with a wide range of disorders of varying severity, including some with multiple severe health conditions. When you were 9



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hired, you were told that the staffing plan for the school included two full-time SLPs as well as a speech-language pathology assistant (SLPA). You recently learned that the other SLP will be going on medical leave and is expected to be out for at least 3 months. You need assistance in demonstrating that the workload is unreasonable for one SLP, particularly given the severity of conditions in the caseload, even with the help of an SLPA.

Ethical Issues As an audiologist working in a private practice, you are interested in maximizing your return on investment and profit margins. You are considering working with a buying group that not only provides a discount based on the number of hearing devices purchased, but also provides the opportunity to bank points based on sales that can be used to purchase additional audiology equipment or other items for the practice. It promises to help you market your practice at no additional cost. The buying group includes a limited number of device manufacturers. You are concerned that there might be some ethical considerations with entering into this contractual agreement with the buying group.

Professional Connection You recently accepted a position in a state with which you are unfamiliar. While you are surrounded by other SLPs in the hospital in which you work, you want the opportunity to connect with the broader community in your state and to understand the specific licensure and other local requirements for practice. You know that the national associations, including ASHA, could be helpful in providing information. You are also hoping the state association can provide information specific to your location.

Advocacy You are an audiologist that is aware of the issue surrounding Medicare reimbursement for services and you know ASHA, AAA, and the Academy for Doctors of Audiology (ADA) have been working together to support maximized payments from government and nongovernment payers. One of the benefits of affiliation is having access to updates in real time about these efforts and their outcomes. Another is being able to see a filtered version of Medicare rules and payment schedules that are specific to audiology. As an SLP providing postacute services, you know there are challenges to payment for rehabilitation services. You want help knowing what is typical in number of sessions you can provide and how to document the

ways the patient benefits from your care. You are also concerned about whether ASHA is advocating for the importance of speech-language pathology services in the postacute setting to facilitate payment.

Benefits for Students in Training One of the benefits of affiliation to individuals in training is early knowledge about professional associations and the leadership opportunities they provide. For example, the ASHA Minority Student Leadership Program (MSLP) educates students in training from ethnic minorities about ASHA and all the benefits of affiliation. The program also is designed to teach students about leadership and how they can develop their own leadership skills. Having an opportunity to engage with successful audiology and speech-language pathology leaders is an important part of the program. Also, getting to know other future leaders during the program helps students to have a community of peers for support. We already briefly discussed the benefits of affiliation related to the MSLP program. There are two national associations for students including the National Student Speech Language Hearing Association (NSSLHA), which is affiliated with ASHA, and the Student Academy of Audiology, which is affiliated with AAA. Both associations provide opportunities for leadership development and volunteer service for students as well as educational materials and scholarly and professional publications. These organizations will be described in more detail later in the chapter.

Organization of the Professions In the late 19th and early 20th centuries, the United States was experiencing social upheaval. The U.S. population nearly doubled at the end of the 19th century, largely due to immigration. At the same time, the population began to move to large urban centers. With urbanization came a shift from small-scale businesses and manufacturing to large-scale factory production. Urbanization, coupled with the industrial revolution, produced increased economic inequality, dangerous working conditions, and inadequate housing in major cities. The concentration of wealth and political power resided with a small elite group while most people did not have opportunities to thrive. At the time, the U.S. government was not equipped to address these issues on a national scale (Editors of the Encyclopedia Britannica, 2020). The profession of speech-language pathology arose out of the needs presented during this era. The seeds of the profession of audiology followed a bit later.



CHAPTER 2   Professional Issues and Organizations:  From the Past to the Present

Progressivism Movement In response to social issues of the time, the progressivism movement was born in the U.S. (McGerr, 2003). Members of the movement included a diverse group of reformers that had a common objective of strengthening the national government and making it more responsive to the demands of everyday Americans. They wanted to better support the needs of the poor, individuals with disabilities, and the voiceless. Individuals supporting the movement were called progressives because they thought social change would yield a better future. The Progressive Era started a tradition of reform that has been present in American society ever since (Milkis, 2023). Examples of reforms that occurred during this era include passage of child labor laws, food and safety requirements, and the normalization of the 8-hour workday, each of which is still in place today. In addition, the Progressive Era included the formation of labor unions, trade groups, and professional, civic, and religious associations; the women’s suffrage movement; the creation of safe havens for blind, deaf, and developmentally disabled people; and building shelters in the inner city to provide food, clothing, and education. Free, compulsory education became law during this period. Also, there was a sense of community to new immigrants. The 19th amendment was ratified in 1920, giving women in the U.S. the right to vote.

Birth of Professional Associations A number of professions were organized in the U.S. during the Progressive Era with the goal of responding to progressive ideals and social needs. One of the first tasks for these new professions was to define qualifications for membership. Another was to create a scope of practice, first by identifying terminology and diagnostic categories pertaining to each. College and university programs were developed, conventions were held, and journals were created so each profession could define its own areas of expertise and exclude individuals without the necessary background and skills. Each profession, then, was able to put forward its own best practices. In the early days, professionals from various backgrounds and disciplines who had a common interest in matters related to speech correction began to develop connections with one another. Initially they held casual meetings in peoples’ homes; later, informal gatherings occurred at allied professional meetings. Many of the charter members were already strongly affiliated with other societies. For example, informal meetings occurred at the National Education Association (NEA) meeting, which consisted primarily of public-school clinicians from the eastern U.S. This group called themselves the

National Society for the Study and Correction of Speech Disorders. Another informal gathering occurred at the National Association of Teachers of Speech (NATS) meeting held in New York City in 1925. While NATS was a professional association whose membership included people working in the areas of theater, debate, and rhetoric, there was a subset of the group that was interested in establishing an organization to promote work in speech correction. In December 1925, the American Academy of Speech Correction was born, which was ASHA’s original predecessor. The evolution of the profession of audiology also began with a few individuals interested in hearing and balance disorders gathering informally at larger professional association meetings or at planned invited meetings of audiology leaders. The interest in having a professional association for audiologists apart from ASHA began officially at the 1987 ASHA convention in New Orleans. As part of the accepted sessions, there was a panel discussion focused on the perceived challenges to audiology and what the future might hold for the profession. The final speaker in the session was James Jerger, who proposed that audiologists should break away from ASHA and start their own group. The rationale was based on his observation that audiologists coming out of training programs were ill prepared to function successfully in a medical center environment and his belief that the professions of audiology and speech-language pathology have disparate clinical, academic, and political needs. His comments were met with a standing ovation. When he returned home following the meeting, he was flooded with phone calls urging him to capture the momentum he had created and to press on (AAA, 2023a; Stach & Northern, 2023). Subsequently, Dr. Jerger contacted a number of colleagues, many from medical centers and others from the hearing aid dispensing community and invited them to a meeting that was to be held in Houston in late January 1988. Thirty-two audiologists attended the 2-day meeting and collectively decided that the best approach for moving the profession forward would be to create a new association of, by, and for audiologists. This group of 32 audiologists is known as the Academy Founders. A second meeting of the group was held in Nashville to develop bylaws and a subsequent meeting was held in Houston to establish the group’s structure and to elect the officers. The first convention was held in the spring of 1989, by which time the membership of the AAA had grown to more than 2,000 (AAA, 2023a; Stach & Northern, 2023). Even before the AAA was born, ASHA supported efforts to move away from the master’s degree as the appropriate minimum educational requirement for

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audiologists entering the field. It is important to note that another professional audiology association was having an influence on the evolution of audiology at that time. Specifically, the Academy of Dispensing Audiologists (ADA) was involved from the beginning in efforts to move audiology to a doctoring profession to support a 1978 ASHA task force recommendation that the master’s degree was not sufficient for professional preparation in audiology. Following an ADA-sponsored conference in 1986 on professional education in audiology, an effort was mounted to promote moving audiology education to a doctoral level and using the Doctor of Audiology (AuD) as the professional degree. In 1989, the Audiology Foundation of America (AFA) was formed to transform audiology into a professional doctorate status. That same year, an ASHA task force recommended that ASHA should fully support the concept of a postbaccalaureate professional doctorate. In 1992, an ASHA Ad Hoc Committee on Professional Education recommended the AuD as the entry-level audiology degree with a proposed implementation date of 2001. Quite a few audiology-related professional organizations (RPOs) asked ASHA to take the lead in AuD degree development and implementation (ADA, 2023b).

Common Characteristics of Professional Associations Professional associations provide a variety of benefits to members. There are other characteristics that are common to most, if not all, professional associations. For example, they typically have a targeted scope related to a particular discipline. Commonly, members need to meet certain requirements related to the profession or discipline. Professional associations each have a statement of purpose included in the mission and vision statements. The mission represents a specific task with which the group is charged that might also be referred to as its calling. The vision statement is a declaration of the principles of the association. Also common to professional associations are bylaws. Bylaws are rules adopted primarily for the government of association members and the management of its affairs (Merriam-Webster, n.d.-a). Typically, the rules for membership are spelled out in the bylaws, including the requirement that members agree to abide by a Code of Ethics (COE), which is a set of standards of professional conduct that specifies members’ responsibilities to colleagues, to consumers, and to the profession. Most professional associations are nonprofit organizations with a governance structure that includes a Board of Directors (BOD). The BOD typically is responsible for establishing policy, while

national office staff members engage in the day-today operations of the association and are charged with implementation of policy. There are certainly costs associated with running a professional association and providing member benefits. Funds are also needed to support the consumer advocacy goals of the association. While it is true that a large portion of the operating budget is generated through membership dues, additional funds may come from other sources including conventions and meetings, product sales, relationships with corporate entities, and investments.

Historical Perspective on Scope and Practice Framework As already discussed, the founders of our earliest professional associations were interested in speech correction and were influenced by the social problems in the U.S. following World War I. The American Academy of Speech Correction that was born in 1925 at the NATS meeting evolved over the years to become ASHA as we know it today. The association’s name changed four times over the years, first in 1927 to become the American Society for the Study of Disorders of Speech, again in 1934 to the American Speech Correction Association, and then to the American Speech and Hearing Association in 1947. It was not until 1978 that “language” was included in the name: American SpeechLanguage-Hearing Association (ASHA). The charter members of the original honorary society included 25 individuals. Membership has grown exponentially since then (ASHA, 2023a). While we have discussed some of the factors involved in the earliest days of our professional associations, there is so much to consider in our history. The sections that follow will briefly discuss important milestones in the evolution of the discipline.

Influence of the Second World War (WWII) The fighting during World War II created health care needs for military personnel. One example has to do with hearing loss associated with combat. As you might imagine, the need for hearing protection was not front of mind for officers during the war. There was a recognition, however, of the potential impact of noise exposure on hearing and the importance of hearing to military personnel. As a result, medical departments were established to provide comprehensive hearing services. Centers were typically staffed with individuals in training for speech correction or otology. The services that were



CHAPTER 2   Professional Issues and Organizations:  From the Past to the Present

provided included hearing testing for servicemen and fitting hearing aids as needed, as well as counseling related to hearing loss and aural rehabilitation in the form of speech reading. A group of fledgling hearing specialists was formed. Once the war was over, servicemen and those involved in their care returned to civilian life. Some of the hearing specialists discussed in the previous paragraph were interested in creating a new specialty practice that they coined “audiology.” Given the needs of the people returning from war, coupled with others with hearing loss in the community, the field grew. Newly minted audiologists were employed by the Veterans Administration (VAMC), the private practices of otolaryngologists, community hearing clinics, and university speech clinics. Many of the audiologists or hearing researchers remained affiliated with the academic discipline of speech pathology, as evidenced by the 1947 renaming of the national organization (ASHA) to include “hearing” in its association title, and in 1948 with the addition of “hearing” to the name of its professional journal. Another change in our discipline occurred in speechlanguage pathology. While the earliest SLPs were primarily interested in speech correction, the brain injuries that occurred during WWII resulted in speech and language disorders that were relatively new to the profession. While it is beyond the scope of this chapter to delineate all the speech and language disorders that are now recognized in speech-language pathology, it is important to note that the return of servicemen with brain injuries from WWII resulted in a change in the practice of SLP. Specifically, the profession evolved to include aphasia and the treatment of other neurological disorders.

Changes Arising From Social Reform The history of our discipline is rich, and it was impacted by social reform movements. These changes started with the civil rights movement. For example, there was a push to eliminate the stigma and biases associated with different dialects of English. Specifically, dialectical differences that were once treated as disorders were reclassified as differences without bias. This change clearly impacted the profession of speech-language pathology. In addition, it was a move to change the personal experience for people of color in our country. Clear evidence of this change and ASHA’s commitment to diversity, equity, and inclusion is exhibited in the establishment of the ASHA Office of Multicultural Affairs (OMA) in 1969. It is not accidental that OMA has a focus on inclusion and equity. OMA addresses cultural and linguistic diversity issues related to professionals and persons with communication disorders and differences. Happily, abundant resources are available on

the ASHA website related to issues related to how best to understand and work with clients from diverse ethnic and cultural backgrounds (ASHA, 2023b). The impact of the disability rights movement on our discipline is without question and dates to the 19th century when formal deaf education began. Thomas H. Gallaudet founded the Connecticut Asylum for the Education and Instruction of Deaf and Dumb Persons in Hartford, Connecticut, which was the first permanent school for the deaf in the U.S. (Temple University, 2023). Franklin D. Roosevelt, the 32nd president of the U.S., served four terms despite experiencing paralysis from the waist down due to polio during his first term. His popularity and commitment to helping those with disabilities was impactful. For example, he signed the Social Securities Act into law in 1935, which established a program of permanent assistance for those with disabilities. Other important milestones related to disability awareness and acceptance included the founding of the National Mental Health Foundation (NMHF) in 1946, the foundation of the Paralyzed Veterans of America (PVA) in 1947 that includes members who have suffered spinal cord injuries due to combat, the beginning of national barrier-free standards for buildings in 1950, and the birth of the Association for Retarded Citizens (ARC) in 1950. Progress on disability rights continued during the 1970s and 1980s in the U.S. While discussing each example is beyond the scope of this chapter, notable changes that occurred in 1975 include enactment of the Developmental Disabilities Assistance and Bill of Rights Act, enactment of the Education for Handicapped Children Act, a United Nations Declaration on the Rights of Disabled Persons, and a paradigm shift away from a medical construct of disability toward a social model that focuses on environmental, systematic, and attitudinal barriers. In 1978, an advisory board within the Department of Education, the National Council on Disability, was established. Of note, the Developmental Disabilities Assistance and Bill of Rights Act was amended in 1993 to specifically recognize that disability is a natural part of the human experience. The 1990s and early 2000s brought numerous significant legislative and societal changes related to how people with disabilities are recognized and treated. In 1990, the Americans With Disabilities Act (ADA) was signed into law by President George H. W. Bush, which prohibits the discrimination of people with disabilities in all areas of public life. The act provides civil rights protections to disabled people that are similar to those provided to others on the basis of race, color, sex, national origin, age, and religion. Particularly important to our discipline, the federal government recognized autism as a special education category in 1991.

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Two additional legislative efforts that were successful in the 1990s are the Federal Communications Act, which requires all computers, telephones, and other electronic communication devices to be accessible, and the Assistive Technologies Act, which expands technology-related assistance for individuals with disabilities. Other milestones important in the disability awareness movement include the first Disability Pride Parade and the Road to Freedom bus tour. The Chicago Disability Pride Parade in 2004 was designed to change the way people think about disability, to end any internalized shame felt by people with disabilities, and to promote the notion that disability is a natural and beautiful part of the human experience. The Road to Freedom bus tour and exhibit traveled to 48 states in 2007 and again in 2014, laying out the history of grassroots efforts that led to the passage of the Americans With Disabilities Act.

Influence of Technologies It is certainly the case that technological advances have impacted our discipline. Early on, in an effort to be more scientific and to increase the credibility of the professions, inventors pursued developing devices to study the underlying mechanisms of speech production and perception. While it is beyond the scope of this chapter to discuss each of the inventors and their incredible contributions to the early history of our field, some examples of technological development are discussed in the following paragraphs. Early in the 20th century, Carl Seashore developed several devices, including the voice tonoscope, which was intended to record, measure, and display aspects of the human voice. He also developed an audiometer that could be used to measure hearing thresholds over a variety of frequencies and intensities with stimuli presented through earphones (Duchan, 2021a). Later in the century, Lee Edward Travis was a pioneer in the use of electrophysiological methods to measure both muscle and brain activity (Duchan, 2021b). Both these pioneers were faculty at the University of Iowa. Another important player in the mix was Bell Telephone Labs, where the first hearing aid, the first artificial larynx prototype, a speech synthesizer, and the first speech spectrograph were developed. These inventions led to significant changes in research and practice in audiology and speech-language pathology. For more detailed information about each of the pioneers that contributed to the early development of our discipline in the 20th century, please refer to A History of Speech-Language Pathology (Duchan, 2021b, 2021c). The invention and development of cochlear implants (CI) has been a game changer in the management of

hearing loss. Initially, this technology enabled individuals who had no access to sound because of the magnitude of their hearing losses to have sound awareness for the first time. This technology transforms an acoustic signal (sound) into an electrical signal that is transmitted to the auditory nerve. While the concept of directly stimulating the cochlear nerve with electrical current dates to the 19th century, additional developments were necessary to enable researchers to conduct safe trials. The U.S. Food and Drug Administration (FDA) has been involved in overseeing the development and safety of medical devices, including CIs, since 1976 (Van Norman, 2016). According to ASHA, the first single-electrode CI was introduced in 1978 (ASHA, 2004). Since then, advancements in cochlear implant technology have exploded and the criteria for implantation have evolved. Another area of evolution in our discipline that is specific to speech-language pathology is in the evaluation and treatment of swallowing. While SLPs became involved in swallowing and swallowing disorders in the 1920s and 1930s when working with children with cerebral palsy and other neuromotor disorders, the primary focus at that time was on oromotor control related to feeding. Early on, relatively few SLPs were employed in medical settings and did not participate in the care of hospitalized patients. It was not until the late 1960s and 1970s that the profession expanded both in numbers and in types of work settings to include medical clinics, hospitals, and rehabilitation settings (Logeman, 2004). SLPs use two types of instrumented swallowing evaluations: flexible endoscopic evaluation of swallowing (FEES) and videofluoroscopic swallowing study (VFSS). FEES is a portable procedure that can be completed at the bedside or in an outpatient clinical setting by passing an endoscope through the nose to evaluate swallowing in real time (Langmore et al., 1988). VFSS may be completed in coordination with a radiologist. SLPs who are interested in the area of swallowing must have access to education and clinical training opportunities to develop competence in this area of practice. It is hard to imagine the practices of speech-language pathology or audiology without portable computers that can talk with one another through the internet, yet both are relatively recent technological advances. The computers in the 1960s, which were owned by the government, were huge and immobile, so sharing information among professionals involved traveling to the computer site or having magnetic tapes sent through the postal service. During the Cold War, national security was a catalyst for the development of a means for government computers to be networked. A precursor to the internet began with the U.S. Defense Department’s ARPAnet (ARPA-A) and many of the ARPA-funded researchers



CHAPTER 2   Professional Issues and Organizations:  From the Past to the Present

developed protocols that are still used for internet communications. January 1, 1983, is considered to be the official birthday of the internet because, with the development of the Transfer Control Protocol/Internetwork Protocol (TCP/IP) communications protocol that was established on that date, all computer networks could be connected by a universal language (Board of Regents of the University System of Georgia, 2000). Interestingly, the first personal computer became available to the public in 1977 when the Apple II was introduced. It was sold as a complete unit with a main logic board, power supply, keyboard, case, and manual, as well as game paddles and a cassette containing the game Breakout. Apple IIs were sold between 1977 and 1993. Apple donated thousands of Apple IIs to schools, providing personal computer access to a new generation of students. The Apple Macintosh, which was introduced in 1984, was the first mouse-driven computer that came with graphics and word processing software; the first practical laptops were introduced in 1996; and the first Apple iPhone was released in 2007. The first Apple iPad came out in 2010 and the first Apple Watch came to market in 2015 (Computer History Museum, 2023). This brief history is not intended to be comprehensive; rather, it is to point out how quickly computer technology has changed, enabling audiologists, SLPs, and speech and hearing scientists to explore practice and research avenues that were not previously possible.

Influence of Conceptual Frameworks Several changes in practices over the past 60 or more years have to do with new ways of thinking about disabilities and their causes. The area of autism is a perfect example of how changes in conceptual framework have altered the speech-language pathology scope of practice. In 1943, autism was considered an emotional disorder caused by a mother’s lack of affection (Kanner, 1943). At that time, the medical community believed the communication problems for those with autism were secondary to their emotional disability. Therapies were focused on the emotional problem in hopes that the communication disabilities would resolve on their own. As a result, physicians and psychologists were the professionals with the appropriate expertise. The work of Ivar Lovaas, a behavioral psychologist, had a huge impact in changing the prevailing view about autism and creating a place for SLPs to participate in research and clinical practice with autistic people. In 1987, Lovaas published the results of a study looking at the efficacy of a behavior modification treatment for two groups of young autistic children. The results showed that the group who received long-term inten-

sive therapy (n = 19) demonstrated significant changes in their communication function, their measured IQ, and their educational performance, with 47% achieving normal intellectual and educational functioning including successful performance in first grade. By contrast, only 2% of the children in the control group (n = 40) had those same outcomes (Lovaas, 1987). As a result, the prevailing view about autism shifted to viewing it as a social-communicative disability. Clinicians started focusing on intentionality, social skill building, and providing augmentative and alternative communication opportunities for children with autism. Clearly, work in autism is an important area in the speech-language pathology scope of practice. The linguistic revolution of the 1970s created an even larger shift in speech-language pathology research and practice. A new discipline was emerging in the social sciences that was grounded in the areas of linguistics and psychology. The combined discipline was called psycholinguistics. The psycholinguistics framework that focused on language structure and processing changed the thinking and practice in areas such as delayed speech, articulation problems, and aphasia. For example, delayed speech was now referred to as childhood language disorders and articulation disorders were called phonological disorders. Linguistic analyses were added to diagnostic testing methods, and new treatment methods were devised to target linguistic rules or psychological processes, including memory and attention (Duchan, 2021d). The emphasis on language learning and processing set the stage for school-based SLPs to play a key role in providing services to children with language and learning problems. As a result, the typical caseload for an SLP in the schools shifted from a majority of children with articulation issues to the same percentage of students having language-based disorders. This change was a segue into SLPs’ involvement with literacy. The influence of an elaborate information processing conceptual framework also impacted audiology. While audiologists had previously focused on peripheral hearing, there was a new interest in how individuals process sound, and tests were developed to assess that aspect of audition. Various tests to measure different types of processing evolved, as did therapies to remediate central auditory processing disorders. Researchers have worked diligently to locate the source of auditory processes with some success, thanks to the influence of electrophysiology and other changes in technology. Over the years, audiologists have expanded their diagnostic and intervention services to include tinnitus, vestibular disorders, and cochlear implants. Importantly, advances in hearing aid technology and licensure laws enabling audiologists

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to dispense hearing aids were also game changers for the profession.

Recent Trends The professions of audiology and speech-language pathology continue to evolve as the world evolves, introducing new challenges and interests into our discipline. A huge impact on the discipline is the fact that we are a global economy and that audiologists and SLPs are no longer able to focus solely on what is happening locally. We only recently experienced a global pandemic that has changed our lives forever. We are also in the midst of international conflict that impacts all of us in ways that remain uncertain. One of the metrics of the impact of recent trends in our professions is to examine the ASHA special interest groups (SIGs) that have been created in recent years. The SIG program enables professionals to easily exchange information about topics that are important to them. There are four new SIGs that have been approved in recent years, demonstrating areas of importance to those in our discipline. SIG 17, Global Issues in Communication Sciences and Related Disorders, is devoted to providing international leadership in audiology and speech-language pathology services through collaboration with our international partners. SIG 18 is devoted to telepractice, which is very important in our current environment. Its purpose is to provide education, leadership, and advocacy surrounding issues related to telepractice in audiology and speech-language pathology. SIG 19 is related to speech science. Its purpose is to be the primary community for the exchange of information about speech science and related technological advances. Finally, SIG 20 is all about counseling. The vision of SIG 20 is to be a community where professionals and students can come together to exchange information about counseling practices, to foster research, and to promote interprofessional collaboration to foster inclusion of counseling into clinical practice. For a complete list of the ASHA SIGs and the mission and vision of each, please refer to the ASHA website (ASHA, 2023c). Another important influence in the evolution of our discipline was the evidence-based practice movement, which entered our field in the late 1990s. Its foundations arose from the positivism movement that favors measurable data over derived or inferential information. This movement resulted in a preference for standardized testing and clinicians’ efforts to obtain measurable data relative to treatment outcomes (ASHA, 2005). While the focus on randomized controlled trials has created a healthy literature comparing findings from different studies, it has tended to result in inattention to important areas of evidence, including the voice of the client.

Some researchers advocated for including qualitative measures, such as client engagement, into the mix. Other recent impacts on the profession will be discussed later in the chapter, and evidence-based practice is also addressed in Chapter 6 of this text.

Common Characteristics of Professional Associations Revisited Already mentioned are some characteristics common to professional associations, including a statement of purpose, bylaws that delineate how the association functions including governance, membership rules, and professional standards. While there are many associations that are important to audiologists and SLPs, ASHA and AAA will serve as examples of some of the common characteristics for professional associations.

Purpose Statement As mentioned previously, professional associations each have a statement of purpose, which is likely included in the vision and mission statements. Mission statements describe an organization’s reason for existence — its purpose — while vision statements describe the ideal state that an organization wants to achieve. So, a vision statement is a declaration of the principles of the association that focuses on its goals and aspirations while the mission represents a specific task with which the group is charged. Vision statements are timeless, even if an organization changes its strategy. Both the vision and mission statements are outward- and inward-facing proclamations of the purpose and values of the association. ASHA includes the vision and mission statements, as well as its core values, in the strategic plan. The current plan is referred to as the Strategic Pathway to Excellence and includes strategic themes (“pillars of excellence”) and strategic objectives. ASHA’s vision, which has been consistent over many years, is “making effective communication, a human right, accessible and achievable to all.” ASHA’s mission, which might be referred to as its purpose, is to empower and support SLPs, audiologists, and speech and hearing scientists through four primary mechanisms: “advancing science, setting standards, fostering excellence in professional practice, and advocating to members and those they serve.” ASHA’s core values are also clearly articulated on the Strategic Pathway to Excellence portion of the website (ASHA, 2023d). While AAA is not the only national association with audiology and hearing scientist members, it strives to be the primary voice of audiology. Its vision is “to be essen-



CHAPTER 2   Professional Issues and Organizations:  From the Past to the Present

tial in the professional lives of audiologists” through advancing both the science and practice of audiology as well as by having audiologists recognized as the experts in hearing and balance care. Its mission or purpose is to promote access to quality hearing and balance care by advancing the profession of audiology. The mechanisms used to pursue its mission are outlined in its Core Values document and include advocacy, education, leadership, increased public awareness, and research (AAA, 2023a, 2023b).

Bylaws The bylaws of an association include the rules and regulations associated with oversight. While each professional association may have its own bylaws structure, some elements remain consistent. We already spoke about vision and mission statements that are the basis for the existence of a professional association. The bylaws are the nuts and bolts of how the association works. In the following sections, we will again use ASHA and AAA as illustrations. While it is not within the scope of this chapter to describe each of the components of the ASHA bylaws, it is important to note that it is a fluid document that is updated on a regular basis. The current sections include purposes, members, BOD, conduct of business, national office, professional standards and ethics, publications, discrimination, honors and awards, recognition of other organizations, special interest groups, parliamentary authority, indemnification, and amendments (ASHA, 2023e). AAA’s bylaws were initially established in 1988 and have been revised as needed by the BOD. They were most recently amended in 2020. As mentioned in the previous paragraph about ASHA, it is beyond the scope of the chapter to provide specifics about the AAA bylaws. Having said that, the current sections include offices, membership, governance, nominations and elections, meetings, publications, interdependent organizations and special committees of the association, policies and procedures, amendment of bylaws, liquidation, and indemnification (AAA, 2023b).

Membership Rules Each professional association has restrictions about who is invited to be included, sometimes to create an exclusive society and in other cases to make sure members support the mission and vision of the association and can contribute in a meaningful way. The following sections provide membership information about ASHA and AAA. Please note that websites are provided as references so the information available to the readers is current.

ASHA.  ASHA has a variety of membership categories that are clearly defined on the ASHA website (ASHA, 2023f ). The first is certified membership, which is available to audiologists and SLPs that currently hold the Certificate of Clinical Competence in SLP (CCCSLP) and/or the Certificate of Clinical Competence in Audiology (CCC-A). Certified members must meet the speech-language pathology and/or audiology Council for Clinical Certification (CFCC) standards in effect at the time of application and adhere to the requirements for obtaining ongoing continuing education hours. At the present time, 30 hours of professional development are required for each 3-year maintenance cycle (ASHA, 2023g). The second ASHA membership category is membership without certification, which is intended for our colleagues who are engaged in research. According to the ASHA bylaws, this membership category is not an option for those engaged in clinical activities or in the supervision of students or clinical fellows. Individuals must have a graduate degree in speech-language pathology, audiology, and/or speech, language, and hearing science to be afforded the benefits of membership in this category (ASHA, 2023f ). There are other ASHA membership categories that are noteworthy. Life membership is available to ASHA members who are 65 years and older and who have had at least 25 consecutive years or 35 years cumulative years of membership prior to turning 65. Those members have demonstrated a commitment to the discipline and to ASHA. Another category that is important to highlight is graduate student membership. Because there are certified members who are returning to graduate school for an additional degree in communication sciences and disorders (CSD) or a related discipline, there is a reduced membership fee through this membership category. It is important to note other membership categories for our members who are not currently practicing for a variety of reasons. For example, the category for medical inactive status applies to those with short- or long-term disabilities. The retired certification status applies to those meeting certain age and longevity requirements who still want to retain this certification designation (i.e., CCC-A [retired] and/or CCC-SLP [retired]). There is a category for individuals who are deployed on active military duty that removes the requirement for certification maintenance hours. Additionally, certification fees are waived for the duration of their active status (ASHA, 2023f ). We already discussed the option of having ASHA membership without certification for those individuals not engaged in clinical practice. Members without certification are considered full members of the association. However, some practicing audiologists and SLPs choose to maintain their certification status only. Importantly,

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those individuals are not members of ASHA and are not eligible for any member benefits (ASHA, 2023f ). AAA.  AAA is a membership-driven organization made up of audiologists from around the world. As is the case with ASHA, AAA has a number of membership categories. Importantly, all members are required to abide by the Academy COE. There is also a strong nondiscrimination statement in the bylaws pertaining to the Academy and the BOD (AAA, 2023b). Fellows of AAA are audiology members who have met the requirements at the time of application. For example, before 2006, applicants needed to have at least a master’s degree in audiology or equivalent from a regionally accredited university. Individuals graduating in 2007 and later must have a doctoral degree, or the equivalent, in audiology to be eligible for fellow membership. For applicants living outside the U.S., membership criteria are similar to those already described with the additional caveat related to the certificate of equivalency in audiology. Only fellow members can vote and hold office (AAA, 2023c). A second membership category for AAA is student membership. Graduate student members of the Student Academy of Audiology (SAA) are enrolled in audiology-related doctoral programs at regionally accredited academic institutions. Student members hold all the responsibilities of fellowship membership and are afforded the same benefits other than being able to vote or hold office in AAA. They can hold office in SAA and vote in that group’s elections. SAA membership ends when the student graduates and becomes eligible for AAA fellow membership. Undergraduate students also have an opportunity to affiliate with AAA although they are not able to vote or hold office in SAA (AAA, 2023c). A third membership category is for affiliate members of AAA. Affiliate membership is designed for the professional with a graduate degree from a regionally accredited institution who has an interest in hearing, hearing science, balance disorders, and audiology but is not a practicing audiologist or eligible for fellow membership. Affiliate members cannot vote or hold office. They also cannot use the academy to promote their products (AAA, 2023c). There are a couple of additional AAA membership categories worth mentioning. The first is for audiology assistants, which is a group that is very important to the profession. It is an affiliate membership category. Audiology assistant affiliate members must be sponsored and supervised by an audiology fellow member. While they enjoy the benefits of membership, they cannot vote or hold office. They are also prohibited from promoting commercial products or services through their AAA affiliation. Another membership category is for international members and is intended for audiologists who were not

educated in the U.S. yet have formal training and/or experience in clinical audiology. While these members have access to all academy publications and materials, they cannot vote or hold office in AAA (AAA, 2023c). There are rules for maintenance of membership in AAA, one of which is paying dues in a timely manner. Dues are considered delinquent at the end of February and, if not paid within 30 days, membership may be suspended and/or eventually terminated per policies laid out in the association bylaws. Other reasons that membership in AAA may be terminated include violations of the COE and revocation or suspension of a license to practice. For additional details about this topic and reinstatement of membership, please refer to the AAA bylaws (AAA, 2023b).

Standards Our professional associations are in the business of creating standards for a variety of purposes. By definition, a standard is something that is established by authority or general consent as a model or criterion for behavior (Merriam-Webster, 2023b). In the following sections we will discuss standards that are important to our professions, including how academic institutions are held accountable for providing quality coursework and clinical education to students, the requirements for certification to practice, and specialty certification in our professions. Accreditation. The Council for Academic Accreditation in Audiology and Speech-Language Pathology (CAA) is a semiautonomous council of ASHA. Semiautonomous means that the council falls within the ASHA umbrella, yet it has the authority to independently develop and enforce standards relative to accreditation of entry-level graduate programs in speech-language pathology and audiology. Specifically, CAA accreditation is limited to master’s degree programs in speechlanguage pathology and clinical doctoral programs in audiology (e.g., AuD). It is beyond the scope of this chapter to provide detailed information about CAA standards and the council’s processes. However, there is complete transparency about deliberations and decisions on the CAA website (CAA, 2023). Interestingly, although volunteer members of the CAA are nominated through the CAA nominating committee, they are elected by faculty members in academic programs in speech-language pathology and audiology. The Accreditation Commission for Audiology Education (ACAE) is the academic accreditation arm of AAA and is involved with establishing academic standards for audiology education programs. The intention of accreditation is to recognize academic programs in audiology that are meeting ACAE standards. ACAE is specifically



CHAPTER 2   Professional Issues and Organizations:  From the Past to the Present

focused on doctoral-level audiology programs, and the standards are about student outcomes. For more information about ACAE and its accreditation process, please refer to its website (ACAE, 2023). Certification.  We have spoken a bit about standards for accreditation of academic programs in audiology and speech-language pathology and the entities responsible for establishing and maintaining accreditation standards. Importantly, accreditation has to do with academic programs and their compliance with CAA and/ or ACAE standards. On the other hand, certification standards established by our professional associations have to do with the minimal requirements for an individual to practice in audiology and/or speech-language pathology apart from licensure. The distinction between accreditation and certification is often misunderstood. Accreditation is about academic program standards while certification is about individual practitioners. The following paragraphs will highlight the certification arms of ASHA and AAA and briefly discuss specialty certification options through both entities. The standards for certification in audiology and speech-language pathology are established by members of ASHA’s Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC). Being ASHA certified means holding the Certificate of Clinical Competence (CCC) in audiology (CCC-A) and/or in speech-language pathology (CCC-SLP). Individuals meeting the requirements for certification in both professions are referred to as being dually certified. Certificate holders are required to abide by the ASHA COE and to uphold the certification standards. Candidates for certification are evaluated solely on the published criteria established by CFCC (ASHA, 2023p). CFCC is a semiautonomous body made up of volunteer audiologists and SLPs with staff support from ASHA. There are separate certification standards for each profession. The audiology members of CFCC are responsible for establishing the certification standards for audiologists, while the SLP members of CFCC are responsible for the speech-language pathology standards (see Chapter 3 for more information on certification standards). Having said that, it is important to know that standard setting involves completing a practice analysis and extensive peer review. In other words, decisions are based on current data about the profession being considered for changes to existing certification standards (ASHA, 2023p). One of the things specific to ASHA is its partnership with the Educational Testing Service (ETS) related to the national exam for both professions (Praxis). ETS is committed to nondiscriminatory practices in the development, administration, and scoring of the exam. The procedures for creating and revising exams are rigorous

and are based on practice analysis data. Obtaining a passing score on the Praxis is not only a requirement for certification, it is also a requirement for licensure in most, if not all, states. For information about the current Praxis requirements for certification, please refer to the ASHA website page about Praxis Scores and Score Reports (ASHA, 2023p). The American Board of Audiology (ABA) falls within the AAA umbrella as the certifying branch. As is the case with ASHA certification, becoming ABA certified represents a commitment to high-quality standards of practice and continuing professional development that is not directly linked to licensure. ABA certification does not require membership in AAA. It does mandate meeting the requirements for certification initially as well as ongoing professional development as established by ABA. ABA also administers several specialty certifications that will be discussed in the following sections. For additional information about ABA certification, please refer to its website (AAA, 2023g). Specialty Certification.  Specialty certification is intended to recognize knowledge and skills in a particular area that go beyond those expected for entry-level certification. Applicants for specialty certification must meet additional requirements beyond those for entry-level certification. ABA and CFCC both administer specialty certification programs in multiple areas. Specialty certification programs through ABA include the Pediatric Audiology Specialty Certification (PASC) and the Cochlear Implant Specialty Certification (CISC). There are also certificate holder options in tinnitus and being a preceptor (CH-TM and CH-AP). Each of the specialty certifications requires passing an examination through ABA. For more information about the specialty certification programs, please refer to AAA (2023h). CFCC also administers specialty certification programs. Clinical specialty certification enables a professional who demonstrates advanced knowledge, skills, and experience in a specified area of practice to be formally identified as a board-certified specialist (BCS) in that area of practice. The intention of the specialty certification program is to enable clients to identify individuals who have specific expertise in an area of practice beyond the minimal requirements. Specialty certification is an optional credential. While CFCC has some measure of oversight for specialty certification, ASHA recognizes independent Specialty Certification Boards (SCBs) that have met the criteria outlined by the CFCC. Each SCB is responsible for specifying the educational, experiential, and clinical experience beyond the CCC-A or CCC-SLP and how they intend to meet the minimum standards outlined by the CFCC to qualify for official recognition of their

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specialty certification. Currently, specialty certification is available through the Audiology Board of Intraoperative Monitoring, the American Board of Child Language and Language Disorders, the American Board of Fluency and Fluency Disorders, and the American Board of Swallowing and Swallowing Disorders. For information about each of these specialty certifications, refer to their individual websites. Direct links to each are included on the ASHA website (ASHA, 2023r).

Governance Governance is the act of overseeing the control and direction of an entity (Merriam-Webster, n.d.-d). The governance structure of an association describes how policies are made and who is responsible for accomplishing work within the association, and provides information to members and consumers about who might be able to address questions they have. ASHA’s governance structure and processes are intended to respond to changing trends in the discipline and future challenges, are effective and efficient in serving members, and are satisfying to individuals engaged in governance activities (ASHA, 2023s). The BOD is the single governing body of ASHA, which is made up of 16 elected volunteer members plus the chief executive officer (CEO). Members of the BOD are actively engaged in promoting the objectives of the association, working in a manner consistent with the policies and procedures that are defined in the bylaws. Ultimately, individuals serving on the BOD are accountable to the ASHA membership (ASHA, 2023t). For more detailed information about the ASHA governance structure, please refer to ASHA (2023u). The governance structure of AAA is spelled out in Article III of the bylaws. Specifically, the BOD is responsible for initiating and establishing the policies governing the academy. The BOD is accountable to the membership for providing the strategic direction of the association and ensuring it is carried out. The AAA BOD is made up of 12 elected volunteer fellows including the president elect, the president, the immediate past president, and nine members at large. The executive director is an ex-officio member of the BOD and, unlike the volunteer members of the BOD, does not have voting privileges. For more information about AAA’s governance structure, please refer to AAA (2023b).

National Office While volunteer leaders accomplish much of the association work, national office staff operationalize the strategic objectives and priorities. One way to think about the relationship between the governing bodies and staff

members is making the distinction between the “what” and the “how.” As we have already discussed, BODs are responsible for establishing the strategic priorities and policies of the association — in other words, the “what.” It is important that the BOD does not get caught up in how to get the work done. The “how” is the responsibility of the national office staff. Sometimes volunteer leaders and staff need to be reminded of the distinct roles of each group. The ASHA national office is located at 2200 Research Boulevard in Rockville, Maryland, and is the association’s fifth national office. The building, which opened in December 2007, became the first 501(c)(6) to have Gold Leadership in Energy and Environmental Design (LEED) Certification in Maryland history (ASHA, 2008). ASHA is committed to work/life balance, social responsibility, professional development, wellness, and diversity. ASHA has won multiple awards for being a great place to work, including for its telework program (ASHA, 2023v). Having served as a volunteer leader of ASHA in multiple roles, I can attest that the ASHA staff are competent, devoted to the membership, and focused on taking care of the “how.” The AAA national office is located at 11480 Commerce Park Drive in Reston, Virginia. The academy website has information about members of the executive staff as well as staff members that are responsible for specific areas of work. For more information about members of the staff leadership team, please refer to the academy staff page on the AAA website (AAA, 2023i).

Related Professional Associations While the primary focus of this chapter has been on the development of two national associations that promote the professions of speech-language pathology and audiology, it is important to note our affiliations with other national associations that serve audiologists, SLPs, and speech and hearing scientists. These groups are included in alphabetical order to avoid the perception of bias. Each one listed may appeal to a subset of our discipline. Importantly, this is not intended to be an exhaustive list. The Academy of Dispensing Audiologists (ADA) was founded in 1977 by a group of nine practicing audiologists. Its original purpose was to support audiologists who were engaged in hearing aid dispensing and providing other audiologic rehabilitation services. ADA was instrumental in developing the concept of the AuD degree and in promoting moving to a clinical doctorate as the entry-level degree for practicing audiologists. Today, the AuD is the minimum clinical degree offered by academic institutions in the U.S. With this goal met, the name and focus of the association changed in 2006



CHAPTER 2   Professional Issues and Organizations:  From the Past to the Present

to the Academy of Doctors of Audiology, and its focus is on supporting students and audiologists who want to be autonomous practitioners regardless of clinical setting. ADA provides numerous resources to its members with a particular emphasis on the business of audiology including best practices (ADA, 2023a, 2023b). The Academy of Neurologic Communication Sciences and Disorders (ANCDS) is a nonprofit association that supports practitioners that serve individuals with neurologic communication disorders. It offers three levels of membership: full membership, student membership, and life membership. ANCDS offers a variety of continuing education options. It also and has a board certification program to distinguish those individuals who are specialists in neurologic communication disorders (ANCDS, 2023). The Acoustical Society of America (ASA) is a national group devoted to the knowledge and practical applications of acoustics. It is committed to racial and ethnic diversity as well as equity and inclusivity in acoustic research. ASA is a scientific society that is very involved in the development of standards related to acoustics, noise, and mechanical vibration. It is also interested in studying the impact of acoustics on animals. ASA holds two meetings each year, mostly in the U.S. and Canada. Membership is open to anyone who is actively involved in acoustics work and has a relevant academic degree (ASA, 2023a). The society’s primary publication is the Journal of the Acoustical Society of America (JASA). Another publication, JASA Express Letters, launched in 2021 and includes rapid conversations about new findings in acoustics and acoustic research (ASA, 2023b). The American Auditory Society (AAS) is a professional association of audiologists, hearing scientists, and other professionals who are interested in the science related to hearing and balance. Its mission is to promote the translation of research into clinical practice. Importantly, it is an interdisciplinary society whose vision is to transform hearing and balance care through discovery. It holds an annual Scientific and Technology Conference in March each year that features translational research presentations, poster sessions, technology updates, and special sessions including lectures delivered by award recipients (AAS, 2023). The Council for Exceptional Children (CEC) is the largest professional organization dedicated to the success of children with disabilities in various nations. CEC has local units in every state in the U.S. and Canada, in addition to student chapters at hundreds of colleges and universities. CEC is known as the primary resource for special educators (CEC, 2023a). Its vision is to provide quality inclusive education for students with disabilities and its purpose is to support education professionals who work with those individuals. This group

has a long history. It was founded at Teachers College, Columbia University in August 1922 with 12 members. The core values of CEC are visionary thinking, integrity, and inclusiveness (CEC, 2023b). There is a variety of membership levels depending on what is important relative to access to CEC content and liability insurance (CEC, 2023c). The Council of Academic Programs in Communication Sciences and Disorders (CAPCSD) is an important allied association that is particularly relevant to our colleagues in academic institutions as well as others involved in standards development. CAPSCD members are not individuals. Rather, the membership consists of academic programs in CSD. As such, member benefits are limited to professionals working in academic programs that are CAPCSD members. These benefits are typically extended to preceptors and mentors of students in affiliated programs. CAPCSD has made huge investments in the development of training for professionals, including in supervision and mentorship, clinical education, and interdisciplinary education and training. Special sessions often occur at the meetings to honor one or more individuals who have made substantial contributions to leadership in the field of communication sciences and disorders. Please refer to the CAPCSD website for additional information and opportunities (CAPCSD, 2023). The National Black Association for Speech-Language and Hearing (NBASLH) has a history that is not unlike the foundation of other associations in our discipline. Its roots date back to 1977 when a small group of Black audiologists and SLPs formed an ad hoc committee to talk about the concept of forming a Black speechlanguage and hearing association. The committee’s first official meeting was held at Howard University on January 26, 1978, and the first meeting of the BOD and executive staff was held in April 1978. NBASLH was incorporated in June of the same year (NBASLH, 2023a). Membership in NBASLH is open to individuals who support the purpose and values of the association. NBASLH holds an annual convention that is attended by a variety of audiology and speech-language pathology professionals from across the country as well many students. NBASLH is known for supporting students and early-career professionals in their path to leadership (NBASLH, 2023b).

State Associations and Impacts on Licensure ASHA has incredible resources related to audiology and speech-language pathology practices on a state-by-state basis. There is an entire team at ASHA that monitors what is happening legislatively in each state and is engaged in

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advocacy work at the state level. Additionally, resources are available for practitioners who are interested in practicing outside the U.S. (ASHA, 2023h). It is important to note that audiologists and SLPs are instructed to check with their specific jurisdiction or regulatory body for current requirements for practice. One of the licensure issues that is particularly relevant to audiology is whether audiologists are required to have separate licenses for audiology and hearing aid dispensing. Our professional associations at the state and national level have been very involved in lobbying for single licensure status. The rationale is clear: Having separate licenses for audiology practice and for hearing aid dispensing creates the need to provide duplicative information to the state and sends a confusing to message to patients about the profession of audiology. While hearing aid specialists/dispensers can be licensed in many states with no more than a high school diploma, audiologists have graduate degrees that provide rigorous theoretical and clinical education, not only about diagnostic audiology, but also about hearing aids and other assistive technology. Given the involvement of our professional associations in licensure rules, state licensure requirements for audiology reflect best practices related to diagnostic and rehabilitative services to individuals with hearing loss and/or balance disorders (AAA, 2023h).

Student Organizations It is exciting to know that there are many options for students to engage with our professional associations, including those described in the previous paragraphs. Current students are the future of our discipline, so it is important to support them and to provide opportunities for them to be involved in leadership. The affiliated associations’ websites have information about student membership when appropriate. There is also great information about support for students in their academic and research pursuits. Since ASHA and AAA have served as examples of other things discussed in the chapter, the next paragraphs provide information about their affiliated student associations. The NSSLHA is the only student organization for preprofessionals in communication sciences and disorders that is affiliated with ASHA. NSSHLA was established in 1972 and has grown over the years both in membership and in impact. Student members of NSSLHA have been involved in advocacy efforts at the state and national level, sending more than 35,000 letters to legislators. The organization’s mission, vision, and core values are clearly articulated on its website (NSSLHA, 2023a). Importantly, NSSLHA has provided a mecha-

nism for students to become involved in leadership with varying levels of commitment including via student state officers and the national NSSLHA executive council. There are also microvolunteering opportunities for students through NSSHLA (NSSLHA, 2023b). The Student Academy of Audiology (SAA) is the student membership group of AAA and is part of the AAA enterprise. Its purpose is to advance students’ rights, welfare, and interests as they work to enter the field of audiology (SAA, 2023a). SAA has resources for undergraduate and graduate students, including what to consider when deciding what doctoral degree(s) to pursue. To be eligible for full membership, students must be enrolled full time in an AuD, AuD/PhD, or PhD program pursuing a first doctoral degree in audiology. Students enrolled in a non-U.S. postsecondary academic program in audiology are also eligible to apply for membership. Additionally, there is an associate membership category for undergraduate students and those taking postbaccalaureate coursework in the U.S. in preparation for graduate school (SAA, 2023b). Similar to NSSLHA, there are lots of opportunities for students to become involved in leadership, advocacy, fundraising, and networking. While there are SAA chapters at various universities, only nationally recognized SAA chapters receive the benefits of SAA including the ability to volunteer for national SAA. Volunteer opportunities with varying time commitments are available, from microvolunteering to participating in a short-term project to serving on one of the SAA committees or as a state ambassador. Only current national SAA members and undergraduate associate members are eligible to apply for volunteer positions (SAA, 2023c). There is an important distinction between NSSLHA and SAA. While national SAA members are considered student members of AAA, national NSSLHA students are not members of ASHA. As mentioned earlier, NSSLHA is a student group that is affiliated with ASHA, but it is not considered to be part of the ASHA enterprise.

International Professional Associations ASHA has a commitment to supporting the international community, which is demonstrated in many ways. ASHA’s Strategic Pathway to Excellence includes a strategic objective related to enhancing international engagement through collaborating with other organizations. A tangible example of this commitment is the relationship between ASHA and the Pan American Health Organization Regional Office of the World Health Organization (PAHO/WHO) that began in 2013. The



CHAPTER 2   Professional Issues and Organizations:  From the Past to the Present

primary objective of the collaboration is to build the capacity of individuals and/or organizations involved in addressing speech, language, swallowing, and hearing disorders. ASHA became a nongovernmental organization (NGO) in 2014 in its official relationship with PAHO. The initial collaboration was with three countries that self-identified as having a need to address communication disorders: El Salvador, Honduras, and Guyana. On-site ASHA-PAHO teams assessed the needs of each country and provided recommendations regarding education and service delivery assistance. ASHA established an ad hoc committee for each country made up of ASHA members (ASHA, 2023i). Additional countries were added to the ASHAPAHO collaboration over the years. Specifically, Paraguay, Belize, and Ecuador were added in 2016, 2017, and 2019, respectively. PAHO approved ASHA’s renewal application to renew nonstate actor (NSA) status in 2018 for an additional 3 years (2018–2020) and again in 2021 for the period of 2021–2023. For specific information about the current status of the ASHAPAHO/WHO efforts, please refer to the ASHA website (ASHA, 2023i). In a related international effort, the WHO launched the Rehabilitation 2030 initiative in February 2017 and called for stakeholders to coordinate globally to address rehabilitation needs. According to the WHO, one in three people globally has a health condition that would benefit from rehabilitation. As chronic health conditions continue and the population ages, the need will only continue to grow (WHO, 2023). Sadly, young people are also impacted by war-related injuries and gun violence that is not related to combat. ASHA has played an active role in this important initiative. ASHA engages with many other professional associations serving audiologists, SLPs, and speech and hearing scientists. As additional evidence of ASHA’s commitment to the international community, the International Issues Board (IIB), which is a standing committee, is charged with monitoring, developing, and recommending actions that the ASHA BOD should consider relative to international issues. It is made up of 10 ASHA members who represent the global community, including at least two audiologists and one NSSLHA member (ASHA, 2023j). While this list is not intended to be comprehensive, examples of international organizations relevant to our discipline are discussed briefly here (ASHA, 2023k). The Coalition for Global Hearing Health is an organization dedicated to advocating for effective hearing health care services and policies as well as empowering professionals, families, educators, and others who are impacted with hearing loss around the world. The European Speech and Language Therapy Association

(ESLA) is an umbrella organization for speech and language therapy associations across Europe, including 31 member associations representing more than 50,000 individual practitioners. The European Federation of Audiology Societies is dedicated to improving education and spreading hearing health care advances throughout Europe. Hearing International is all about improving hearing care for people in developing countries. International Association of Communication Sciences and Disorders (IALP) is committed to improving the quality of life for individuals with speech, language, hearing, voice, and swallowing disorders across the globe. The International Evoked Response Audiometry Study Group (IERASG) has played an essential role in our understanding of physiologic signals generated within the auditory system and their measurement. Finally, the purpose of the International Society of Audiology (ISA) is to serve as a reference center for those engaged in the practice of audiology (ASHA, 2023k). For comprehensive information about ASHA’s international programs, please refer to the ASHA website (ASHA, 2023l).

Focus on Recent History It seems that the world is changing with lightning speed, including with our professions. The next paragraphs highlight how some of the recent local and world events have influenced the practices of speech-language pathology and audiology. This is not intended to be an exhaustive discussion about impacts, but rather to provide context for how recent events have transformed how we practice currently and might practice in the future.

The Impact of COVID-19 on the Professions We begin with how COVID-19 came into the world and created a situation in which some of our existing models of practice no longer made sense. While it is beyond the scope of this chapter to provide a detailed history of COVID-19 worldwide, it is important to include some early milestones to illustrate the rapid progression of the disease. According to the Centers for Disease Control and Prevention (CDC), a small group of individuals in Wuhan, China, started experiencing the symptoms of a pneumonialike illness in December 2019, which reportedly did not respond to typical treatments. The WHO Country Office in China was notified of these cases on December 31, 2019. By early January 2020, the WHO announced that the cause of the illness was the 2019 novel coronavirus (2019-nCoV) and the CDC published information about the virus on its website. Soon thereafter, the CDC began screening passengers on

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both direct and connecting flights from Wuhan, China, to San Francisco, New York, and Los Angeles. The first laboratory-confirmed case of 2019-nCoV in the U.S. was detected in Washington state and was reported by the CDC on January 20, 2020. By the end of January 2020, the number of confirmed cases in the U.S. was up to seven and the secretary of the Department of Health and Human Services (HHS) declared that the 2019nCoV outbreak was a public health emergency (PHE). On February 11, 2020, the WHO announced that the official name of the virus is COVID-19. Roughly a year after COVID-19 was detected in the U.S., the death toll from the disease had surpassed 400,000 individuals (CDC Museum, 2022). COVID-19 has had serious impacts on our discipline and the individuals we serve. States began to implement shutdowns in mid-March 2020, including the closure of many schools and businesses. On February 19, 2020, California Governor Gavin Newsom issued a statewide stay-at-home order, shuttering all but essential businesses (CDC Museum, 2022). Other states followed shortly thereafter, including Michigan. Outpatient audiology and speech-language pathology practices were considered nonessential businesses and many clinics closed, having a huge impact not only on our colleagues, but also on the children and adults needing our care. For example, while newborn hearing screening continued in many newborn nurseries, follow-up testing for infants not passing the screen was not available. Also, since hospitals were spending most of their resources evaluating and treating patients with COVID-19, elective surgeries, including cochlear implantation, were postponed. The Trump administration reported that between mid-March and the end of April 2020, more than 26.5 million people in the U.S. had filed for unemployment, including audiologists, SLPs, and other health care workers. For those of us that lost our jobs due to COVID-19 restrictions, not only did we experience financial challenges, we also experienced grief since we did not necessarily plan to stop providing clinical care at that time. For some audiologists and SLPs, the layoffs due to COVID-19 have been permanent. As a result, we continue to experience loss (Handelsman, 2023). Fortunately, our professional associations provided numerous resources to help navigate the pandemic. For example, AAA provided an entire section on its website devoted to COVID-19 that included regularly updated active links to information about COVID-19 vaccines; practice management resources; clinical recommendations specific to various practice settings; telehealth resources; treatment and management considerations; ototoxicity, medications, and supplements; government resources; public awareness and educational resources; communication resources; mental health; and resources

for students (AAA, 2023d). Similarly, the ASHA website provided a page dedicated to COVID-19 updates available to members and consumers alike and was also updated on a regular basis. The topics covered on the site included recent updates; online events; telepractice; and setting-specific resources with subsections related to clinical audiologists and health care SLPs, private practice, early intervention, educational audiologists and SLPs, and academics (ASHA, 2023m).

Impact of Telehealth on the Professions One of the results of COVID-19 was the need to expand access to telehealth. Telehealth, by definition, is health care provided to a patient remotely using technology that allows for two-way voice and visual communication (Merriam-Webster, n.d.-b). Since COVID-19 severely limited audiologists’ and SLPs’ ability to work with patients in person, there was an urgent need to expand the legal ability of audiologists and SLPs to engage in telehealth and to get paid for services delivered via that modality. Also important is the quality of services delivered via telehealth, which should be equal to those delivered in person. The ASHA practice portal has an abundance of information about topics related to telepractice including evidence maps and payment for telehealth services (ASHA, 2023n). Separately, audiologists and SLPs need to be aware of state licensure laws and standard practice guidelines for the delivery of services via telehealth. The federal government enacted legislation due to COVID-19 that was intended to make it easier for individuals to secure the health care needed on an outpatient basis. For example, they ruled that Medicare and Medicaid recipients were eligible to receive telehealth services from various providers, including audiologists and SLPs, during the COVID-19 public health emergency (PHE; Telehealth.HHS.Gov, 2023). Although the PHE expired on May 11, 2023, there are elements of the program that remain including some provisions for teleservices. For information on COVID-19 actions relative to payment for services on a state-by-state basis, please refer to the Center for Connected Health Policy (CCHP), which is the national telehealth policy resource center that is working to maximize telehealth’s ability to improve health care outcomes, cost effectiveness, and care delivery (CCHP, 2023). While COVID-19 is not the only reason for an increased need for flexibility in delivering professional services, it was an impetus for examining barriers, including licensure. Previously, clinicians in our discipline were accustomed to the expectation of providing services in person. However, because technology facilitates remote



CHAPTER 2   Professional Issues and Organizations:  From the Past to the Present

delivery of services and evidence suggests that this mode of delivery is effective for at least some services, there is an interest in providing a mechanism for audiologists and SLPs to be able to legally provide services across state lines without having to apply for separate licenses. Imagine that you have a patient in Michigan, a state in which you have a license to practice, who spends the winter months in the warmth of Arizona. You have another patient that winters in Florida. You want to be able to care for your patients year-round but you do not want to get separate licenses in Arizona and Florida. You also have patients in Ohio, Illinois, and Indiana due to their proximity to you and because you provide services that are not available locally. This is not an unusual situation in our discipline. Because of this dilemma, ASHA has engaged with other stakeholders in the development and implementation of the Audiology and Speech-Language Pathology Interstate Compact (ASLP-IC). The ASLP-IC is a licensure compact that allows audiologists and SLPs to practice in multiple states without having to obtain licenses in each of those states. The intent of this compact is to address increased need for services and to enable audiologists and SLPs to provide in-person and telehealth services across state lines. Before the compact could be implemented, the ASLP-IC commissions needed to create bylaws, rules, and a data management system. The impact of the ASLP-IC, once ratified, is to facilitate delivery and coordination of care across state lines. Importantly, individual states have to decide whether to participate in the compact. Clearly the goal is to have all 50 states sign on to the compact (ASHA, 2023o). For an updated map of the states that have and have not signed onto the compact, please refer to ASLP-IC (2023). It is important to note that the website has up-to-date information about states for which legislation has been enacted, states where legislation is pending, states for which legislation has not been introduced, and one state for which legislation was introduced but not enacted (ASLP-IC, 2023). As you can see, there is an interesting interface of technology and the legal requirements of seeing our patients across state lines. You can read more about this in Chapter 23.

Interprofessional Education and Practice An important change in how we educate students and how we practice is a recent focus on interprofessional education and practice (IPE/IPP). Not so long ago, SLPs were in conflict with occupational therapists (OTs) about scope of practice issues for children with feeding disorders. More recently, SLPs and applied behavioral analysts (ABAs) had serious differences of opinion

about who should treat autistic children and with which modalities. While some differences continue to exist, it has become clear that individuals with autism spectrum disorder (ASD) benefit most from the involvement of professionals from multiple disciplines who are actively collaborating with one another. ASHA has consistently advocated for the recognition that SLPs are critical members of the multidisciplinary team (ASHA, 2023p). Because of the recognition of the importance of interprofessional collaborative practice, not only related to autism but also to the evaluation and management of other disorders such as hearing loss, there is now a concerted effort to provide IPE opportunities for audiology and speech-language pathology students in the classroom and the clinical environment. Practitioners also benefit from the opportunity to collaborate. Rather than competing for territory, there is a recognition that collaborative care is best for professionals and those we serve. For those individuals interested in knowing more about IPE/ IPP, see Chapter 19 and refer to ASHA (2023aa) for more information on this important topic.

Recent Audiology Changes In addition to the audiology impacts we have discussed already, there have been additional changes that have impacted the practice of audiology. For example, the FDA approval of over-the-counter hearing aids has clearly impacted access and delivery of hearing aid technology to patients as well as the service delivery model for audiologists trying to interact with patients who have purchased hearing aids apart from an audiologist. Another example is increased access to cochlear implants. Fortunately, our professional associations, including ASHA, AAA, and ADA, have been working together to provide guidance to practicing audiologists about how best to navigate recent changes. The FDA issued its final ruling in August 2022 establishing over-the-counter (OTC) hearing aids as an effective and affordable option for adults with perceived mild to moderate hearing loss, enabling individuals to purchase devices directly from stores or online companies without any involvement from audiologists or physicians (FDA, 2022). Together with the ruling, FDA issued guidance intended to clarify the difference between hearing aids and personal sound amplification products (PSAPs), which are not regulated by the FDA. While the guidance was intended to provide clarity for consumers and professionals, it does not appear to have done either based on the direct links that are provided on the FDA website. Still, the website is an important resource about OTC hearing aids (FDA, 2022). ASHA has an entire site devoted to OTC hearing aids that is intended to provide members with the most

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up-to-date information about how to navigate regulations as well as how the availability of OTC hearing aids might provide audiologists with new opportunities to collaborate and to convey the importance of audiologists on the hearing health care team (ASHA, 2023w). In a perfect example of how our professional associations have collaborated on issues that are important to audiology practice, AAA joined in conversations with ADA and ASHA, as well as with the Hearing Industries Association (HIA), the Hearing Loss Association of America (HLAA), the International Hearing Society (IHS), and other interested parties to discuss common concerns about the FDA ruling. Together these groups sent a letter to the FDA asking for clarification (AAA, 2022). There is no doubt that the introduction of OTC hearing aids into the market is having an impact on practicing audiologists and consumers. The regulations rely on consumers’ ability to judge their degree of hearing loss to determine if OTC hearing aids are appropriate, which may not be realistic. Those of us who have experience with adults with hearing loss know that there is a tendency among many to underestimate the significance of their hearing loss, which might negatively impact their ability to decide whether OTC devices are appropriate. As a result, people may purchase OTC hearing aids that are not appropriate for their hearing loss. Separately, many dispensing audiologists have pricing structures that bundle the price of the hearing aids purchased in their practice with services for a specific period of time. To accommodate individuals coming into the practice with OTC devices, practices using that pricing structure will need to develop a model for charging for services that are not related to hearing aids dispensed through the practice. Another complicating factor is the issue of proprietary software to program OTC hearing aids. It is possible that an audiologist will be unable to make changes in how the OTC is programmed when a patient has a problem. Consumers might not recognize that their purchase of OTC hearing aids limits their ability to receive support from audiologists who would have been able to counsel them about their hearing device options given their degree and configuration of hearing loss. One can only hope for transparency in the advantages and limitations of access to OTC hearing aids in the general population. Without that, consumers and professionals alike will be frustrated. Another important change to our discipline is increased access to cochlear implants (CIs). When CIs were first approved by the FDA for adults, candidacy was limited to individuals with bilateral profound sensorineural hearing loss (SNHL) with no demonstrated ability to understand speech. However, improvements in technology have led to improved patient outcomes, which in turn have resulted in changes in clinical deci-

sion making (Zwolan & Basura, 2021). For example, in 2014, the FDA approved the use of hybrid devices for adults. Hybrid CIs are intended to preserve low-frequency hearing, expanding availability of CIs to adults with normal low-frequency thresholds for the first time. At the same time, greater weight for determining candidacy was placed on speech understanding and other test results in the ear to be implanted as opposed to considering binaural aided scores. For a summary of recent FDA criteria for adults, please refer to Zwolan and Basura (2021). Modifications in CI candidacy and practice patterns illustrate that changes in practice patterns often move more quickly than do government regulations, both in FDA candidacy criteria and in approval for payment. Universal newborn hearing screening and follow-up have made it possible to begin the process of fitting infants with hearing technology to minimize language delays. However, infants with severe to profound hearing loss, for whom hearing aids will not provide adequate access to sound, typically experience a delay in hearing loss management that is sufficient for them to make use of auditory cues to establish connections between sound and meaning. We know that children who are implanted by 9 months of age have a better opportunity to reach typical language developmental milestones by the time they are school aged (American Cochlear Implant Alliance, n.d.). However, while we know that giving children early access to sound is critical for auditory skills and speech and language development, it is still the case that most government insurance (i.e., Medicaid) will not approve payment for CI surgery before the age of 12 months. Because audiologists, SLPs, and other members of a CI team are committed to providing the earliest possible access to sound, it is not uncommon for patients to undergo off-label CI surgery prior to the age of 12 months, in which case the provider to has to lobby for payment. Another example of off-label use is in an infant who has hearing loss due to bacterial meningitis. Ossification of the cochlea is common following bacterial meningitis, so time is of the essence for the surgeon to successfully insert electrodes into the cochlea and achieve adequate electrode impedances. Data suggest that children who are implanted after bacterial meningitis have higher impedances than do children with deafness not due to meningitis. In a study looking at outcomes in implanted children postmeningitis, the authors concluded that early-stage surgery, prior to ossification, is important for improved outcomes (Durisin et al., 2015). Additional examples of off-label use include in infants with unilateral profound SNHL, those with auditory neuropathy spectrum disorder (ANSD), those with congenital cytomegalovirus (CMV), and other children for whom hearing aids are not adequate for providing access to speech.



CHAPTER 2   Professional Issues and Organizations:  From the Past to the Present

One of the amazing recent developments in audiology has been the collaboration among the various audiology associations, some of which have already been mentioned in previous sections including specific examples. As an audiologist, I am so thankful that our professional associations have individually and collectively concluded that we are better able to accomplish things that are important to audiologists and to the people we serve when we work together. We are working together to drive legislation that is important at the state and federal level, and we are delivering communication to colleagues and consumers that is of one mind. I hope we will continue down this road, since it is better for all of us.

Summary of the Evolution of the Professions This chapter has been a walk down memory lane from the founding of our discipline to recent developments that have substantially influenced audiology and speechlanguage pathology practice over the decades. I am thankful to our founders for having the dedication to those with communication disorders and finding ways to collaborate to solve problems. It has been quite a journey that has included so many professional associations, each of which stitched its place in this history and remains today. We are strong because of the sum of our parts. Hopefully you have come to that conclusion reading this chapter. There are a few additional reminders before we conclude. The requirements for practice in audiology and speech-language pathology have certainly changed over the years. Audiologists were initially expected to have a master’s degree to practice and, in some cases, SLPs were able to practice with a bachelor’s degree, particularly in schools. In many states, separate requirements have existed for audiologists and SLPs practicing in schools and those practicing in other environments. For example, having a separate teaching certificate may be required to work in schools. Licensure has also significantly impacted the professions. It is important that audiologists and SLPs are recognized by the government as qualified providers of services, and our professional associations were involved in advocating for state licensure. Each state has its own requirements for obtaining a license to practice in our discipline, which can be confusing in an era of portability. All 50 states and the District of Columbia (D.C.) now require SLPs and audiologists to have a license to practice professionally. Given the changing demographics in our country, including people spending part of the year in one state and another part of the year in a different state, we need to be able to move beyond state lines. The ALSP Compact is a move

in the right direction to enable audiologists and SLPs to serve patients wherever they reside (ASLP-IC, 2023). There is a shortage of public-school teachers in the U.S. according to the National Coalition on Personnel Shortages in Special Education and Related Services (NCPSSERS). According to the data, 15% of educational audiologists report shortages and 54% of SLPs report shortages. Forty-nine states report a shortage of special education teachers, and a recent survey indicated there is a severe shortage of teachers of the deaf (NCPSSERS, 2023). There are also significant shortages of personnel who would typically interact with the students we serve. For SLPs working in or intending to work in schools, ASHA has amazing resources all in one place (ASHA, 2023y). Continuing education (CE) requirements are specified by our professional associations and by our licensure laws. Each audiologist and SLP should be informed about the CE requirement for licensure initially and for license renewal, including specific requirements for ethics education or issues related to diversity, equity, and inclusion. For example, there are now requirements in Michigan to have completed training in identifying victims of human trafficking as well as implicit bias training in addition to the CE maintenance hours (Michigan Department of Licensing and Regulatory Affairs [LARA], 2023a, 2023b). ASHA and AAA both have well-defined expectations for continuing professional development related to certification maintenance. Employers may also have specific training requirements above and beyond those already mentioned. Importantly, audiologists and SLPs are responsible for knowing and completing their specific CE requirements for practice. An important change in our discipline is the recognition that trauma, no matter what the cause and when it occurs, impacts brain function. Perhaps it was the pandemic that caused us to focus on mental health and how the things we have or experience impact our ability to do what we need to do. Trauma can refer to a physical injury, but it also refers to changes in status due to mental or emotional upset (Merriam-Webster, n.d.-e). Trauma-informed care emphasizes the need for audiologists and SLPs to recognize the prevalence and pervasive impact of trauma on the lives of the individuals we serve. We also need to recognize and respond to the impact of trauma on practitioners. Trauma-informed care is another example that supports the importance of interdisciplinary collaboration. We also need to teach our students about how trauma might be impacting them, faculty members, and others in their academic community. A great resource is found at ASHA (2023ab). Before we close the chapter, I want to alert you to a place where you can look for and engage with topics that are hot from a state advocacy perspective. Current hot topics include some of the things we have already spoken

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about including ABA, the interstate compact, and telepractice. Additional current topics we did not address are Language Equality and Acquisition for Deaf Kids (LEAD-K), school choice programs, occupational licensure reform, and universal licensure. Readers are referred to Chapter 25 and the ASHA resource about state advocacy hot topics to be up to date on issues impacting the discipline at the state level (ASHA, 2023ac).

Summary This chapter has provided the reader with important information about the development and growth of the professions of speech-language pathology and audiology. I am grateful for each of the historians and others who have provided details about the origins of speechlanguage pathology and audiology, without whom this chapter would not have been possible. It has been an amazing ride and I hope you have enjoyed the journey as much as I have.

References Academy of Doctors of Audiology. (2023a). ADA home page. https://www.audiologist.org/ Academy of Doctors of Audiology. (2023b). ADA mission statement, history, and strategic plan. https:// www.audiologist.org/about-us/membership/ au-d-history Academy of Neurologic Communication Disorders and Sciences. (2023). ANCDS home page. https:// www.ancds.org/ Acoustical Society of America. (2023a). ACA home page. https://acousticalsociety.org/ Acoustical Society of America. (2023b). ACA publications. https://acousticalsociety.org/asa-publications/ Accreditation Commission for Audiology Education. (2023). Why ACAE accreditation. https://acaeaccred.org/accreditation-process/ why-acae-accreditation/ American Academy of Audiology. (2022). Advocacy update: OTC final rule and direct access. https:// www.audiology.org/advocacy-update-otc-final-ruleand-direct-access/ American Academy of Audiology. (2023a). American Academy of Audiology core values. https://www​ .audiology.org/wp-content/uploads/legacy/about/ aaaLeadership/documents/CoreValuesModel.pdf

American Academy of Audiology. (2023b). Introducing the academy bylaws. https://www.audiology.org/ practice-resources/practice-guidelines-and-standards/ academy-bylaws/ American Academy of Audiology. (2023c). Academy membership. https://www.audiology.org/about/ academy-membership/ American Academy of Audiology. (2023d). Academy history. https://www.audiology.org/about/ academy-history/ American Academy of Audiology. (2023e). About the academy. https://www.audiology.org/about/ American Academy of Audiology. (2023f ). Single licensure status. https://www.audiology.org/advocacy/ legislative-and-regulatory-activities/state-affairs/ single-licensure-status/ American Academy of Audiology. (2023g). American Board of Audiology. https://www.audiology.org/ american-board-of-audiology/ American Academy of Audiology. (2023h). American Board of Audiology certified. https://www.audiology. org/american-board-of-audiology/aba-certification/ American Academy of Audiology. (2023i). Contact us. https://www.audiology.org/about/academy-contactus/#metro American Auditory Society. (2023). American Auditory Society home page. https://www.amauditorysoc.org/ American Cochlear Implant Alliance. (n.d.). Cochlear implants in infants and young children/FAQs. https:// www.acialliance.org/page/CIinfantsandchildren American Speech-Language-Hearing Association. (2004). Technical report: Cochlear implants. https:// www.asha.org/policy/TR2004-00041/ American Speech-Language-Hearing Association. (2005). Evidence-based practice in communication disorders. https://www.asha.org/policy/ ps2005-00221/ American Speech-Language-Hearing Association. (2008). ASHA archives: Fifth national office. https:// ashaarchives.omeka.net/exhibits/show/offices/ office5 American Speech-Language-Hearing Association. (2023a). History of ASHA. https://www.asha.org/ about/history/ American Speech-Language-Hearing Association. (2023b). The Office of Multicultural Affairs. https:// www.asha.org/practice/multicultural/about/



CHAPTER 2   Professional Issues and Organizations:  From the Past to the Present

American Speech-Language-Hearing Association. (2023c). About ASHA’s special interest groups. https://www.asha.org/sig/about-special-interestgroups/ American Speech-Language-Hearing Association. (2023d). Strategic pathway to excellence. https:// www.asha.org/about/strategic-pathway/ American Speech-Language-Hearing Association. (2023e). Bylaws of the American Speech-LanguageHearing Association. https://www.asha.org/policy/ by2017-00347/ American Speech-Language-Hearing Association. (2023f ). ASHA membership categories. https://www​ .asha.org/members/membershipcategories/ American Speech-Language-Hearing Association. (2023g). ASHA certification maintenance requirements. https://www.asha.org/certification/ maintain-ccc/ American Speech-Language-Hearing Association. (2023h). ASHA state-by-state. https://www.asha.org/ advocacy/state/ American Speech-Language-Hearing Association. (2023i). ASHA and the Pan American Health Organization (PAHO). https://www.asha.org/ members/international/paho/ American Speech-Language-Hearing Association. (2023j). International Issues Board (IIB). https:// www.asha.org/about/governance/committees/ committees/international-issues-board/ American Speech-Language-Hearing Association. (2023k). International professional associations. https://www.asha.org/members/international/ international-professional-associations/ American Speech-Language-Hearing Association. (2023l). International programs. https://www.asha​ .org/members/international/ American Speech-Language-Hearing Association. (2023m). COVID-19 updates. https://www.asha​ .org/about/coronavirus-updates/ American Speech-Language-Hearing Association. (2023n). Telepractice. https://www.asha.org/ practice-portal/professional-issues/telepractice/ American Speech-Language-Hearing Association. (2023o). Audiology and speech-language pathology interstate compact. https://www.asha.org/advocacy/ state/audiology-and-speech-language-pathologyinterstate-compact/

American Speech-Language-Hearing Association. (2023p). Applied behavior analysis. https://www​ .asha.org/advocacy/applied-behavior-analysis/ American Speech-Language-Hearing Association. (2023q). General information about ASHA certification. https://www.asha.org/certification/ aboutcertificationgeninfo/ American Speech-Language-Hearing Association. (2023r). Praxis scores and score reports. https://www​ .asha.org/certification/praxis/praxis_scores/ American Speech-Language-Hearing Association. (2023s). Clinical specialty certification. https://www​ .asha.org/certification/clinical-specialty-certification/ American Speech-Language-Hearing Association. (2023t). ASHA leadership and governance. https:// www.asha.org/about/governance/ American Speech-Language-Hearing Association. (2023u). 2023 ASHA board of directors. https:// www.asha.org/about/governance/board-of-directors/ asha-board-of-directors/ American Speech-Language-Hearing Association. (2023v). ASHA governance structure. https://www​ .asha.org/siteassets/uploadedfiles/asha-governancestructure.pdf American Speech-Language-Hearing Association. (2023w). Working at ASHA. https://www.asha.org/ careers/asha-jobs/workatasha/ American Speech-Language-Hearing Association. (2023x). Over-the-counter hearing aid toolkit. https://www.asha.org/aud/otc-hearing-aid-toolkit/ American Speech-Language-Hearing Association. (2023y). Information for school-based SLPs. https:// www.asha.org/slp/schools/ American Speech-Language-Hearing Association. (2023z). About state contracts and licensure information. https://www.asha.org/advocacy/state/info/ more-info/ American Speech-Language Hearing Association. (2023aa). Interprofessional education/interprofessional practice (IPE/IPP). https://www.asha.org/practice/ ipe-ipp/ American Speech-Language-Hearing Association. (2023ab). Trauma informed care. https://www.asha​ .org/practice/trauma-informed-care/ American Speech-Language-Hearing Association. (2023ac). State advocacy hot topics. https://www​ .asha.org/advocacy/hot-topics/

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American Speech-Language-Hearing Association Interstate Compact. (2023). ASLP-IC compact map. https://aslpcompact.com/compact-map/?location​ =nm Board of Regents of the University System of Georgia. (2000). A brief history of the internet. Online Library Learning Center. https://www.usg.edu/ galileo/skills/unit07/internet07_02.phtml Center for Connected Health Policy. (2023). Understanding telehealth policy. https://www.cchpca.org/ Computer History Museum. (2023). Timeline of computer history. https://www.computerhistory.org/ timeline/computers/ Council for Academic Accreditation in Audiology and Speech-Language Pathology. (2023). Standards for accreditation of graduate programs in audiology and speech-language pathology. https://caa.asha.org/ siteassets/files/accreditation-standards-for-graduateprograms.pdf Council for Exceptional Children. (2023a.). About the Council for Exceptional Children. https://exceptional​ children.org/about-us Council for Exceptional Children. (2023b). CEC’s core values. https://exceptionalchildren.org/about-us/ our-values

pathology in America. acsu.buffalo.edu/~duchan/​ 1965-1975.html Durisin, M., Buchner, A., Lesinski-Schiedat, A., Bartling, S., Warnecke, A., & Lenarz, T. (2015). Cochlear implantation in children with bacterial meningitic deafness: The influence of the degree of ossification and obliteration on impedance and charge of the implant. Cochlear Implants International, 16(3), 147–158. Editors of the Encyclopedia Britannica. (2020, September 28). The progressive era timeline. Encyclopedia Britannica. https://www.britannica​ .com/summary/The-Progressive-Era-Timeline Editors of the Encyclopedia Britannica. (2020, September 28). Causes and effects of the progressive era. Encyclopedia Britannica. https://www.britan​ nica.com/summary/Causes-and-Effects-of-theProgressive-Era Federal Drug Administration. (2022). Hearing aids. https://www.fda.gov/medical-devices/consumerproducts/hearing-aids Handelsman, J. (2023). Personal statement about the impact of COVID-19 on audiology practice. Kanner, L. (1943). Autistic disturbances of affective contact. Nervous Child, 2(3), 217–250.

Council for Exceptional Children. (2023c). Professional membership. https://exceptionalchildren.org/member ship/professional-membership

Langmore, S., Kenneth, S., & Olson, N. (1988). Fiberoptic endoscopic examination of swallowing safety: A new procedure. Dysphagia, 2(4), 216–219.

Council of Academic Programs in Communication Sciences and Disorders. (2023a). CAPSCD home page. https://www.capcsd.org/

Logeman, J. (2004). Dysphagia management by speech-language pathologists. Perspectives on Swallowing and Swallowing Disorders, 13(2), 4–6.

Council of Academic Programs in Communication Sciences and Disorders. (2023b). Lisa Scott Leadership Academy. https://www.capcsd.org/ leadership-academy/

Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55(1), 3–9.

Duchan, J. (2021a). A history of speech-language pathology: Carl Emil Seashore 1866–1949. http:// www.acsu.buffalo.edu/~duchan/new_history/ hist19c/subpages/seashore.html

McGerr, M. (2003). A fierce discontent: The rise and fall of the progressive movement in America, 1870–1920. Free Press.

Duchan, J. (2021b). A history of speech-language pathology: Lee Edward Travis 1896–1987. http:// www.acsu.buffalo.edu/~duchan/history_subpages/ leeedwardtravis.html

Merriam-Webster. (n.d.-a). Bylaw. In Merriam-Webster .com dictionary. Retrieved February 14, 2023, from https://www.merriam-webster.com/dictionary/ bylaw

Duchan, J. (2021c). Introduction to 20th century speech pathology history. http://www.acsu.buffalo​ .edu/~duchan/history.html

Merriam-Webster. (n.d.-b). Standard. In MerriamWebster.com dictionary. Retrieved February 28, 2023, from https://www.merriam-webster.com/ dictionary/standard

Duchan, J. (2021d). The linguistic era, 1965–1975. In getting here: A short history of speech-language

Merriam-Webster. (n.d.-c). Telehealth. In MerriamWebster.com dictionary. Retrieved February 14,



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2023, from https://www.merriam-webster.com/ dictionary/telehealth Merriam-Webster. (n.d.-d). Governance. In MerriamWebster.com dictionary. Retrieved March 1, 2023, from https://www.merriam-webster.com/ dictionary/governance Merriam-Webster. (n.d.-e). Trauma. In MerriamWebster.com dictionary. Retrieved March 1, 2023, from https://www.merriam-webster.com/ dictionary/governance Michigan Department of Licensing and Regulatory Affairs. (2023a). Audiologist licensing information. https://www.michigan.gov/lara/bureau-list/bpl/ health/hp-lic-health-prof/audiologist Michigan Department of Licensing and Regulatory Affairs. (2023b). Speech-language pathologist licensing information. https://www.michigan.gov/ lara/bureau-list/bpl/health/hp-lic-health-prof/ speechlanguage Milkis, S. M. (2023, January 10). Progressivism. In Encyclopedia Britannica. https://www.britannica. com/topic/progressivism National Black Association for Speech-Language and Hearing. (2023a). History of the National Black Association for Speech-Language and Hearing. https://www.nbaslh.org/history National Black Association for Speech-Language and Hearing. (2023b). Membership. https://www​ .nbaslh.org/membership National Student Speech-Language-Hearing Association. (2023a). About us. https://www.nsslha.org/ about/

National Student Speech-Language-Hearing Association. (2023b). Student leadership. https://www.nssl​ ha.org/student-leadership/ Stach, B., & Northern, J. (2023). A founders’ history. Audiology Today, Jan/Feb, 12–17. Student Academy of Audiology. (2023a). SAA home page. https://saa.audiology.org/ Student Academy of Audiology. (2023b). SAA membership. https://saa.audiology.org/about/membership/ Student Academy of Audiology. (2023c). Volunteer. https://saa.audiology.org/get-involved/volunteer/ Temple University. (2023). Disability rights timeline. https://disabilities.temple.edu/resources/disabilityrights-timeline U.S. Department of Health and Human Services (HHS). (2023). Medicare payment policies during COVID-19. https://telehealth.hhs.gov/providers/ billing-and-reimbursement/medicare-paymentpolicies-during-COVID-19/ Van Norman, G. (2016). Drugs, devices, and the FDA: Part 2: An overview of approval processes: FDA approval of medical devices. JACC Basic to Translational Science, 1(4), 277–287. World Health Organization. (2023). Rehabilitation 2030 initiatives. https://www.who.int/initiatives/ rehabilitation-2030 Zwolan, T., & Basura, G. (2021). Determining cochlear implant candidacy in adults: Limitations, expansions, and opportunities for improvement. In S. Sydlowski (Ed.), Barriers to cochlear implant access. Seminars in Hearing, 42, 331–341.

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3 Establishing Our Competencies as Professionals:  Education, Certification, and Licensure Lissa Power-deFur

Introduction What do you do when selecting a professional, from automotive service to financial advice? You look for their credentials — those initials after a person’s name that represent their qualifications: ABOHNS, ASE, CFP, CPA, RDN.1 Why? You are seeking a professional or organization that is competent in the field. These initials reflect credentials, indicating that the practitioner or organization has a commitment to meet the expectations for the chosen field. Persons or organizations that achieve such credentials do so voluntarily. They have demonstrated the knowledge, skills, and expertise established by their education and experience and, in general, successfully passed a competency examination. This chapter will explore the competencies required for certification, licensure, and professional education for speech-language pathologists (SLPs) and audiologists (AUDs). As these standards intersect with the ethical standards of professional organizations, supervision, telepractice, and international practice, readers will want to connect the information in this chapter with the information in Chapters 4, 5, 22, and 23. It is best to begin by ensuring a common understanding of the terminology related to credentialing: accreditation, credentialing, credential, certification, and license. The lay public often uses these terms interchangeably. However, there are distinctive differences in meaning, as shown in Table 3–1. Credentialing requirements are not static, as credentialing agencies periodically update requirements to reflect changes in practice patterns, consumer protection approaches, and legislative intent. Agencies and organizations make changes to practice patterns to ensure practice aligns with current evidence. Legislative requirements (i.e., statutes and laws) are generally responsive to public issues and concerns and typically trigger regulations to enact the laws. A fundamental value of credentialing programs is that the organization solicits public input, especially from those persons governed by the 1

 BO-HNS = American Board of Otolaryngology — Head and Neck Surgery; ASE = National Association of Automotive A Service Excellence; CFP = Certified Financial Planner; CPA = Certified Public Accountant; RDN = Registered Dietitian.

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Table 3–1. Terminology Associated With Credentialing Accreditation

A process of evaluating an education or credentialing program based on specific standards.

Certification

A process whereby an individual earns a certificate after having met academic and professional standards.

Credential

A designation of a qualification or achievement.

Credentialing

The process of evaluating an individual’s or organization’s qualifications in comparison with established standards.

License

An official permit to do something (e.g., drive a car or practice as a speech-language pathologist or audiologist).

Licensure

Regulation of a license, typically by a state agency.

credentialing program, whenever they propose changes. This chapter will provide an overview of the credentialing processes and generic requirements, but will refrain from addressing specific requirements, as these are not static and may very well have changed between the time of this writing and the reader’s review of the material. Therefore, this chapter will provide links and resources for professionals and aspiring professionals to use to understand and adhere to current requirements.

How Do You Know You Are Competent? Aspiring SLPs and audiologists want to present themselves to the public and their peers as competent professionals. Professionals demonstrate this through attainment of credentials; in our professions, this is national certification and state licensure. In addition to demonstrating professional credibility and achieving public recognition, employers and third-party payers generally require a profession-specific credential (American Speech-Language-Hearing Association [ASHA], n.d.-g). Professionals do not become competent simply by completing a degree program; rather, they attain competency through skills continuously developed throughout their professional careers. Professionals are increasingly being expected to engage in self-assessment and identify their learning needs to attain and retain their competencies (Lu et al., 2021). Such self-assessment is most effective when the individual follows assessment standards, gathers feedback from others, and maintains a growth mindset (Lu et al., 2021). Unfortunately, research has identified that professionals do not demonstrate good self-assessment abilities. Lu et al. (2021) point to the

Dunning-Kruger effect (Cherry, 2022), which identified that learners who are least skilled often overestimate their performance, while highly skilled learned underestimate their performance. Professionals should have a plan for developing and maintaining their continuing competence, ideally one that is created during their graduate education and regularly reviewed and updated. Such plans focus on the competence required to effectively serve the clientele. The National Institutes of Health (NIH) offers a Competencies Proficiency Scale, designed to measure a professional’s competency, that reflects a continuum from Fundamental Awareness (basic knowledge) through Expert (recognized authority; NIH, n.d.). NIH’s five levels can serve as a guide for lifelong learning, working with mentors, and securing professional employment and volunteer opportunities. The first level, Fundamental Awareness (basic knowledge), is one’s common knowledge or understanding of the basic techniques and concepts of the profession. This would be associated with one’s graduate education. The next level, Novice (limited experience), is a period when an individual is developing on-the-job experience; using terminology, concepts and principles related to the profession; and utilizing a wide collection of references and resource materials (NIH, n.d.). Clinical fellows (CFs) and fourth-year AuD students are typically at this level. As professionals continue in the field, they enter the Intermediate level (practical application), successfully completing tasks generally independently, but securing assistance from an expert from time to time. During this period, the individual focuses on applying and enhancing knowledge and skills. The professional can understand and discuss application and implications of process, policies, and procedures. As practi-



CHAPTER 3   Establishing Our Competencies as Professionals:  Education, Certification, and Licensure

tioners further progress in their skills, they reach the Advanced level (applied theory), where they perform actions associated with their practice without assistance and their organizations recognize them for their ability to answer questions related to this skill. Becoming a leader in the organization, the professional provides practice ideas and perspectives on process or practice improvement, coaches others, and develops reference or resource materials related to their competency. As individuals transition between work settings (e.g., medical and educational) or clinical populations served (e.g., by age or clinical focus), they will transition between the intermediate and advanced levels (and potentially the novice level if approaching a completely new population or setting). These transitions should prompt a review of one’s professional development plan, making appropriate adjustments to ensure competency in the new setting or with the new populations (NIH, n.d.). NIH identifies the highest level as Expert (recognized authority). These professionals have demonstrated consistent excellence in applying their competency across multiple settings. The profession and employer consider the professional a go-to person in this area. The practitioner is a recognized authority, generally creating new applications, leading research, or developing resources (NIH, n.d.). As professionals in speech-language pathology and audiology develop and refine their own professional development plans, they will want to rely on a valid self-assessment such as these NIH competency levels. In addition, professionals should use other resources, such as their annual evaluations, feedback from supervisors and peers, and a review of current practice patterns, all

the while resisting the natural inclination to overestimate their skills. Figure 3–1 presents the continuum of competency aligned with the NIH competency levels.

Credentialing Programs The Institute for Credentialing Excellence (ICE) is an organization that accredits credentialing programs. ICE further identifies that professional certification is a process in which persons elect to have a credentialing organization determine if they have met standards for knowledge, skills, and competencies set by that certifying entity (ICE, 2010). The national credential that SLPs and audiologists acquire is a certification credential, the Certificate of Clinical Competence. This reflects an independent assessment of individuals’ competencies as required for performance in speech-language pathology and audiology. The intention is to demonstrate that individuals have met the profession-specific knowledge, skills, and competencies. Certification programs also establish standards regarding academic and clinical experience. ICE identifies an assessment-based certificate program as one that (a) provides instruction to enable acquisition of specified learning outcomes in knowledge, skills, and abilities; (b) evaluates participants’ attainment of these outcomes; and (c) awards certificates to those participants who meet the standards for assessment (ICE, 2010). In addition to establishing initial certification requirements, certification programs create standards for and measure continued competence through recertification and renewal programs (ICE, 2010). An assessment-based certification program contrasts with a

Figure 3–1. The continuum of competency aligned with the NIH competency levels.

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certificate program that reflects attendance (or participation), which merely signifies presence or participation in a program or event without any required demonstration of competency or proficiency in learning outcomes (ICE, 2010).

American Speech-LanguageHearing Association (ASHA) ASHA established its program for certifying SLPs and audiologists in 1952 (ASHA, n.d.-a). The number of certified SLPs and audiologists in the United States has grown substantially in the intervening 70 years. At yearend 2021, there were 193,799 SLPs, with 98.8% certified; 13,910 audiologists, with 93.9% certified; and 707 individuals dually certified in audiology and speech-language pathology (ASHA, 2021). The initial certification program did not require a graduate degree or national examination. In 1965, ASHA established the Certificate of Clinical Competence (CCC), with its requirement of a master’s degree or equivalent, supervised full-time employment, and a passing score on the National Examination in Speech Pathology and/or Audiology (NESPA). Over the years, the semester hours of graduate coursework, practicum, clinical fellowship, and examination requirements have evolved. The ASHA website (https:// www.asha.org/certification/) includes the current standards in both speech-language pathology and audiology (ASHA, n.d.-e). Individuals who have met these standards may refer to themselves with the credentials CCCSLP (speech-language pathology), CCC-A (audiology), or CCC-A/SLP (dual certification). The National Commission for Credentialing Agencies (NCCA), an industry leader in credentialing, is an independent organization that accredits more than 300 programs from over 130 organizations (ICE, n.d.). ASHA achieved accreditation from NCCA in 2018 after a rigorous review of the quality of ASHA’s certification processes and products (ASHA, 2018). Achievement of this accreditation reflects ASHA’s commitment to a credentialing program that ensures the health, welfare, and safety of the public (ICE, n.d.). The Council for Clinical Certification (CFCC), a group of SLPs, audiologists, certified specialists, and members of the public, governs ASHA’s certification program (ASHA, n.d.-e). The CFCC defines the standards for clinical certification and applies those standards in the certification of individuals. The CFCC is a semiautonomous standardsetting body of ASHA (ASHA, 2023b). As is common with credentialing programs, the CFCC establishes the rigorous academic and clinical preparation of entry-level SLPs and audiologists (ASHA, n.d.-e). The elements include specific details regarding the professional’s academic preparation,

clinical experience, and demonstration of knowledge through a national examination. The academic preparation includes completion of a master’s (speech-language pathology) or doctoral (audiology) degree (or equivalent) from a college or university institution that is regionally accredited and a speech-language pathology and/ or audiology program that is accredited by the Council on Academic Accreditation in Audiology and SpeechLanguage Pathology (CAA). The clinical component addresses the amount and type of clinical experience the applicants must acquire (ASHA, 2020a, 2020b). The CCC-SLP includes a clinical fellowship period following graduation, in which the graduate (a clinical fellow, or CF) receives mentoring (ASHA, n.d.-i). Students and graduates may hear the outdated term “clinical fellowship year” to refer to this period after graduation. The term “clinical fellowship” is now used, dropping “year,” as the period of fellowship does not necessarily equate to a 12-month period. The clinical fellowship is a transition period after completion of an SLP master’s degree (or equivalent) and the period when the SLP provides clinical services independently. CFs are paid during this period, as they are no longer students. The CF is a minimum 36-week full-time (or equivalent part-time) mentored professional experience. The purpose of this transition period is to integrate and apply information from the graduate program, evaluate strengths and limitations, refine clinical skills, and move toward independence as a practitioner (ASHA, n.d.-m). This mentored experience is valuable for refining the practitioner’s professional development plan. As graduates move into their clinical fellowship experience, they will want to be sure this experience meets the requirements. For example, their mentor must hold the CCC-SLP throughout the fellowship period (ASHA, n.d.-m). CFs can verify current ASHA certification status prior to embarking on their fellowship experience by using the ASHA certification verification system (available at https://www.asha.org/Certification/cert-verify/). In addition, there are parameters for the percentage of time spent in direct clinical contact in alignment with the Speech-Language Pathology Scope of Practice (ASHA, n.d.-b). Failure to ensure the CF experience meets these requirements may have devastating consequences for the new graduate, as the new SLP may be required to repeat some or all the CF experience prior to earning the CCC. As they pursue their first professional positions, new graduates will want to review ASHA’s list of suggestion questions to ask when considering a CF placement (ASHA, n.d.-i). See Chapter 22 for more information on the CF experience. Audiologists pursuing the CCC do not complete a CF experience, but have a comparable clinical experience. They must have a minimum of 9 months of full-



CHAPTER 3   Establishing Our Competencies as Professionals:  Education, Certification, and Licensure

time clinical experience (or part-time equivalent) as part of the graduate AuD program. Credentialing generally involves achieving a passing score on an exam to demonstrate one’s acquisition of the requisite knowledge to enter the profession. In our fields, the Educational Testing Service (ETS) administers the national examinations in speech-language pathology and audiology, which are termed “Praxis” (ASHA, n.d.-g). ETS develops test questions designed to meet high standards for assessments. Professionals working in the field and discipline-specific specialists meet with ETS in a rigorous process that ensures the assessments reflect the skills necessary for the profession (ETS, n.d.). The certifying agency sets passing scores for the various Praxis examples. In speech-language pathology and audiology, the CFCC sets the passing score (ASHA, n.d.-h). ETS provides reasonable accommodations for test takers with disabilities or health-related needs. Refer to ETS for further information on accommodations (ets.org). In 1989, the National Board for Professional Teaching Standards (NBPTS) established standards for teachers to demonstrate that they have the knowledge and expertise to have a positive impact on student learning (NBPTS, n.d.). Teachers achieving national board certification generally receive a pay increase and other recognition of their expertise. As SLPs and audiologists work in school settings, ASHA has provided resources to advocate for salary supplements that address the how the CCCis a specialization comparable to that of the NBPTS (ASHA, n.d.b. ). Professionals will find that earning and maintaining their CCC-A, CCC-SLP, or CCC-A/SLP is a valuable vehicle to present themselves to the public as qualified. Not only does the CCC clarify that the practitioner has met rigorous national standards, it also demonstrates commitment to the knowledge and skills expected of a highly qualified professional and facilitates professionals’ ability to meet the qualifications for state licensure.

The American Academy of Audiology (AAA) The American Academy of Audiology (AAA) operates a credentialing program for audiologists, enabling them to become certified by the American Board of Audiology (ABA, 2016). AAA’s purpose for board certification is comparable to the industry standard, demonstrating that the individual meets professional standards. Board certification is based on education (i.e., doctoral degree in audiology from a regionally accredited institution), state license, and mentored professional practice (ABA, n.d.-b). Individuals with this credential may refer to themselves as “ABA Certified or “ABAC” (ABA, n.d.-b). As of this

writing, the NCCA has not credentialed the ABA. The ABA certified credential requires annual renewal, with the completion of continuing education each year.

State Licensure To provide services to consumers, all 50 states require that SLPs and audiologists hold a license to practice in the state where they provide services (National Council of State Boards of Examiners [NCSB], n.d.-b). Graduating students must apply for and receive a state license prior to providing clinical services. Applicants need to document completion of their masters’ program, so while the licensure board processes the application, graduates will likely experience a period after graduation before they can provide clinical services. Some states permit submission of the application prior to graduation and communicate with universities to verify the students’ upcoming graduation. Students will work closely with their graduate program during this process. State licensure requirements generally track the ASHA certification requirements, but it is common for states to include state-specific requirements. As a result, applicants for licensure will need to review carefully the licensure requirements in the state in which they plan to practice. In general, it is in the professionals’ best interest to retain ASHA certification, as this facilitates licensure across the country. Professionals must remember that the ASHA certification is voluntary, but licensure as SLPs or audiologists in the state in which they are practicing is mandatory. SLPs and audiologists may not practice (i.e., serve clients) without a current license from the state where they serve the client (not just the state where they live). Whenever professionals move to a new state, they must secure a license in that state prior to providing clinical services. Failure to meet licensure requirements (including maintenance requirements) can result in fines and/or withholding or removal of licensure. In addition, SLPs and audiologists who work across state lines, must hold a license to practice in every state where they provide services. With the growth in telepractice during the COVID19 pandemic it has become more common for professionals to provide services remotely. When this is the case, the professional must hold licensure in the state where the client is located. State licensure requirements and state law may have unique requirements for professionals providing telehealth services and practitioners should carefully review these requirements before embarking on telehealth practice. Individuals pursuing telepractice will want to review Chapter 23 and comply with the licensure requirements for each state in which they will be serving clients.

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Many states require a separate credential to work in public education settings. In these states, the state boards of education set these standards for school-based personnel, which may be unrelated to the requirements of the state licensure board for work in other settings. The public education credential may be a “license” in some states and a “certificate” in others. The education license or certificate typically includes an area of endorsement such as “speech-language impairment” or “speech-language pathology” for SLPs. In some states, SLPs employed in public education who wish to also work in other settings (e.g., health care, contract agency, private schools) must also hold a license from the state’s board of audiology and speech-language pathology. The requirement for a credential to work in public schools preceded the establishment of requirements for working in all other settings. When states began passing licensure for SLPs and audiologists, they created dual credentialing for education and non-education settings. ASHA maintains a website of state requirements for licensure, tracking information regarding whether a separate credential is required to work in the schools (http://www​ .asha.org/advocacy/state). Other states require individuals to hold a single license, issued by the board of audiology and speechlanguage pathology that authorizes them to work in both educational and health care settings. This is termed “universal licensure,” when one license (credential) serves all settings. The move toward “universal licensure” is a relatively recent phenomenon, as state audiology and speech-language pathology professional organizations have advocated with their legislature to require only the single licensure through the board of audiology and speech-language pathology to practice universally, in all settings. The NCSB is an organization that represents state licensure boards in audiology and speech-language pathology. Its role is to engage licensure boards in discussion of regulatory and policy issues related to licensure in our fields (NCSB, n.d.-a, n.d.-b, n.d.-c, n.d.-d). Its website includes links to state licensure agencies and summarizes current licensure requirements in such areas as continuing education, hearing aid dispensing with an audiology license, support personnel requirements (e.g., speech-language pathology assistants), and telepractice. Both the ASHA and NCSB websites are valuable resources; however, practitioners should review the website of the state’s licensure board and/or department of education to ensure they are meeting the requirement to obtain and maintain a license to practice in that state. Individuals who provide telepractice services in multiple states, who live at the juncture of two or more states and service clients in both states, or who travel to serve clients in more than one state often find it challenging to

secure and maintain licensure in all states. Professionals must pay license fees and meet the requirements for continuing education in each state in which they practice. Responding to this challenge, the NCSB has worked with the Council of State Governments and their Interstate Compact Advisory Workgroup to develop a proposal in our fields. The Audiology and SpeechLanguage Pathology Interstate Compact (ASLP-IC) proposal would authorize both telehealth and in-person practice without additional licensure within the ASLPIC states. This enhances the provider’s ability to provide services to populations underserved or geographically isolated and allows military personnel and spouses who relocate to maintain their ability to practice more easily (NCSB, 2021). Occasionally, professionals will practice in other countries. A few countries have credentialing requirements, but most do not. Individuals must review the requirements to practice abroad prior to initiating services. This includes individuals on short-term mission or professional trips to other countries. It is common for agencies supporting such trips to require persons to demonstrate their license to practice before granting permission to practice in that country. For more information on international practice of speech-language pathology, please consult Chapter 5 on international alliances.

Professional Development and Certification Maintenance The ASHA Code of Ethics reflects the profession’s societal and professional expectation to remain current in the field. Principle II states that “individuals shall honor their responsibility to achieve and maintain the highest level of professional competence and performance” (ASHA, 2023a). Rule C of this principle states that “individuals shall enhance and refine their professional competence and expertise through engagement in lifelong learning applicable to their professional activities and skills” (ASHA, 2023a). For a more in-depth discussion of ethics, refer to Chapter 4. Certification and licensing entities (e.g., the CFCC, state licensing boards) expect practitioners to maintain their competency through ongoing professional development (ASHA, n.d.-e). This standard, generally termed “certification maintenance,” requires a specific amount of continuing education units (CEUs) in a set time (e.g., 2 years). The credentialing organization (e.g., CFCC or the state licensure board) may have specific professional development topic requirements, and it is incumbent upon the credentialed professional to be aware of and meet these requirements. For example, CFCC certification requirements and many states’ licensure require-



CHAPTER 3   Establishing Our Competencies as Professionals:  Education, Certification, and Licensure

ments require completion of professional development in ethics for continuing certification or licensure. Professionals must attest to the fact that they have completed the needed professional development for maintenance of the credentials (certification and/or licensure). Licensing and certification agencies may require demonstration that the practitioner has met the continuing education requirements, so individuals must ensure they have the records to support such attestation. ASHA operates a continuing education registry (ASHA, n.d.-f ) that facilitates tracking of CEUs. These registries are comparable to a college registrar, maintaining a cumulative record of courses and earned CEUs. Like college registrar offices, transcripts are available to demonstrate the amount of CEUs attained over time. ASHA offers CEUs with a host of ASHA-approved providers (ASHA, n.d.-c). ASHA’s Continuing Education Board (CEB), a board of audiologists and SLPs, establishes standards for offering continuing education, which ASHA-approved CE providers meet. CE providers plan, offer, and assess their CE courses, ensuring they meet the high standards set by the CEB. CEB designed these standards to conform to industry standards as identified by the International Association for Continuing Education and Training (IACET; ASHA, n.d.-f ). AAA also offers certificate programs that provide CEUs. Students can begin pursuing professional development opportunities and are encouraged to do so by attending national and state conventions while in graduate school,

although mandatory professional development does not begin until the individual is certified and/or licensed. When pursuing professional development, professionals will want to ensure the provider is offering a quality program. Such programs should include learning outcomes, faculty qualifications and disclosures of financial or nonfinancial relationships to the course content, evidence-based practice as identified by citations, and the availability of CEUs. The faculty disclosures ensure balance and independence in the professional development events. A careful review of CE opportunities can guide SLPs and audiologists in ensuring these opportunities will further their competency.

Demonstrating Expertise in Particular Areas of Practice ASHA certification and AAA board certification demonstrate entry-level credentials for SLPs or audiologists. Many professionals develop expertise in certain areas of the profession and wish to demonstrate their advanced knowledge, skills, and experience to the public (ASHA, n.d.-d). Professionals with the entry level credential (CCC or ABAC) often wish to seek formal recognition of their advanced knowledge and skills. Various organizations offer specialty certification in such areas as fluency, child language, swallowing, hearing, pediatric audiology, and neurological disorders, as displayed in Table 3–2.

Table 3–2.  Advanced Certifications in Speech-Language Pathology and Audiology Academy of Neurologic Communication Disorders and Sciences https://www.ancds.org/board-certification A.G. Bell Academy for Listening and Spoken Language https://agbellacademy.org/certification/ American Board of Audiology: Cochlear Implant Specialty Certification and Pediatric Audiology Specialty Certification https://www.audiology.org/american-board-of-audiology/cochlear-implant-specialty-certification/ https://www.audiology.org/american-board-of-audiology/pediatric-audiology-certification/ American Board of Child Language and Language Disorders https://www.childlanguagespecialist.org/ American Board of Fluency and Fluency Disorders https://www.stutteringspecialists.org/ American Board of Swallowing and Swallowing Disorders https://www.swallowingdisorders.org/ American Audiology Board of Intraoperative Monitoring https://www.aabiom.com/

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The specialty certification boards associated with ASHA are autonomous bodies that develop policies and procedures and grant specialty recognition (ASHA, n.d.-d). The Committee on Clinical Specialty Certification (CCSC) of the CFCC recognizes these specialty boards. Other professional organizations (e.g., A.G. Bell Academy for Listening and Spoken Language, ABA, and Academy of Neurologic Communication Disorders and Sciences) also offer specialty recognition. These recognitions have various terms but are all designed to demonstrate to consumers, colleagues, employers, and payers that the individual has expertise beyond what is required for general certification. These voluntary programs enable consumers to identify professionals with recognized specialties. Such recognition promotes practitioners’ advanced practice areas, validates their expertise, and may support professional advancement. Professionals aspiring for such special recognition find the accompanying professional development enriching. Professionals desiring to attain such specialization will be mindful to review the requirements and plan their acquisition of professional development and clinical experiences to align with the specialization standards. It is likely that continued specializations will emerge as several areas are under consideration by the CCSC and the CFCC at the time of this writing.

Credentialing Graduate Programs Students desiring to become SLPs and audiologists should ensure their graduate education programs are qualified to provide them with the necessary training and clinical experience to enter the profession. Accreditation is the credentialing vehicle for colleges and universities (frequently termed “institutions of higher education,” or IHEs). The purpose of this accreditation is to evaluate programs in comparison to standards specified by an external entity. Accreditation enables the IHE to inform the public that a third party has evaluated the program against defined standards (ICE, n.d., 2010). The Council of Higher Education Accreditation (CHEA) establishes standards for accrediting organizations to ensure academic quality, improvement, and accountability (CHEA, n.d.). An organization’s recognition by CHEA identifies the organization as having completed a rigorous external review of its standards, policies, practices, and procedures. Whereas the U.S. Department of Education (USDE) maintains oversight of federal funds in IHEs, CHEA’s recognition verifies academic quality (CHEA, n.d.). CHEA recognizes various regional accreditation agencies for accreditation of IHEs, as shown in Table 3–3.

Table 3–3. Regional Organizations That Accredit Institutions of Higher Education That Are Recognized by the Council of Higher Education Regional Accrediting Organization

States, Districts, and Territories

Higher Learning Commission (HLC)

Arizona, Arkansas, Colorado, Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, New Mexico, North Dakota, Ohio, Oklahoma, South Dakota, West Virginia, Wisconsin, and Wyoming

Middle States Commission on Higher Education (MSCHE)

Delaware, the District of Columbia, Maryland, New Jersey, New York, Pennsylvania, Puerto Rico, and the Virgin Islands

New England Commission of Higher Education (NECHE)

Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont, and internationally

Northwest Commission on Colleges and Universities (NWCCU)

Alaska, Idaho, Montana, Nevada, Oregon, Utah, Washington, and internally

Southern Association of Colleges and Schools Commission on Colleges (SACSCOC)

Alabama, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Texas, Virginia, Latin American, and certain international sites

WASC Senior College and University Commission (WSCUC)

California, Hawaii, and the Pacific Basin

Source:  Based on information from CHEA, n.d.



CHAPTER 3   Establishing Our Competencies as Professionals:  Education, Certification, and Licensure

CHEA has approved the Council on Academic Accreditation (CAA) in audiology and speech-language pathology to accredit graduate programs in these fields. CAA comprises professionals in the fields from both university and clinical settings as well as a public member (CAA, 2022). CAA created standards in the 1960s, with the first accreditation of speech-language pathology and audiology programs awarded in 1965 (CAA, n.d.-b). Earlier iterations of CAA had different names: first the American Board of Examiners for Speech Pathology and Audiology (ABESPA), then the Educational Testing Board (ETB), followed by the Educational Standards Board (ESB), and finally CAA as of 1996 (CAA, n.d.-b). CAA has a long history of recognition, first recognized in 1964 by the Council on Postsecondary Accreditation (now CHEA) and shortly after in 1967 by the U.S. Secretary of Education (now referred to as the USDE; CAA, n.d.-b). These recognitions are the gold star for the accreditation standards set for our professions and have high expectations for academic quality and accountability. In addition, USDE recognition is critical for eligibility to participate in federal student aid and other federal programs (CAA, n.d.-b). CAA completes a comprehensive review of its standards every 5 to 8 years to meet the requirements of USDE and CHEA. CAA is responsible for formulating standards for graduate programs that provide entry-level preparation in audiology or speech-language pathology (CAA, n.d.-a). These standards promote excellence in preparation programs to ensure students entering the field have been appropriately prepared to serve the public. Entry-level preparation is at the master’s level in speechlanguage pathology and the clinical doctoral level in audiology. As a result, CAA standards only address these degree programs. CAA does not address bachelor’s-level programs in communication sciences and disorders, nor does it address research doctorates (e.g., PhDs) in either field or clinical doctorates in speechlanguage pathology. In addition to creating standards, CAA evaluates programs that apply for accreditation on a voluntary basis. Evaluation includes review of university programs’ self-studies and completion of site visits. Accredited programs are recognized and available to the public (caa.asha.org). Students should plan to get their degrees from a CAA-accredited program to ensure their educational and clinical education meet the standards that will enable them to earn national certification and state licensure. As is typical of credentialing standards, the CAA has reviewed and revised the standards numerous times over the years. Perhaps one of the more significant revisions was the move in accreditation of audiology graduate programs from the master’s to the doctoral level. Revisions

have also created standards for program improvement. CAA standards expect higher education programs to institute ongoing review of their current programs to keep up with the dynamic changes that occur in evidence-based practices, technology, shifts in policy, insurability, law, and general political and social movements that affect our services and scope of practice. The CAA standards for accreditation of graduate programs are available at https://caa.asha.org/reporting/standards/. The Accreditation Commission for Audiology Education (ACAE) was founded in 2003 by the American Academy of Audiology (AAA) and the Academy of Doctors of Audiology (ADA; previously the Academy of Dispensing Audiologists). Similar to the Council on Academic Accreditation, the ACAE accredits Doctor of Audiology programs. At the time of this writing there are five fully accredited ACAE Doctor of Audiology programs, with another four in development. See https://acaeaccred.org/ for more information.

Financial Aid and Scholarships The cost of getting a graduate degree in speech-language pathology and audiology is significant. Students may wish to review the resources found in Table 3–4 for information about financial aid and scholarships. The list includes both generic resources and some specific to speech-language pathology and audiology. As many universities have scholarships, fellowships, and graduate assistants available, students will want to contact the financial aid office, graduate school, and the speechlanguage pathology and audiology program at their university for more information.

Next Steps:  After Graduation Congratulations! You are well on your way to demonstrating your qualifications now that you have (or are on your way to have): n

graduated from a regionally accredited university that holds CAA accreditation in audiology and/or speech-language pathology, gathering the required knowledge and skills needed for entrance into the professions;

n

passed the national certification exam; and

n

completed needed clinical experience with required supervision and mentoring.

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Table 3–4.  Assorted Financial Aid and Scholarship Information Financial Aid Federal Student Aid   • https://studentaid.gov/ State Government Financial Aid Information   • https://www2.ed.gov/about/contacts/state/index.html Scholarships and Awards — CSD Program Specific American Speech-Language-Hearing Association:  Minority Student Leadership Program   • https://www.asha.org/Students/MSLP-Award/ American Speech-Language-Hearing Association:  Student Ethics Essay Award   • https://www.asha.org/practice/ethics/essay_award/ American Speech-Language-Hearing Association:  Students Preparing for Academic-Research Careers Award   • https://www.asha.org/Students/SPARC-Award/ American Speech-Language-Hearing Foundation   • https://www.ashfoundation.org/ Council of Academic Programs in Communication Sciences and Disorders   • https://www.capcsd.org/scholarships/ National Student Speech Language Hearing Association Scholarship   • https://www.nsslha.org/Programs/Scholarships/ National Black Association for Speech-Language and Hearing:  Supporting Career Growth Through Mentoring Scholarship   • https://www.nbaslh.org/scholarships Sertoma Communicative Disorders Scholarship Program   • https://sertoma.org/what-we-do/scholarships/ Note:  This information should not be considered exhaustive and students should meet with the financial aid officers at their selected university for more specific information on financial aid and scholarships.

Attainment of the graduate degree and CCC is not sufficient. Returning to the NIH Competency Levels, this places the student at the Novice level. To advance in personal and professional competence, ensuring the necessary knowledge and skills to serve our clients, professionals must engage in lifelong learning. Through self-reflection, professionals will pursue continuing education and mentoring to become intermediate and advanced professionals and potentially experts. In addition, professionals may pursue specialty credentials as they focus their expertise in a particular area. Another approach for furthering one’s expertise is to pursue an advanced degree. SLPs may wish to investigate doctoral programs such as research doctorate (PhD or EdD) or clinical doctorates (SLPD). Degrees in related fields might be another approach to furthering one’s expertise.

However, this chapter would be incomplete if it did not remind credentialed professionals of the following. n

Read the requirements to become licensed or certified in the state(s) where you have chosen to practice. If practicing in more than one state (either on-site or through telehealth) be sure to secure the needed license. Identify whether your state requires separate credentials to work in public education and for all other settings or if a single license from the state’s board of audiology and speech-language pathology is sufficient.

n

Retain your national certification. Most states’ licensure requirements build upon the ASHA certification, which facilitates attainment of



CHAPTER 3   Establishing Our Competencies as Professionals:  Education, Certification, and Licensure

licensure when moving to another state. If practitioners drop their ASHA certification, they must meet the CFCC’s current requirements for coursework and clinical experience, which may have changed since the applicant was originally credentialed. n

n

Review and adhere to continuing education requirements for state licensure and national certification. Increasingly, licensure boards and certification bodies are requiring specific topics for renewal, such as ethics and cultural competency or diversity. Professionals serving students and/or CFs must adhere to continuing education requirements related to supervision. Develop and adhere to a plan for gaining professional competence at the intermediate, advanced, or expert level. The use of self-assessment tools, supervisor feedback, and reviews of current practice standards are fundamental to creating a sound professional development plan. Maintain an accurate record of continuing education and ensure that recognized continuing education providers are the source of CE.

With these caveats, you will enjoy practicing in your profession for decades!

Summary SLPs and audiologists have the honor of serving persons with speech, language, hearing, and swallowing difficulties, opening avenues for communication and swallowing. Our clients deserve to have the very best services from highly qualified personnel. Our professions of speech-language pathology and audiology meet the public’s desire for competent professionals by achieving the credentials that demonstrate our knowledge, skills, and expertise. By attaining national certification, SLPs and audiologists demonstrate that they have met the highest standards for serving the public. Professionals ensure they acquire and maintain their license to practice in the state where they provide services, as this license is necessary to demonstrate state specific competencies. By adhering to a professional development plan and gathering CE and experiences that align with the plan, practitioners not only maintain their CCC and state license, but also progress in their competence level. Some professionals elect to pursue additional credentials to demonstrate their expertise in a particular area of practice, achieving these specializations from any of a variety of professional organizations. Licensure and certification are essential to demonstrate that our professions have

high regard for the client’s welfare, as they demonstrate that the professionals have met the standards for knowledge, skills, and abilities.

References Academy of Neurologic Communication Disorders and Sciences. (n.d.). ANCDS board certification. https://www.ancds.org/board-certification A.G. Bell Academy for Listening and Spoken Language. (n.d.). About the LSL specialist certification. https://agbellacademy.org/certification/ American Board of Audiology. (n.d.-a). Apply now for the ABA certified credential. https://www.audiology​ .org/american-board-of-audiology/aba-certification/ apply-now/ American Board of Audiology. (n.d.-b). American Board of Audiology certified. https://www.audiology​ .org/american-board-of-audiology/aba-certification/ American Speech-Language-Hearing Association. (n.d.-a). A chronology of changes in ASHA’s certification standards. https://www.asha.org/certification/ CCC_history/ American Speech-Language-Hearing Association. (n.d.-b). Advocacy resource guide for the salary supplement initiative. https://www.asha.org/advocacy/ state/issues/advocacy-resource-guide-for-the-salarysupplement-initiative/ American Speech-Language-Hearing Association. (n.d.-c). ASHA approved continuing education provider status. https://www.asha.org/ce/forproviders/ American Speech-Language-Hearing Association. (n.d.-d). Clinical specialty certification. https://www​ .asha.org/certification/clinical-specialty-certification/ American Speech-Language-Hearing Association. (n.d.-e). General information about ASHA certification. https://www.asha.org/ American Speech-Language-Hearing Association. (n.d.-f ). Maintaining your certification. https:// www.asha.org/certification/maintain-ccc/ American Speech-Language-Hearing Association. (n.d.-g). Praxis examinations in audiology and speech-language pathology. https://www.asha.org/ certification/praxis/ American Speech-Language-Hearing Association. (n.d.-h). Praxis scores and score reports. https://www​ .asha.org/certification/praxis/praxis_scores

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American Speech-Language-Hearing Association. (n.d.-i. A guide to the ASHA clinical fellowship experience. https://www.asha.org/certification/ clinical-fellowship

Council on Academic Accreditation in Audiology and Speech-Language Pathology. (2022). Accreditation handbook. American Speech-Language-Hearing Association.

American Speech-Language-Hearing Association. (n.d.-j). The ASHA CE registry: Convenient, accessible, secure. https://www.asha.org/CE/CEUs/ default/

Council for Higher Education Accreditation. (n.d.). Regional accrediting organizations. https://www​ .chea.org/regional-accrediting-organizations

American Speech-Language-Hearing Association. (n.d.-k). What are ASHA continuing education units (CEUs)? https://www.asha.org/ce/ceus/ what-are-asha-continuing-education-units/ American Speech-Language-Hearing Association. (2018). ASHA certification programs receive prestigious accreditation. https://www.asha.org/ news/2018/asha-certification-programs-receiveprestigious-accreditation/ American Speech-Language-Hearing Association. (2020a). 2020 standards and implementation procedures for the certificate of clinical competence in audiology. https://www.asha.org/certification/2020audiology-certification-standards/ American Speech-Language-Hearing Association. (2020b). 2020 standards and implementation procedures for the certificate of clinical competence in speech-language pathology. https://www.asha.org/ certification/2020-slp-certification-standards/ American Speech-Language-Hearing Association. (2021). Annual demographic and employer data: 2021 highlights and trends: Member and affiliate profile. https://www.asha.org/siteassets/ surveys/2021-member-affiliate-profile.pdf American Speech-Language-Hearing Association. (2023a). Code of ethics. www.asha.org/policy/ American Speech-Language-Hearing Association. (2023b). Responsibility of CAA and CFCC. https://caa.asha.org/about/coronavirus-covid-19/ responsibility-of-caa-and-cfcc/ Cherry, K. (2022, November 8). What is the Dunning-Kruger effect? Verywell Mind. https:// www.verywellmind.com/an-overview-of-thedunning-kruger-effect-4160740 Council on Academic Accreditation in Audiology and Speech-Language Pathology. (n.d.-a). About the CAA. https://caa.asha.org/about/ Council on Academic Accreditation in Audiology and Speech-Language Pathology. (n.d.-b). Accreditation milestones. https://caa.asha.org/about/ accreditation-milestones/

Educational Testing Services. (n.d.). The Praxis study companion: Speech-language pathology. https://www​ .ets.org/pdfs/praxis/5331.pdf Institute for Credentialing Excellence. (n.d.). NCCA accreditation. https://www.credentialingexcellence. org/Accreditation/Earn-Accreditation/NCCA Institute for Credentialing Excellence. (2010). Defining features of quality certification and assessment-based certificate programs. https://www.credentialing excellence.org/Portals/0/Docs/Accreditation/ Features%20Document.pdf?ver=hM-JvunDqe9b Gfilji1ezQ%3d%3d Jackson-Hammond, C. (2022). The importance and value of CHEA recognition. Inside accreditation. https://www.chea.org/chea-president-commentaryvalue-chea-recognition Lu, F., Takahashi, S. G., & Kerr, C. (2021). Myth or reality: Self-assessment is central to effective curriculum in anatomical pathology graduate medical education. Academic Pathology. https:// pubmed.ncbi.nlm.nih.gov/34027054/ National Board for Professional Teaching Standards. (n.d.). Five core propositions. https://www.nbpts.org/ certification/five-core-propostions/ National Council of State Boards of Examiners. (2021). NCSB position statement on the ASLP-IC. https://www.ncsb.info/position-statements#t8 National Council of State Boards of Examiners. (n.d.-a). States with continuing education requirements. http://www.ncsb.info/continuing National Council of State Boards of Examiners. (n.d.-b). States permitting hearing aid dispensing with audiology license. http://www.ncsb.info/dispensing National Council of State Boards of Examiners. (n.d.-c). States with regulation of support personnel. http:// www.ncsb.info/support National Council of State Boards of Examiners. (n.d.-d). States that regulate audiology and speech-language pathology. http://www.ncsb.info/regulate National Institutes of Health. (n.d.). Competencies proficiency scale. https://hr.nih.gov/working-nih/ competencies/competencies-proficiency-scale

4 Professional Ethics, Accountability, and Liability Jaynee A. Handelsman

Introduction We all agree that ethical behavior is the cornerstone of professionalism and is essential to maintaining the highest standards of practice. It also pertains to topics in this chapter related to accountability and professional liability. This is a complicated chapter dealing with these topics that may, at face value, seem unrelated. Yet, audiologists, speech-language pathologists (SLPs), and speech and hearing scientists are all connected by our interest and commitment to doing what is best for one another and for the patients and families we serve. In addition to talking about professional ethics as we have discussed in earlier versions of this chapter, we will cover information about accountable care and issues of professional liability. Please stay tuned — it will be an interesting and informative journey into these important issues.

Standards of Professional Conduct Audiologists, SLPs, and speech and hearing scientists are subject to standards of professional practice developed by various entities. For example, the professional associations we choose to affiliate with each have expectations that members abide by a code of ethics. Employers may have expectations that are explicitly covered in standard practice guidelines. Finally, regulatory bodies, such as licensure boards, have requirements for eligibility to practice in speech-language pathology and audiology. It is important for audiologists, SLPs, and speech and hearing scientists to be aware of the current requirements specified for each group and to ensure compliance. The following sections will provide more information about some of those expectations, as well as ways to make sure we are complying.

Conflicts of Interest Conflicts of interest occur when there are competing priorities affecting the decisions we make. Audiologists, SLPs, and speech and hearing scientists are compelled to avoid situations in which a 45



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personal, professional, financial, or any other interest might interfere with their ability to remain objective, competent, and effective in taking care of their professional duties (American Speech-Language-Hearing Association [ASHA], 2023a). At stake is the fact that conflicts may cloud an individual’s judgment about what is best. Conflicts are unavoidable in our professional lives, yet they need to be understood and acknowledged through proper disclosure (ASHA, 2023a). The examples that follow will address various types of conflicts and when we might need to be aware of hidden conflicts. 1. You are a pediatric audiologist with oversight responsibilities for the Early Hearing Detection and Intervention (EHDI) program in the hospital in which you are employed. You know your existing equipment is obsolete and failing. You also know there are budget constraints in your department. Since there are not many opportunities to update equipment, you want to be sure you recommend purchasing the newest technology with a proven track record. One of the vendors with which you have done business for many years has deeply discounted the price of an older system and you are concerned that the discounted equip­ ment will not serve the needs of the EHDI program in the long run. Think about whether there is a potential conflict of interest in this scenario, and if so, what are the competing priorities? 2. You are an experienced SLP working in the schools who is committed to evidence-based practice and doing what is best for the students in your caseload. Recently, the school district decided to purchase new computer equipment and software to be used in the treatment of children diagnosed with language and auditory processing disorders. The administration did not solicit your input. When you asked about efficacy data, neither the vendor nor the school district provided any. Think about your commitment to evidencebased practice and whether the situation involves any potential conflict of interest. 3. You are a hearing scientist working at a university and are the primary investigator (PI) on a grant focused on the development and testing of a formula designed to protect the auditory system from the impact of noise exposure. Your preliminary phase I and phase II data look promising and you are planning on applying for a patent. You also have an opportunity to create a start-up company to commercially produce and market the use of the formula you have been studying.

If it is successful, you stand to benefit financially from the business. You intend to remain the PI on the grant as well. Think about whether there are any conflicts of interest related to your roles: simultaneously serving as PI on the grant and leading the new business. If there are conflicts, what are the competing priorities and how might they be resolved? There are two types of conflicts to be aware of: real and perceived. Real conflicts are more easily identified, as in the scenarios mentioned above. In the first example, although the pediatric audiologist does not stand to personally benefit from recommending the purchase of a deeply discounted older piece of equipment, the conflict is between saving money for the department in the short term versus making a decision that is in the best interest of the EHDI program and the babies being tested with the updated equipment. In the second example, the SLP is put in the position of using equipment and software that have not been shown to be effective in the treatment of children with language and auditory processing disorders, potentially compromising their professional standards and jeopardizing the quality of care delivered to the students on their caseload. For the third example, the conflict occurs when the faculty member has a financial interest in the company and still serves as the PI on a project to assess its effectiveness while continuing to enroll patients in the study. In all three examples, real conflicts of interest exist. Perceived conflicts of interest occur when there is no real opportunity for the individual to benefit personally, financially, or professionally from a particular circumstance. However, consumers or other individuals may have concerns about bias entering the decision-making process. An example of a perceived conflict of interest can occur when the Council on Academic Accreditation in Audiology and Speech-Language Pathology (CAA) is evaluating entry-level graduate programs to determine if the program meets accreditation standards. To avoid perceived conflicts based on potential bias, council members are recused from participating in the evaluation of programs within their state. While a particular council member may not have any relationship with the other academic programs in their state, there may be a perception of bias should that member be involved in the program evaluation. We are all faced with making decisions in our personal and professional lives that impact and ultimately determine our behavior, the people we interact with as friends and colleagues, where we spend time, and the relative value we place on how those things shape our lives. In making each choice, we consider various options



CHAPTER 4   Professional Ethics, Accountability, and Liability

and determine which variables are most important to us. There are consequences for each choice we make (Handelsman, 2006). We are each obligated to uphold the Code of Ethics (COE) of each professional association with which we choose to affiliate. The ASHA Code of Ethics has for many years included a statement that conflicts of interest are unethical. The specific language in the current code occurs in Principle of Ethics III, Rule B, which states that “individuals shall avoid engaging in conflicts of interest whereby a personal, professional, financial, or other interest or relationship could influence their objectivity, competence, or effectiveness in performing professional responsibilities” (ASHA, 2023a). Similarly, the COE of the American Academy of Audiology (AAA) specifies in Principle 4, Rule 4c that “individuals shall not participate in activities that constitute a conflict of professional interest” (AAA, 2021). The Academy of Doctors of Audiology (ADA) has a statement in its COE that defines what is to be avoided. Specifically, Principle II, Rule 5 says that “member’s clinical judgment and practice must not be determined by economic interest in, commitment to or benefit from, professionally related commercial enterprises” (ADA, 2023a). One of the challenges for audiologists and SLPs has to do with implied expectations or strings attached. Something as simple as permitting a hearing aid manufacturer’s representative to bring in lunch for the audiologists being trained on a particular technology might carry with it the expectation of bias to preferentially recommend that company’s products. In another example, a physician who refers patients to an SLP’s private practice might have the expectation of reciprocity related to referral for medical or surgical management. In the same way, a colleague working in an academic setting that you have come to know well from volunteering together on an association committee or board might have the expectation that you will recommend their graduate program to inquiring students. In all three examples, the key to knowing whether there are expectations of reciprocity is clear and honest communication (Handelsman, 2006). Audiologists and SLPs must be aware of both real and perceived conflicts of interest to avoid both. When conflicts cannot be avoided, disclosure is essential.

Role of Professional Associations Moral principles are guidelines that we each live by to ensure we are making good decisions and doing the right things. They typically include things like honesty, fairness, and equality and can be different for everyone because they are dependent on factors such as upbring-

ing and what individuals consider to be important in life. Many professional associations also have moral principles that underlie their guidelines (Kitchner, 1984). Most groups’ principles include freedom of action and choice, justice and fairness, doing good for others, preventing or avoiding harm, and fidelity and loyalty (Bupp, 2012). In the next sections, we will be exploring how these principles are exemplified in the ethical codes and practices of three professional associations: ASHA, ADA, and AAA. We will also talk about how the COE is enforced for each of the professional associations we are covering.

ASHA The core principles of the ASHA Code of Ethics are duty, accountability, fairness, and responsibility. The code is intended to not only ensure the welfare of the consumer but also to protect the reputation and integrity of the professions of speech-language pathology and audiology (ASHA, 2023a). The code serves as a framework for decision making. It is obligatory and disciplinary, meaning that members are required to abide by the code and may suffer sanctions when the code is violated. It is also intended to be aspirational as it describes the roles of SLPs, audiologists, and speech and hearing scientists in maintaining the highest levels of professionalism (ASHA, 2023a). The charge of the ASHA Board of Ethics (BOE) is multifaceted. The BOE is a semiautonomous body of ASHA that is not only responsible for creating and at times amending the code, which specifies the professional and ethical responsibilities of members and certificate holders, but it is also charged with creating and amending a Code of Conduct for assistants. Additional responsibilities of the BOE include developing ethics education materials for distribution and adjudicating complaints of unethical behavior (ASHA, 2022, 2023b). In process, the BOE members are appointed by the Committee on Committees of the ASHA Board of Directors (BOD). While the BOE is responsible for amending the code as necessary and recommending changes to policies and procedures relative to adjudicating complaints of code violations, the approval for these modifications rests with the ASHA BOD (ASHA, 2023b). Sanctions for violations are determined by the BOE and will be outlined in another section of this chapter. The ASHA BOE is composed of 17 certified members of ASHA. The composition includes at least six audiologists and six SLPs, including a chair and vice chair, and two public members. The composition requirements specify that at least four of the 12 members are practitioners (current or within past 10 years) and

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at least two of the four practitioners have school-based experience. During the first 3 years of service on the BOE, responsibilities include voting and adjudicating complaints brought before the BOE. During the fourth and final year of service, members serve on the Ethics Education Subcommittee, which is charged with developing educational materials on ethics (ASHA, 2023b). ASHA has been committed to providing a framework for ethical behavior from the beginning. The first code was published in 1952 and it has been modified and adapted over the years to reflect changes in practice and to respond to evolving issues within the discipline. The most recent revision to the code became effective on March 1, 2023. The primary purposes of the 2023 revisions were to clarify language in the code and to address contemporary ethical issues and concepts that have arisen since the previous revision in 2016. For example, discrimination provisions were updated and the conflict of interest provision speaks to the need to disclose and manage conflicts when they cannot be avoided. There is also a new rule related to supervision and another about self-reporting timelines. For more specific information about the changes, please refer to the webinar about navigating the revised code (ASHA, 2023c). Ensuring the highest standards of integrity and ethical principles is essential to fulfilling our roles as educators, supervisors, mentors, clinical service providers, researchers, and administrators. The purpose of the code is to protect consumers of our services as well as to protect the integrity of the discipline. Expectations for behavior are specified in the principles and rules of the code, which apply to members of the association, nonmembers holding the Certificate of Clinical Competence (CCC-A and/or CCC-SLP), and applicants for ASHA certification or for ASHA membership and certification (ASHA, 2023a). The fundamentals of ethical conduct for audiologists, SLPs, and speech and hearing scientists are described by principles of ethics and by rules of ethics. The principles of ethics form the underlying philosophical basis for the code and include the following areas: (I) responsibility to persons served professionally and to research participants, both human and animal; (II) responsibility for one’s professional competence; (III) responsibility to the public; and (IV) responsibility for professional relationships. Principle I, which addresses the need to pay attention to the needs of persons served, is supported by 20 rules that specify expected behaviors as well as those that are prohibited. Principle II, which addresses the responsibility to maintain high standards of professional competence, is supported by eight rules. Principle III, which is dedicated to honesty and integrity when engaging with the public, is supported by seven rules. Finally, Principle IV, which speaks to the dignity and autonomy

of the professions as well as the importance of intra- and interprofessional relationships, is supported by 21 statements of appropriate and inappropriate behavior. While the code is intended to provide guidance to members, certificate holders, and those in the application process as we all make decisions about professional behavior, it is not intended to provide specific examples of situations we might encounter and how best to respond (ASHA, 2023a). The current code can be downloaded from the ASHA website at http://www.asha.org/policy/ It is important to note that an effective code requires fairness in the administration and enforcement of all its elements as well as complete compliance by members and certificate holders. Decisions by the BOE are made on a case-by-case basis, considering the merits of each (ASHA, 2023a). The policies and procedures used by the BOE in adjudicating cases will be reviewed in a later section of this chapter.

ADA The purpose of the ADA COE is to make sure that the highest quality of professional services is rendered to patients served. There are six fundamental principles of the COE that indicate members’ responsibility to the commitment to professional standards, to the welfare of patients and families served, to professional growth and development, to products and services, and to public information (ADA, 2023a). As is the case with the ASHA COE, ethical conduct is described in the ADA COE through fundamental principles and rules underlying each principle. Specifically, Principle I addresses the responsibility to protect the welfare of persons served. It is supported by six rules that spell out what members may and may not do in that regard. Principle II speaks to the expectation of maintaining high standards related to professional competence, integrity, behavior, and ethics and is supported by seven rules, including the requirement that members report violations of the COE to the ADA Board of Directors (BOD). Principle III addresses the importance of maintaining a professional demeanor when working with patients, which is supported by four rules. Examples of appropriate behavior delineated in the rules are using professional judgment when recommending products or services and the need for transparency regarding pricing. Principle IV addresses the requirement to be truthful in communications with patients and the public. It is supported by three rules including the mandate that promotional activities comply with applicable regulations. Principle V addresses the responsibility to behave in a manner that enhances the status of the profession. The five supporting rules speak to educating the public about hearing, hearing loss, and options for helping



CHAPTER 4   Professional Ethics, Accountability, and Liability

individuals with hearing loss. Also, increasing knowledge within the profession is listed as being important. Finally, Principle VI speaks directly to the requirement to maintain ethical standards as specified in the ADA COE. The second of the two underlying rules addresses the expectation that members agree to report violations of the COE to the ADA BOD and to cooperate with any actions the BOD may take in the matter (ADA, 2023a). The ADA bylaws are silent about enforcement of the COE and there is no separate board or committee that is specifically charged with ethical matters (ADA, 2017). It is apparent from the wording in the COE itself that the ADA BOD is responsible for dealing with reported violations of the COE (ADA, 2023a).

AAA The AAA COE specifies professional standards of behavior related to members’ responsibilities to individuals served as well as to the integrity of the profession. The COE consists of two parts, the first of which is the Statement of Principles and Rules. The second part outlines the processes related to compliance with and enforcement of the principles and rules. The COE applies to all members of AAA, regardless of membership category (AAA, 2021). For more information about AAA membership categories, please refer to Chapter 2 in this text. As was the case with the ASHA BOE, the charge of the AAA Ethical Practices Committee (EPC) is multifaceted. While the primary role of the EPC is to educate and increase members’ awareness of the COE, it is also responsible for maintaining a current COE, updating policies and procedures as needed, reviewing complaints alleging unethical behavior by members and determining appropriate disciplinary action, and tracking state licensure professional development requirements relative to ethics education. The EPC has nine volunteer members in addition to the chair, who is a volunteer; the BOD liaison, who is also a volunteer; and a staff liaison (AAA, 2023). Part I of the AAA COE is the Statement of Principles and Rules. There are eight principles, each of which is supported by several rules. Principle 1 speaks to members’ responsibility to treat persons served with honesty and compassion while respecting their dignity, rights, and worth. It is supported by two rules, one of which addresses nondiscrimination. Principle 2 addresses maintaining high standards of professional competence in service delivery and is supported by six rules, one of which covers providing appropriate supervision and delegation of services to others. Principle 3 and its one supporting rule address the need for maintaining confidentiality. Doing what is in the best interests of individuals served is the focus of Principle 4, which is supported

by four rules. Principle 5 addresses the requirement that members provide accurate information about both the nature and management of communicative disorders. Of the five supporting rules, two address research activities and another speaks to the requirement to maintain accurate records of services rendered. Principle 6 addresses ethical conduct related to making public statements and is supported by two rules while Principle 7, which is supported by two rules, addresses members’ responsibilities to the public and to colleagues. Finally, Principle 8 directly speaks to upholding the dignity of the profession of audiology by complying with the COE and cooperating with reviews being conducted by the AAA EPC (AAA, 2021). Part II of the AAA COE is Procedures for the Management of Alleged Noncompliance, which indicates that the primary objective of the EPC is to increase member awareness of the COE and its practical implications including how to be compliant. It is also responsible for reviewing and adjudicating instances of alleged violations of the COE. Specifically, the EPC will convene and use established criteria in its decision making, including whether there is evidence of violation of a specific COE principle or rule and whether there is current or pending litigation (AAA, 2021). Information about the how the EPC moves forward with allegations of noncompliance will be discussed later in this chapter.

Ethical Issues in Practice Management While there are ethical issues that cross all professional domains in which SLPs, audiologists, and speech and hearing scientists work, there are some issues that primarily affect clinical practice and practice management. The following sections address some of the ethical issues related to clinical practice, including relationships with vendors, professional communication, and other miscellaneous topics such as confidentiality, billing practices, and documentation.

Relationships With Vendors The importance of avoiding or managing conflicts of interest was discussed in an earlier section of this chapter. Audiologists and SLPs who are in practice often need to have professional relationships with vendors, including making decisions about equipment purchases as well as recommending products for patients or clients to improve their ability to communicate. For example, a pediatric audiologist working with a child with newly diagnosed hearing loss typically makes recommendations to the family regarding the most appropriate

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amplification options given the degree and configuration of the hearing loss as well as the family’s goals for their child. Similarly, an SLP working with a patient who has neurodevelopmental disabilities that prevent them from using speech to communicate may recommend the most appropriate augmentative and alternative communication (AAC) device given their abilities and communication needs. While not directly related to clinical care, an audiology and speech pathology clinic manager who has the responsibility to purchase equipment and materials for use in the clinic should make those decisions based on what is best for the clinic, taking into account the population being served and the needs of the professionals working in the clinic. In all three examples described above, there is a potential risk of conflict based on relationships with vendors, particularly when there are incentives for purchasing a particular product. For example, audiologists attending professional meetings may be invited to private dinners paid for by individual hearing aid manufacturers or equipment vendors in appreciation of the use of their products. Similarly, a clinic manager may feel compelled to purchase a product created by a faculty or staff member who is employed by their department. Another example of a possible conflict is related to “camps” offered for doctoral audiology students by specific hearing aid manufacturers. The camps, which occur over several days, are free of charge for the students. While the educational opportunity is excellent, the conflict occurs when the hearing aid company completely underwrites the cost of attending, often including travel. This conflict could be easily managed by finding alternative funding sources to enable students to participate without relying on vendor money for travel and housing. As mentioned earlier, decisions should be made based on what is best for the patient or clinic rather than on opportunities for personal or professional gain. Principle 4 of the AAA COE indicates that members should limit services and products provided to those that are in the best interest of individuals being served (AAA, 2021). Principle of Ethics I of the ASHA code has to do with professionals honoring their responsibility to persons served and to participants in research and scholarly activities. Rule K specifically addresses evaluating the effectiveness of technology employed and products dispensed and making decisions about both based on their potential benefit to individuals served (ASHA, 2023a).

Professional Communication There are important ethical issues related to professional communication with individuals being served and with colleagues. Two areas for consideration that pertain to both audiologists and SLPs are offering second opinions

when requested and dismissing patients when the SLP or audiologist believes it is in the best interest of the individual served. SLPs and audiologists are often asked to provide second opinions about patient diagnoses or treatment of a disorder. It is important that the audiologist or SLP who is providing the second opinion demonstrates objectivity, sensitivity, and humility. As professionals, we need to be mindful of what has happened with the patient before our involvement and recognize the efforts of everyone, including the patient, family, and professionals, prior to our involvement. When agreeing to provide a second opinion, we become part of a team that is larger than our immediate colleagues and ultimately includes everyone who has been involved. For example, if parents request a second opinion about their child’s hearing status from a pediatric audiology clinic due to concerns about speech and language development, it is important that the audiologist providing that opinion report the results to the parents and offer them a variety of options for follow-up. If the child has documented hearing loss, the audiologist must provide information about management options in an unbiased manner. Similarly, if an individual who is an actor asks for a second opinion from a professional voice clinic about healthy voice use, the SLP also must provide recommendations in an unbiased fashion. The audiologist or SLP needs to be aware of the need to communicate recommendations with referral sources, with patient/clients and their families when appropriate, and with other health care or educational personnel as needed. They also need to be transparent about management options including returning to the provider of the first opinion (Metz, 2006). Another issue related to professional communication has to do with dismissing patients when the SLP or audiologist believes it is in the best interest of the individual served, or when the professional determines that client variables are negatively impacting progress. Consider an audiologist who has been working with an adult with hearing loss to fit and program hearing aids that will help to improve their ability to hear in a variety of contexts. The audiologist has tried many hearing aid fitting strategies and hearing aids from multiple manufacturers, yet the individual continues to struggle and is not satisfied. In that case, it may be in the best interest of the patient to try a different audiologist for hearing loss management strategies. It may also be the case that the individual served was only trying hearing aids because their family pressed them to do so, yet their lack of interest in hearing aids prevents them from succeeding. A clinician can ethically dismiss a patient if notification is provided in writing, including the reason for dismissal, and then offers to send copies of patient records when a release of information is provided (Metz, 2006).



CHAPTER 4   Professional Ethics, Accountability, and Liability

Consider the SLP who has been involved in the diagnosis of a 3-year-old child who is not talking and has normal hearing. The child demonstrates characteristics of autism spectrum disorder (ASD), so the SLP recommends referral to an interdisciplinary autism clinic for evaluation. The parents are not yet ready to accept the possibility that their child may have autism and refuse to follow up on the recommendation. While the SLP can provide therapy to improve communication options, progress may be negatively impacted by the child’s behavior and the parents’ unwillingness to pursue an autism evaluation. If the SLP believes it is in the best interest of the child to refer to a different provider, it may be ethically appropriate to do so. Clearly, SLPs and audiologists must attend to how decisions they make relative to professional communication apply to the ethical practice requirements imposed by our professional associations’ codes. Principle of Ethics I, Rule B in the ASHA code specifies the requirement that audiologists and SLPs utilize all resources, including referral and/or interdisciplinary collaboration when needed to ensure quality services are provided (ASHA, 2023a). Principle 2, Rule 2b of the AAA COE compels audiologists to use all available resources, including referrals to other professionals when appropriate (AAA, 2021).

Confidentiality As audiologists and SLPs, we are required to maintain the confidentially and security of records, not only related to professional practice, but also related to research and scholarly activities. In the ASHA code, specific requirements fall under Principle I, which speaks to our responsibility to hold paramount the welfare of individuals with whom we interact professionally. The 2023 code speaks to confidentiality in Rules O and P, and the wording in the new code is intended to provide greater clarity. The bottom line is that we need to protect confidentiality of records and that access to records is only permissible when legally authorized or mandated by law (ASHA, 2023a). Confidentiality is addressed in the AAA COE in Principle 3, which is consistent with the ASHA code (AAA, 2021). ADA does not have an explicit statement about confidentiality but refers to the Model Licensure Statute (ADA, 2023b).

Informed Consent Directly related to the previous section about confidentiality, professionals need to get permission to release records and to obtain informed consent before engaging an individual in clinical care and/or research. There are so many issues involved in thinking about informed

consent including when it is required and what barriers might present themselves to obtaining informed consent. By definition, informed consent initially referred to consent for surgery or to participation in a medical experiment once the individual fully understood what was involved (Merriam-Webster, n.d.). In our discipline, informed consent requires that patients in clinical settings and participants in research voluntarily agree to their participation once they have a full understanding of the proposed clinical action plan or their role in a research study. It is essential that audiologists, SLPs, and speech and hearing scientists provide a clear and thorough presentation of the purpose of what is proposed as well as potential risks, benefits, and alternatives (Sharp, 2015). It is important that we do not make assumptions about who is able to legally provide consent. For that reason, the 2023 ASHA code in Principle I, Rule H removed spouses and family members from those who would be assumed to be able to provide consent. The current language specifies that if the person served has diminished decision-making capability, professionals should seek authorization from a legally authorized/appointed representative for the patient (ASHA, 2023a). Informed consent is mentioned in the ADA Model Licensure Statute (ADA, 2023b). The AAA COE addresses informed consent in Principle 4, Rule 4d, which is limited to the need for informed consent relative to investigational procedures (AAA, 2021).

Documentation Audiologists and SLPs are required to accurately document encounters with individuals served and those who are subjects in research. Principle I, Rule Q of the ASHA code specifies that audiologists and SLPs maintain timely records and bill only for services provided. It also requires accurate representation of products dispensed as well as research and scholarly activities conducted. The overarching requirement in Principle I is to honor our responsibility to the welfare of persons served professionally and to participants in research (ASHA, 2023a). Maintaining accurate records is an important part of that responsibility.

At-Risk Practitioners One of the updates in the 2023 ASHA code is the elimination of the phrase “impaired practitioners” to clarify the ethical responsibility of audiologists and SLPs to provide services in a competent and safe manner and factors that might interfere. Principle of Ethics I, Rule R provides examples of personal factors that might impede individuals’ ability to fulfill that duty including substance use/misuse, physical or mental health conditions,

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psychosocial distress, and personal hardships. In addition, it encourages SLPs and audiologists whose practice is adversely impacted by any of those factors to seek professional assistance in determining whether their professional responsibilities should be limited or suspended (ASHA, 2023a). In addition to the requirement for members and certificate holders to appropriately manage their responsibilities to safely provide competent services, we also have a duty to report information to the appropriate authority when we have knowledge that a colleague is unable to provide services with “reasonable skill and safety.” Principle of Ethics I, Rule S further specifies the options to report information internally if there is a mechanism to do so and, when appropriate, to external bodies such as a licensure board and/or the appropriate body within a professional association (ASHA, 2023a). In the case of an ASHA member, certificate holder, or candidate for certification, the BOE would be that entity. While reporting a colleague for any violation of the code makes some feel uncomfortable, failure to do so is a violation of the code. While the AAA COE does not specifically address at-risk practitioners, Principle 8, Rule 8c speaks to the requirement to inform the EPC when there are reasons to believe that an AAA member has violated the AAA COE (AAA, 2021). Similarly, the ADA COE specifies in Principle VI, Rule 2 that members agree to report violations of the COE to the BOD of ADA (ADA, 2023a).

Ethical Issues in Supervision There are several ethical issues related to supervision and delegation of service provision to audiology and speech-language pathology students, including audiology externs and clinical fellows. Please refer to Chapter 22 in this text for more specific information about supervision, precepting, and mentoring. Each of our professional associations’ COEs has ethical requirements related to this topic. The 2023 ASHA code has two rules, one of which is new and the other revised to provide more clarity related to supervision of undergraduate and graduate students, assistants, serving as a preceptor for audiology externs, and supervising clinical fellows (CFs) in speech-language pathology. Principle of Ethics IV, Rule F, which is a new rule, says that professionals in these roles must provide appropriate supervision and comply with all ASHA certification and supervisory requirements (ASHA, 2023a). For example, all supervisors and mentors must complete training in supervision. According to the 2020 audiology and speech-language pathology certification standards, 2 hours of professional development in supervision are required prior

to engaging in supervision or mentorship (ASHA, 2020). The intent of this requirement is to be mindful that supervision and mentorship require additional knowledge and skills beyond those needed for clinical service delivery. Also related to supervision, there is a need to address physical relationships between mentors or supervisors and the students and young professionals under their guidance. Principle of Ethics IV, Rule I addresses sexual activities between members and those over whom they have professional authority or influence. The revision in this rule is intended to clarify that those with an ongoing consensual sexual relationship prior to the supervisory relationship are exempt from this requirement (ASHA, 2023a).

Delegating Service Provision to Trainees Explicit in the ASHA code is the expectation that audiologists and SLPs delegate the responsibility for service provision in a manner that informs individuals being served about the status of the trainee and provides the opportunity for the individual served to deny the trainee participation in service delivery. Principle of Ethics I, Rule E speaks directly to delegation of services to personnel who are not audiologists or SLPs only when they are appropriately supervised. It is important to remember that the welfare of the individual served rests solely in the hands of the certified professional (ASHA, 2023a). The AAA COE also speaks to supervision and delegation of services to trainees and assistants. Specifically, Principle 2, Rule 2d indicates that audiologists who are providing supervision ensure the supervision is appropriate and that they assume full responsibility for services provided (AAA, 2021). The ADA COE addresses delegations of service in Principle II regarding the maintenance of high standards of competence, integrity, and ethical behavior. It specifies that members shall not allow services to be provided by someone who is not qualified to provide those services (ADA, 2023a).

Communication About Expectations and Feedback It is essential that those of us who enter a supervisory or mentoring relationship with trainees at various levels provide clear expectations to the individuals with whom we are involved. It is also important that we provide regular and ongoing feedback about how things are going. Imagine you are a pediatric audiologist who has taken on the responsibility to mentor a full-time extern during their fourth-year clinical experience. The extern has not done a clinical rotation in your clinic so is unaware



CHAPTER 4   Professional Ethics, Accountability, and Liability

of policies and procedures that apply to patient care in the clinic. Think about the onboarding process for this trainee and the importance of outlining short- and longterm expectations for someone in this role. Please refer to Chapter 22 in this text for additional information about issues related to supervision and mentorship.

Ethical Issues in Academia As is the case with ethical issues in supervision, there are issues that specifically relate to academia including academic integrity, research responsibilities, and student/ faculty relationships. The ASHA code provides guidance for each of these topics. For example, Principle of Ethics I, Rule I addresses the need for informed consent in recruiting and engaging individuals in research. Principle of Ethics I, Rule P addresses the confidentiality of participants in research and restrictions about the disclosure of information only when legally permissible or required by law (ASHA, 2023a). Principle of Ethics II, Rule D addresses the responsibility of members who are engaged in research to comply with all institutional, state, and federal regulations (ASHA, 2023a).

Ethical Dilemmas Ethical dilemmas occur when an individual has witnessed or is asked to do something that would place them in jeopardy of violating ethical principles. These situations can occur in a variety of clinical and academic settings, so it is important for audiologists and SLPs to have a framework for ethical decision making to resolve the problem and come up with a solution. The model proposed uses a five-step process: gathering data; identifying whether the dilemma includes moral, ethical, and/ or legal issues; consulting resources; brainstorming possible solutions; and selecting the appropriate solutions (Power-deFur, 2020). Bupp (2012) outlined several examples of ethical dilemmas based on inquiries to the ASHA Ethics Office as well as complaints filed about potential violations of the ASHA code. One of the topics included has to do with documentation of clinical encounters. An example is when a supervisor asks an SLP to sign off on paperwork for individuals the SLP did not evaluate or treat, including services provided by students or assistants the SLP did not adequately supervise. Another example is when ASHA members are asked to alter or supplement evaluation or treatment paperwork to increase reimbursements (Bupp, 2012). Audiologists and SLPs must adhere to their ethical responsibilities as outlined by our professional associations’ COEs related to documentation.

A related situation in which audiologists and SLPs are faced with an ethical dilemma has to do with employer demands relative to caseloads, time limits, and productivity quotas. Employer expectations can place the professional in an untenable situation of having to choose between ethical behavior and meeting the demands of the employer (Bupp, 2012). For example, imagine you are an experienced pediatric audiologist working in a large medical center. Your caseload includes children with complex medical conditions and neurodevelopmental disabilities in addition to hearing loss. The department administration has decided to reduce the appointment lengths to match the times allotted in the adult clinic and you are concerned that you will be unable to provide quality care to your patients as a result. It is important to note that Ethics Office staff are always available to provide guidance at [email protected].

Unethical Complaint Process The next sections of the chapter cover the policies and procedures for filing a complaint of unethical behavior for ASHA, ADA, and AAA based on the information provided on each association’s respective website. Information is also provided about the adjudication process. Various types of complaints, possible sanctions imposed, and the appeals process are also briefly summarized.

ASHA As mentioned earlier in this chapter, the BOE is charged with maintaining and administering the code as well as providing education to ensure individuals understand its significance (ASHA, 2023a). The jurisdiction of the BOE relative to the code is limited to members, certificate holders, and those in the application process. The BOE only adjudicates cases that are brought to it. Complaints of unethical behavior can be filed by individuals affiliated with ASHA as well as others, including patients, consumers, licensure boards, students, and employers (ASHA, 2023b). Unlike licensure boards, the BOE does not have investigative powers, nor can it compel witnesses to testify or produce documents as evidence of wrongdoing. However, since members and certificate holders are obligated by the code to self-disclose their own unethical behavior and to report others’ unethical behavior, they assist the BOE in enforcing the code (ASHA, 2023a). An important concept in ethical practice has to do with willful blindness, which dictates members’ responsibility to address unethical conduct on the part of others, even when it seems awkward or difficult. The ASHA code Principle IV, Rules N and O specify that

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ASHA members who are aware of areas of noncompliance are expected to work collaboratively with colleagues to resolve the situation where possible or to inform the BOE through its established procedures. Rule O specifies that ASHA members recognize their responsibility to report individuals from other professions to the appropriate regulatory bodies when they are aware of unethical behavior (ASHA, 2023a). ASHA has established a complaint process to allow for due process and ensure fairness. Information about the process is easily accessible on the ASHA website (ASHA, 2022). ASHA will not accept anonymous complaints or agree to keep confidential the identity of the person filing the complaint (complainant) from the person about whom the complaint is rendered (respondent). Part of the reason for this policy is to enable the respondent to present and support a claim of bias when appropriate. Also, individuals are less likely to file malicious or frivolous complaints if the respondent is aware of their identity. Finally, transparency regarding the identity of the complainant helps the BOE determine the credibility of the evidence submitted (ASHA, 2022). In its deliberations, the BOE will only consider evidence provided by the complainant and the respondent. When a complaint is filed, the respondent is given a copy of the complaint and the opportunity to submit a written response to the BOE. The adjudication process is confidential. If the BOE determines there is not sufficient evidence to support a claim of wrongdoing, both the complainant and the respondent are notified of the decision and the case is considered closed. If the BOE finds there is sufficient evidence of a code violation, both parties will be notified about the specific rules of ethics that were violated and the BOE will determine a sanction (ASHA, 2022).

AAA The EPC is responsible for responding to inquiries submitted about unethical behavior and adjudicating allegations of COE violations by members of AAA. Allegations of suspected code violations can be made to the EPC by AAA members or consumers of members’ services. Complaints must be made in writing, including documentation to support the claim. The complainant will be asked to sign a waiver of confidentiality permitting the EPC to disclose their name and the complaint details, should that be necessary during the investigation. However, a signed waiver is not required to move forward with deliberations. If the EPC learns from a state licensure board that a member’s license has been suspended or revoked, the EPC will proceed with its investigation without having a complainant. The chair of the EPC is permitted to communicate with other agencies or individuals to gather additional information

that may be needed at any time during the deliberations (AAA, 2019). Following receipt of a complaint, the EPC will convene to discuss the merits of the alleged violation of the code. If the allegations include behaviors that have a high likelihood of being illegal, the case may be referred to the appropriate agency and the EPC will suspend its investigation until the legal process is complete (AAA, 2019). If the EPC finds sufficient preliminary evidence that a violation of the code has occurred, the member will be notified in writing about the complaint, including a description of the circumstances of the alleged behavior and which ethical principles and/or rules are implicated in the complaint. The member will be asked to provide a written response to the allegation and supporting documents within 30 days (AAA, 2019). Following receipt of a response from the member, the EPC will convene in person or via teleconference to consider all the evidence. If no response is received from the respondent, the EPC will still convene to review the existing evidence. If the EPC finds sufficient evidence of a COE violation, the member will be notified of their right to a hearing in person or by teleconference, the ethical noncompliance being cited, possible sanctions, and the right to defend the charges. This is the final opportunity for the respondent to provide additional information to the EPC. If the EPC finds insufficient evidence of a code violation, all parties will be notified and the case closed. If the ruling is that sufficient evidence exists, the principles and rules will be cited and sanctions will be specified (AAA, 2019).

ADA The ADA COE specifies in Principle II, Rule 6 that members agree to govern their professional practices by the ADA COE. It goes on to define unethical practice as any action that violates either the letter or spirit of the COE. Members also agree to report concerns of unethical behavior to the ADA BOD or its designee and to fully cooperate with any investigation the BOD may undertake. Principle VI of the ADA COE, which specifies the requirement of members to maintain ethical standards and practices of ADA, includes two rules that are duplications of the requirements provided in Principle II, Rule 6 (ADA, 2023a). No information is provided in the COE or in the ADA bylaws about specific procedures regarding investigation of reports of unethical behavior by ADA members.

Types of Complaints The most common types of ethics complaints about ASHA members and certificate holders are reflected in the topics included in the ASHA Issues in Ethics state-



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ments. The Education Subcommittee of the BOE creates and periodically revises these documents to address specific issues of ethical conduct. They are intended to provide guidance in ethical decision making. The topics included reflect issues that have been referred to the ASHA BOE. For a complete list of Issues in Ethics statements and the advice presented, please refer to ASHA (2023d).

Distinctions Between Association Policies and Procedures There are some important differences between the procedures of the AAA EPC and the ASHA BOE. First, while ASHA will not allow anonymous complaints, the EPC will convene to discuss a case even when the complainant refuses to sign a waiver that would allow the EPC to share their identity with the respondent. A second difference has to do with the timing of the respondent discovering the complaint and having a chance to provide evidence of compliance with the COE. Specifically, in the ASHA BOE procedures, the respondent is notified immediately of the complaint. The respondent is also given a copy of the complaint so an appropriate response can be submitted to the BOE. The BOE does not meet until the response has been received, and deliberations occur only in person. In addition, the ASHA BOE does not have investigative ability and will only consider the evidence provided by the complainant and the respondent, whereas the EPC procedures allow the chair to seek information from individuals and/or agencies to obtain information about the case beyond what is included by the complainant or respondent. Differences in possible sanctions are discussed in another section of this chapter. Disclosure. The 2023 ASHA code provides greater clarity about professional self-disclosure than did previous versions. In addition, timelines have been modified relative to the 2016 code and the requirement to provide certified copies of records has been eliminated. The code provides guidance for members and certificate holders about ethical reporting, including the need to report one’s own violation of the code. Examples of violations of the code that must be self-disclosed include misdemeanors, felonies, public sanctions, and denials of licenses or other credentials (ASHA, 2023a). During the process of applying for ASHA membership and/or certification, applicants are required to answer questions related to previous behavior that resulted in criminal conviction or formal professional discipline. Applicants must answer the questions honestly and supply documentation related to the conviction or discipline when asked to do so. The specific requirements for members and certificate holders fol-

lowing the application process are included in Principle of Ethics IV, Rules T and U. Rule T addresses individuals who have been convicted of or entered a guilty or nolo contendere plea for misdemeanors involving dishonesty, physical harm, or the threat of physical harm; or any felony. Reporting must occur within 60 days of an action using a self-report notification with a copy of the conviction or plea record. Should the ASHA Ethics Office request additional records, individuals are required to submit them (ASHA, 2023a). Rule U is related to self-reporting on state licensure or other association action. Specifically, audiologists and SLPs who have been publicly sanctioned by a licensure board or denied a credential by any professional association or other regulatory body must self-report. This rule was revised in the 2023 code to provide greater clarity about requirements to report during an investigation. With a voluntary surrender of a license, registration, or certification during an investigation of alleged misconduct, the member must notify the ASHA Ethics Office in writing within 60 days of the final action or resolution of the case (ASHA, 2023a). Honesty and transparency in reporting information are foundational to proper, professional, and ethical conduct. While various work environments can create tension between the obligation to choose ethical behavior versus personal preference and the opportunity for personal gain, audiologists and SLPs are expected to remain ethically compliant with the code, including accurate self-disclosure (ASHA, 2023a). There is no clear statement regarding self-disclosure in the AAA or ADA COEs. Sanctions. Possible sanctions for violation of the ASHA code are either private or public. Public sanctions provide evidence to other ASHA members that the code is important and that ASHA is willing to enforce its standards. Additionally, public sanctions may serve as education for the respondent as well as all members of ASHA. Sanctions include written warning (private); reprimand (private); censure (public); or withholding, suspension, or revocation of membership and/or certification for a specified period, including up to life. In addition to sanctions, the BOE can issue a cease-and-desist order relative to behavior that violates the code (ASHA, 2023e). Public sanctions resulting from a violation of the ASHA code are published in the ASHA Leader and on the ASHA website (ASHA, 2023f ), including the name and location of the respondent, the rationale for the decision, the specific principles and rules of ethics that were violated, and the sanction violation date. This information is also forwarded to the appropriate state licensure body (ASHA, 2022). Possible sanctions for violations of the AAA code include an educative letter, cease-and-desist order,

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reprimand, mandatory continuing education, probation of suspension, suspension of membership, or revocation of membership. Sanctions are imposed by a simple majority vote of the EPC with the exception of revocation of membership, which requires a two-thirds majority vote of the EPC. To educate the membership, the circumstances and nature of all cases are published in Audiology Today and on the AAA website, although the members’ names are not revealed (AAA, 2021). Appeals.  Both AAA and ASHA have appeals processes for individuals found to be in violation of their respective codes. The AAA member may appeal the final decision of the EPC to the Academy BOD. Requests for appeal must be made within 30 days of notification of the final decision, stating the basis for the appeal. No new information can be provided during that time. The AAA BOD will review all the evidence and deliberate the case at the earliest possible BOD meeting. The decision by the BOD is considered final (AAA, 2021). The policies and procedures of the ASHA BOE include two levels of appeal following the initial determination. Specifically, when a code violation has been determined and a sanction imposed, the respondent may request further consideration by the BOE within 30 days of the initial determination. The respondent is permitted to submit a written defense prior to the hearing and the complainant is also able to provide additional information. Further consideration hearings are held before the adjudicating body of the BOE. The respondent may appear in person and may be accompanied by counsel. The respondent must be available for questioning by the BOE at the time of the hearing and must not permit counsel to answer questions. Following the further consideration hearing, the BOE shall render a decision and notify the respondent (ASHA, 2022). The respondent may appeal the BOE’s decision after further consideration to the ASHA Ethics Appeal Panel in writing within 30 days after the decision was mailed to the respondent. The only basis for appeal is if the BOE did not follow its own procedures and/or the decision was arbitrary and capricious and without evidentiary basis. The three members on the appeal panel will not consider any evidence other than that included in the record of the further consideration hearing, and their decision is final (ASHA, 2017, 2022). Ethics Education.  Our professional associations provide ample opportunities for ethics education for SLPs and audiologists, much of which is accessible from the associations’ websites and at both state and national conferences. The Ethics in Audiology Second Edition CEU Program is described on the AAA website and includes nine modules based on the Ethics in Audiol-

ogy (2nd ed.) book published in 2012. The program is available through eAudiology and is intended to provide in-depth information on ethical conduct for audiologists working in various clinical, educational, and research settings (AAA, 2023b). We have already discussed some of the many topics about ethics available on the Ethics section of the ASHA website. A list of ethics resources is available with quick links to items that may be particularly useful not only to members and certificate holders but also to consumers and students (ASHA, 2023g). Practicing ASHA members and nonmembers with CCC-A and or CCC-SLP have been required since 2020 to earn one of the 30 required certification maintenance hours in ethics (ASHA, 2023h). Many states also require continuing education in ethics for license holders in both audiology and speech-language pathology, and that information is available from https://www.asha.org/advocacy/state/

Recent Changes and Future Directions As stated in the preamble to the 2023 code, the intention of the code revisions is to reflect both the current state of practice in our discipline and to address evolving issues within the professions of speech-language pathology, audiology, and speech and hearing science (ASHA, 2023a). The process, which took over a year, involved conducting research about trends in the profession. It also included peer review, with modification made based on the comments received from the membership (ASHA, 2023c). Thinking about factors that have impacted how we practice and educate students, certainly an increased focus on diversity, equity, inclusion (DEI) and belonging (the “B”) has driven change. While DEI is all about bringing diverse perspectives to the table, that is not sufficient if the individuals seated at the table do not feel heard. As a result, we need to pay attention to the “B.” Similarly, there have been changes to how protected classes are defined relative to discrimination and antidiscrimination policies. For example, Principle of Ethics I, Rule C now includes accent, gender, and genetic information to the list of personal variables covered in the prohibition of discrimination (ASHA, 2023a). Another important recent trend in our professions has been the increased use of remote technology in all aspects of what we do as professionals. Because of the COVID-19 pandemic and the restrictions resulting from it, audiologists, SLPs, and speech and hearing scientists had to quickly shift to doing what we do without being in close proximity to one another. Education shifted to remote learning, not only for the learners in our professions but also to children in schools. Audiolo-



CHAPTER 4   Professional Ethics, Accountability, and Liability

gists and SLPs working in private practice or health care settings also needed to pivot. For the purposes of this chapter, the need to ethically find a way to continue to teach and mentor trainees and to provide clinical care is important. Please refer to Chapter 2 in this text for additional information about the impact of the pandemic on our professions. Also, please refer to Chapter 23 for additional information about the appropriate use of technology for student training and professional practice including telepractice and telesupervision. One additional trend in the professions is the growing use of assistants in both audiology and speech-language pathology. The ASHA code addresses members’ responsibility regarding the appropriate roles for assistants and their supervision (ASHA, 2023a). There is also now an optional certification program for assistants supporting both professions. While the reliance on assistants is not new, the ASHA BOE has recently provided greater clarity in this area. In addition to modifications in the code, there is now an Assistants Code of Conduct that took effect on June 1, 2020. Interestingly, while the ASHA BOE does not have jurisdiction over assistants, the code of conduct was created to guide certified assistants in their clinical practice (ASHA, 2023i).

Summary of Professional Ethics The first sections of this chapter have provided an overview of topics related to professional ethics in audiology, speech-language pathology, and speech and hearing science including standards of professional conduct, conflicts of interest, the role of professional associations, ethical issues in practice management, ethical issues in supervision and academia, how to manage ethical dilemmas, and unethical behavior complaint processes for ASHA and AAA. Information was also provided about the COE for ADA, although specific procedures for addressing ethical complaints were not available. The importance of ethics education was discussed and resources were provided in the references. Stay tuned for our discussions about professional accountability and liability.

Introduction to Professional Accountability Much of what we have already talked about has to do with accountability — to individuals served professionally, for our own professional competence, to the public for the things we say and do, and to one another. We are accountable for the standards we follow and how we implement them (Chabon & Cornett, 2021). Also

important in this discussion is the notion of accountable care as it relates to delivery of services, which will be briefly discussed in the following sections of the chapter.

Accountable Care Accountable care refers to organizing and delivering care in a manner that focuses on both effectiveness and efficiency. The overarching goal is to provide care that is highly reliable and valuable to all stakeholders. Some of the precepts of accountable care include the acknowledgment that we do not have all the answers and the expectation that we will continue to seek them. Inquiry, introspection, and integrity are keys to professionalism. This approach is also rooted in the need for heightened accountability due to safety concerns. Evidence based decision making and patient-/family-centered care are essential in this model. As a result, there is an expectation of increased communication and cooperation among professionals involved with a patient (e.g., interprofessional education [IPE]/interprofessional practice [IPP]). The notion of value-based health care (VBHC) has become increasingly important not only in the U.S. but also in other countries. The “Triple Aim” framework developed by the U.S. Institute for Health Care Improvement (IHI) is an approach to optimizing health system performance in population health, cost of care, and the patient experience. A recent systematic review of the literature highlights the evidence about the effects of VBHC on performance across all dimensions of the Triple Aim goals (Kokko, 2022). Sadly, while the VBHC movement has attracted increasing interest in the performance assessment of national-level health care policies and has also impacted health care systems in the U.S., there is a lack of evidence on health care performance related to pursuing the goals of the Triple Aim (Kokko, 2022).

Managing Risks and Risk Intelligence for Accountable Clinicians and Organizations Health care is highly regulated due to risks involved and the misalignment of incentives among the players. For example, there is a disconnect between incentives for providers of services and suppliers of products, which was alluded to in the discussion of conflicts of interest. There might also be a disconnect between life science research and practice and incentives for medical device companies. There is certainly a misalignment between the incentives for payers, both commercial and government, and the needs of our patients.

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One of the important factors driving the need for change is the high level of waste in the health care system. For example, there are failures of health care delivery, failures of care coordination, and evidence of overtreatment. Administrative complexity results in waste in the system. There are also failures related to setting prices for services and products delivered, and fraud and abuse drive the high level of waste in health care. Additional issues in this conundrum about accountable care and payment for services provided has to do with the tension between the fee-for-service model, which provides payment to providers based on the documented services provided, versus other payment models. A feefor-service model provides an incentive for increased diagnostic procedures and for overtreatment. On the other hand, a payment model based on outcomes drives accountability by assigning responsibility to personnel. In a perfect world, audiologists and SLPs would make decisions about evaluation tools and management strategies for individual patients based on what is in their best interests rather than considering the competing pressures related to payment for services.

Current Critical Risks Facing Health Care There are several critical risks to health care in general that also spill over to our discipline. For example, professional liability, including cases related to medical errors, is an important consideration. Another is related to the opioid crisis and its ongoing litigation. Infections that occur as a part of hospitalization are problematic and seem to be increasing over time, particularly since the COVID-19 pandemic first entered our health care environments. Other issues include clinical alarm fatigue, which refers to professionals becoming desensitized to alarm sounds, and workplace violence. Approximately 75% of workplace violence occurs in health care and social service settings (see Chapter 18 for further discussion about safety in the workplace). We also need to be concerned about cybersecurity and emergency preparedness. We know, in hindsight, that the health care system was not prepared for the extraordinary needs that occurred because of the COVID-19 pandemic.

Concept of Risk Intelligence Risk intelligence is the ability to accurately estimate probabilities of something occurring. While the concept of risk for many of us is aligned with danger, risk intelligence is an important tool that enables us to have the right amount of certainty in decision making based on evidence (Evans, 2012).

Raising the Bar on Accountability — The Value Equation We have briefly mentioned the importance of value in health care without really talking about the need to raise the bar on accountability related to the value equation. Specifically, we are talking about aligning out-of-pocket costs for patients with the value of health care services. As mentioned previously, fee-for-service models might result in professionals providing diagnostic and/or treatment procedures that are not entirely necessary since there is a tension between quality care and payment for services. In this model, barriers to high-value treatments are reduced through lowering costs while patients are discouraged from seeking low-value treatments by increasing costs to patients. The Center for Value-Based Insurance Design (V-BID) aims to improve health care outcomes while containing costs. The health care community is also having an impact by defining, describing, and practicing high-value care. The High-Value Practice Alliance (HVPA) was established in 2017 with the goal of engaging hospitals, private practices, and systems in all settings to come together to ensure the quality, safety, and effectiveness of a new high-value model for health care delivery (HVPA, 2023). Rehabilitation professionals have been under pressure regarding payment for services and focusing on quality of care, particularly related to the postoperative period. Postacute care is thought to be a significant source of wasteful spending. Accountable care organizations (ACOs) are expected to help reduce those costs. One of the problems is that interventions have not been well delineated. In communication sciences and disorders (CSD), the focus needs to be on helping individuals participate in life situations in which information or ideas are exchanged between people, recognizing that participation is influenced by communication effort, resilience, and support systems (see Chapter 15 for further discussion in this area).

Learning Health Systems — An Opportunity to Shape the Future of Accountability One of the important developments in health care that impacts accountability is learning health systems. By definition, a learning health system provides real-time access to knowledge gleaned from patient encounters. It includes a paradigm shift to redefine the relationship between research and practice to be a bidirectional evidence-generating approach. In other words, data



CHAPTER 4   Professional Ethics, Accountability, and Liability

captured in the electronic medical record (EMR) can be used to inform quality-improvement projects and enhancements to clinical care. An example of implementation of this approach is the Learn From Every Patient (LFEP) program that has been applied to a variety of conditions at various institutions. In an article related to clinical care of children with cerebral palsy (CP), the results suggested that a learning health system that allows for the integration of clinical care and research can be created and implemented in a cost-effective manner (Lowes et al., 2017). Digital capture of the patient experience and the ability of the system to learn and adapt are essential qualities of learning health systems. It is worth mentioning that there is now an open-access journal, Learning Health Systems, related to this topic that is published in collaboration with the University of Michigan (Friedman, 2023).

Professional Accountability Requires Relentless Reimagining It is important to recognize that our own professional accountability requires ongoing self-reflection and reimagining. We need to think about new business models that will enable us to more effectively and efficiently serve the individuals who rely on our expertise. Artificial intelligence (AI) is clearly a force that is already impacting society. We need to think about how we can utilize AI to enhance, and perhaps transform, what we do as audiologists, SLPs, and speech and hearing scientists.

Conclusion and Summary of Professional Accountability As we conclude the portion of the chapter related to professional accountability, it is important to reflect on the discussion of professional ethics that occurred earlier. Professional accountability is directly related to the responsibilities we have to practice in an ethical manner. Ethical behavior and accountability as audiologists, SLPs, and speech and hearing scientists are inseparable.

Introduction to Professional Liability We have already spoken about factors that are important to consider relative to ethical conduct including ethical dilemmas, conflicts of interest, the importance of adhering to standard practice guidelines, and honesty and transparency in all professional interactions. When we think about liability, it is important to consider the

potential legal impact of our actions. It is clear that proximity to patients can increase our exposure risk. For example, imagine you are an audiologist working in an otolaryngology (ENT) practice and you have an adult patient with severe mixed hearing loss who wears hearing aids. The patient needs new earmolds. You note that they have a surgically modified external and middle ear, so are taking precautions to avoid getting ear impression material beyond the ear canal. In spite of your best efforts, impression material makes its way into the middle ear, which requires physician intervention. In this case, are there liability concerns? Now, imagine you are a pediatric audiologist evaluating a 2-year-old child due to parental concerns about speech and language development. The child failed their newborn hearing screen but follow-up testing at an outside institution yielded normal results. You are able to obtain reliable results that suggest a mild to moderate sensorineural hearing loss in both ears. When you look at the raw data from the previous follow-up testing, it is clear that the data were misinterpreted. What are the potential liability issues in this case? As audiologists and SLPs, we need to be aware of issues related to liability, not only as we provide clinical care, but also related to hiring practices. Fortunately, our professional associations have resources available to help navigate these waters. Although some circumstances may put us in jeopardy of liability concerns, we are most likely to avoid professional liability issues when we uphold our ethical responsibilities to individuals served, to the public, and to colleagues.

Summary This chapter provided a journey through professional ethics and on to a brief discussion of accountability and liability. There is so much more we could have talked about, particularly related to accountable care organizations, learning health care systems, and professional liability. I encourage you to investigate the information and tools available to you through the websites of our professional associations and our state licensure boards using the references included with this chapter.

References Academy of Doctors of Audiology. (2017). Bylaws of the Academy of Doctors of Audiology. Adopted September 2017. https://audiologist.org/ Academy of Doctors of Audiology. (2023a). Code of ethics. https://www.audiologist.org/about-us/ academy-documents/code-of-ethics

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Academy of Doctors of Audiology. (2023b). Model licensure statute. https://www.audiologist.org/ about-us/academy-documents/model-licensurestatute

American Speech-Language-Hearing Association. (2023e). How ASHA’s board of ethics sanctions individuals found in violation of the code of ethics. https://www.asha.org/practice/ethics/sanctions/

American Academy of Audiology. (2021). Code of ethics. https://www.audiology.org/wp-content/uploads/​ 2021/05/201910-CodeOfEthicsOf-AAA​.pdf

American Speech-Language-Hearing Association. (2023f ). Board of ethics decisions. https://www.asha​ .org/practice/ethics/boe-decisions/

American Academy of Audiology. (2023a). Ethical practices committee. https://www.audiology.org/ about/committees-and-task-forces/ethical-practicescommittee/

American Speech-Language-Hearing Association. (2023g). Ethics resources. https://www.asha.org/ practice/ethics/

American Academy of Audiology. (2023b). Ethics inquiry and complaint guidelines. https://www.audi​ ology.org/about/academy-membership/ethics-2/ ethics-inquiry-and-complaint-guidelines/ American Academy of Audiology. (2023c). Ethics in audiology (2nd ed.). CEU Program. https:// www.audiology.org/education-and-events/ eaudiology-online-learning/ethics-in-audiology/ American Speech-Language-Hearing Association. (2017). Practices and procedures for appeals of board of ethics decisions. https://www.asha.org/policy/ et2017-00348/ American Speech-Language-Hearing Association. (2018). Issues in ethics: Conflicts of professional interest. https://www.asha.org/practice/ethics/ conflicts-of-professional-interest/ American Speech-Language-Hearing Association. (2020). Supervision requirements for clinical educators and clinical fellowship mentors. https://www​ .asha.org/certification/supervision-requirements/ American Speech-Language-Hearing Association. (2022). Practices and procedures of the board of ethics. https://www.asha.org/policy/practices-andprocedures-of-the-board-of-ethics/ American Speech-Language-Hearing Association. (2023a). Code of ethics. www.asha.org/policy/ American Speech-Language-Hearing Association. (2023b). Board of ethics. https://www.asha.org/ about/governance/committees/committees/ board-of-ethics/ American Speech-Language-Hearing Association. (2023c). Navigating the revised ASHA code of ethics (2023) [Webinar]. https://www.asha.org/events/ navigating-the-revised-asha-code-of-ethics/ American Speech-Language-Hearing Association. (2023d). Issues in ethics statements. https://www​ .asha.org/practice/ethics/ethics_issues_index/

American Speech-Language-Hearing Association. (2023h). Maintaining your certification. https:// www.asha.org/certification/maintain-ccc/ American Speech-Language-Hearing Association. (2023i). Assistants code of conduct. https://www​ .asha.org/policy/assistants-code-of-conduct/ Bupp, H. (2012). 9 upsetting dilemmas. The ASHA Leader, 17(14), 10–13. https://doi.org/10.1044/ leader.FTR1.17142012.10 Chabon, S., & Cornett, B. (2021). Professional accountability. In M. Hudson & M. DeRuiter (Eds.), Professional issues in speech-language pathology (5th ed.). Plural Publishing. Evans, D. (2012). Risk intelligence: How to live with uncertainty. A Free Press Subsidiary of Simon and Schuster, Inc. Friedman, C. (Ed.). (2023). Learning health systems. Wiley Online Library. https://onlinelibrary.wiley​ .com/journal/23796146 Handelsman, J. (2006). Recognizing when strings are attached. The ASHA Leader, 11(1), 18. https://doi​ .org/10.1044/leader.MIW.11012006.18 High Value Practice Alliance. (2023). https://hvpaa.org/ Kitchner, K. S. (1984). Intuition, critical evaluation and ethical principles: The foundation for ethical decisions in counselling psychology. Counselling Psychologist, 12, 43–55. Kokko, P. (2022). Improving the value of health care systems using the Triple Aim framework: A systematic literature review. Health Policy, 126(4), 302–309. Lowes, L., Noritz, G., Newmeyer, A., Embi, P., Yin, H., & Smoyer, W. (2017). ‘Learn from every patient’: Implementation and early results of a learning health system. Developmental Medicine and Child Neurology, 59(2), 183–191. https://pubmed​ .ncbi.nlm.nih.gov/27545839/



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Merriam-Webster. (n.d.). Informed consent. In Merriam-Webster.com dictionary. Retrieved February 15, 2023, from https://www.merriam-webster.com/ dictionary/informed%20consent Metz, M. J. (2006). Ethics of professional communication. In T. Hamill (Ed.), Guidelines for ethical conduct in clinical, educational, and research settings (pp. 37–47). American Academy of Audiology. Power-deFur, L. (2020). What do I do now? Resolving school-based ethical challenges. Perspectives on School-Based Issues, 5(1), 282–289. https://doi.org/​ 10.1044/2019_PERSP-19-00084

Sharp, H. M. (2015). Informed consent in clinical and research settings: What do patients and families need to make informed decisions? Perspectives on Swallowing and Swallowing Disorders, 24(4), 130–139. https://doi.org/10.1044/sasd24.4.130 University of Michigan Board of Regents. (2023). Center for Value-Based Insurance Design (V-BID). https://ihpi.umich.edu/our-experts-partners/ collaborating-centers-programs/V-BID

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5 International Alliances Robert M. Augustine, Tina K. Veale, and Kelly M. Holland

Introduction The president of the American Council of Education (ACE), Ted Mitchell, stated in the foreword to the 2022 edition of Mapping Internationalization on U.S. Campuses (Soler et al., 2022) that, following the global health crisis, “the world is smaller and more interconnected than ever before.” He noted that during the pandemic, for the first time in U.S. history, the U.S. Department of State and U.S. Department of Education (2021) issued a joint statement supporting the value of international education to creating a globally prepared workforce. International alliances, often referenced as collaborations or partnerships, help create a global network in which all professionals — including those in training, those already in the workforce, and those with advanced expertise — engage in culturally diverse experiences. The interconnected global workforce that emerges from international alliances will develop, advance, and support culturally responsive practices (Hyter & Salas-Provance, 2023). “Cultural responsiveness” has been promoted as a more accurate term to describe the outcome of international engagement than “cultural competence” (Hyter & Salas-Provance, 2023). Cultural responsiveness reflects our willingness to learn from people with whom we interact, whereas cultural competence suggests a skill set that we achieve and apply. International alliances foster cultural responsiveness, a dynamic perspective that cultural knowledge evolves and advances as we engage with multicultural populations throughout our careers. Hyter and Salas-Provance (2023) agree that the world is more interconnected as we emerge from the pandemic. International alliances are now viewed as foundational to the preparation and advancement of new talent in education, business, science, innovation, and the economy, disciplines for which international collaboration is essential (U.S. Department of State & U.S. Department of Education, 2021). Readiness for global careers will be supported with globally accessible microcredentials and portable digital credentials (Gallagher, 2016; UNESCO, 2019). Glass et al. (2021) observed that videoconference technologies have eliminated physical barriers to global engagement. Well-prepared professionals will engage and network with global populations, both on site and virtually. These global experiences will provide them with opportunities to develop culturally responsive practices. In the professions of audiology and speech-language pathology, international alliances promote the cultural responsiveness defined by Hyter and Salas-Provance (2023). They create interconnections to advance research (Ghali et al., 2021), promote evidence-based culturally responsive practices (Pillay & 63



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Pillay, 2021), strengthen interprofessional competence (Chakraborty & Proctor, 2019; Ross-Swain et al., 2017), and extend access to services to underserved populations (Randazzo & Garcia, 2018). The American SpeechLanguage-Hearing Association (ASHA), in the document titled ASHA’s Envisioned Future: 2025 (ASHA, 2022a), states its support for preparation and credentialing of speech-language-hearing professionals in a global marketplace. In preparation for a future-focused global workforce outlined by Soler et al. (2022), Glass et al. (2021), and UNESCO (2019), ASHA has negotiated agreements to recognize credentials worldwide. Further, the document verifies that ASHA, in collaboration with other speech-language-hearing and health- and education-related organizations, has developed global relationships for the exchange of new knowledge and advancement of evidence-based practices aligned with diversity, equity, and inclusion essential to cultural competence/responsiveness. The association’s Strategic Pathway to Excellence (ASHA, 2022b) includes Strategic Objective 7: ASHA is engaged internationally with service providers, educators, scientists, and other groups to proliferate research, and improve professional preparation and service delivery. These commitments have launched a series of international alliances to foster the exchange of global practices, research, and knowledge essential for advancing disciplinary research, professional practice, and access to services. For preservice students, international alliances create learning experiences for acquisition of the cultural responsivity needed to appropriately assess and treat multicultural patients and to collaborate with multicultural clients and professionals serving on interprofessional teams, both domestically and abroad. Universities invest in international alliances to recruit multicultural populations from around the world to study and engage in teaching, research, and service at the university and to create distinctive, diverse communities for promoting multicultural engagement for all learners, including students, faculty, supervisors, and staff. For in-service practitioners who seek global careers, the alliances create pathways to access the expertise, professional networks, and international credentialing required for practice in English-speaking and non-English-speaking countries. Service-learning alliances create the potential for access to sustainable services and cohorts of practitioners who hone culturally appropriate skills and knowledge for underresourced countries and communities. Service-learning alliances also provide opportunities to share best practices for the advancement of effective treatment outcomes on a global scale. For researchers, international alliances connect the science and evidence behind diagnostic and intervention tools to foster crosscultural applications. This chapter will explore a variety of traditional and newly launched international alliances

designed to guide achievement of cultural responsiveness and associated with global career paths and characteristics that define a quality global experience.

Definitions:  Alliances, Partnerships, and Collaborations The ACE Center for Internationalization and Global Engagement originally defined an international alliance as a collaboration with international partners. The purpose of the alliance is to prepare those who participate with competencies, sometimes referred to as knowledge and skills, needed to achieve career success in the global community that represents today’s workforce (Helms, 2015). In a recent publication titled Internationalization in Action: International Partnerships, Gatewood and Sutton (2022) connect the concept of collaboration to the concept of partnerships, noting that the term “partnerships” reflects the current environment where universities are increasing the number of partners and expanding the goals of the partnerships to address the demand for culturally competent/culturally responsive workforces. In defining international partnerships, Gatewood and Sutton (2022) outline five dimensions. These include specification of goals, breadth of activities, levels of engagement, partnering entities abroad, and type of partnership agreement. Gatewood (2018) and Hoseth and Thampapillai (2020) state that international partnerships create engagement essential to acquiring the knowledge and skills to achieve cultural responsiveness. Throughout this chapter, the terms “alliances,” “partnerships,” and “collaborations” will be used to represent the in-person and virtual international experiences designed to achieve a globally prepared workforce in the health professions including audiology and speech-language pathology.

International Alliances, Partnerships, and Collaborations Promoting Cultural Responsiveness for a Global Workforce Graduate degrees from accredited programs in audiology and speech-language pathology that lead to clinical practice require demonstration of a wide range of competencies specified by discipline certification standards and state licensing requirements. While employers expect knowledge and skills competency in disciplinary practice areas for employees holding a master’s degree or professional doctorate, the competencies critical to the success of entry-level professionals include a core set of skills that are transferrable across a range of career pathways (Gallagher, 2014a, 2014b). These skills are embedded within graduate training programs in audiology and



speech-language pathology, and students are expected to engage in learning experiences that foster these competencies in addition to clinical practice skills. An original set of transferrable professional competencies included leadership, communication, critical thinking, problem solving, collaborative teaming, and access to a network of new professionals who contribute additional expertise to the employer’s network. The National Association of Colleges and Employers (NACE, 2021) redefined and updated the definition of transferrable competencies based the concept of career readiness. NACE’s 2021 list includes eight transferrable competencies essential for college-graduate career readiness that enhance and expand the original work of Gallagher (2014a, 2014b). Among those competencies is global/intercultural fluency, defined as understanding and valuing multicultural differences. NACE included global knowledge and skills among the transferrable competencies essential for career readiness for professionals who seek to practice clinically, foster research, or advance to leadership roles within the global workplace. Following the recent pandemic health crisis, new research verified shifts from the original sets of transferrable competencies. NACE (2022a) originally identified four career readiness competencies that employers value most among early-career professionals. These included critical thinking/problem solving, teamwork/collaboration, professionalism/work ethic, and oral/written communications. In a follow-up study, NACE (2022b) published an updated set of eight core competencies transferrable across the workforce that define career readiness. The updated set of transferrable competencies includes career self-development, communication, critical thinking, equity and inclusion, leadership, professionalism, teamwork, and technology. NACE (2022b) shared that equity and inclusion offers a broader level of competence than the original focus on respect for cultures and values; the updated focus is on cultural competence and responsiveness. Equity and inclusion are defined as demonstrating the awareness, attitude, knowledge, and skills required to equitably engage and include people of different local and global cultures. Included with this definition is competence in antiracism. Appendix 5–A offers the NACE (2022b) summary of all eight transferrable competencies and their definitions. Similar to NACE (2022b), the American Association of Colleges and Universities (AAC&U, 2022a) identifies key cultural responsiveness skills that emerge from an international alliance. These have been organized into a rubric and include global self-awareness, perspective taking, cultural diversity, personal and social responsibility, global systems, and knowledge application. See Appendix 5–B for a summary and definitions of the AAC&U (2022a) Global Learning Value Rubric definitions.

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Prior research has also verified that employers most value employees who have developed transferrable professional competencies within the context of integrated professional experiences (Gallagher, 2014a, 2014b). When career self-development, communication, critical thinking, equity and inclusion, leadership, professionalism, teamwork, and technology are practiced simultaneously with disciplinary competencies, the skills translate more readily to the workplace than when they are acquired in discrete experiences through workshops or seminars. Sekuler (2011) found that the global diversity of today’s workforce requires transferrable professional knowledge and skills such as leadership, entrepreneurship, and knowledge transfer as pathways to valuable career opportunities for those with global competencies. Recent research conducted by Hayward et al. (2022) verified the impact of acquiring transferrable global competencies integrated with a global learning experience. Their study examined the impact of global health experience (GHE) on the Accreditation Council for Graduate Medical Examination (ACGME) competencies of residents training in emergency medicine. Statistical analysis documented statistically significant differences between residents who had a global experience and those who did not on all six competencies measured with most significant impact on competencies related to medical knowledge, practice-based learning and improvement, and professionalism. Caligiuri and Caprar (2022) further verified that international experiences foster global talent development, leading to cross-cultural competencies that professionals employ to successfully respond to cultural demands of the work environment, and recommend international experiences for those who seek to lead in global careers. Hyter et al. (2017) documented the value of international learning experiences to the professions of audiology and speech-language pathology. The authors completed a comprehensive literature review focusing on the cultural competencies/responsiveness associated with global careers in audiology and speech-language pathology. Based on their analysis, Hyter et al. (2017) established the Framework for Global Engagement Competencies. This framework expands the global competencies in audiology and speech-language pathology to include dispositions and attitudes, in addition to knowledge and skills as originally discussed by Helms (2015) and Sekuler (2011) and more recently expanded by NACE (2022a, 2022b), AAC&U (2022a), and Caligiuri and Caprar (2022). The original 2017 model offers a rubric for defining and evaluating competencies organized into categories. For example, the authors note that humility, self-reflection, empathy, inquisitiveness, and promotion of social justice are behaviors that exemplify competencies associated with a person’s

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dispositions. Understanding one’s own culture and that of others, the impact of economic privilege, and the political and cultural elements of the country are among the competencies associated with knowledge. Evidence of competence associated with skills includes experiences with diverse cultures and the ability to create an environment that is culturally/globally responsive, while evidence of the competencies associated with attitudes includes reciprocity of knowledge and beliefs associated with communication as a human right. Appendix 5–C includes the framework created by Hyter et al. (2017) to guide professionals in self-analysis of current global competence. It can also guide development of the kind of international alliance that can foster development of global competencies important for global practice or research. In addition to the Framework for Global Engagement Competencies, Hyter created a Conceptual Framework for Culturally Responsive and Sustainable Global Engagement (Hyter, 2014) to serve as a guide for culturally responsive decision making in globally focused speech-language-hearing clinical practice. The original concept was updated and renamed Hyter’s Pathway for Responsive and Sustainable Engagement (Hyter, 2022) to emphasize culturally responsive decision making to establish and sustain practice associated with an international partnership. Among the continuum of culturally responsive practices that foster sustainable global engagement are cultural humility, the valuing of diverse cultures; self-reflection, the practice of acknowledging biases and their influence; cultural knowledge, dedication to learning about the culture where global engagement is being practiced; and cultural reciprocity, using acquired cultural knowledge to engage in practices that align with cultural values (Hyter, 2022). Harten et al. (2018) affirm the workforce demand for global competencies, such as those developed through international alliances and partnerships. They recommend that universities develop international alliances to address the growing need for globally prepared practitioners and researchers, as currently outlined in ASHA’s Strategic Pathway to Excellence (ASHA, 2022b). International alliances build, extend, and strengthen the cultural competencies and responsiveness required for multicultural domestic practice, adding cultural experiences required of practitioners and researchers in the global community. The knowledge and skills acquired within international alliances establish interprofessional collaborations required for culturally informed and appropriate practices. When the international alliances follow culturally responsive guidelines, the alliances also create sustainable services in countries where audiology and speech-language pathology services may be limited or nonexistent. International alliances that seek to establish sustainable services in an underresourced country

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support the advocacy roles of professionals in training and those who are credentialed. Sustainable services have the potential to foster international partnerships focusing on research that can further inform global practice. These sustainable partnerships reflect the level of cultural awareness and diverse perspectives that build on the global knowledge competencies described by Hyter et al. (2017) and Hyter et al. (2023), and impact practice as envisioned by Franca et al. (2007). In addition, Pillay and Pillay (2021) offer new guidance on preparing for global practice in the health professions. They note that, historically, treating patients focused exclusively or singularly on cognitive analysis of the biological factors underpinning of the case. This practice of singular focus in clinical decision making minimizes the impact of context, including the cultural context, in which a patient lives. The broader context includes cultural beliefs as well as socioeconomic and political influences. These contextual factors significantly impact those being served and are outside the realm of the biological factors associated with diagnosis and treatment. The authors affirm that globally prepared practice in the health professions demands comprehensive or “macro” consideration of these contextual factors. Respecting different life experiences, valuing these differences, and adapting practice patterns to support the culture where practice is offered begins the process of “contextualized clinical reasoning” (Pillay & Pillay, 2021). International alliances and partnerships present the contexts in which speech-language pathologists (SLPs) and audiologists acquire these culturally responsive practices. The COVID-19 pandemic fostered virtual international discussions that strengthened the critical value of international alliances and collaborations with rapid development of the professions of audiology and speechlanguage pathology globally. Coello et al. (2022) provide a summary of the outcomes of the virtual roundtable hosted by the University of Cuenca, Ecuador, in 2020. The authors review the history of the professions in the Ibero-American countries of Argentina, Brazil, Colombia, Chile, Ecuador, Spain, and Venezuela. International collaborations create the context required for acquisition of the cultural responsiveness essential for practice and research globally. Among the knowledge and skills acquired through collaborations are the contextual elements of the professions in the partnership countries. Contextual features, described previously by Pillay and Pillay (2021), include academic, legislative, and scientific underpinnings of the professions. Knowledge of these contextual features advances culturally linguisticaffirming practice. Coello et al. (2022) conclude that acquiring contextual competencies requires continued commitment to engage in international collaborations

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virtually and on site to promote global practice, adding to the rapid advancement the professions worldwide. Research aligned with culturally responsive practices was documented by Lindsay Nurse et al. (2021) based on a study of the impact of the Zika virus (ZIKV) on the speech and language development of infants and toddlers in Saint Lucia, West Indies. The results of their study yielded several culturally responsive research practices. The first was to engage in self-reflection by acknowledging one’s own attitudes and beliefs regarding the culture involved in the research and by reviewing and discussing these beliefs with the research team. The second was to advance research practice to, at minimum, a “value stage” described by Hyter et al. (2023). This level of culturally responsive research requires appreciation for cultures beyond stereotypes and valuing the strengths of the people and culture represented in the research. Culturally responsive researchers adjust research methods to respect the needs of the subject and the community. They engage in community activities to familiarize the research team with the socioeconomic, political, educational, and medical practices that impact the people involved in the research. Randazzo and Garcia (2018) further amplify the viewpoint that practitioners who intend to offer culturally relevant services in underresourced environments require specific knowledge and expertise. The authors connect their work to the World Health Organization’s World Report on Disability (WHO, 2011). Based on an international service delivery model in Cambodia, Randazzo and Garcia (2018) identified guidelines for effective global service delivery models in underresourced countries. The guidelines are based on biopsychosocial clinical practices, which use culturally appropriate training to engage members of the family and community as intervention partners so that services will continue after the professionals depart. This approach contrasts with earlier models that focused on training a clinical service provider for that role. Randazzo and Garcia (2018) identified culturally relevant, holistic, accessible, and sustainable clinical competencies as those aligned with biopsychosocial practices. They suggested that international alliances that provide voluntary short-term access to services in underresourced countries should be coordinated with local health care programs to promote sustainability of services through the transfer of expertise to local providers. International alliances create experiences for professionals in training, credentialed professionals, and researchers that are essential for developing key cultural competencies/responsiveness and an understanding of the contexts of the professions in other countries. Among the essential knowledge and skills are cultural humility, self-reflection, cultural reciprocity, contextual-

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ized clinical reasoning, intercultural fluency, and equitable engagement. These competencies define success for careers that intersect with global communities that are now accessible via traditional on-site experiences and virtual services via telehealth and telepractice. The increased demand for globally prepared professionals following the COVID-19 crisis strengthened the commitment to provide practitioners with global competencies integrated with disciplinary competencies, leading to transferrable professional knowledge, skills, and professional networks essential for today’s global clinical and research communities.

International Alliances, Partnerships, and Collaborations Promoting Cultural Responsiveness for a Global Workforce Grounded in Standards of Practice The escalation of a globally engaged society following the health crisis is an imperative for educators and health care providers, such as SLPs and audiologists, to be prepared to deliver services that are culturally responsive and contextually relevant to multicultural populations. The International Issues Board of ASHA (2022c) monitors global issues that impact science and our professions and emphasizes the multicultural impact that professionals trained in communication sciences and disorders can exact.

ASHA Certification Standards and Scopes of Practice Aligned With Culturally Responsive Global Practice The current standards in preparation for the Certificate of Clinical Competence in Speech-Language Pathology (CCC-SLP; CFCC, 2018a) were adopted for entrylevel professionals completing a master’s degree from an accredited program effective January 1, 2023. The current standards identify and define cultural competence, cultural humility, and culturally responsive practice and embed these within and across the standards of practice. In addition, CCC-SLP Certification Standard V: Skills Outcome #F (CFCC, 2018a) specifies that supervised practicum must include experiences with culturally/ linguistically diverse populations. The scope of practice (ASHA, 2022d) and certification standards for speechlanguage pathology assistants (SLPAs; CFCC, 2020a), who perform tasks as assigned by the supervising SLP, must also meet equivalent standards of care for cultural



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responsiveness. The Scope of Practice in Speech-Language Pathology (ASHA, 2016) specifies that certified professionals are competent in providing culturally and linguistically appropriate assessment and treatment protocols. In addition, the scope of practice document specifies that the international exchange of resources and knowledge is expected of professionals practicing in a globally connected society. The current standards in preparation for the Certification of Clinical Competence in Audiology (CCC-A; CFCC, 2018b) were adopted for entry-level professionals completing the appropriate doctoral practice degree from an accredited program effective January 1, 2022. The current standards for audiology practice identify and define cultural competence, cultural humility, and culturally responsive practice and embed these within standards of practice. CCC-A Certification Standard V mandates that professional development experiences required to maintain the certificate include cultural competency, cultural humility, and culturally responsive practice and/or diversity, equity, and inclusion (CFCC, 2018b). The scope of practice (ASHA, 2022e) and standards for practice for audiology assistants (AAs) who perform tasks assigned and supervised by a certified audiologist (CFCC, 2020b) require that the supervisor uphold competencies in cultural responsiveness as specified for practice as an audiologist (CFCC, 2018b). The Scope of Practice in Audiology (ASHA, 2018a) states that “audiologists serve diverse populations” and that assessment and treatment services must reflect culturally centered practice. To further embed cultural responsiveness in practice, ASHA’s practice portal includes definitions of cultural responsiveness, cultural competence, and cultural humility (ASHA, 2022f ) so that all SLPs and audiologists are provided with multicultural experiences to prepare for culturally and linguistically appropriate practice for their clients. These practice documents outline preparation for culturally responsive competencies that are required in both domestic practice and a global workforce.

ASHA Scopes of Practice and Standards of Certification Aligned With the World Health Organization’s International Classification of Functioning and International Alliances Promoting Culturally Responsive Global Practices The WHO’s (2014) International Classification of Functioning, Disability, and Health (ICF) serves as a global framework for management of health care practices. A significant number of countries use the framework as

a collaborative approach for evaluating health and disability status (McNeilly, 2018). The framework focuses on the contexts that affect an individual’s life, including family, work, government agencies, laws, and cultural beliefs. These contexts can positively or negatively influence health conditions and outcomes. The ICF classification system creates a common set of concepts for health care professions among different countries and cultures. These common concepts create the global connections and networks to engage in science to advance care. The framework translates health practices among health professionals and offers a platform to analyze and evaluate data globally. The framework guides international policy and serves as an advocacy tool for the rights of persons with disabilities and strengthens collaborations to increase access to care. The Scope of Practice in Speech-Language Pathology (ASHA, 2016), the Scope of Practice in Audiology (ASHA, 2018a), and the standards for certification for both professions (CFCC, 2018a, 2018b) are consistent with diagnostic categories of the ICF classification system. All these documents collectively identify cultural responsiveness practices among the essential knowledge and skills required for practice. Further, each of these documents acknowledges that increased national and international exchange via on-site and virtual networks strengthens access to services globally. Expanded access increases demand for collaborative international research and networks to further advance science to inform global services, emphasizing the role of international alliances and partnerships in advancing the professions.

ASHA Standards of Practice Aligned With Interprofessional Practice Promoting Culturally Responsive Global Practices In addition to alignment with WHO standards, ASHA (2016, 2018a, 2018b) and McNeilly (2018) acknowledge the integration of interprofessional practice competencies within the scopes of practice in audiology and speech-language pathology. The Interprofessional Education Collaborative (2016) specifies among its core competencies for interprofessional collaborative practice that members of collaborative teams should embrace and mutually respect the cultural diversity and values of patients and of the members of the health professions who may represent many domestic and global cultures. Building on a shared vision, interprofessional practice fosters the community building essential for sustainable practice. Such effective approaches to clinical management require an understanding of the cultural issues that influence health care and education.



ASHA’s Envisioned Future and Strategic Pathways Aligned With Culturally Responsive Global Engagement As stated in the introduction to this chapter, two of ASHA’s guiding documents establish global engagement as association priorities. The first, ASHA’s Envisioned Future: 2025 (ASHA, 2022a), verifies the overall goal of collaborating with speech-language, hearing, and health organizations worldwide to strengthen the exchange of knowledge. The second, ASHA’s Strategic Pathway to Excellence (ASHA, 2022b), establishes international engagement to increase research and inform service delivery. Key areas of engagement include partnering with the Pan American Health Organization (PAHO), increasing the number of international affiliates, collaborating with the WHO and the International Communication Project, partnering to create joint international conferences, participating in WHO and PAHO meetings, and increasing international authorship in ASHA journals. These guiding documents create pathways for enhancing international engagement and opportunities for practitioners, researchers, and educators to strengthen their cultural responsiveness and competence. Details regarding these international initiatives are outlined in the section titled International Alliances Through the American Speech-Language-Hearing Association.

Role of International Alliances, Collaborations, and Partnerships Promoting Cultural Responsiveness for a Global Workforce Aligned With Standards of Practice International alliances, collaborations, and partnerships create a broad, multicultural knowledge base and offer culturally responsive strategies for engaging with families to enhance clinical outcomes. An international professional network provides access to resources for clinical decision making and practice resources important for serving the broad demographic of a multicultural society. The opportunity to complete a clinical practicum experience at an international location, or to study and observe clinical practice internationally, creates a foundational understanding of the global community (Helms, 2015; Gatewood, 2018; Hoseth & Thampapillai, 2020). International alliances are designed to provide preprofessionals, certified practitioners, and researchers with a wide range of options (e.g., initial exposure, courses, clinical practicum, research engagement) needed to meet the demands for career success in a global community. Alliances may provide a pathway to credentialed clinical

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practice in English-speaking countries, including Canada, the United Kingdom, and Australia. The experience may include practice in non-English-speaking countries for practitioners fluent in multiple languages. The alliance may serve as a pathway to promote and advocate for sustainable services in underresourced countries where speech-language pathology and audiology services are limited or unavailable. The alliance can create international research partnerships to promote global investigation of dynamic research questions. Presenting new knowledge in international forums provides context for broadening the impact of research and fosters important professional partnerships (Watters et al., 2010).

International Alliances and Access International alliances are developed by a variety of organizations, including professional societies, colleges and universities, service-learning programs, and research and scholarship programs. The alliances offer access to multicultural learning, clinical practice, and research incorporating on-site and virtual models.

On-Site Alliances Augustine (2012) outlined practices that promote onsite global collaborations at colleges and universities where challenges, such as funding and curricular expansion, can be barriers to establishing international alliances. For professional programs where the academic offerings must meet accreditation standards for graduates to be eligible for clinical practice, domestic and international disciplinary societies can eliminate barriers by establishing collaborative standards of accreditation and practice that promote global exchange of professionals. This approach, sometimes called “globalization of the profession,” has been more widely adopted in business and engineering. ASHA’s International Issues Board (IIB; ASHA, 2019a) currently provides leadership to facilitate global relationships that advance the science and research of the professions. Examples from ASHA’s IIB and other organizations are outlined in more detail in the section that follows. Programs that seek to globalize their curriculum through international alliances can create a global mentor or supervisors’ network to connect students and practitioners with certified personnel abroad. This ensures their global clinical experiences will meet certification standards. Another important practice includes hosting a global ambassador’s program that connects those who are ready to launch global careers with international



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opportunities for employment. Colleges and universities offer alliances to achieve important mission-focused goals. One goal is to promote cultural responsiveness for a global workforce for both degree-seeking and non-degree-seeking students or program alumni. Universities also create alliances to promote international scholarship and facilitate scholarly exchanges, each of which is important to the institution’s commitment to knowledge creation. Disciplinary and health organizations create international alliances to achieve the international strategic goals established by their governing boards, often through service-learning models. Servicelearning programs foster alliances to strengthen access to services in underserved areas and create international learning experiences for practitioners, university faculty, and practicum students. Our professional societies also collaborate with universities to strengthen opportunities for international exchange of knowledge and to create new educational programs at international locations. Research alliances are available through several key programs designed to foster global exchanges of knowledge and scholarship. Research alliances strengthen evidence for practice and add new knowledge about the cultural elements of practice important for achieving treatment outcomes.

Virtual Alliances Virtual alliances including telehealth, telepractice, and telesupervision are among the strategies available to provide clinical services to both domestic and international populations. Virtual research partnerships to advance study at international locations promote international collaborations and advance the science of our disciplines. Following the pandemic, virtual international alliances promoting cultural responsiveness for a global workforce have strengthened both access to international opportunities and continuation of interaction after an on-site experience is concluded. Telehealth, telepractice, telesupervision, and virtual research alliances have all assumed a significant role in advancing global interactions and offering opportunities for practitioners and researchers to acquire culturally responsive expertise in the global workforce. To guide both standard and telepractice at international locations, ASHA provides a portfolio of resources (ASHA, 2022g) and publishes a list of associations that govern practice internationally so that practitioners can contact the international association and verify their status to practice. ASHA offers access to ASHA certification to those holding certification in another country via the Mutual Recognition Agreement (MRA). These resources are reviewed in more detail in the next section.

Voniati et al. (2021) documented evidence of the success of international telehealth practices. To examine the effectiveness of virtual practice tools, the European University of Cyprus, which prepares SLPs to meet standards established by the Cyprus Association of Registered Speech-Language Pathologists, compared treatment outcomes following the shift to telepractice and telesupervison during the pandemic (Voniati et al., 2021). The data supported success meeting clinical goals with a majority of the children served, with an added benefit of observing and connecting with families in their home environments. The authors noted that telepractice and telesupervison will be integrated into the curriculum as tools to promote access to services. In support of telepractice and its potential to foster preparation for a global workforce, the Council for Clinical Certification (CFCC, 2018a, 2018b) allows students in training to complete some requirements for practice in both speech-language pathology and audiology via telepractice. Ghali et al. (2021) examined the potential to foster international research virtually. The authors piloted an international collaboration remotely during the health crisis to create new opportunities to use an ASHA mentorship program, Mentoring Academic Research Careers (MARC), to engage in networking and professional development for doctoral students across continents. The focus of the research mentoring partnership was to create a sustainable research experience to foster cultural responsiveness for global careers essential for advancing services to diverse populations on diverse teams. The authors provide a series of guidelines for developing such remote mentoring/partnership programs and share that the program successfully met expectations for students acquiring key international research competencies when traditional on-site research collaborations are inaccessible due to costs, travel restrictions, or related barriers. Telehealth and its associated practices, telepractice and telesupervision, continue to provide new access to multicultural populations. These practices also advance the demand for a culturally responsive and globally ready workforce.

International Alliances Through the American SpeechLanguage-Hearing Association To achieve the strategic goals of promoting international engagement and practicing at the top of the license, and with an aim to globalize professional knowledge, skills,



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and research, ASHA has established six internationally focused goals that all require partnerships. In addition, ASHA’s Special Interest Group (SIG) 17, Global Issues in Communication Sciences and Disorders (ASHA, 2019) focuses on programs to advance research, clinical practice, and related experiences that promote globalization of the professions. SIG 17 publishes Perspectives of the ASHA Special Interest Group 17 and offers webinars, discussions, courses, and conference and convention sessions on globalization and global careers. The group hosts an online community to discuss international issues and an annual meeting at the ASHA Convention each November.

an efficient process for earning mutual certification in participating countries. Once certification in the home country is achieved, professionals are recognized as having the qualifications required for credentialing needed to practice within these English-speaking countries. The agreement alerts those who earn mutual certification that other legal or immigration standards emerging from national, state, or provincial laws may need to be considered. This agreement was designed to promote global exchange. See ASHA (2017) for details for earning mutual recognition credentials, including any additional requirements related to examinations, internships, or certification.

ASHA-PAHO Alliance

Alliances to Promote Exchanges, Joint Conferences, Summits, and Research

The ASHA-PAHO alliance was launched in 2013 to strengthen services in three key countries: Guyana, El Salvador, and Honduras (Schuermann et al., 2014). ASHA serves as a nonstate actor (NSA) in an alliance with the PAHO Regional Office for the Americas of the WHO to advance the professions of audiology and speechlanguage pathology in selected countries. In response to the WHO’s publication of Rehabilitation 2030 (WHO, 2020), ASHA extended the ASHA-PAHO alliance in 2022 to also promote services in Paraguay, Belize, and Ecuador. Rehabilitation 2030 identifies 10 areas of action to strengthen rehabilitation, foster sustainable services, and increase educational resources (Waterson et al., 2018). In addition, the ASHA-PAHO partnership will be extended to advance to important areas of global need. These include providing technical assistants and analyzing speech-language-hearing services among the countries within the region of the Americas.

Mutual Recognition of Professional Association Credentials Among ASHA’s international alliances is the 2017 Agreement of Mutual Recognition of Professional Association Credentials (ASHA, 2017). This powerful international alliance creates a pathway for mutual recognition of the requirements for certification or membership of SLPs. Such organizations in English-speaking countries include ASHA, the Speech-Language and Audiology Association of Canada, the Irish Association of SpeechLanguage Therapists, the New Zealand Speech-Language Therapists’ Association, the Royal College of Speech and Language Therapists, and the Speech Language Association of Australia Limited. The Agreement for Mutual Recognition of Professional Association Credentials advanced by ASHA’s SIG 17, Global Issues in Communication Sciences and Related Disorders (ASHA, 2019) creates

In addition to the ASHA-PAHO Alliance and credential recognition, ASHA is collaborating with the WHO and the International Communication Project to promote public awareness. ASHA has partnered with the European Speech Language Therapy Association (ESLA) as part of its 2022 conference and has contributed to the Global Disability Summit and other international meetings supporting a global workforce. ASHA is committed to increasing the number of its international affiliates that currently include 61 countries. Finally, ASHA is committed to increasing publications from international authors to strengthen translational knowledge and resources for non-English-speaking colleagues.

International Alliances Through Other Professional Organizations Like ASHA, other professional associations and professions create opportunities for advancing research and practice in health science through international alliances. Professionals in the disciplines of audiology and speechlanguage pathology are often potential partners.

Europe’s International Alliances Promoting Global Competencies Beyond the United States, speech-language pathology has been acknowledged as a global autonomous profession practiced across many countries. To create standards for competent speech-language therapists (SLTs) to practice across cultures in Europe, the Network for Tuning Standards and Quality of Education Programs in Speech and Language Therapy/Logopedics Across Europe (NetQues) was initiated. This multinational



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collaboration created benchmarks for educational and clinical competencies of SLTs in participating countries in Europe and developed a model of cross-border collaboration in education and research to improve clinical practice (Patterson et al., 2015). The principles of practice emerging from this alliance have amplified competencies in diversity and multiculturalism to form benchmarks for clinical practice across many countries and cultures in Europe.

The Lancet Commission The Lancet, among the most respected journals addressing research in medicine and health, creates commissions to address pressing issues in global health to improve practice. In 2022, a Lancet commission on autism was organized to conduct a comprehensive examination of available research to consider how to better serve the diagnostic and intervention needs of autistic individuals and their families globally. The commission included representatives from six continents who have been impacted by autism. The focus of the commission was to consider a long-term plan to strengthen clinical management for people with autism across cultures. Lord et al. (2022) verified that most evidencebased research has focused on high-income countries with primarily White populations, yet the impact of autism is reported globally and those who live in lowand middle-income countries are rarely included in the research. As a result, the cultural impact of the diagnosis and culturally responsive tools to assess and treat autism globally is unavailable. The commission urged the launch of an international research alliance to document effective assessment and intervention practices that reflect cultural diversity and can promote success in underserved communities by adapting to the socioeconomic and related factors aligned with the culture. Further supporting the commission, Al-Dakroury et al. (2022) amplify the urgency for international alliances in research on autism spectrum disorders (ASD), acknowledging that primary work has been completed in English-speaking counties. However, the Kingdom of Saudi Arabia (KSA) has invested in research and programs to strengthen services for those diagnosed with ASD in the KSA. The study found that international collaboration is needed to develop evidence-based services aligned with global populations to understand the cultural correlates of the diagnosis. Recommendations included conducting research with diverse populations that include both attention to characteristics such as age and development as well as attention to socioeconomic and cultural backgrounds. The authors concluded that globally focused research is critical to achieving the goal of strengthening speech-language-hearing and related interventions for

ASD patients globally and urge research collaborations among public and private universities to address critical needs in this area of practice.

International Alliances and Attributes of High-Quality Programs Offered Through Colleges and Universities Colleges and universities are essential resources for access to international alliances that provide a pathway to cultural responsiveness for a global workforce. Alliances represent a broad range of potential learning experiences. Experiences may offer introduction to on-site or virtual practitioners who provide overviews of how audiology and speech-language pathology are practiced at an international location and the requirements for practice. Short-term alliances also focus on fostering interest in travel to a host country to engage in a more long-term program designed to acquire multicultural, interprofessional, cross-cultural experience that promotes culturally responsive global competencies that may be extended and supplemented with continuing telepractice and telesupervision engagement. Other alliances offer experiences to achieve standards of academic and cultural competence for careers in global markets. Selecting the most suitable alliance requires an understanding of the characteristics that define their quality. In 2015, the ACE Center for Internationalization and Global Engagement published the essential elements for prospective students or practitioners to consider when seeking a successful international alliance to promote global career options. The original parameters included quality assurance, engagement, and transparency (ACE, 2015). Additionally, Soler et al. (2022) remind practitioners to “exercise greater discernment and strategy in international partnership development” in the wake of the pandemic. With worldwide impacts on staffing and resources, the years following the crisis have been a key time to reevaluate the strength and utility of international alliances. Risk management, emergency protocol, and crisis response procedures are key components of the assessment process where institutions and practitioners must assess a program’s ability to respond to critical needs efficiently and effectively. The implementation of technology also plays a role in a comprehensive, supportive alliance between organizations and may increase access for students who may not otherwise take part in traditional mobility programs (Soler et al., 2022.) Further expanding the three parameters originally proposed by ACE (2015) and those added by Soler



et al. (2022), Gatewood and Sutton (2022) identify six dimensions that define quality international partnerships. These include having well defined goals, experiences, leaders, partners, agreements, and impact. These are detailed in the section that follows.

Quality Assurance Quality Through Defined Attributes. Gatewood and Sutton (2022) identify and define six attributes within Dimension 1: Definitions of Quality Attributes that serve as quality markers of high-quality international alliances. Faculty, students, and alumni should think of these attributes as they consider an international experience. Each of the definitions is briefly summarized so that practitioners and participants can apply the definitions to evaluate the alliance under consideration. 1. Goals Defined.  A quality partnership begins with specifying all the elements of the institutional mission the experiences are designed to advance. Some alliances focus on teaching and learning such as exchanges and study abroad, while others focus on the research mission through joint research partnerships. Still others focus on the university’s service mission and are designed to strengthen the communities where the alliances are located. To meet the demand for a culturally responsive and globally ready workforce, well-developed alliances may support and advance multiple areas of the mission. 2. Experiences Defined.  Once goals are defined, a quality alliance specifies the experiences that will support achieving the teaching/learning, research, and service goals. This quality assurance process creates a pathway to capacity building. The teaching/learning activities may launch with shared courses and faculty and progress to joint/ dual degrees to further advance cultural responsiveness. Building the teaching/learning experience may connect to capacity for research and the additional research partners to address global research needs that require a multicultural focus. Similarly, service-learning experiences may be added to address cultural responsiveness needs in the discipline. Those considering an alliance will want to understand all the experiences available for participation. 3. Leaders Defined.  Quality alliances establish clearly defined leadership roles. These include alliances established and maintained by an individual faculty member with the capacity to grow to include faculty within a disciplinary unit or units.

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These alliances may offer additional opportunities to integrate global learning across the institution, requiring senior central leadership’s commitment to an entire system. Roles and responsibilities of alliance leaders are clearly defined and supported. Participants should verify the leaders and support staff as they consider an alliance. 4. Partners Defined.  Further advancing the value of global competencies emerging from alliances, universities include partnerships that not only immerse students in the academic community, but also offer internship, practicum, and research experiences within the working contexts of government agencies, private industries, and nongovernment organizations. Quality alliances specify these opportunities and include capacity building to add these experiences to the alliance. Those considering an alliance should verify the range of opportunities as they plan their program of study. 5. Agreements Defined.  Quality alliances may begin with intentionality agreements or nonwritten understanding to engage in mutually beneficial activities. However, a written agreement, typically called a memorandum of understanding (MOU), remains the hallmark of a quality alliance. Those participating in an alliance should inquire about the specific arrangements to assess its benefits and outcomes. See Denecke and Kent (2010) for guidance on writing an MOU. 6. Impact Defined.  Gatewood and Sutton (2022) conclude their outline of attributes of a quality alliance by providing a summary of potential impacts an alliance may have. The defining dimension of a quality alliance is impact that mutually benefits all partners. Participants should consider if outcomes and benefits are publicly shared and integrated with the institution’s messaging and success. Quality Through Regional Institutional Accreditation.  The Council for Higher Education Accreditation (CHEA; 2023) recognizes the regional organizations that accredit universities. Recognition by CHEA verifies that the institution meets required standards of academic quality and accountability to offer degree programs and support students with federal financial aid. Institutions engaging in international alliances should meet the standards for regional accreditation to ensure all the programs offered align with the standards of practice specified in an accreditation report. Quality Through Program Accreditation. As reviewed in detail in the section of this chapter titled



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“ASHA Certification Standards and Scopes of Practice Aligned With Culturally Responsive Global Practice,” accreditation in audiology (CFCC, 2018b) and speechlanguage pathology (CFCC, 2018a) verifies that the program meets standards of quality required for professional practice in each specific profession. Accreditation verifies that upon degree completion, degree candidates are eligible for certification to practice in the selected profession. Following guidelines developed by ACE (2015), students participating in an international alliance in the speech-language-hearing professions should verify if the alliance is a credit-bearing, integral part of the degree and certification process or if it is limited to elective or noncredit status. Courses and practicum that meet degree and certification requirements and that are part of an international alliance will be specified in the curriculum, along with delineation of which experiences meet the requirements for a joint or dual degree. Quality Through Learning Outcomes. Universities and programs collect data on each learning experience to assess and verify that students completing the learning experience meet established learning outcomes. All programs that offer international experiences should collect assessment data on the student learning outcomes of each experience. The assessment data should offer evidence that the students who participated in the program achieved the desired learning outcomes and stated objectives of each experience. Students should also find the changes made to the program to improve the learning outcomes that were guided by the program assessment data. Quality Through Risk Management, Emergency Protocols, and Crisis Response Procedures. With the onset of the pandemic, international alliances were challenged in new ways that underscored the importance of working collaboratively. Additionally, as organizations, institutions, and individuals learned to work through an unprecedented crisis, certain gaps may have been exposed in risk, emergency, and crisis response procedures and processes. All programs, even virtual ones, have inherent risks that should be detailed and addressed in the assessment process. The Standards of Good Practice for Education Abroad, 6th Edition (Forum on Education Abroad, 2020a) established that all participants in an international alliance should be informed of the potential risks of participation and how to manage those risks. Common risk factors when traveling abroad include economic, health, and safety concerns. Risks associated with virtual programs may include exchange of confidential personal or organizational information and potential engagement with platforms or products that have not been properly vetted. These issues are often

manageable, but participants should be informed of the risks, suggested strategies for dealing with them, and the university and program supports that will be available to assist in risk management during the experience. In Guidelines for Conducting Education Abroad during COVID-19, the Forum on Education Abroad (2020b) wrote specific guiding questions for organizations and institutions to use while evaluating partnerships and the future of international mobility. It provides a comprehensive outline addressing multiple aspects of partnerships including health, safety, and risk mitigation practices. Utilizing scenario-based questions and reflecting on current Forum on Education Abroad resources (2020b) as a reference, a thoughtful and thorough investigation into existing or potential new alliances can be conducted. Quality Supported Through Technology. While online learning is not a replacement for in-person experiences, it can act as a complement, a transitional solution or risk response, or a new opportunity. According to the International Institute of Education’s Open Doors 2021 Report on International Educational Exchange, more than 10,000 U.S. students received academic credit for online global learning experiences in 2019–2020 (Martel & Baer, 2022). When assessing potential partners to establish an international alliance, it is imperative to ask what their digital, virtual, or hybrid programming may include. An Education Abroad Professional’s Guide to Online Global Learning Experiences (Forum on Education Abroad, 2020c) highlights key considerations for “transitioning existing programming online, developing new online global learning opportunities, and/ or evaluating third-party online offerings on behalf of their students.” As a curricular complement, an existing on-ground program may benefit from added virtual learning before or after the on-ground portion of the program; i.e., a hybrid delivery model. Whether in predeparture meetings or postprogram debriefs, the ability to meet online with program leaders or fellow students abroad can profoundly impact the group dynamic and build rapport. During the pandemic, organizations and institutions also utilized technology as a solution in transition, pivoting traditional programming to a virtual environment. It is important for partners in an alliance to identify if either partner can support online learning as a risk response on an individual or group level (for example, if a student tests positive for illness and is quarantined and unable to attend classes, or if a group is prevented from entering a location due to unavoidable border entry complications). Soler et al. (2022) maintain that collaborative online international learning (COIL; AAC&U, 2022b) or other



virtual opportunities provide access for students who may not otherwise take part in international programming. Creating an entirely virtual program, or a hybrid program with virtual components, requires infrastructure and resources. Ideally, a partner organization will demonstrate the available technology and provide examples of how it can be used to complement a program. Organizations should also be aware of any risks related to utilizing technology, including learning management systems (LMS), how to store sensitive and confidential information, and any international privacy laws, such as the General Data Protection Regulation (GDPR; Proton Technologies AG, 2018) in the European Union. An assessment by all parties’ legal and information technology services personnel is recommended.

Engagement Engagement of Faculty.  ACE (2015) acknowledges the engagement of program faculty as key to quality assurance. It is important that faculty have decisionmaking responsibilities associated with the alliance as their engagement shapes the nature and quality of the experience. Faculty engagement may range from a single faculty member with an international network who initiates alliances and champions additional faculty and student engagement, to faculty who teach and lead programs, such as program directors. When deciding whether to participate in an international experience, students should understand the level of faculty engagement to ensure the program will meet their needs and help them achieve their individual objectives. The university should also have the infrastructure to support faculty alliances, either virtually or in person. For example, universities typically designate a senior international office (SIO) as the administrative unit that systematically reviews its programs and can provide information about the value of the program to anyone interested in the program. Engagement of the Institution Through Strategic Planning.  Gatewood and Sutton (2022) identify Dimension 2: Strategic Planning Fostering Engagement as the second of four dimensions for assessing the quality of an international alliance. The authors offer guidance to institutions for planning international alliances and understanding the factors that contribute to a key quality marker: international engagement (ACE, 2015). Internationalization is best achieved when international engagement is reflected within the institution’s planning documents. These documents should establish the institution’s current commitments and ongoing plans to continue development of a portfolio of alliances that foster cultural responsiveness and global career prepara-

CHAPTER 5  International Alliances 75

tion. The analysis offers a review of current engagement strategies, leading to a plan for future partnerships and analysis of policies and procedures to further enhance the alliance experiences. Engagement of Campus Leadership.  Dimension 3: Campus Leaders Engaged is the third of four dimensions for assessing quality and adds perspective on engagement (Gatewood & Sutton, 2022). The authors identify access to the SIO that serves as the central resource for promoting and advancing alliances as an additional engagement strategy for high-quality internationalization. The SIO leads development of policies, creates pathways to new alliances, advocates for funding to support participation, collects data for assessment, and organizes all the key institutional leaders to create a hub of engagement. Those leaders include upper administration, deans and department chairs, faculty, and representatives who offer support services. This completes the range of practices to verify that the institution has the infrastructure and staff to foster the engagement of key participants.

Transparency ACE (2015) identified transparency as a critical element to assess when considering international alliances focused on learning outcomes, global competencies, and costs. Gatewood and Sutton (2022) expanded the attribute of transparency to include transparency about the partnerships. The Organisation for Economic Co-operation and Development (OECD) defines transparency as a complete description of the “knowledge, understanding and skills that a successful student should acquire” through this alliance (OECD, 2005). Transparency Through Published Learning Outcomes. As in other courses, how learning will be assessed and the assessment data should be explicit and published as evidence that the program is meeting both its learning objectives and accreditation standards. Outcomes assessment data is typically publicized on websites and in annual reports available to stakeholders. Transparency Through Documentation of Global Competencies and Responsiveness.  When developing an international alliance, it is critical to articulate a well-defined list of cultural competencies and applied skills that, in conjunction with other experiences, will yield the global responsiveness that alliances promote. Some alliances are designed to develop broad cultural competencies and networking essential for future culturally responsive research and practice. These alliances may focus on visiting research laboratories and/or clinical facilities to observe and engage in supervised research



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or practice. Some may focus on service delivery and provide appropriately credentialed alumni with opportunities to engage in community service abroad. Other alliances may be specifically designed to meet cultural competencies specified in clinical certification and/or program accreditation standards. Programs should publicly share how an international alliance promotes cultural competence/responsiveness. Examples include, but are not limited to, interprofessional research and teaching collaborations; development of student competencies through culturally relevant instruction, research, or clinical practice opportunities; and/or coursework that develops global professional competencies not otherwise available within the degree program. In fields such as communication sciences and disorders that require program accreditation, public information should specify how the experience facilitates professional development of students or faculty in support of the program’s stated mission and standards. Transparency Through Published Costs, Financial Aid, and Support Services.  Costs and financial aid relative to the experience should also be clearly stated (New England Association of Schools and Colleges, 2003). Support services should be published. Transparency Through Documented Partnership Relationships.  Dimension 4: Sustaining Partnerships Fostering Transparency is the fourth of four alliance dimensions offered by Gatewood and Sutton (2022). The authors specify that ensuring transparency of responsibilities within the partnerships further defines a quality internationalization alliance. This dimension includes institutional guidance on best practices for writing the MOUs that outline the agreed-upon responsibilities of each partner to provide participants with clear and unambiguous outcomes of the alliance that meet quality standards. For the institution, the steps in this process require assembling the right leaders and holding them accountable for developing the MOU. The leadership team’s responsibilities require specifying details and resolving challenges associated with different cultures, languages, and operations. Once details are understood and approved, the team assesses the alliance from launch through continued and updated agreements, adjusting for clarity and quality as the alliance progresses. These practices create the necessary transparency and quality assurance.

College and University Alliances for Students and Alumni College and university alliances range from faculty-led programs abroad and international exchanges to dual

and joint degree programs, along with virtual and hybrid program delivery models to support COIL (AAC&U, 2022b). A variety of offerings allows students to assess which type of program may be best suited to their interests, their degree, and their future career pathways. In the fields of audiology and speech-language pathology, some faculty-led programs and exchanges are offered on a recurring basis so that multiple cohorts of students have access to the experience. Dual and joint degree programs create more intensive and mmerseve programs of study for students. Faculty members leading degree programs may hold joint appointments in both a U.S. institution and an international university and may hold credentials to practice and supervise at an international location. Faculty-led international programs may be taught at one or more partner universities or clinical facilities abroad and may include a third-party organization responsible for the structure of the experience. International alliance experiences may be open to alumni as well as enrolled students. Alumni can enhance the international experience for student participants while simultaneously expanding their own cultural competence. Faculty-Led Study Abroad Programs. Universities often offer opportunities for informal international alliance experiences that incorporate study at one or more international locations. These experiences are led or taught by domestic program faculty members alone or in collaboration with international faculty members on site. They are informal in the sense that they are not necessary for degree completion, may not be offered for academic credit, and may be offered infrequently depending on demand and faculty availability. Important considerations for informal faculty-led alliances include student status and transcript-approved credit. In terms of student status to participate in an international alliance experience, requirements often vary. Programs may be offered to students currently enrolled in a degree program, students enrolled at the university but not in the program that developed the experience, or to credentialed practitioners who return as non-degree-seeking students who may or may not be affiliated with the institution. Programs often include an opportunity to network with clinical service providers and administrators to foster interest in international clinical practice. Designed to be experiential in nature, the programs may help participants understand the steps needed to be eligible to practice internationally. Facultyled programs may be offered during scheduled university breaks when students are not enrolled in other classes, during breaks between academic terms, or at times when practicing professionals can participate. Faculty-led programs often offer opportunities to observe clinical practice, sometimes across multiple international locations.



This allows participants to broaden their perspective on practice standards and methods and helps them understand international similarities and differences in audiology and speech-language pathology. Faculty-led programs may vary in the academic credit associated with the experience. Some programs are offered for academic credit, while others may be offered for optional or no academic credit. Credit-bearing seminars complement the international experience by increasing content knowledge, providing clinical practice experience, and/or allowing for evidence-based research in an international forum. Noncredit opportunities are equally valuable experiences and may include acknowledgment of the experience on the participant’s academic transcript upon successful completion of the program. Availability of programs in an abbreviated format, offered during 1- or 2-week breaks in the traditional academic schedule and led by program faculty familiar to participants, make these informal alliances ideal as an initial global immersion experience. Their structure increases opportunities for participation by both degreeand non-degree-practicing professionals. With the onset of the pandemic in recent years, colleges and universities have reviewed their procedures and preferences for faculty-led program management and administration. This may include the introduction of a third-party provider or higher education organization (HEO) that provides additional structure, support, and services for a fee. These organizations specialize in education abroad programming and can provide significant support for risk mitigation and crisis management. This may include additional staff on site, insurance policies, emergency protocols, student support services, and robust health and safety measures. As with all alliances, these organizations require vetting, and roles for all parties should be clearly identified for a successful facultyled program. Exchange Programs.  One type of interinstitutional collaboration with an international partner, typically a university, is an international exchange program. The collaborating or exchange universities develop a formal legal agreement often called an MOU or memorandum of agreement (MOA). The MOU establishes guiding principles of the alliance. The Council of Graduate Schools (2010) identified 10 principles of effective graduate-level collaborations during the 2009 Strategic Leaders Global Summit on Graduate Education. Denecke and Kent (2010) created an MOU checklist to guide development of international collaborations, and Klomparens (2008) developed best-practice guidelines on interinstitutional agreements. Best-practice principles for MOUs and interinstitutional agreements should include clearly established benefits for all stake-

CHAPTER 5  International Alliances 77

holders, including the students, faculty, institutions, and countries. Another important standard includes identifying the learning outcomes and ways they will be measured. A third standard requires identification of support mechanisms to foster the success of those who participate. Appendix 5–D includes the MOU Checklist for International Collaborations created by Denecke and Kent (2010) to guide best practices for development of MOUs/MOAs. Based on the MOU, exchange programs may be designed as a one- or two-way exchange. A oneway alliance may present a student from an institution in the United States with a cultural immersion opportunity abroad for a term of study or a longer period. At some universities, a one-way alliance may be referred to as “direct enrollment with the international institution.” A one-way alliance does not require that students from the United States exchange with an equal number of students from an international partner institution. This type of agreement allows students from the United States to experience cultural immersion abroad. Alternatively, other one-way agreements that do not require an exchange create access to multicultural students who can be recruited from the collaborating international institution to systematically introduce domestic students to multicultural perspectives. For students from the United States going abroad through a one-way exchange, the program must demonstrate that the curriculum at the international location meets regional and professional accreditation requirements, that the international partner has the faculty and clinical supervisors who meet required standards, and that there are appropriate housing and support services for students who participate. To allow for the transfer of academic credit, courses and practicum experiences must meet university and program requirements, as governed by clinical certification and program accreditation standards. Program faculty serve in an advisory capacity and support participation in the program. A site visit by a department or program representative to the international location prior to enrollment of students ensures all the curricular, facilities, and housing arrangements are in place to support the students who participate in the program. One-way programs are valued as an opportunity for students in the United States to study with well-regarded international faculty members. The study may include courses that offer advanced coursework in a specialized area of the curriculum, provide access to content knowledge that may not be available at the U.S. university, and allow comparative study of educational systems in the host country. In some cases, areas of specialization in the curriculum may be linked to a student’s research interests. The alliance is often accompanied by opportunities to observe and network with professionals who are practicing in a variety of clinical locations.



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Some one-way programs are specifically developed to provide advanced clinical training and intraprofessional practice. Another important goal of a one-way international program is for students in the United States to learn about international disciplinary organizations that influence practice abroad. Knowledge of the requirements for clinical practice beyond those expected for practice in the United States helps participants plan for future international employment, if that is their goal. Students from the United States enrolled in a oneway study abroad program at an international location must work with their academic advisor to affirm that the specialized course of study meets requirements for transfer of academic credit upon return from the international experience. Based on a student’s intended career pathway, the focus of the program may be coursework, research, supervised clinical practicum in a multicultural environment, or a combination of these activities. The program may require certain courses for all participants, such as an introductory course to the culture. Some programs may allow a student and faculty advisor to develop coursework that is highly specific to the student’s interests. Exchange programs, sometimes referenced as “reciprocating exchanges” (Harten et al., 2018), require that domestic students exchange with international students from a partnering institution and that a balance of exchanges is achieved over a specified period. During an exchange, the international partner selects candidates to study in the United States and the domestic university selects candidates to study at the international partner university. The MOU outlines the process used to maintain an equal balance of exchange students. Each institution benefits from the disciplinary and cultural knowledge shared by engagement with students who participate in the exchange. Students considering participation in an exchange program value strategies that help to manage program costs. The MOU between the collaborating institutions typically specifies that exchange students are assessed costs associated with enrolling in the home institution. The programs often offer comparable living accommodations at the exchange institution as well. Given the familiar parameters of the cost structure of their home university and the assurance of housing at the partner institution, students may feel more comfortable enrolling in international exchange experiences. Another valuable function of an exchange alliance is to offer a predetermined curriculum completed by all students selected for the exchange. Exchange programs may be part of an undergraduate or graduate curriculum. The curriculum is delivered in English and transfers back to the student’s home institution at the conclusion of the exchange. The curriculum is developed in conjunction with university constituents for study abroad experiences

(i.e., SIO, registrar, student health services) to ensure it meets required regional and disciplinary clinical certification and accreditation standards, as appropriate. The curriculum may include didactic courses or clinical practicum experiences. Program faculty and advisors are tasked with confirming that the experiences meet clinical certification and/or program accreditation standards so the courses taken abroad apply to the student’s degree program. A member of the program faculty advises and maintains contact with exchange students during the experience. Exchanges often include opportunities for students to present and share information about the discipline and their culture to a broad range of constituents, including current students, program alumni, practitioners, and faculty. The value of the exchange to students is the opportunity to learn about the discipline from local practitioners and faculty and to master transferrable competencies associated with multicultural awareness via engagement with them and other students at the site. The opportunity for a full-term or longer period of study establishes a long-term impact for participants, creating an international network of colleagues for years to come. The networks foster additional interest in both practice at an international location and practice in the United States and help create pipelines of potential professionals who have developed the transferrable international competencies important to preparing for an international career. Exchange programs following an MOU that adhere to principles of best practices also include a comprehensive orientation or predeparture program. This ensures those selected for the program have the required travel documents and guidance on travel practices prior to initiating the program. This predeparture program is often delivered by the SIO prior to departure, and additional support is available during the term abroad. When exchange students return to the home department, they are often invited to share their experience with the larger program community. An established study abroad exchange often advances an alliance toward a transformational high-impact learning experience that strengthens a student’s disciplinary, research, and professional competencies and career pathways (ACE, 2015, p. 36). The National Survey of Student Engagement (NSSE, 2021) advises that all students should participate in at least two of six high-impact practices during undergraduate study. Study abroad is included among the six high-impact practices that also include service learning, learning communities, research, internships, and a culminating senior experience. High-impact practices, such as study abroad, promote greater levels of deep learning and greater gains in learning and personal development.



The Sister 2 Sister exchange program, funded by the U.S. Embassy in Pakistan with multiple university partnerships in the United States and offered through the Society for International Education (SIE, 2022) creates opportunities for women in Pakistan to study in the United States in selected areas of science including the health professions through a one-way exchange. As a summer exchange program, women have access to mentors to advance global competencies for professional and academic careers. The program creates opportunities for domestic students and faculty to learn about cultural elements in Pakistan that inform STEM research. Dr. Ayasakanta Rout, professor and academic head and director of the Hearing Aid Research Laboratory in the Department of Communication Sciences and Disorders at James Madison University in Harrisonburg, Virginia, shared the following regarding his recent experience mentoring a student enrolled in the Sister 2 Sister program: “It is a program administered through American University. They sponsor female students from Pakistan selected through a highly competitive process to come to the U.S. for short-term experiences in STEM research. Our university joined the partnership last year to be a site. I received a phone call from the provost’s office last spring to verify if I could serve as a host for one of the two students. The student was a final year MBBS student (entry-level medical degree). She spent two weeks in my lab and two weeks in Health Sciences. In my lab we worked with her on affordable and accessible hearing health care in a global context using the WHO hearing report. She was given selected readings and a lot of handson practice with hearing evaluation and hearing aids” (A. Rout, personal communication, January 19, 2023). The Cultural Connections in Senegal program at Western Michigan University (2019) reflects the standards of best practice described previously. The program evolved from a collaboration with a visiting scholar with ties to the country and advanced with two grants from the Fulbright-Hays Program that funded travel critical for strengthening the network of relationships needed to create the current faculty-led study abroad experience. Faculty from multiple colleges and disciplines, including speech-language and hearing sciences, special education, education, political science, health administration, and others, contribute to the program’s interdisciplinary and interprofessional experiences. The program’s learning outcomes promote understanding of cultural differences to think critically about culturally responsive practices across the multiple disciplines participating in the program. A comprehensive predeparture program includes the cultural history of Senegal. While on site, participants visit surrounding communities to learn about the culture and history of the country and to gain insights about how communities have addressed the effects of

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globalization with limited resources. The program supports undergraduates, graduates, and practicing professionals who may enroll as nondegree or temporary students. Three hours of credit are earned, and participants are required to complete a capstone project. Another example of international alliances offering high-impact learning experiences are those created between the speech-language pathology program at DePaul University in Chicago and Belize and Honduras. Program director Jayne Jaskolski (J. Jaskolski, personal communication, February 2, 2023) stated that the DePaul University speech-language pathology program’s mission focus on unserved and underserved populations both domestically and globally drives the commitment to global alliances. The program offers access to multicultural experiences in Chicago and has extended the multicultural responsiveness of its graduate students though its international alliances. For the Belize alliance, the program has established partners who are hired and work in the alliance countries. Students begin preparation on campus with a special topics seminar that presents the cultural, political, social, educational, economic, and health care policies and practices in the country. Students then complete a 10-day experience on site with professionals who provide continuous and sustainable services for local clientele. The Honduras alliance is part of the program’s bilingual education program and offers an on-site practicum experience to advance clinical practice in a second language. Both programs create mission-focused learning opportunities to serve unserved and underserved global partners that impact the cultural humility, competencies, and responsiveness for students and faculty. Dual Degree and Joint Degree Programs. Dual international degrees offer a course of study, usually between one domestic university and one international university, that earns two diplomas, including one from each institution, upon completion of the degree requirements. In contrast, a joint international degree provides a curriculum of study, typically at one domestic and one international university, that leads to a single diploma upon completion of the work at the participating institutions. The single diploma, issued by the domestic institution, should either include the seals and signatures of officials from both institutions or be accompanied by documents, such as transcripts or certificates, that verify the international elements of the program. Joint and dual degree programs are international alliances that often evolve over a period in which the partner institutions have benefited from an informal alliance and determined that strengthening the alliance by creating a degree program would be mutually beneficial. Joint and dual degrees are sometimes initiated through faculty



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who are alumni of an international university and have maintained an ongoing strategic research or professional relationship with the institution. An alumnus faculty connection is important for program success and sustainability because such individuals are stakeholders in both university partners and are often committed to the long-term success of the degree program. Dual and joint degree programs may also emerge from networking with faculty at international universities via research, service, or professional outreach at international conferences and meetings. Based on the informal alliances, programs can establish an equal and vested interest in a formal strategic international alliance. Factors that motivate shifting from an informal or ad hoc alliance to a formal, strategic, long-term arrangement are connected to a commitment to meeting academic program or institutional goals to foster tangible benefits. Such benefits include attracting international students to bolster program quality through the multicultural competencies in research and practice that these degrees create (Denecke & Kent, 2010). Denecke and Kent (2010) further describe other features of dual and joint degrees that should be considered as universities evaluate their potential for achieving program and institutional goals. Joint and dual degrees are more prevalent at the master’s level in comparison to the doctoral level. Dual and joint degrees have been most frequently developed in the disciplines of business and engineering, fields that also require attention not only to regional accreditation and state oversight, but also academic accreditation. These disciplines are often used as templates for considering development of dual or joint programs. Nonfinancial factors to consider for strategic long-term international alliances include negotiating the memorandum of understanding, ensuring sustainability, and recruiting students. Financial factors focus on the funding needed to develop the programs and fee structures important to their success. Resolution of academic credit issues can present challenges; however, many institutions have established double credit counting and thesis/dissertation credit policies that can be attractive to applicants. Among available degree options, dual degrees are the most prevalent, but are rare in professional fields leading to clinical practice. The challenges associated with meeting disciplinary program accreditation standards, as well as credentialing standards required for practice, can present barriers for degree programs in clinical practice disciplines. Joint and dual degree programs typically require that faculty travel between alliance locations, often requiring institutional or external funds to support their travel requirements. These degree programs may be offered for a specific time period, and decisions regarding their continuance may depend upon student, faculty, and university assessment of their effectiveness in meeting expected outcomes.

Service Learning for Practitioners and Students. Service-learning experiences involve the provision of volunteer services to countries with limited or no access to audiology and speech-language pathology services. Such international alliances create cultural experience, lead to culturally responsive practices for volunteers including student clinicians and their faculty supervisors and collaborators, and provide access to services for communities where they are otherwise scarce. Such alliances should be guided by principles of best practice for each discipline delivering services and should incorporate clinical methods that are relevant to and appropriate for other cultures (Karle et al., 2008). Service-learning opportunities are most often non-credit-bearing experiences arranged by universities in partnerships with local communities, health care organizations, and nonprofit organizations.

College and University Offices and Agencies That Guide Access to International Alliances Academic programs in communication sciences and disorders are the initial starting point for seeking an international experience while studying or after degree completion. An academic advisor or faculty mentor can provide guidance and assistance in finding a program that best suits an individual student’s degree progress and interests. Many colleges and universities maintain a global office that can include international students and scholars, education abroad, international recruitment, English language learning, or other divisions of global education. At smaller institutions, one faculty or staff member may be the primary point of contact for students interested in reviewing international education opportunities. The education abroad office is responsible for maintaining alliances around the world and supporting conversations across campus about international activity. At larger decentralized institutions, each college or school may maintain a staff member who acts as an international education liaison and may operate separately from the main education abroad office. During the process of creating an alliance, a variety of offices are likely to be included in the discussions. This is an important opportunity to include multiple voices and perspectives on campus, including but not limited to academic advisors who assist students with course selection and degree progression; the office of the registrar, which supports all academic credit-bearing activities and transcription; general counsel, who will assess all legal engagements with international entities; the risk management office or committee, which is responsible for the health and safety of all university community members; and the procurement or busi-



ness office, which assists with all fiscal commitments on behalf of the university. At the school or college level, faculty, staff, and administrators may all take part in the creation and nurturing of a successful alliance. The university’s SIO is another resource for students or practitioners returning for professional development who seek an international experience when a program or department currently does not offer one. The SIO may have information on international experiences offered through partner universities or through other programs that may be valuable to those in the speech-language pathology and audiology disciplines. The SIO can provide information about multicultural experiences offered on campus. Engaging with the local community of international students, faculty, and staff may help begin a network important for access to a future international experience. Individuals may seek to research programs on their own, without the assistance of a university. In the realm of international education, private companies and both nonprofit and for-profit organizations offer a wide variety of programs including study, internship, research, volunteer, and work abroad opportunities. It is imperative prior to committing to a program that an individual can verify the operating status of the company, partners with whom they work, professional associations they belong to, and alumni who have successfully completed the program. A thorough investigation of participant support services is recommended, ranging from housing to visa application assistance to professional liability insurance for experiences in clinical settings. Many university SIOs are open to assisting in the research of a unique program. They may allow a student to petition for an independent study opportunity not already vetted and approved by the institution. A petition may consist of a written proposal, estimated budget, and faculty letters of support. A committee composed of faculty and staff review the petition and determine if the program is suitable for an academic credit-bearing experience. If the program is not associated with university credit, the institution may not engage in a petition process with the student but will instead point to outside vetting resources to ensure the program is safe and well executed.

Alliances Promoting Macro International Experiences In the section of a chapter entitled International Alliances, Partnerships, Collaborations Promoting Responsiveness for a Global Workforce, Pillay and Pillay (2021) cite the importance of recognizing all of the contextual features that influence multicultural practice. Dr. Pillay further explained that macro standards of practice

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emerge from the cultural, political, social, and resource context of the families and patients who are served (M. Pillay, personal communication, February 2, 2023). He offered an example focusing on dysphagia management by observing that, when SLPs apply standards of practice for dysphagia management in the United States, those professionals have access to the food, equipment, allied health professionals, and resources necessary to meet the diagnosis and treatment practices available in this country. He contrasted dysphagia management in other countries where access to food, preparation of food for treatment, and access to allied health professionals is not equivalent to those in the United States. Therefore, imposing the standards of practice of SLPs from the United States devalues the culture, people, and resources of the alliance partner. To address this, he and his team studied dysphagia management standards of practice and developed evidence for community-based rehabilitation programs when working in a global environment where resources are different from those in the United States. He outlined four key culturally responsive practices within the context of a differently resourced global environment. The first practice required collaborating with the family on food access. In this study, a home garden was the primary source of food. Therefore, the professionals required an understanding of the dysphagia-friendly foods that could be grown along with the foods that were indigenous and considered to have healing properties. He and his team conducted studies to evaluate which of these foods worked well for texture modifications (e.g., soft/moist or pureed foods) and thickening liquids required for dysphagia management. The second culturally responsive practice focused on how the indigenous foods could be prepared for pureeing and thickening in an environment where electricity and equipment were poorly available. Dr. Pillay and his colleagues examined use of accessible tools, such as forks or whisks, that could be used without electricity to prepare food for dysphagia management to determine which of these tools yielded the best outcome. The third culturally responsive practice required aligning indigenous foods and food preparation with definitions for texture-modified diets guided by the International Dysphagia Diet Standardization Initiative (IDDSI, 2019). Seeking local interprofessional partners, offering professional development to educate and apply these standards advanced the quality of services, and incorporating the expertise of local professionals created sustainable services. A final practice incorporated by the alliance team ensured training for all risk management personnel so that those involved recognized and could engage in practices to manage the risks associated with dysphagia treatment. These culturally responsive and sustainable practices value the resources, cultures, and



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services available in the global community rather than imposing practices from other cultures that are not effective or sustainable.

Alliances Promoting Sustainable Practices Gill, Bharadwaj, Chance, et al. (2016) identified recent global developments that positively influence the potential for expansion of speech-language pathology services in countries with limited access to services. Global efforts to educate more countries about health-related services and strengthen access offer new opportunities for collaborative international alliances. Universities may partner with international universities and local agencies to create long-term volunteer immersion opportunities that lead to critically needed sustainable services and training programs within underserved host countries. Gill, Bharadwaj, Quick, et al. (2016) offer an exemplary international alliance model of long-term volunteering to establish sustainable services where access is limited or not available. The long-term volunteer program included a partnership between a charitable organization, the Connective Link Among Special Needs Programs International, the University of Zambia, Texas Woman’s University, George Washington University, and Texas Tech University. The partnership was supported by university professors, lecturers, students, and practicing SLPs who volunteered to create an SLP training program that would provide long-term access to service after the volunteers were gone. Gill, Bharadwaj, Quick, et al. (2016) stated that the alliance was guided by principles of community-based participatory research developed by Israel et al. (1998). These principles were designed to foster cultural relevance and sustainability of volunteer programs and to avoid the failures associated with methods of practice that are not relevant to other cultures, as described by Karle et al. (2008). Guided by these principles, the university-agency volunteer service alliance resulted in a cohort of new master’s-prepared practitioners and opportunities. Factors contributing to the program’s success were building on existing strengths, creating culturally sensitive materials, achieving mutual benefits for all partners, recognizing and facilitating community involvement promoting co-learning, and cultivating a long-term solution.

Alliances Promoting Exchange of Best Practices Ross-Swain et al. (2017) offered an alliance to promote international interprofessional collaboration. This alliance focused on the exchange of professional views on practice and the sharing of best practices globally. The collaborators in the exchange were 12 SLP members

of the California Speech-Language-Hearing Association (CSHA) representing multiple work settings and representatives of the Finnish National Board of Education. The collaborating team met in Finland to review practices, including an emphasis on early intervention and implementation of interprofessional collaborations among many professions. These practices, along with other investments in education, reduced the impact of speech-language delays on educational and social achievement and earned Finland high global status (Ross-Swain et al., 2017). An important practice for maximizing treatment outcomes emerged from this exchange. Participants conducted a systematic review of Finland’s interprofessional collaborative practices that employ a cross-training of professionals’ model, consisting of multidisciplinary teams that include physicians, social workers, SLPs, and psychologists, to provide services to families. The intervention approaches used in Finland offer models for interprofessional collaborations that integrate international-level expertise into clinical practice. Dr. Ross-Swain highlighted several long-term successes that evolved from the international alliance between the CSHA and the Finnish National Board of Education. Continued invitations to present on key global topics at the Congress of the Union of European Phoneticians were among the most impactful. In Europe, the discipline of phoniatrics is a medical area of specialty focusing on the study and treatment of voice, speech, language, hearing, and swallowing disorders. The Union of the European Phoniatricians (UEP) supports access to research to inform clinical practice. The Congress welcomes phoneticians, laryngologists, otorhinolaryngologists, vocologists, SLPs, audiologists, acousticians, voice teachers, and all those with interest in human voice and communication disorders to their meetings. The Congress meets every 2 years. During the meetings, CSHA members become part of the global network that strengthens our professions globally by building coalitions that foster the global exchange of culturally responsive approaches to practice. Dr. RossSwain shared that creating global networks leads to understanding of global service delivery models and access to globally responsive practices (D. Ross-Swain, personal communication, February 2, 2023).

International Alliances Promoting Global Research for Scholars Universities and academic programs frequently promote development of transferrable global competencies using an international faculty model. Visiting international scholars may offer courses, practicum, and research



that contribute to students’ degrees. Programs may use a faculty exchange model that is similar to the student exchange model, but in this model, faculty members execute the exchange. As with student exchanges, faculty exchanges and visiting international scholar programs typically require an MOU that specifies details about the experience including support from both the home and exchange institutions. Typical arrangements require that the home institution handle compensation and travel for the faculty member, while the exchange institution will provide appropriate housing and access to an office, laboratory, library, internet, and related university facilities. Faculty exchange programs often promote joint research in areas of specialization and provide graduate students with access to an international research mentor. For example, there may be subsequent opportunity to continue the experience through a student exchange or one-way program of study at the international faculty member’s institution. Another important outcome may include presenting research at the international university or at an international research conference. Networking with other international scholars and opportunities to publish in international journals are additional outcomes that enhance the value of faculty exchanges. Similarly, faculty in the program who exchange with the international partners may form research alliances with faculty and graduate students at the international location who may, in turn, be invited to the United States to discuss their projects and network with domestic students and faculty. With additional opportunities available in virtual environments, the possibilities of faculty exchange across borders have increased significantly. This also allows for a hybrid model where virtual meetings are conducted over a period of time, and a travel component is added at one or more key junctures of the project. Visiting international scholars are often invited to teach courses or engage in clinical supervision to foster mastery of internationally focused content and practice strategies. Visiting scholars may focus on case studies in rare disorder areas or offer new insights on treatment emerging from internationally focused evidence. Program alumni and practitioners are often invited to seminars to learn more about requirements for practice at the international location and to foster an interest in preparing for an international career pathway. Visiting scholars may also be invited to campus via faculty who have earned a Fulbright award.

Research Alliances Through the Fulbright Program Launched in 1947, the Fulbright program (United States Department of State Bureau of Educational and Cultural Affairs, 2022) offers international exchange pro-

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grams in 160 countries for students, scholars, teachers, professionals, and groups. The exchanges are designed to fund opportunities to promote multicultural responsiveness, foster research, and promote the global exchange of ideas. Fulbright programs for U.S. students include pathways for seniors, graduate students, early-career professionals, and artists to study, conduct research, and teach English abroad. Students engage in research, teaching, and opportunities to advance long-term collaborations that maintain the alliance after the conclusion of the projects. Fulbright awards are available to non-U.S. students to study, conduct research, and engage in teaching a foreign language and culture to students in the United States. Fulbright programs for scholars and professionals across many disciplines create multiple pathways to pursue projects. Fulbright scholars may propose a teaching award designed to advance the academic mission of both the home and host institutions while also reflecting the culture of the host country. Teaching awards often create long-term curricular alliances that infuse transferrable multicultural competencies across both institutions. Research awards create opportunities to understand research questions from multicultural perspectives and address critical gaps in our understanding of human communication and evidence-based practice. Scholar awards may also consider joint teaching/research projects that connect the teaching and research missions of both universities. A focal point for many Fulbright programs for scholars includes establishing a long-term alliance to broaden the impact of the project beyond the universities. Programs for early-career scholars create an international network for scholars from across the globe, fostering long-term potential for high-impact international collaborations important for both research and professional practice. In addition to creating alliances abroad, Fulbright provides resources to promote access to visiting international scholars in multiple ways. The Visiting Scholars program offers access for international scholars to conduct research and/or lecture in the United States. The Scholar-in-Residence program creates access to international scholars for institutions that seek to strategically build a strong international component. In 2022, the U.S. Department of State’s Bureau of Educational and Cultural Affairs established the Fulbright Historically Black College and University (HBCU) Institutional Leaders Initiative to foster and increase engagement with students, faculty, and staff from HBCUs to promote internationalization and engage HBCUs in Fulbright awards. Comprehensive information on all Fulbright programs is available at fulbrightonline.org. Fulbright awards are also available to practicing professionals to provide consulting and guidance to strengthen multicultural responsiveness within the practice of the



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professions. Professional programs offer opportunities to support institutions and communities and to strengthen society and cultural connections to institutions in the United States. Reciprocal programs for non-U.S. professionals to consult, engage in research, and lecture complete the connections for long-term alliance impacts. Fulbright exchanges for teachers create access to multicultural knowledge to promote competencies essential for a globalized economy. Fulbright programs are also available to groups to engage in teaching, research, and scholarship. King Chung (2020), professor of audiology from Northern Illinois University, earned a Fulbright award for academic exchange in Brazil. The award included opportunities for community outreach, education, and research in collaboration with the University of São Paulo, Bauru, Federal University of Rio Grande do Norte in Natal, and Federal University of Paraiba in João Pessoa. Dr. Chung’s partnership adds new knowledge about the success of using a game-based automatic testing app developed in her lab to evaluate the hearing health of children and adults in a country with a shortage of audiologists, as audiology services are mostly unavailable in rural areas of Brazil. With the help of Brazilian faculty, Chung (2020) reported that more than 100 undergraduate and graduate students from three universities engaged in audiometric testing of more than 1,200 adults and children. Service sites included a riverine community in the Amazon and rural cities in three Brazilian states. They serviced people in preschools and local schools, at job sites, and in community centers for the elderly. During a discussion with Dr. Chung, she identified three key outcomes of international alliances supported during her Fulbright award. The first focused on the long-term friendships and collaborations established with the participating universities and how these relationships foster additional opportunities to advance global initiatives with other partners. The second and third outcomes included continuing opportunities to create new alliances and, through these alliances, to develop new service models that strengthen long-term access to services. She shared that she and her students joined forces with students and faculty from all three Brazilian universities to provide hearing services to preschool and school students in Poland. The Jewish Community Center also arranged for them to test Holocaust survivors and refugees from Ukraine. Additionally, she introduced the Brazilian teams to Entepesi Kenya to provide much-needed speech and dental services in Kajiado, Kenya. Dr. Chung emphasized that the networks and connections promoted though her Fulbright award built new collaborations to advance access to much-needed health services for underserved populations (K. Chung, personal communication, January 25, 2023).

University of the Pacific (2020) highlights speechlanguage pathology graduate student Rachel Convey, who earned a Fulbright award to study, conduct research, and supervise students at Tampere University in Finland in collaboration with Professor Nelly Penttila. Her research will add new knowledge about the treatment of voice disorders associated with Parkinson’s disease. SLP Sue Lee (2021) shared the impact of her Fulbright to offer services and consultation and conduct research in Vietnam, explaining how her Fulbright provided multicultural experience that advanced her own cultural awareness, cultural humility, and cultural responsiveness and how the experience created a network of colleagues through opportunities to lecture at multiple universities including the School of Medicine and Pharmacy at Vietnam National University Hanoi, Hung Yen University of Technology and Education, Hai Phong Private University, Thai Nguyen University, University of Social Sciences and Humanities at Vietnam National University Ho Chi Minh City, Danang University — Kon Tum campus, and Pham Van Dong University, as well as Jakarta International University in Indonesia (Lee, 2021). Publication of the resulting research can be found in the Journal of Speech, Language, and Hearing Research (Nguyen et al., 2021). Convoy, now a doctoral candidate at Tampere University in Finland, shared how the award promoted experiences that fostered culturally responsive practice and research, including the long-term impacts of the experience. She stated that during her time in Finland as part of the Fulbright U.S. Student Program, she had the opportunity to work with an international, multidisciplinary team of researchers. From this collaboration, she discovered that the potential to ask more thoughtful research questions and develop more impactful technology is cultivated by working with those who hold different perspectives. SLPs are facing many of the same difficulties all over the world. By embracing cultural differences, we can come together to solve the most pressing issues in the field. Her time living in Finland also allowed her to closely observe the subtle intricacies of Finnish culture, which on the surface initially appeared to hold many similarities to the U.S. culture she was accustomed to. Becoming a more perceptive observer allowed her to readily integrate into the new culture she found herself living in. She is excited and eager to understand those who come from different backgrounds and cultures from herself. Her time as a researcher and observer enabled her to see that, despite our backgrounds, we are more similar than different, and with a little bit of effort, we can bridge the differences that separate us. The Fulbright U.S. Student Program has had a profound impact on her early career. As a doctoral student at Tampere University, she has had the opportunity to teach and continue the research



she began during the grant. Through this research, she hopes to further our understanding of acoustic measures and their application in objective analysis of speech and voice in patients with Parkinson’s disease. She has been privileged to present at several conferences and broaden her network of international collaborators. She hopes to continue this research and contribute to the development of technology that will allow for the early detection and tracking of neurodegenerative diseases. To promote international cooperation, she also hopes to develop a program connecting speech-language pathology students in the U.S. with their international colleagues (R. Convoy, personal communication, February 2, 2023). Molrine and Drayton (2013) provided another example of research conducted in part through a Fulbright Exchange Scholars grant. The project focused on competencies associated with culturally sensitive speech-language pathology service delivery in the English-speaking twin-island Republic of Trinidad and Tobago. The cohort included eight SLPs, six trained in accredited programs in the United States and two trained in the United Kingdom. Based on their experience practicing in Trinidad and Tobago, the cohort identified modifications that could allow graduate programs to align certification standards with cultural competence. Their research affirmed that culturally responsive practice requires understanding the cultural, ethnic, and language differences, understanding the need for intense client/family education, and collaborating with social and health systems.

Research Alliances Through the Fogarty International Center The Fogarty International Center also provides funding for scholars to advance the mission of the National Institutes of Health (NIH) and the National Institute on Deafness and Other Communication Disorders (NIDCD) through funding to facilitate research collaborations between U.S. and international scholars. Research on deafness and communication disorders are among the research topics for which funding is available. Training awards often focus on low-resource locations that advance scientific knowledge for development of the best tools and practices for diagnosis and treatment. Funding support through the Fogarty Program (NIH, 2022) may be accessed through the Fogarty International Center at the NIH.

Research Alliances Through Partnerships With Health/ Medical Organizations Legg and Penn (2014) developed a model for conducting research abroad that was partially funded by a part-

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nership with the Medical Research Council of South Africa. Their anthropological research in an underresourced area of South Africa focused on addressing gaps in our understanding of culturally sensitive approaches to aphasia. Legg and Penn (2014) found that treatment outcomes rely on building culturally relevant spaces of support within the community. Their work amplified the importance of evaluating cultural and social factors that support clinical treatment. Culturally relevant clinical practices are essential for creating the family and community networks that ensure sustained clinical improvements in patients, such as their clients with aphasia.

Research Alliances Through Other Research Partnerships ASHA provides additional resources for research funding, leading to international research alliances. ASHA members can access resources such as modules to guide development of interdisciplinary collaborations and clinicians and researchers collaborating (CLARC), among others, at https://www.asha.org/research/

Summary International alliances produce benefits that extend well beyond the experience itself. For credentialed professionals, acquiring cultural responsiveness through an international alliance provides a pathway to career success in today’s global workforce. For students, an international experience expands their knowledge of clinical practice standards and methods in another country, enhances their bilingual competence, and encourages them to envision creative solutions to improving access to speech-language pathology and audiology services in underserved global communities. For faculty, international alliances extend their knowledge of pedagogy and forge new research alliances. For individuals with communication and hearing disorders, international alliances not only provide necessary services for the duration of the program, but also may be the impetus for creating sustainable services for their community for years into the future. The combined impact of an international alliance is difficult to estimate, but hard to overstate. While SLPs and audiologists have not traditionally relocated outside the United States for employment, more are embracing bilingual practice and looking for opportunities to make a difference for underserved populations. Universities in partnership with one another, combined with faculty committed to developing global competencies for future SLPs and audiologists, will continue to advance



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our professions as they meet the challenge of increasing the cultural relevance of clinical practice for clients around the world through international alliances.

American Speech-Language-Hearing Association. (2022a). ASHA’s envisioned future: 2025. https:// www.asha.org/about/ashas-envisioned-future/

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Gill, C., Bharadwaj, S., Chance, P., Quick, N., & Wainscott, S. (2016). Impetus for change: Speechlanguage pathology around the globe. Perspectives of the ASHA Special Interest Group 17, 1(Part 1), 3‒6. https://pubs.asha.org/doi/pdf/10.1044/persp1​ .SIG17.3 Gill, C., Bharadwaj, S., Quick, N., Wainscott, S., & Chance, P. (2016). From volunteering to academic programming: A case example. Perspectives of the ASHA Special Interest Group 17, 1(Part 1), 7‒11. https://pubs.asha.org/doi/pdf/10.1044/persp1​ .SIG17.7 Glass, C., Godwin, K., & Helms, R. (2021). Toward greater inclusion and success: A new compact for international students. American Council on Education. https://www.acenet.edu/Documents/ Intl-Students-Monograph.pdf Harten, A., Franca, M., Boyer, V., & Pegoraro-Krook, M. (2018). Across the universe of speech-language pathology: Developing international alliances. Perspectives of the ASHA Special Interest Group 17, 3(Part 1), 49‒58. https://doi.org/10.1044/persp3​ .SIG17.49 Hayward, A., Lee, S., Douglass, K., Jacquet, G., Hudspeth, J., Walrath, J., . . . Tupesis, J. (2022). The impact of global health experiences on the emergency medicine residency milestones. The Journal of Medical Education and Curricular Development, 9, 1–8. https://www.ncbi.nlm.nih​ .gov/pmc/articles/PMC9102119/ Helms, R. M. (2015). International higher education partnerships: A global review of standards and practices. American Council on Education. https:// www.acenet.edu/news-room/Documents/CIGEInsights-Intl-Higher-Ed-Partnerships.pdf Hoseth, C., & Thampapillai, S. (2020). International partnerships: Dynamics and types. In J. Gatewood (Ed.), NAFSA’s guide to international partnerships. NAFSA: Association of International Educators. Hyter, Y. (2014). A conceptual framework for responsive global engagement in communication sciences and disorders. Topics in Language Disorders, 34(2), 103–120. Hyter, Y., Roman, T., Staley, B., & McPherson, B. (2017). Competencies for effective global engagement: A proposal for communication sciences and disorders. Perspectives of the ASHA Special Interest Groups 17, 2(Part 1), 9–20. https://doi.org/10.10​ 44/persp2.SIG17.9

Hyter, Y. D. (2022). Engaging in culturally responsive and globally sustainable practices. International Journal of Speech-Language Pathology, 24(7), 239–247. Hyter, Y. D., & Salas-Provance, M. B. (2023). Culturally responsive practice in speech, language, and hearing sciences (2nd ed.). Plural Publishing. Interprofessional Education Collaborative. (2016). Core competencies for interprofessional collaborative practice: Report of the expert panel. https://ipec​ .memberclicks.net/assets/2016-Update.pdf Israel, B., Schulz, A., Parker, E., & Becker, A. (1998). Review of community-based research: Assessing partnership approaches to improve public health. Annual Review Public Health, 19, 173–202. Karle, H., Christensen, L., Gordon, D., & Nystrup, J. (2008). Neo-colonialism versus sound globalization policy in medical education. Medical Education, 10, 954–958. https://www.ncbi.nlm.nih.gov/ pubmed/18823513 Klomparens, K. (2008). Inter-institutional agreements. Global Perspectives on Graduate Education: Proceedings of the Strategic Leaders Global Summit on Graduate Education. Council of Graduate Schools. https://cgsnet.org/wp-content/uploads/2022/01/ global_perspectives_on_research_ethics_and_schol​ arly_integrity2.pdf Lee, S. A. (2021). Beyond services in the United States of America: Fulbright U.S. scholar experience in Vietnam. Perspectives of the ASHA Special Interest Group 17, 6(6), 1825–1831. https://pubs.asha.org/ doi/10.1044/2021_PERSP-21-00187 Legg, C., & Penn, C. (2014). The relevance of context in understanding the lived experience of aphasia: Lessons from South Africa. Perspectives of the ASHA Special Interest Group 17, 4(Part 1), 4–11. https:// pubs.asha.org/doi/10.1044/gics4.1.4 Lindsay Nurse, K., Gardner, K., & Brea, M. (2021). Operationalizing culturally responsive research practices: Documenting the communication skills of children with confirmed or possible exposure to the Zika Virus in Saint Lucia, West Indies. Perspectives of the ASHA Special Interest Group 17, 6(1), 191–206. https://doi.org/10.1044/2020_ PERSP-19-00140 Lord, C., Charman, T., Havdahl, A., Carbone, P., Anagnostou, E., Boyd, B., . . . McCauley, J. (2022). The Lancet Commission on the future of care and clinical research in autism. https://www.thelancet​.

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com/journals/lancet/article/PIIS0140-6736(21)01​ 541-5/fulltext Martel, M., & Baer, J. (2022.) Spring 2022 snapshot on international educational exchange. Institute for International Education. https://www.iie.org/ publications/spring-2022-snapshot-on-interna​ tional-educational-exchange/ McNeilly, L. (2018). Requisite knowledge for teaching graduate students to utilize the International Classification of Functioning, Disability and Health framework. Perspectives of the ASHA Special Interest Group 17, 3(Part 2), 14–21. https://pubs.asha.org/ doi/full/10.1044/persp3.SIG17.78 Molrine, C., & Drayton, K. (2013). International clinical standards and cultural practices in speechlanguage pathology graduate education: A model from Trinidad and Tobago. Perspectives of the ASHA Special Interest Group 17, 3(Part 1), 14–21. https:// pubs.asha.org/doi/pdf/10.1044/gics3.1.14 National Association of Colleges and Employers (NACE). (2021). Career readiness for new college graduates: A definition of competencies. https://www​ .naceweb.org/uploadedfiles/files/2021/resources/ nace-career-readiness-competencies-revised-apr-​ 2021.pdf National Association for Colleges and Employers (NACE). (2022a). The four career competencies employers value most. https://www.naceweb.org/ career-readiness/competencies/the-four-careercompetencies-employers-value-most/#:~:text=​ Employers%20responding%20to%20NACE%E2​ %80%99s%20Job%20Outlook%20surveys%20 have,competencies%20have%20remained%20 consistent%20the%20past%20three%20years National Association for Colleges and Employers (NACE). (2022b). Development and validation of the NACE career readiness competencies. https:// www.naceweb.org/uploadedfiles/files/2022/ resources/2022-nace-career-readiness-developmentand-validation.pdf National Institutes of Health. (2022). Fogarty International Center. https://www.fic.nih.gov/Funding/ Pages/Fogarty-Funding-Opps.aspx National Survey of Student Engagement. (2021). NSSE 2021 High Impact Practices Report. Indiana University Center for Postsecondary Research. https://irds.iupui.edu/_documents/students/ student-surveys/nsse/2021/NSSE21 High-Impact Practices - IUPUI.pdf

New England Association of Schools and Colleges. (2003). Principles of good practice in over-seas international education programs for non-U.S. nationals. https://www.neche.org/wp-content/ uploads/2018/12/Pp47-Overseas_programs_for_ non-US_Nationals.pdf Nguyen, D. M., Lee, S. A. S., Hayakawa, T., Yamamoto, M., & Natsume, N. (2021). Normative nasalance values in Vietnamese with Southern dialect: Vowel and tone effects. Journal of Speech, Language, and Hearing Research, 64(5), 1515–1525. https://doi​ .org/10.1044/2021_JSLHR-20-00723 Organisation for Economic Co-operation and Development. (2005). Guidelines for quality provision in cross-border higher education. http://www.oecd.org/ edu/skills-beyond-school/35779480.pdf Patterson, A., Hansson, K., Lowit, A., Stansfield, J., & Trinite, B. (2015). EU collaboration in speech and language therapy education: The NetQues Project. Perspectives of the ASHA Special Interest Group 17, 5, 21–31. https://pubs.asha.org/doi/pdf/10.1044/ gics5.1.21 Pillay, T., & Pillay, M. (2021). Syncing our global thinking: A framework for contextualized clinical reasoning. Perspectives of the ASHA Special Interest Group 17, 6(5), 1281–1290. https://pubs.asha.org/ doi/epdf/10.1044/2021_PERSP-21-00054 Proton Technologies AG. (2018). General data protection regulation. https://gdpr-info.eu/ Randazzo, M., & Garcia, F. (2018). An international service delivery model for sustainable practices: Insights from Cambodia. Perspectives of the ASHA Special Interest Group 17, 3(Part 1), 4–13. https:// pubs.asha.org/doi/full/10.1044/persp3.SIG17.4 Ross-Swain, D., Fogel, B., & Schneider, E. (2017). International interprofessional collaboration: The benefits of global networking. Perspectives of the ASHA Special Interest Group 17, 2(Part 2), 73–81. https:// pubs.asha.org/doi/pdf/10.1044/persp2.SIG​17.73 Schuermann, L., Martinez, S., Weddington, G., & Rosa-Lugo, L. (2014). Strengthening relationship between the American Speech-Language-Hearing Association (ASHA) and the Pan American Health Organization, regional office for the Americas of the World Health Organization (PAHO/WHO). Perspectives of the ASHA Special Interest Group 17, 4, 2. https://pubs.asha.org/doi/10.1044/gics4.2.75 Sekuler, A. (2011). Ecosystems for developing transferrable skills. 2011 Strategic Leaders Global Summit



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on Graduate Education: Agenda 3 Papers, 76–79. https://cgsnet.org/wp-content/uploads/2022/01/ global_perspectives_on_career_outcomes_for_ grad_students_tracking_and_building_pathways​ 2.pdf Society for International Education. (2022). Sister to sister exchange program. https://www.siepk.org/ programs Soler, M. C., Kim, J. H., & Cecil, B. G. (2022). Mapping internationalization on U.S. campuses: 2022 edition. American Council on Education. https://www.acenet.edu/Documents/MappingInternationalization-2022.pdf The International Dysphagia Diet Standardization Initiative (IDDSI). (2019). The International Dysphagia Diet Standardization framework. https:// iddsi.org United Nations Educational, Scientific, and Cultural Organization (UNESCO). (2019, September 3). Progress report on the preparation of the draft global convention on the recognition of qualifications concerning higher education. UNESCO General Conference, 40th Session, Paris, France. https:// unesdoc.unesco.org/ark:/48223/pf0000372125?​ posInSet=2&queryId=N-EXPLORE-5d747aa6f22c-423e-9a19-b83f83c58be1 United States Department of State Bureau of Educational and Cultural Affairs. (2022). The Fulbright program. https://eca.state.gov/fulbright United States Department of State & United States Department of Education. (2021). Joint statement of principles in support of international education: Engaging the world to make the United States stronger at home: A renewed U.S. commitment to international education. https://educationusa.state. gov/sites/default/files/intl_ed_joint_statement .pdf University of the Pacific. (2020). Speech-language pathology student awarded Fulbright scholarship. https://www.pacific.edu/pacific-newsroom/

speech-language-pathology-student-awardedfulbright-scholarship Voniati, L., Kilili-Lesta, M., & Christopoulou, M. (2021). Cyprus speech-language therapy clinical services, student education, and practical training in the time of COVID-19: The rise of telepractice, telesupervision, and distance learning in Cyprus. Perspectives of the ASHA Special Interest Group 17, 6(4), 955–963. https://doi.org/​10.1044/2021_ PERSP-21-00022 Waterson, L., Duttine, A., Roman, T. R., & Caesar, L. (2018). The American Speech-Language-Hearing Association–Pan American Health Organization partnership: Progress, future plans and connecting to World Health Organization Rehabilitation 2030. Perspectives of the ASHA Special Interest Group 17, 3(Part 1), 60–68. https://pubs.asha.org/doi/pdf/​ 10.1044/2018_PERS-SIG17-2018-0000 Watters, C., King, M., Min, K., Chambaz, J., Jablonski, C., & DePauw, K. (2010). National and regional perspectives on graduate international collaborations. Proceedings from the 2009 Strategic Global Summit on Graduate Education: Global Perspectives on Graduate International Collaborations. Council of Graduate Schools. https://cgsnet​ .org/wp-content/uploads/2022/01/global_perspec​ tives_on_graduate_international_collaborations.pdf Western Michigan University. (2019). Cultural connections in Senegal: Outcomes of a study abroad course. https://scholarworks.wmich.edu/cgi/viewcontent​ .cgi?article=1069&context=acad_leadership World Health Organization. (2011). World report on disability. http://www.9789240685215_eng.pdf World Health Organization. (2014). International Classification of Functioning, Disability and Health. www.who.int/classifications/icf/en/ World Health Organization. (2020). Rehabilitation 2030: A call to action [Meeting report]. WHO Headquarters, February 6–7, 2017. https://www​ .who.int/publications/i/item/9789240007208

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Appendix 5–A Definitions of Eight Transferrable Competencies Valued in the Workforce No.

Competencies

Definition

1

Career and self-development

Proactively develop oneself and one’s career through continual personal and professional learning awareness of one’s strengths and weaknesses, navigation of career opportunities, and networking to build relationships within and without one’s organization

2

Communication

Clearly and effectively exchange information, ideas, facts, and perspectives with persons inside and outside of an organization

3

Critical thinking

Identify and respond to needs based upon an understanding of situational context and logical analysis of relevant information

4

Equity and inclusion

Demonstrate the awareness, attitude, knowledge, and skills required to equitably engage and include people from different local global cultures. Engage in antiracism practices that actively challenge the systems, structures, and policies of racism

5

Leadership

Recognize and capitalize on personal and team strengths to achieve organizational goals

6

Professionalism

Knowing work environments differ greatly, understand and demonstrate effective work habits and act in the interest of larger community and workplace

7

Teamwork

Build and maintain collaborative relationships to work effectively toward common goals while appreciating diverse viewpoints and shared responsibilities

8

Technology

Understand and leverage technologies ethically to enhance efficiencies, complete tasks, and accomplish goals

Source:  National Association for Colleges and Employers (NACE). (2022). Development and Validation of the NACE Career Readiness Competencies. http://www.naceweb.org. Reprinted with the permission.



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Appendix 5–B Global Learning Value Rubric Glossary Competency

Definition

Definition of global learning

Global learning is a critical analysis of and an engagement with complex, interdependent global systems and legacies (such as natural, physical, social, cultural, economic, and political) and their implications for people’s lives and the Earth’s sustainability. Through global learning, students should (a) become informed, open-minded, and responsible people who are attentive to diversity across the spectrum of differences, (b) seek to understand how their actions affect both local and global communities, and (c) address the world’s most pressing and enduring issues collaboratively and equitably.

Global self-awareness

In the context of global learning, the continuum through which students develop a mature, integrated identity with a systemic understanding of the interrelationships among the self, local and global communities, and the natural and physical world

Perspective taking

The ability to engage and learn from perspectives and experiences different from one’s own and to understand how one’s place in the world both informs and limits one’s knowledge. The goal is to develop the capacity to understand the interrelationships between multiple perspectives, such as personal, social, cultural, disciplinary, environmental, local, and global.

Cultural diversity

The ability to recognize the origins and influences of one’s own cultural heritage along with its limitations in providing all that one needs to know in the world. This includes the curiosity to learn respectfully about the cultural diversity of other people and on an individual level to traverse cultural boundaries to bridge differences and collaboratively reach common goals. On a systems level, the important skill of comparatively analyzing how cultures can be marked and assigned a place within power structures that determine hierarchies, inequalities, and opportunities and that can vary over time and place. This can include, but is not limited to, understanding race, ethnicity, gender, nationhood, religion, and class.

Personal and social responsibility

The ability to recognize one’s responsibilities to society — locally, nationally, and globally — and to develop a perspective on ethical and power relations both across the globe and within individual societies. This requires developing competence in ethical and moral reasoning and action.

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Competency

Definition

Global systems

The complex and overlapping worldwide systems, including natural systems (those systems associated with the natural world including biological, chemical, and physical sciences) and human systems (those systems developed by humans such as cultural, economic, political, and built), which operate in observable patterns and are often affected by or are the result of human design or disruption. These systems influence how life is lived and what options are open to whom. Students need to understand how these systems (a) are influenced and/or constructed, (b) operate with differential consequences, (c) affect the human and natural world, and (d) can be altered.

Knowledge application

In the context of global learning, the application of an integrated and systemic understanding of the interrelationships between contemporary and past challenges facing cultures, societies, and the natural world (i.e., contexts) on the local and global levels. An ability to apply knowledge and skills gained through higher learning to real-life problem-solving both alone and with others.

Source:  From Association of American Colleges and Universities. (2009). Critical Thinking VALUE Rubric. https://www.aacu.org/initiatives/value. Reprinted with permission. continues



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From “Critical Thinking VALUE Rubric” by the Association of American Colleges and Universities, 2009 (https://www.aacu.org/initiatives/value). Reprinted with permission.

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Appendix 5–C Proposed Competencies for Global Engagement Competencies

Description

Dispositions Humility

Being humble enough to recognize values, beliefs, and worldviews different from one’s own (Hyter, 2014; Ortega & Faller, 2011)

Self-reflectiveness

Having engaged in daily living experiences in cultures different from one’s own (Longview Foundation, 2014)

Empathy

The ability to be aware and sensitive to others’ needs, emotions, or perspectives (Jokinen, 2005)

Inquisitiveness

Curiosity, seeking information beyond what is required, being an active and engaged learner (Ebbeck, 2006; Gupta & Govindarajan, 2002; Jokinen, 2005)

Responsibility to promote equity and social justice

Taking initiative to combat injustices and to improve the lives of others (AACU, 2015)

Knowledge Knowledge of one’s own and others’ culture and worldview

The beliefs, values, and assumptions that determine daily practices (TingToomey & Chung, 2011). Having knowledge of one’s own culture and worldview is an essential first step to moving along the continuum of global responsiveness (Green & Kreuter, 2004; Hyter, 2014; Lynch & Hanson, 2011; National Education Association [NEA], 2010).

Globalization’s consequences around the world

The interconnectedness and interdependence among nation states, frequently resulting in uneven consequences (Green & Mertova, 2009; Hyter, 2014; Jogerst et al., 2015; Steger, 2013; Wilson et al., 2012)

Relations of power between different countries and different groups of people

The “ability to define goals and make decisions in the interests of one’s own group” (Hyter, 2014, p. 114; Kahn & Agnew, 2015; San Jose State University, 2007)

Impact of privilege

Unmerited advantages (McIntosh, 2003)

Differences and similarities in economic, political, cultural, and ecological realities of high-, middle-, and low-resource countries

Economics (access to resources), politics (ability to exercise power), culture, and the ecology are social structures that impact daily life (Green & Whitsed, 2015; Hyter, 2014; Kahn & Agnew, 2015; Lustig & Koester, 2013). The terms high-, middle-, and low-resource refer to the level of material resources available in a country (Murray et al., 2011).

Skills Self-awareness

The ability to know one’s own beliefs, values, and assumptions (Hyter, 2014; Jokinen, 2005; Mansilla & Jackson, 2014; Pillay & Kathard, 2015)

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Competencies

Description

Awareness of others

The ability to know the beliefs, values, and assumptions of others (Mansilla & Jackson, 2014; NEA, 2010)

Experiences with diverse cultures

Having engaged in daily living experiences in cultures different from one’s own (Longview Foundation, 2014)

Ability to communicate in more than one language

Having the capacity to communicate (e.g., speak, read, write) in a language or other languages in addition to one’s first language (Longview Foundation, 2014; NEA, 2010)

Ability to create an environment that is culturally and globally responsive

The ability to create an environment that demonstrates consideration of cultural and global diversity (Longview Foundation, 2014; Wickenden, 2013; Wylie et al., 2013)

Ability to engage in critical and dialectical thinking, and critical dialogue

Critical thinking is the precursor to dialectical thinking. Dialectical thinking and critical dialogue are important for being able to think of possibilities beyond what you believe is reality. These are essential skills for becoming a more culturally and globally competent provider (Bean, 2011; Brookfield, 2012; Freire, 1990; Hyter, 2014; Marchel, 2007; Pillay & Kathard, 2015).

Ability to engage in international conversations

The ability to facilitate and participate in conversation across nations (Longview Foundation, 2014)

Ability to develop international partnerships (communities of practices) and sustainable practices

The ability to facilitate, develop, and maintain partnerships with colleagues around the world in ways that can be sustained by the local populations (Green & Kreuter, 2004; Green & Whitsed, 2015; Longview Foundation, 2014)

Attitudes Willingness to provide services and engage with others from a posture of reciprocity

Kalyanpur and Harry (2012) define reciprocity as a bidirectional exchange of knowledge, values, and perspectives (see also Hyter, 2014; Jogerst et al., 2015; Wilson et al., 2012).

Willingness to promote equity and social justice

The belief that communication is a human right and that all human beings have a right to be treated fairly and equally (Green & Whitsed, 2015; Jogerst et al., 2015)

Willingness to value ethical behavior

The practice of consistently adhering to moral and ethical principles (Green & Whitsed, 2015; Jogerst et al., 2015)

Source:  From Competencies for effective global engagement: A proposal for communication sciences and disorders by Y. Hyter, T. Roman, B. Staley, and B. McPherson, 2017, Perspectives of the ASHA Special Interest Group 17, Vol. 2(Part 1), pp. 13–14. Copyright 2017 by the American Speech-Language-Hearing Association (ASHA). Used with permission.

References Cited in the Table Association of American Colleges and Universities. (2015). Global learning VALUE rubric. Bean, J. C. (2011). Engaging ideas: The professors’ guide to integrating writing, critical thinking, and active learning in the classroom (2nd ed.). John Wiley & Sons.

Ebbeck, M. (2006). The challenges of global citizenship: Some issues for policy and practice in early childhood. Childhood Education, 82(6), 353–357. Freire, P. (1990). Education for critical consciousness. Continuum. Green, L., & Kreuter, M. (2004). Health program planning: An educational and ecological approach. McGraw-Hill.



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Green, W., & Mertova, P. (2009). Internationalization of teaching and learning at the University of Queensland: A report on current perceptions and practices. https://isana.proceedings.com.au/ docs/2010/paper_mertova.pdf Green, W., & Whitsed, C. (2015). Internationalising the curriculum in business: An overview. In W. Green & C. Whitsed (Eds.), Critical perspectives on internationalising the curriculum in disciplines: Reflective narrative accounts from business, education and health (pp. 3–24). Sense Publishers. Gupta, A. K., & Govindarajan, V. (2002). Cultivating global mindset. Academy of Management Executive, 16(1), 116–126. Hyter, Y. D. (2014). A conceptual framework for responsive global engagement in communication sciences and disorders. Topics in Language Disorders, 34, 103–120. Jogerst, K., Callender, B., Adams, V., Evert, J., Fields, E., Hall, T., … Wilson, L. L. (2015). Identifying interprofessional global health competencies for 21st-century health professionals. Annals of Global Health, 81, 239–247. Jokinen, T. (2005). Global leadership competencies: A review and discussion. Journal of European Industrial Training, 29, 199–216. Kahn, H. E., & Agnew, M. (2015). Global learning through difference: Considerations for teaching, learning, and the internalization of higher education. Journal of Studies in International Education, 1–13. Kalyanpur, M., & Harry, B. (2012). Cultural Reciprocity in Special Education: Building Family Professional Relationships, 21(1). Paul H. Brookes. Longview Foundation. (2014). The globally competent teaching continuum. https://longviewfdn.org/ files/4415/4100/9243/Ohio_U_Local_Global_ Guidebook.pdf Lustig, M. Q., & Koester, J. (2013). Intercultural competence: Interpersonal communication across cultures (7th ed.). Pearson. Lynch, E. W., & Hanson, M. J. (2011). Developing cross-cultural competence: A guide for working with children and their families (4th ed.). Paul H. Brookes. Mansilla, V. B., & Jackson, A. (2014). Educating for global competence: Learning redefined for an interconnected world. In H. Jacobs (Ed.), Mastering

global literacy: Contemporary perspectives (pp. 5–29). Solution Tree. Marchel, C. (2007). Learning to talk/talking to learn: Teaching critical dialogue. Teaching Educational Psychology, 2(1), 1–15. McIntosh, P. (2003). White privilege: Unpacking the invisible knapsack. In S. Plous (Ed.), Understanding prejudice and discrimination (pp. 191–196). McGraw-Hill. Murray, J. P., Wenger, A. F. Z., Downes, E. A., & Terrazas, S. B. (2011). Educating health professionals in low-resource countries: A global approach. Springer. National Education Association. (2010). An NEA policy brief. https://www.nea.org/professionalexcellence/professional-learning/resources/ cultural-competence Ortega, R., & Faller, K. (2011). Training child welfare workers from an intersectional cultural humility perspective: A paradigm shift. Child Welfare, 90(5), 27–49. Pillay, M., & Kathard, H. (2015). Decolonizing health professionals’ education: Audiology and speech therapy in South Africa. African Journal of Rhetoric, 7, 196–227. San Jose State University. (2007). School of Social Work transcultural perspective: A working definition. https://sjsu.edu/socialwork/programs/fieldeduca​ tion/transculturalperspective.php Steger, M. (2013). Globalization: A very short introduction. Oxford University Press. Ting-Toomey, S., & Chung, L. C. (2011). Understanding intercultural communication. Oxford University Press. Wickenden, M. (2013). Widening the SLP lens: How can we improve the well-being of people with communication disabilities globally? International Journal of Speech-Language Pathology, 15(1), 14–20. Wilson, L., Harper, D. C., Tami-Maury, I., Zarate, R., Salas, S., Farley, J., . . . Ventura, C. (2012). Global health competencies for nurses in the Americas. Journal of Professional Nursing, 28, 213–222. Wylie, K., McAllister, L., Davidson, B., & Marshall, J. (2013). Changing practice: Implications of the World Report on Disability for responding to communication disability in under-served populations. International Journal of Speech-Language Pathology, 15(1), 1–13.

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Appendix 5–D An MOU Checklist for International Collaborations Memoranda of Understanding (MOUs) and Memoranda of Agreement (MOAs) for international collaborations vary considerably, depending on the scope and objectives of the partnership and the national and institutional contexts of the universities involved. The following checklist addresses general programmatic issues that should be considered when developing an MOU or MOA for a formal international partnership. The guidelines described in this checklist have been culled from sample memoranda and MOU checklists provided to CGS by institutions that participated in the discussions and activities sponsored by the CGS Graduate International Collaborations Project. While this checklist is designed to cover a range of collaborations, components specific to international joint and dual degree programs are signaled with a “J/D” below. In addition to considering the guidelines below, institutions with experience overseeing collaborations recommend providing detailed information to faculty members about the process of submitting an MOU or other agreement for approval. Many institutions elect to include this information in online resources for faculty and/or with planning documents that must precede or accompany the MOU, such as an application to submit with a collaborative exchange proposal. It is recommended that these documents: A. Define the types of possible agreements (MOU, Agreement of Friendship and Cooperation, etc.) and the purpose of each. B. Describe the different types of documents that must be completed and approved. Explain the approvals process for different types of agreements, indicating routing and required signatures. C. Provide an estimated timeline for approval once a proposed MOU and accompanying documentation has been submitted. D. Provide names and contact information for senior administrators and staff members who can offer support and assistance for different types of questions.

VALUE 1. Establish the value of the collaboration to the university and to any other relevant groups of stakeholders. Refer to any documents that demonstrate the commitment of the institution and institutional leadership to internationalization and collaboration (for example, a vision statement or strategic plan). 2. Outline the rationale or objectives motivating the collaboration, outlining benefits to all groups of stakeholders. 3. Describe the potential for development of the collaboration across other departments, programs or schools. 4. Describe the potential of the proposed project to complement existing programs or to enhance areas of priority for the university. PLANNING 5. Articulate concrete outcomes or actions that will result from the collaboration. 6. Summarize planning and communication activities that have already taken place between partners. 7. Define the program structure, including: a. The title of the program and the title of any degree(s) and certification(s) that will result (J/D) b. The duration of the program (with start date and end date, as applicable) and duration of the MOU, including provisions for early termination by mutual or single agreement (e.g., What happens to students who are already in progress at the time of termination?) c. The accreditation status of the partner institutions and programs, if appropriate (J/D) d. If applicable, the process of adding participating institutions



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8. Define terms that may be interpreted differently between various academic contexts (“academic year,” “full-time enrollment,” etc.). (J/D) LEGAL ISSUES 9. Describe basic legal requirements for student mobility between the countries where partner institutions are located. 10. Define legal rights and liabilities of universities in relation to the program and its intellectual and material outcomes. (Issues to be considered would include, but would not be limited to, intellectual property, equal opportunity law, and monetary exchanges or reimbursements between universities as the result of profits generated or expenses incurred.) 11. Establish which institutional rules and policies apply to students studying at the host institution, and terms of disciplinary action. (J/D) ADMISSIONS (J/D) 12. Establish equivalencies for units of credit awarded by partner institutions. 13. Establish academic criteria for student participation in the program and mechanisms by which eligibility and admission to the program will be determined.

15. Describe graduation requirements and mechanisms for awarding credit and certifying student work; i.e., transfer credit policy (including the number of credits, if any, that can be double counted at each institution), extenuating circumstances, and transcript release. RESOURCES AND FINANCING 16. Outline the funding structure for the collab­ oration. Basic categories for funding sources may include internal university budget, U.S. federal or state funding sources, private U.S. funders, and international sources (including the partner institution or self-supporting students). Basic categories of expenditures may include research expenses, facilities for faculty and administrative support staff, tuition/fees, housing, and travel. 17. Establish terms and resources for student advising and support (i.e., visa support services, academic advising, terms of student access to academic, social, and health facilities). (J/D) 18. Establish student responsibilities and expenses, (i.e., registration, payment of tuition and living expenses, housing, immigration compliance, health insurance and medical expenses). (J/D)

CURRICULUM (J/D)

ASSESSMENT AND REVIEW

14. Describe modes and mechanisms of delivering program content, including, as appropriate:

19. Establish benchmarks for program success. (J/D)

a. The language(s) of instruction b. The curriculum, including courses and/ or instruction that will be provided by each institution c. Requirements for the thesis, dissertation, or capstone project, and mechanisms of supervision and defense of the project

20. Describe mechanisms and timeline for program evaluation and, if applicable, assessment of learning outcomes. (J/D) 21. Define the period within which the MOU may be renewed or terminated with mutual consent of institutions. For agreements of indefinite length, describe university policy on inactive agreements.

Source:  Denecke, D., & Kent, J. (2010). Joint degrees, dual degrees, and international research collaborations (pp. 80–83). Council of Graduate Schools. Reprinted with permission.

6 Applying Evidence to Clinical Practice Lizbeth H. Finestack and Stacy K. Betz

Introduction This chapter focuses on the use of evidence in clinical practice. Although the American SpeechLanguage-Hearing Association (ASHA) emphasizes research methodology and evidence-based practice (EBP) across multiple accreditation standards for both speech-language pathology and audiology (Council on Academic Accreditation in Audiology and Speech-Language Pathology of the American Speech-Language-Hearing Association, 2023), you might still be wondering why this topic is included in a book about professional issues when the evidence for assessment and treatment methods is repeatedly emphasized in each clinical-focused course you have taken. The reason is simple. A client will come to you, the speech-language pathologist (SLP) or audiologist, because you are the professional. A client will seek out your services because you have the knowledge and expertise to provide effective services. In today’s world, anyone can search the internet for the signs and symptoms they are experiencing, make a self-diagnosis, and even determine what treatment they think they need. For example, a parent might decide their nonverbal 2-year-old doesn’t need to see an SLP after reading a blog about another family whose child didn’t start speaking until they were 3 years old and is now graduating valedictorian of their high school class. Someone else might decide the solution to their hearing difficulty is to purchase a hearing aid online without a professional evaluation or fitting. In each of these examples, neither individual can determine the quality of evidence they found online and whether that evidence validly applies to their communication needs. As a professional you will be expected to use evidence as the foundation of your clinical decisions. In this chapter we frame the application of evidence to clinical practice around the three-pronged view of clinical evidence: external scientific evidence, clinical expertise, and client perspectives (Guyatt et al., 2000). After providing an overview of this evidence-based approach to clinical practice, the chapter primarily focuses on how you, as a professional, can incorporate research evidence into your practice. We first discuss how research informs clinical assessment, particularly the need for evaluation methods to be both reliable and valid. We then summarize types of treatment evidence, how to evaluate the quality of treatment evidence, and how to incorporate this evidence when planning services for a client. The ways in which research evidence interact with clinician expertise and client values will 101



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also be discussed. As you read through the chapter, consider that your goal as a clinical professional is for the use of evidence to become second nature in all your clinical decisions. Think not only about how you will apply evidence to making decisions for an individual client, but also how you will become an evidence-based professional.

Evidence-Based Practice Evidence-based medicine is traditionally defined as “the integration of best research evidence with clinical expertise and patient values” (Sackett et al., 2000, p. 1). ASHA further defines the goal of EBP as the integration of: “(a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve” (Robey et al., 2004, p. 1). Figure 6–1 displays the integration of these three key elements. EBP applies to clinical decisions regarding both the assessment and intervention of individuals with communication disorders. Below we define each of the three key components of EBP. Clinical expertise refers to the clinician’s experience and comfort level with a particular assessment or intervention. It includes the outcomes the clinician has previously experienced with the assessment or intervention. Clinical expertise allows the clinician to clearly understand the client’s history and needs. Based on those needs, clinicians can use their clinical expertise

Figure 6–1. Key components of evidencebased practice.

to identify possible diagnostic and intervention options and then seek out external scientific evidence for those clinical procedures. Clinical expertise also allows clinicians to judge the generalizability of external evidence to their particular client. It is important to note that along with clinical expertise and knowledge, for EBP to be successful, the clinician must display compassion, sensitive listening skills, and deep respect for their clients’ culture and values (Guyatt et al., 2000). Client perspectives comprise the experience, personalities, values, and culture of the client. The client perspective also includes the knowledge the client brings to the treatment, their financial resources, and social supports. Often, depending on cultural values, the client perspective also includes these same features of family members who play key roles in the assessment and intervention of the client. When conducting evidence-based treatment, the clinician will help educate the client and family on possible benefits, risks, and inconveniences associated with each treatment option. Ultimately, the client makes treatment decisions and must decide if a particular assessment or intervention is a good fit; however, clinicians embracing EBP should gain a good understanding of their client’s perspective so they can effectively advocate for their client (Guyatt et al., 2000). External scientific evidence refers to research that relates to the specific assessment or intervention method the clinician is considering. Typically, this scientific evidence is patient centered and clinically oriented, as opposed to basic research. Clinicians must carefully evaluate the quality of external evidence to determine how much weight each piece of evidence should have in their clinical decision-making process. Locating and evaluating external scientific evidence is the main focus of the current chapter, although we will also discuss how the internal evidence (i.e., clinician expertise and client perspectives) should be integrated and used to conduct EBP. Table 6–1 presents one possible process for systematically engaging in EBP. These steps have been adapted from the strategies suggested by other researchers (e.g., Gillam & Gillam, 2006; Porzsolt et al., 2003). Step 1 involves formulating a clinical question based on a specific clinical case. Traditionally this is in the form of a PICO (patient, intervention/index measure, comparison, and outcome) question. A PICO question defines the clinical question, which then helps focus the search for external scientific evidence. Example PICO questions include: 1. For a 5-year-old child with autism who verbally produces fewer than 25 words, does a parent-implemented or clinician-implemented intervention lead to greater requests and



CHAPTER 6   Applying Evidence to Clinical Practice

Table 6–1.  Process to Guide Evidence-Based Practice 1.  Transform the clinical problem into a clinical question (PICO). 2.  Evaluate the internal evidence based on clinical expertise. 3. Evaluate the internal evidence based on client and familial perspectives. 4.  Find external evidence that addresses the question. 5.  Evaluate the quality of the external evidence. 6.  Evaluate the level of the external evidence. 7.  Integrate the internal and external evidence to guide a decision. 8.  Evaluate the outcomes of your decision.

comments using augmentative and alternative communication (AAC)? 2. For a 75-year-old man with moderate bilateral hearing loss, does hearing aid use improve word recognition compared with no hearing aid use? Patient refers to your client or the population to whom you will be delivering your services. In the above examples, the patients are a 5-year-old child with autism with few spoken words and a 75-year-old man with moderate bilateral hearing loss. Intervention/index refers to the main intervention or assessment of interest. Often, this is a new or alternative assessment or intervention approach you are considering using. When developing a PICO question, it is necessary to identify a specific intervention or assessment method to investigate. Questions such as “What treatment should I use to improve the expressive language skills of a 5-year-old autistic child?” and “How should I improve the auditory skills of a 75-year-old man with moderate hearing loss?” are too broad in scope. Instead, the intervention needs to be specified. The interventions in the above examples are parent-implemented interventions and use of hearing aids. Comparison refers to the treatment to which the main intervention is being compared or an alternative means for assessment. The comparison might be another specific approach, a traditional or “business as usual” approach, or even no treatment. In the first example, the comparison treatment is a traditional, clinicianimplemented intervention; in the second example, the comparison treatment is no treatment. Outcome is the primary behavior or measure of interest or the expected result. The outcome could be narrow, such as performance on a specific probe or test, or broad and more generalized, such as overall improvement in

quality of life. In the first example, the identified outcome is requesting and commenting using AAC; in the second example, the outcome is more broadly specified as improved word-recognition abilities. Steps 2 and 3 of the EBP process involve gathering internal evidence. This includes both the clinician and client perspectives described above. Considering the internal evidence prior to gathering external evidence can help guide the search to focus on viable and feasible approaches. Client perspectives should be gathered through conversations, interviews on history and background, and potentially surveys regarding the client’s beliefs and treatment goals. Step 4 involves gathering external evidence. Clinicians should use their PICO question to guide the search for external evidence. Broad searches can be completed using databases such as ASHA Wire, Google Scholar, PubMed, and Ovid. Key words from the PICO question can be searched to identify primary research that addresses relevant topics. Such searches may prove to be onerous for full-time clinicians, however. Other databases enable clinicians to more specifically search for research reviews that support EBP, such as ASHA’s Evidence Maps (https://apps.asha.org/EvidenceMaps/), which includes relevant research sorted by topic (e.g., dementia, speech sound disorders, tinnitus). Under each topic, clinicians can view the research by study type, including external scientific evidence, clinical expertise, and client perspectives. Other databases are available that contain systematic reviews, such as the Cochrane Library (https://www.cochranelibrary.com/ cdsr/reviews). The Cochrane Library comprises more than 8,000 reviews that can be searched using key words. The Institute of Education Science’s What Works Clearinghouse (https://ies.ed.gov/ncee/wwc/) also offers systematic reviews specifically focused on topics related to school-based clinical practice. Other collections are

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available from Campbell Collaboration (https://www​ .campbellcollaboration.org/better-evidence) and the Agency for Healthcare Research and Quality (https:// www.ahrq.gov/research/findings). If one or more recent reviews address the clinician’s PICO question, this may be all the external evidence needed. However, if a review does not exist or if the review is out of date, it may be necessary for the clinician to identify several relevant research studies to review and evaluate. Some published research is openly accessible and available to the public. Alternatively, the clinician may access original studies through their libraries; check the authors’ websites for access; or email authors directly to request a copy. Steps 5 and 6 pertain to the evaluation of external evidence. To complete these steps, clinicians need to consider the level and quality of the evidence obtained in Step 4. In the following sections, we provide more guidance on how to evaluate external evidence for both assessment and intervention clinical questions. Step 7 is the integration of the internal and external evidence to make a clinical decision. Not all evidence should be weighted equally. Each EBP prong, including clinician expertise, client perspective, and external scientific evidence, must be carefully considered and integrated as a whole. For example, if the external evidence focused on parent-implemented AAC interventions did not suggest strong outcomes, but the family was incredibly motivated to play an active role in therapy and the clinician had limited availability for individual therapy, the integration of these pieces of evidence would warrant a parent-implemented intervention. As another example, if a client is unwilling to wear a particular type of hearing aid because of feeling physically or socially uncomfortable despite strong external evidence and clinician expertise, the hearing aid intervention would not be an EBP approach. Step 8, the final step of the evidence-based process, is evaluation of outcomes. Outcomes should be evaluated based on performance on the outcome measures defined in the PICO question as well as the client’s individual goals. Additionally, when conducting treatment, the clinician’s compliance in implementation and the client’s adherence to the intervention and their satisfaction with the approach should be considered. EBP requires the clinician to carefully consider each of the three evidence components. In the following sections, we describe all three aspects of evidence for both assessment and intervention clinical decisions; however, the greatest emphasis is on evaluating the scientific evidence (Steps 5 and 6). Each section includes descriptions of methods to evaluate external evidence as well as examples demonstrating how all three types of evidence can be integrated to conduct EBP for individuals with communication support needs.

Evaluating Assessment Evidence Purposes of Assessment Before evaluating the quality of assessment evidence or determining the intended outcome when developing a PICO question, you must identify your purpose for assessing a client. When we think of assessment, the first thing that typically comes to mind is diagnosing a client. Making a diagnosis consists of two primary clinical decisions: first, whether the client has a disorder and if so, which disorder. Determining an initial diagnosis for a client is certainly one of the primary purposes of assessment, but not the only one. Another purpose is to conduct a formal reevaluation for a client. This includes cases where a client has been receiving intervention services but also cases where a client was previously assessed and determined not to need services and now needs a reevaluation because concerns about their communication have not resolved. Intertwined with the purpose of determining a diagnosis is the use of assessment information to determine eligibility for services or reimbursement. Screening is another purpose of assessment in which the aim is not to diagnose, but to evaluate whether the client should receive a more comprehensive evaluation to determine whether a disorder is present. Assessment can also have more qualitative purposes such as identifying the primary strengths and weaknesses of someone’s communication abilities. Finally, assessment is used continually during the treatment process to develop treatment goals and document treatment progress. In many cases, one assessment method might be used for multiple purposes. For example, an SLP might administer a formal aphasia test primarily to determine an individual’s relative performance in each language domain and modality (i.e., identifying communication strengths and weaknesses) and subsequently use those results to determine the type of aphasia the client has (i.e., determining a diagnosis). Because the purposes of assessment are interrelated, using the same assessment method for multiple purposes is often beneficial; however, to evaluate the evidence for a particular assessment method you must know your purpose because one assessment method might be considered high quality for one purpose but not for another. For example, an SLP might use a portable audiometer in a nonsoundproof room to assess hearing. This procedure might be an evidence-based way to screen hearing, but not to diagnose a hearing loss.

External Evidence:  Reliability The external, scientific evidence for assessment methods typically addresses two essential factors: reliability



and validity. In colloquial language, the terms reliability and validity are often used interchangeably, with both intended to refer to the general quality of an assessment; however, within a professional context, these two terms should be used more precisely because the distinction between the two helps to systematically evaluate the clinical evidence for a particular assessment method. By formal definition, reliability reflects the consistency of results obtained from an assessment, whereas validity reflects the accuracy with which an assessment measures what it claims to measure. An evidence-based assessment method will have both high reliability and validity for the purpose for which you are using it. From a clinical perspective, the evidence regarding an assessment method’s validity is ultimately the most important to evaluate. However, because an assessment method cannot be valid if it is not reliable, external evidence for reliability is often evaluated first. Multiple types of evidence can document an assessment method’s reliability. One important clinical consideration is whether the method yields similar results regardless of when the assessment is administered or who administers it. The consistency with which clinicians can administer the assessment is measured in two ways: intrajudge and interjudge reliability. Intrajudge reliability measures how consistent the same clinician is in using the assessment measure (i.e., in both administering and scoring/interpreting the results). Interjudge reliability measures the extent to which different clinicians score an assessment measure in the same way. Low intrajudge and/or interjudge reliability can indicate that the procedures for administering and scoring the assessment are not clear enough to consistently obtain the same assessment result for a client. For example, a standardized assessment of child language might include questions rated on a 1 to 3 scale for accuracy without clear guidelines on what types of responses should receive each rating. This can lead to the same clinician scoring the child’s response differently on different days (i.e., low intrajudge reliability). It can also lead to two clinicians scoring the same child’s response differently (i.e., low interjudge reliability). The more an assessment involves subjective interpretation of client responses and the more complicated the administration procedures are, the more important it is for you to evaluate the intrajudge and interjudge reliability of the assessment. On the other hand, if an assessment method has extremely straightforward and objective scoring and administration procedures, it might not be essential for this information to be documented. For example, one common method for assessing receptive vocabulary is for the clinician to say a word; show the client a few pictures, one of which depicts the meaning of the word said; and then ask the client to select the picture that best matches the meaning

CHAPTER 6   Applying Evidence to Clinical Practice

of the word. In this case, the administration and scoring are straightforward with little chance that intrajudge and interjudge reliability would be low. Therefore, when evaluating the quality of reliability evidence, it is always important to ask how likely it is for intrajudge and interjudge reliability to be low. If the potential is low, the lack of documentation of this type of consistency should not be a primary concern, assuming other types of reliability document the consistency of the evaluation method. A second type of reliability, item reliability, relates to the consistency of the items within the same assessment method. For example, a formal measure of receptive vocabulary typically includes numerous test items that are all intended to assess vocabulary. If those items do in fact all measure vocabulary, there should be consistency in how a client responds to each item. If there is not high consistency among items, the test might assess multiple and/or different skills rather than primarily vocabulary. Reliability of the test items can be documented through measures of internal consistency. Cronbach’s alpha measures the consistency of all items in a test. Split-half reliability divides the test into two halves and then compares the scores of the two halves to determine their similarity. If the creator of the assessment measure has developed two different versions of the same test, alternate form’s reliability can be computed by administering both versions of the test to the same group of people and comparing performance on each version. A third type of reliability that can be documented is test-retest reliability. When computing test-retest reliability, the creators of the assessment will administer the same assessment to a group of individuals on two different occasions within a time period when spontaneous change in performance would not be expected. The scores from each day of testing (i.e., the test and retest) are compared to determine consistency. Test-retest reliability is usually interpreted as measuring how consistent the test is in assessing the client’s performance. Assuming the underlying communication deficit is stable, you would expect a test to give the same results for the same client across multiple different test administrations. If it does not, the results of the test might lead you to diagnose a disorder after one of the test administrations, but not the other! Most measures of reliability are calculated as statistical correlations ranging from 0 to 1.0. A correlation of 1.0 indicates perfect consistency, whereas a value of 0 indicates a complete lack of consistency. Therefore, the closer the correlation is to 1.0, the more reliable the assessment method. A benchmark for acceptable levels of reliability used within the field of special education is requiring correlations higher than .90 if the assessment is to be used for a high-stakes decision, such as diagnosing a disorder. Other values may be slightly lower, with

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values down to .80 being acceptable for other types of evaluation, such as screening (Salvia et al., 2013). Establishing the acceptable reliability of an evaluation method is essential because a measure must be reliable to be valid.

External Evidence:  Validity Once an assessment is determined to be reliable, its validity can be evaluated. Because validity refers to whether the assessment truly measures what it claims to measure, you cannot evaluate validity without first clearly identifying your purpose for using the assessment method. The most important aspects of validity are evaluated subjectively using your clinical expertise. After reviewing the procedures of the assessment, use your knowledge of typical communication and communication disorders to determine whether the procedures used are appropriate for the intended purpose. The review of the procedures should include analyzing each test item individually as well as determining how the entire set of test items functions together. For example, if an assessment claims to assess receptive vocabulary, a valid measure would require the client’s response to be nonverbal and include a wide range of test items representing different parts of speech, levels of concreteness, and so on. This type of validity has traditionally been referred to as construct and content validity. If an assessment method includes the use of a procedure that is new to you, another source of external evidence is to search the literature for research studies documenting that the procedure is a valid measure for the disorder being evaluated. Validity can also be evaluated statistically using criterion-related validity. For this type of reliability, a second criterion measure is selected. Both the criterion measure and the measure being evaluated are administered to a group of people. If a criterion measure whose purpose is similar to the assessment method being evaluated is used, the statistical comparison is considered convergent criterion-related validity, and you would expect people to perform similarly on both measures. For example, one could compare a traditional standardized test of receptive language to a newly developed test of receptive language. In contrast, if a criterion measure with a purpose that is different from that of the assessment method being evaluated is used, the measure is divergent criterion-related validity. For example, comparing a measure of receptive vocabulary and a measure of expressive morphology would assess divergent criterion validity. In this case, the expectation is that the two assessments will not be highly related to each other. Unlike the interpretation of reliability correlations, there is no specific benchmark for indicating high or low criterion-related validity. As with reliability correlations, values closer to 1.0 indicate a high similarity between the

two measures. Thus, you would expect convergent validity measures to be closer to 1.0 than divergent measures. The exact interpretation will require clinical expertise to determine how similar (or different) the intended purpose of the assessment is to the criterion measure. For example, the authors of a single-word receptive vocabulary measure might demonstrate convergent-related validity by comparing their assessment to an existing standardized receptive language measure with the result being a correlation of .87. They might also demonstrate divergent criterion-related validity by comparing their assessment to a measure of expressive morphology and finding a correlation of only .51. Because criterionrelated validity is assessed using a number, it can be easy to want to rely on this value as the main indicator of validity; however, criterion-related validity is not as important as construct and content validity. When evaluating evidence of validity, do not let statistical values be your guide; you must use clinical expertise to determine whether the assessment is an accurate method to meet your evaluation purpose. The methods of measuring reliability and validity described above are based on the classical test theory approach. Item response theory is another method for designing and evaluating the quality of an assessment; however, it is beyond the scope of this chapter to describe the theoretical rationale for which approach is most appropriate for each assessment. The primary focus here is to stress that, to adequately evaluate the quality of external evidence for an assessment measure, you must determine whether the assessment is reliable and valid.

External Evidence:  Diagnostic Accuracy If your assessment purpose is to determine the presence of a disorder, it will be essential to evaluate how accurate an assessment measure is in identifying that disorder. Evaluating this type of external evidence can be done statistically using a variety of mathematical measures of diagnostic accuracy. All these statistics approach the concept of diagnostic accuracy from the perspective of the clinician’s need to accurately diagnose both individuals with and without a disorder. To understand how to evaluate diagnostic accuracy, imagine you are considering a new assessment method, which will be referred to as the “New Assessment.” Also assume the currently available best method for diagnosing the disorder is the “Best Method.” The evaluation of diagnostic accuracy is considered part of the external scientific evidence component of the EBP model (see Figure 6–1); however, you would not determine these calculations as a clinician. They are a type of evidence that would be provided by the developer of the assessment or by other researchers conducting an independent analysis of the accuracy of



CHAPTER 6   Applying Evidence to Clinical Practice

the measure. To do this, the developers or the external researchers administer both the New Assessment and the Best Method to a large group of people. This group of people will include people who have the disorder that the New Assessment is intended to diagnose as well as people who do not have the disorder. To compute measures of diagnostic accuracy, a few quantitative values are needed: the number of people determined to have the disorder based on the Best Method and, of these, the number who have or do not have the disorder based on the New Assessment; the number of people determined not to have the disorder based on the Best Method and, of these, the number who have or do not have the disorder based on the New Assessment. In this example, pretend the developers of the New Assessment included 1,000 people in their sample to determine the accuracy of the New Assessment in diagnosing Disorder X. Each of the 1,000 people completed the Best Method with the results showing that 155 have Disorder X and 845 people do not. All 1,000 people also completed the New Assessment. According to the New Assessment, 150 people have Disorder X. Of those 150

people, 140 also were determined by the Best Method to have Disorder X. Of the 850 people that the New Assessment found did not have a disorder, 835 of them also were determined by the New Assessment to not have Disorder X. These numbers can then be organized in a table to easily compare each person’s results on the Best Method and the New Assessment (Table 6–2). Table 6–3 uses more technical terminology to pre­sent a general format for how to organize the information about diagnostic accuracy. The term “Index Measure” is used in the same way the term “Index” is used when developing a PICO question for diagnostic purposes: it is the measure you are considering using (i.e., New Assessment in Table 6–2). The term “Reference Measure” refers to the existing way to diagnose the disorder (i.e., Best Method in Table 6–2). The terms “positive” and “negative” refer to an individual’s assessment result. A positive result means the assessment method indicates the person is positive for the disorder (i.e., the person has the disorder according to that assessment). A negative result means the person is negative for the disorder (i.e., the person does not have the disorder). Because each

Table 6–2.  Example of Diagnostic Accuracy Best Method

New Assessment

Based on the results from Best Method: Has disorder X

Based on the results from Best Method: Does not have disorder X

Based on the results from New Assessment: Has disorder X

140

10

Based on the results from New Assessment: Does not have disorder X

15

835

Total:

155

845

Table 6–3. Terminology for Calculating Diagnostic Accuracy Reference Measure Result

Index Measure Result

+

−

+

True Positives

False Positives

−

False Negatives

True Negatives

Total 150

850

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person was administered both the index measure and the reference measure, they will have two results: whether they were positive or negative for the disorder based on the index measure and whether they were positive or negative for the disorder based on the reference measure. The terms “true positive,” “true negative,” “false positive,” and “false negative” refer to how an individual’s result on the index measure compares to their result on the reference measure. A true result means those results are the same, which then implies that the result from the index test is accurate. A false result means the results of the index and reference measure are different. Because the reference measure is considered the best way to diagnose the disorder, when the results of the index and reference measure differ, the reference measure is considered the accurate diagnosis. Two measures of diagnostic accuracy that evaluate the overall quality of the assessment method are sensitivity and specificity. The formulas for each are given in Table 6–4. Sensitivity can be interpreted as how accurate the index measure is in diagnosing the presence of a disorder. Mathematically, it can be analyzed as a proportion

(i.e., a decimal value of 1.0 or below) or that proportion can be multiplied by 100 and evaluated as a percentage. In the example in Table 6–2, the sensitivity is .903 or 90.3%, indicating that 90.3% of people with Disorder X (as determined by the reference measure) were correctly diagnosed by the index measure. Specificity refers to how accurate an assessment is in classifying individuals who do not have the disorder being evaluated. Specificity for the example in Table 6-2 is .988 or 98.8%, indicating that 98.8% of people without Disorder X were correctly identified as not having a communication impairment based on the results of the New Assessment. Clinical expertise is needed to determine how high sensitivity and specificity should be to consider an assessment accurate. One recommendation in the field is that values over .90 are preferred, with values as low as .80 being acceptable (Plante & Vance, 1994). Another set of measures to assess diagnostic accuracy are positive predictive power and negative predictive power. Table 6–5 includes the formulas for these measures. Positive predictive power is interpreted as the percentage of people who are determined by the index mea-

Table 6–4.  Sensitivity and Specificity Formulas and Examples General Formula (From Table 6–3)

Specific Example (From Table 6–2)

Sensitivity

True Positives / (True Positives + False Negatives)

= 140/140 + 15 = 140/155 = .903 or 90.3%

Specificity

True Negatives / (False Positives + True Negatives)

= 835/10 + 835 = 835/845 = .988 or 98.8%

Table 6–5.  Positive Predictive Power and Negative Predictive Power Formulas and Examples

Positive Predictive Power

Negative Predictive Power

General Formula (from Table 6–3)

Specific Example (from Table 6–2)

True Positives / (True Positives + False Positives)

= 140/140 + 10 = 140/150 = .933 or 93.3%

True Negatives / (False Negatives + True Negatives)

= 835/15 + 835 = 835/850 = .982 or 98.2%



CHAPTER 6   Applying Evidence to Clinical Practice

sure to have a disorder who do have a disorder according to the reference measure. Vice versa, negative predictive power identifies the percentage of people who the index measure identifies as not having a disorder who also do not have a disorder according to the reference measure. Sensitivity, specificity, positive predictive power, and negative predictive power all quantify the diagnostic accuracy of the index measure; however, none of these measures considers the accuracy in diagnosing all four cells in Table 6–3 simultaneously (i.e., true positives, true negatives, false positives, and false negatives). To do that, positive and negative likelihood ratios are used. Table 6–6 includes the formulas for these measures. A positive likelihood ratio can be broadly interpreted as indicating how much the likelihood a person has the disorder is increased if they get a positive result on the index measure, whereas a negative likelihood ratio indicates how likely a negative result on the index test is. When using likelihood ratios to evaluate the quality of an assessment, the higher the positive likelihood ratio, the better, and the closer to 0 the negative likelihood ratio is, the better. Current benchmarks to identify a high-quality test suggest values near 1 are uninformative, positive likelihood ratios greater than 10 are informative, and negative likelihood ratios below .1 are informative (Guyatt, Rennie, et al., 2008; Haynes et al., 2006). Using the example from Table 6–2, a positive result on the New Assessment is 75.25% more likely to be the result of someone who has Disorder X compared with someone who does not have Disorder X. Similarly, a negative result on the New Assessment is only .098% more likely to be from someone who has the disorder. Likelihood ratios have a statistical advantage because they combine sensitivity and specificity into a single measure. When using any of these methods of diagnostic accuracy, it is important to keep two points in mind. First, the meaningfulness of any of these statistics is only

as useful as the quality of the reference measure. For all diagnostic accuracy measures, the index measure is compared with a reference measure. The intent is for the reference measure to reflect the best possible means to diagnose the disorder. However, if the reference measure has significant flaws, any measure of diagnostic accuracy will not truly provide information about the accuracy of the index measure because the reference measure does not accurately diagnose people. You must use your clinical expertise to evaluate the quality of the reference measure. Second, it is important to remember that diagnostic accuracy provides information about the validity of an assessment in its truthfulness in diagnosing a disorder. Therefore, if an assessment measure does not claim to diagnose a disorder and you do not intend to use the assessment for that purpose, measures of diagnostic accuracy are not relevant. For example, if you collect a communication sample to document communication deficits in naturalistic situations but do not use your observations to diagnose a disorder, there is no need to worry about the diagnostic accuracy of your observations because you are using the observations to characterize communication strengths and weaknesses, not diagnose a disorder. It is still important to document the validity of a communication sample for this purpose, but diagnostic accuracy measures are not needed.

Using Assessment Evidence This section presents two hypothetical examples to demonstrate how to apply evidence to clinical practice when determining whether to use a specific assessment procedure. The combination of examples aims to highlight that, based on the situation, the scientific evidence, clinician expertise, and client perspectives each play a relatively different role in creating a PICO question and in the overall evaluation of the assessment.

Table 6–6.  Likelihood Ratio Formulas and Examples

Positive Likelihood Ratio

Negative Likelihood Ratio

General Formula (From Table 6–3)

Specific Example (From Table 6–2)

Sensitivity / (1 − Specificity)

= .903/(1 − .988) = .903/.012 = 75.25

(1 − Sensitivity) / Specificity

= (1 − .903)/.988 = .097/.988 = .098

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Assessment Example 1:  Evaluating a New Standardized Test Imagine you are an SLP who needs to assess a child’s single-word expressive vocabulary. You know a new standardized test is available that claims it can be used to assess expressive vocabulary. The test involves showing the child a picture and asking the child to either name the picture or describe what a person in the picture is doing. The first step in systematically evaluating assessment evidence is to create a PICO question that aligns with your clinical purpose. In this scenario, you do not have a standardized expressive vocabulary test but you know that having one could improve your ability to diagnose language disorders in children. Based on the children on your caseload, the “P” in your PICO question could be phrased for a specific population such as children with a developmental language disorder. Because you are considering using the new standardized test, it is the “I.” The “C” in the PICO question is a comparison evaluation you believe is high quality. You can use your own clinical expertise to identify what an ideal comparison measure would be. For example, this might be an existing standardized expressive vocabulary test that you have experience with and know is valid. The “O” could also vary depending on your purpose, which could be to identify word-finding problems. Combined, your question becomes: When evaluating children with developmental language disorder (P), is the new standardized test (I) more accurate than the existing standardized test (C) in identifying word-finding problems (O)? Because this is a commercially available standardized test, it is likely you will start your evaluation of the evidence by reading the test manual as a source of external evidence. When reading the manual, you should evaluate both the reliability and validity of the test. For reliability, you should investigate the reliability of raters. Because each test item requires the child to name a word, the test manual will likely include many of the most common responses that should be scored as correct as well as examples of incorrect responses; however, children will give other responses that are not listed. Therefore, it is important to know if there is consistency in how those other responses are scored in terms of both interjudge and intrajudge reliability. However, if the test directions state that only responses listed on the score form as possible correct answers should be awarded credit, even if the child’s response indicates some knowledge of the word, the scoring is very straightforward and interjudge and intrajudge reliability likely can be assumed to be high, even if the author of the test did not document this type of reliability. Test-retest reliability is important to evaluate because you need to ensure the child’s abilities can be consistently measured using this new test.

After confirming the test has adequate reliability, you can proceed to evaluating its validity. The test manual will likely provide a qualitative description of why the authors of the test believe the individual items and the overall design of the test assess expressive vocabulary. This description is similar to an expert opinion level of evidence. You should also make your own determination of the validity of the test design based on your clinical experience. For example, as an expressive measure, ensure the child is required to respond verbally (e.g., not pointing or acting out the word). Because this test requires the child to name the picture associated with each test item, it uses a valid method for assessing expressive vocabulary. The test manual might also include information on why the authors believe the individual vocabulary items selected are valid to use for assessing vocabulary. Again, evaluate this type of validity using your own clinical experience and your specific needs for using this test. To start, review the test items for each age. Based on your own clinical experience, determine whether those test items are appropriate for your community. For example, if a test item for young children was the word “soda” but in your region the word “pop” is used and “pop” is not considered a correct answer, it might be invalid for that item to be used to assess vocabulary in your community. Likewise, if one of the pictures to name was a baler, children from urban areas might call it a tractor, but children from farming communities might be more likely to name it more precisely. A standardized test that is created to be used (and purchased) by SLPs throughout the country has likely taken these regional vocabulary differences into account; however, you should not assume this. You need to use your clinical experience to verify this. If there are multiple test items that you think would bias the test for children in your community (including providing invalidly high or low scores), you should consider the test invalid for your needs. The PICO question for this scenario is to identify semantic weaknesses. In this case, your outcome is not to diagnose a disorder; therefore, diagnostic accuracy is not a relevant validity measure. However, you are interested in characterizing whether a child has semantic deficits. One source of evidence for this outcome can be criterion-related validity. Read the test manual to determine whether convergent criterion-related validity data is provided, comparing this new standardized test to an existing expressive vocabulary measure. In addition, your subjective evaluation of the content and construct validity of the test will determine whether you believe the task provides useful information about children’s word-finding skills. After evaluating the external evidence provided by the test manual, integrate this evidence with your clinical expertise and the perspectives of the children you



typically assess. For example, if the test is so expensive that your budget does not allow you to purchase it, then it does not matter how reliable and valid the measure is; you will not be able to obtain it. You should also use your clinical experience to determine whether the children you assess are likely to engage in a task that requires them to look at books and name pictures.

Assessment Example 2:  Evaluating New Technology to Supplement Existing Equipment Imagine you are an audiologist who frequently assesses the hearing of children who will not wear headphones or enter a sound booth for hearing testing. You consider purchasing a new device that claims to assess hearing thresholds using procedures that only require insert earphones to be placed in a child’s ear for 2 seconds and the testing can be conducted in any room. One PICO question you could ask is: For children who will not wear headphones or sit in a sound booth (P), can the new technology (I) compared with pure-tone threshold testing in a sound booth (C) be used to accurately diagnose a hearing loss (O)? The need for this PICO question largely centers on the need for accurate testing for a difficult-to-test population of children whose hearing cannot be assessed using traditional methods. Therefore, the client perspective component of EBP is extremely important. Pure-tone audiometry is an accurate method to assess hearing; however, you cannot use it with this population. Therefore, regardless of the external evidence supporting the traditional method, it is not useful in this scenario. External evidence for the reliability and validity of this new technology can be obtained from the equipment manufacturer and possibly also from research studies conducted prior to this technology being commercially developed. Because the “O” in this question focuses on accuracy in diagnosing hearing loss, you should find and use diagnostic accuracy results to evaluate the quality of this new technology. Assume for this example that there is substantial high-quality external evidence documenting the reliability and validity of this new technology, including reliability correlations greater than .90 and high diagnostic accuracy values such as sensitivity and specificity close to 1.0 using a reference measure you believe to be valid. The next step is to evaluate the internal evidence related to your clinical experience. When considering new technology for assessment, part of the clinical evidence will be your own expertise using the equipment. For example, imagine your workplace purchases this new technology and the equipment manufacturer sends two audiologists to conduct an on-site training. Both of the training audiologists demonstrate how they can

CHAPTER 6   Applying Evidence to Clinical Practice

consistently and validly insert the needed test probe into a child’s ear and complete the entire testing in under 2 seconds. They demonstrate this multiple times with the same child and obtain the same results (i.e., testretest reliability). They also compare their results to each other’s (i.e., interjudge reliability) and show they obtain consistent results. When it comes time for you to try, it takes you more than 1 minute to get the accurate probe placement and even then, you cannot get the correct probe insertion every time (i.e., low intrajudge reliability, which will lead to poor validity). After practicing for 3 months, your timing does not get any faster than 50 seconds. Based on your clinical experience working with this difficultto-test population, you know that 50 seconds is too long and the children who are the “P” in your PICO question will not allow having an insert earphone in for almost 1 minute. In this case, regardless of how validly someone else can use the equipment, it will not be a valid method for you to use with this specific population. You might find this technology useful for other populations, but not the one that was the focus of your PICO question. The two examples above show how all three types of evidence (i.e., external, clinician, and client) are essential to consider when evaluating the quality of an assessment procedure. In addition, you cannot evaluate the quality of an assessment method without first identifying your purpose for using it. External research evidence will provide the data documenting whether a particular assessment method is reliable and valid when used according to the intended directions. You will also need to use your clinical expertise to determine whether you personally can reliably and validly administer that assessment. You must also consider whether your client is willing and able to participate in the assessment. If all three sources of evidence do not indicate an evaluation method will be reliable and valid, you should start the process again by either continuing to investigate your PICO question or modifying your PICO question to identify the most effective assessment method available for your client.

Evaluating Intervention Evidence External Evidence:  Levels of Evidence When evaluating external scientific evidence, it is important to consider that not all external evidence should be weighted equally. The study design differentially weights the value of a study. Studies with more rigorous designs are weighted more heavily than those with less rigorous designs. Several hierarchies exist that provide weightings to study designs. For example, the Oxford Centre for Evidence-Based Medicine (2009) offers evidence

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hierarchies focused on different clinical areas, including therapy, prognosis, diagnosis, differential diagnosis, and economic and decision analyses. Robey (2004) presents a hierarchy with five levels specifically tailored for research focused on communication disorders. Robey’s levels are included in Table 6–7. In Robey’s hierarchy, systematic reviews of randomized control trials are considered the highest level of evidence (1a). In general, a systematic review is a research study that integrates the findings of multiple peer-reviewed publications focused on a similar clinical question, which may take the form of a PICO question. Because they combine evidence from multiple sources, systematic reviews are considered a higher level of evidence than a single study. If the systematic review statistically analyzes the combined results of all those prior publications, the review is considered a meta-analysis. Meta-analyses offer the advantage of being able to quantify outcomes across studies. The key component of a systematic review is the use of prespecified, rigorous, and reproducible methodology that leads to comprehensive results (Bettany-Saltikov, 2010). Systematic reviews that only include randomized control trials (see below) are weighted more heavily than reviews that also include nonrandomized trials, especially when there is homogeneity (i.e., consistency) across results across studies. The next level of evidence (1b) comprises single randomized controlled trials (RCTs). The key feature of RCTs is that participants are randomized to a treatment group or a control group before the study begins. There may be more than one treatment group, and the control group may receive an alternative treatment, no treatment, delayed treatment, or business as usual, which is the intervention that would be delivered in the absence of the research study. Randomization adds rigor and integrity to the study design and helps to avoid effects due to biases. For example, if a researcher assigns participants to study groups in a nonrandomized fashion,

implicit biases may affect a participant’s group assignment. Suppose that every other eligible participant is placed in the intervention group. Knowing the next participant will be assigned to the intervention group, the researcher may schedule a potential participant who they think is likely to benefit from the study intervention prior to a potential participant with more severe impairments. Randomization also helps to ensure that the study groups are similarly heterogeneous. Level 2 evidence includes well-designed, nonrandomized controlled trials, which are also referred to as quasi-experiments. Studies are considered nonrandomized if participants are not prospectively and randomly assigned to study groups. An example of a nonrandomized study is one in which audiologists within a large health care network had the opportunity to participate in a study examining a new hearing aid. Half of the audiologists agreed to participate. All the clients being served by these audiologists were eligible to participate in the study. These clients made up the treatment group and received the new hearing aid. Clients of the audiologists who did not want to be involved in the study were still eligible to participate in the study. However, these clients were all assigned to the control group and did not receive the new hearing aid. Instead, their progress was monitored without any additional intervention. A study of this nature is considered quasi-experimental because even though there is a control group, random assignment was not used. This example of nonrandomization can be a concern because there may be a factor associated with the audiologists who self-selected to be involved in the study and their clients that could impact the study outcomes, such as having smaller caseloads or practicing in areas in which clients are financially stable. Level 3 evidence comprises observational studies with controls. Such studies include retrospective studies, case-control studies, and cohort studies with controls.

Table 6–7.  Robey (2004) Levels of Intervention Evidence Level

Intervention Study Design

1a

Systematic review/meta-analysis of randomized control trials

1b

Individual randomized control trial

2

Well-designed nonrandomized controlled trial (quasi-experiments)

3

Observational studies with controls (retrospective studies, casecontrol studies, cohort studies with controls)

4

Observational studies without controls (cohort studies without controls and case series)



Retrospective studies usually involve record reviews that document the outcomes of intervention approaches that were used with previous clients as well as the characteristics of those clients. Case-control studies are a specific type of retrospective study. To conduct a case-control study, the researcher identifies a group of cases that demonstrates the outcome of interest and a group that does not demonstrate the desired outcome. The researcher then examines the case records to identify which cases received the target intervention and which did not. Cohort studies involve the observation of a large group, typically over a long period of time — for example, comparing the outcomes of a new reading program for struggling readers delivered to an entire school district for 3 years with the outcomes of another district that did not receive the reading program. Level 4 evidence includes observational studies without controls. These may be case studies that include only individuals with desired outcomes or cohort studies that do not have a comparison group. Because they lack control groups and randomization, observational studies without controls are considered the lowest level of external evidence. Another factor to consider when assessing the level of research for EBP is the state of conditions under which the study was conducted. Here, we make the distinction between efficacy studies and effectiveness studies. Efficacy studies evaluate treatment outcomes under highly controlled, ideal conditions. An example is a highly trained researcher providing language intervention to a child one on one in a laboratory setting. In contrast, effectiveness studies evaluate treatment outcomes under more typical conditions. Consider, for example, training a paraprofessional to provide language interventions to small groups of children in the back corner of a classroom. Both types of studies serve important roles in the programmatic development and evaluation of interventions (Fey & Finestack, 2009). Efficacy studies generally precede effectiveness studies to establish a causal relationship between an intervention approach and the target outcome. Once this relationship has been established, the generalization of this effect to more typical conditions can be examined in effectiveness studies. Effectiveness studies can also be used to examine for whom the treatment is most beneficial and under what conditions. Thus, when characterizing the level of evidence, it is also important to determine if the study examined efficacy or effectiveness. Effectiveness studies have greater external validity and should be weighted stronger than efficacy studies. Beyond studies of efficacy and effectiveness are implementation studies. Implementation research is designed to identify and test possible barriers to the adoption and use of evidence-based approaches as standard care, with

CHAPTER 6   Applying Evidence to Clinical Practice

the ultimate goal to overcome barriers so that evidencebased approaches can be incorporated into community health policies and practices (Finestack & Fey, 2017). Implementation studies range in focus, with the goal to change the practice of individual clinicians at one end and to change the policies of national organizations at the other end. Once positive outcomes associated with effectiveness studies are established, clinicians, researchers, and policymakers need to work together to ensure adequate implementation of the approach.

External Evidence:  Quality of Evidence As is the case for levels of research, several systems exist for quantifying the rigor or quality of external scientific research. One such system is GRADE, which stands for Grading of Recommendation, Assessment, Development, and Evaluation (Guyatt, Oxman, et al., 2008; Schünemann et al., 2013). The GRADE approach considers the following study qualities: risk of bias (study limitations), inconsistency, indirectness, imprecision, and publication bias. Based on ratings related to these qualities, an overall score of high, moderate, low, or very low is assigned to the study. Next, we briefly define each of the GRADE metrics to evaluate study qualities. It is not our assumption that, as professionals, you will need to systematically evaluate each of these qualities, but you should be aware of key qualities to help you generally evaluate external evidence and distinguish high-quality studies from low-quality studies. Risk of bias evaluates how study limitations may bias estimates of treatment outcomes. The more study limitations, the greater the risk of bias and the lower the quality of the study. Study limitations that are prone to exist in RCTs include: n

Lack of Allocation Concealment — the person enrolling study participants knows the group assignment sequence. This bias is similar to the limitations mentioned above of using a nonrandomized treatment study design, as the allocation concealment is a key component of randomization. If the person enrolling participants knows the randomization sequence, implicit biases may affect scheduling or assessment. These biases may inadvertently influence study outcomes.

n

Lack of Blinding — clients, caregivers, assessors, or coders know to which study group they were enrolled. Blinding is necessary as much as possible to avoid placebo effects or expected results based on group assignment. Typically, in the fields of speech-language pathology

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and audiology, blinding of the client and clinician is difficult. The client will know they are receiving treatment and the approaches used, as will the clinician. For example, the client and their family would know if they are assigned to the treatment group that receives a parent-implemented AAC intervention or a clinician-implemented intervention. Likewise, the client will be aware if they are in a group receiving a new hearing aid, although it may be possible to disguise different hearing aid technologies to facilitate blinding. To mitigate biases due to lack of blinding, researchers may be vague regarding the primary study outcomes and include outcome measures on which they would not expect intervention-induced changes to function as a control measure. Although more expensive, researchers can hire assistants unaware of preintervention performance levels and group assignments to evaluate and/or code posttreatment performance. n

n

Incomplete Accounting of Patients and Outcome Events — researchers not reporting the number of participants who did not complete the study and instead reporting outcomes only for those who completed the study. For various reasons, participants in a treatment study do not always complete the entire study. These reasons may not be tied directly to the study and therefore should not necessarily be interpreted as a reason for concern. For example, participants may relocate, their schedule may change, or they may no longer have necessary transportation to participate in the study. Other reasons for withdrawing from a study may be closely related to the study and can indicate weaknesses in the treatment. For example, participants may not like their group assignment, the intervention may be difficult or cause discomfort, they may no longer see benefit of the study, or they may meet their desired outcomes and no longer value their participation even though the study protocol requires additional sessions or followup. When evaluating outcomes, it is important to know how many participants in each group did not complete the study and the reasons for withdrawal. If participants withdraw from a study, the researchers might statistically account for those withdrawals when reporting their treatment outcomes (e.g., using “intention to treat” methods; see Hollis & Campbell, 1999). Selective Outcome Reporting — researchers not reporting outcomes on all primary and

secondary measures. Before conducting their study, researchers should identify the primary and secondary outcome measures they will use to evaluate the intervention. Ideally, they will also register their study protocol and plans for analyses prior to initiating data collection. This ensures that the outcomes published are not the result of data mining, where the researchers examine multiple outcomes to find any significant results to report. Conducting multiple analyses increases the odds that analyses will reach a level considered to be of statistical significance and decreases the confidence consumers can have in the reported outcomes. n

Other Limitations — including ending the trial early and using unvalidated outcome measures (e.g., patient-reported outcomes). One reason researchers may choose to end a trial prior to the time established in study protocol is due to loss of adequate study funding, which is likely out of the researchers’ control. However, if researchers end a trial early because they believe they have enough data or have conducted unplanned analyses prior to the study’s conclusion that indicate positive outcomes, this increases the risk of biases impacting outcomes. In this case, the ending of the trial may be premature because analyses with additional participants or longterm measures may yield different outcomes. Thus, researchers should always follow their registered protocol to reduce biases. The use of unvalidated measures may also increase bias in study outcomes. Outcome measures based on self-report or family report are prone to be biased because the client and family are likely to be aware of their group assignment. Those reporting on individuals who they know received the intervention may be more likely to rate themselves or the client higher than those reporting on individuals who they know did not receive the intervention. It is important for outcome measures, especially primary outcome measures, to be based on objective assessments as much as possible to mitigate such biases.

Inconsistency refers to inconsistency of the study’s outcomes relative to outcomes of previous studies by the same or different researchers. When researchers cannot identify plausible reasons for inconsistent results, it suggests that the study’s quality may have been compromised. One reason for outcome inconsistencies across studies may be differences in characteristics of study participants based on factors such as age, diagnosis, level of



impairment, and socioeconomic status. Researchers can mitigate the impact of heterogeneous samples through statistical analyses that focus on outcomes relative to participant characteristics. If researchers cannot explain inconsistent outcomes based on differences in participant samples, intervention approaches, outcomes measures, or other study methods, the perceived quality of study should be reduced. Indirectness occurs when features of the study under evaluation differ from the components defined in your PICO question. It will likely be difficult to find a systematic review, several studies, or even a single study that maps perfectly to your PICO question. For example, considering the example PICO questions presented at the beginning of the chapter, the study may include a slightly different population such as 5-year-olds with Down syndrome instead of 5-year-olds with autism or men with moderate hearing loss above the age of 80 years instead of 75 years. The study may examine a teacher-implemented intervention instead of a parent intervention or use of a single hearing aid instead of bilateral hearing aids. The study may measure word combinations instead of comments and requests or conversational skills instead of word-recognition skills. Some minor differences in study features may be acceptable, but significant differences limit the direct relevance of the study being evaluated. The weight of studies that do not offer direct application to your PICO question should be downgraded. Imprecision reflects the degree of confidence surrounding a study’s outcomes. Generally, studies that include few participants will have large confidence intervals associated with the treatment effect. Thus, small-scale studies with few participants generally have lower-quality ratings because there is greater variability in treatment effects. Thus, studies with a large number of participants should be weighted more heavily than studies with a small number of participants. Publication bias refers to the selective publication of studies. Not all studies are published. In some cases, there may be fatal flaws in the research design or methodology that prohibit interpretation of study results. In other cases, the methodology may be sound, but the outcomes do not support a positive intervention effect (i.e., there is a “negative effect”). When studies with negative effects are not published, the remaining published outcomes may under- or overestimate the potential benefits or harms of an intervention. Some reasons for the occurrence of publication bias in the publication process include attempting to report small-scale studies with a negative effect, authors uninterested in or unmotivated to publish a study with a negative effect, and authors choosing to submit manuscripts associated with a negative effect to non-peer-reviewed journals. Thus, when

CHAPTER 6   Applying Evidence to Clinical Practice

evaluating systematic reviews, it is important to keep in mind that the studies included in the review likely do not reflect all research outcomes to date and their results should be interpreted with some caution. If a study or review appears compromised based on any of the aforementioned factors, you should downgrade the weight of the study when evaluating the external evidence. It is important to note that there are also some study elements that may increase the weight of a particular study, such as when the study demonstrates a very large effect. For example, the quality of a nonrandomized trial should be upgraded if the treatment demonstrates very large effects.

External Evidence:  Integrating Levels and Quality of Evidence Levels of evidence and quality of evidence are both critical factors to consider when examining external evidence; however, it is necessary to consider these factors in tandem. Guyatt et al. (2011) suggest that evidence levels be used to establish an initial level of quality such that systematic reviews and RCTs are initially considered to provide high levels of evidence and observational studies are initially considered to provide low levels of evidence. Studies can be upgraded or downgraded based on previously defined features. Table 6–8 displays how level and quality of specific features can be integrated to establish a single quality descriptor.

Using Intervention Evidence:  An Example Imagine you are a school-based SLP working in a rural area. You are new to the area but worked for a large urban school district for 5 years. In your current position, you provide services for three elementary schools across two counties. One of your clients, Ronny, is a 5-year-old boy who was diagnosed with autism at 4 years of age. Ronny’s expressive vocabulary includes 10 words, most of which he uses to request food and drinks. Ronny’s parents report that he becomes easily frustrated when his needs are not met and he does not engage in social interactions with them or Ronny’s older brother. Ronny’s mother works part-time from home. She is highly motivated to support Ronny’s communication skills. After evaluating Ronny, you determine that his treatment goals should focus on increasing his requests and comments. Based on previous experience, you believe Ronny would benefit from use of a picture-based AAC system that will allow him to make single-word requests and comments. Given the demands of your caseload and the high motivation level of Ronny’s mother, you

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Table 6–8.  Evaluating the Quality of Intervention Evidence Level

Intervention Study Design

1a

Systematic review/meta-analysis of randomized control trials

1b

Individual randomized control trial

2

Well-designed nonrandomized controlled trial

3

Observational studies with controls

4

Observational studies without controls

Quality of Evidence

Moderate

consider teaching Ronny’s mother to implement the AAC-based intervention. However, you do not have much experience with parent-implemented interventions and the lead SLP wants you to justify the treatment approach. You decide to systematically evaluate the internal and external evidence using the principles of EBP. You begin by developing your PICO question. In this case, the PICO question is the same as the first example PICO question provided at the beginning of the chapter: For a 5-year-old child with autism who verbally produces less than 25 words (P), does a parentimplemented intervention (I) or clinician-implemented intervention (C) lead to greater requests and comments using AAC (O)? Next, you consider the internal evidence: your clinical expertise and the client’s perspectives. In this case, you do not have experience with parent-implemented approaches, but you are open to the approach and believe it may be of greater benefit to Ronny than a clinician-implemented intervention given that you will only be able to work with Ronny twice a week for 30 minutes each session. Additionally, you feel you have strong skills targeting communication using AAC that would help you in working with Ronny’s mother to develop the skills necessary to support her implementation of the intervention. Through your conversations with Ronny’s parents, you believe Ronny’s mother would be open to learning how to support his communication at home. Ronny’s mother has offered to come to his school and attend sessions with Ronny to learn intervention strategies to use with Ronny at home. Given that the internal evidence supports using a parent-implemented intervention approach with Ronny, 1

Hypothetical study.

For presence of each of the following:

High

Low

Lower Quality

• Risk of bias • Inconsistency • Indirectness • Imprecision • Publication bias lower quality −1 if serious; −2 if very serious

Raise Quality

If large intervention effect, raise quality +1 for large effect; +2 for very large effect

you continue to pursue this approach by examining the external evidence. You begin by searching ASHA’s Evidence Maps (ASHA, 2019). You search two maps: Spoken Language Disorders (>190 articles) and Autism (>490 articles). On these maps, you find several relevant systematic reviews, which were all published within the past 3 years. You identify two relevant reviews1 on the Spoken Language Disorders map. One is focused on parent-implemented interventions for children with developmental delays, which included 10 studies involving children under 3 years of age but did not include autistic children or use of AAC. All studies were ranked as RCTs of moderate to high quality. The second review is focused on parent programs and includes 20 studies with child participants older than 2 years of age. This study also excluded studies in which the participants were on the autism spectrum or focused on AAC. All but two studies were judged to be of low quality due to small sample sizes, lack of description of the intervention, and incomplete accounting of participants. Both of these reviews indicate that parent-implemented interventions are more beneficial than no intervention, although the quality of the studies was somewhat mixed. While both studies focus on parent-implemented intervention, neither includes participants who match the “P” in your PICO question or Ronny’s specific profile. You decide to continue to search for more external evidence. On the Autism map, you find a review of RCTs1 focused on autistic children who produce few spoken words. This is a good match to Ronny’s profile. Examination of the review indicates that it includes only three studies, all of which are RCTs and included autistic children. Two studies included a verbal intervention strategy that



taught parents to implement the intervention. Both studies included children under the age of 7 years; however, results did not indicate significant differences between the treatment and control groups. The third study focused on improving communication using a high-technology AAC with children between the ages of 4 and 8 years. Parents received approximately 20 hours of instruction. Results indicated that children in the treatment group were five times more likely to use their technology to communicate than children in the control group who did not receive treatment. Using GRADE, the authors of the systematic review judged all studies to be of low quality. Although none of these reviews perfectly map onto your PICO question, you feel you have adequate external evidence to guide your clinical decision. There is fairly strong evidence supporting the general use of parent-implemented interventions; however, evidence for 5-year-olds who use few spoken words is limited. One study that examined a high-technology AAC method with parent-implementation revealed positive treatment outcomes, although the study was judged to be of low quality. This evidence, combined with strong clinician and client internal evidence, supports the use of a parent-implemented treatment approach for Ronny. For the past 3 months, you have been working with Ronny and his mother. For the first month, Ronny’s mother attended every session you had with Ronny; for the past 2 months, Ronny’s mother has been attending one session per week. During these sessions, you have Ronny’s mother use basic strategies for encouraging Ronny to use AAC to request activities and to comment on things in his environment. You have been targeting similar goals in your individual sessions with Ronny with a focus on classroom activities and the school environment. Using a clinician-designed probe administered in school, Ronny spontaneously used his AAC device to request 15 different activities and comment on seven different events after 3 months of intervention. Ronny’s mother reports that he currently uses his AAC device at home to request seven different activities and comment on eight different events. Ronny’s mother further reports that in the last month, Ronny has had fewer meltdowns and he appears to be less frustrated. You notice that Ronny enjoys having his mother attend sessions with him and that Ronny’s mother appreciates learning strategies that support Ronny’s communication. Ronny’s mother tells you that she wants to continue using the parent-implemented approach, but would like to focus on verbal requests and comments. Given all this evidence, you decide to begin to integrate verbal communication into your goals and continue having Ronny’s mother attend one of his intervention sessions each week. You will continue to monitor Ronny’s treatment progress using your clinician-designed probes.

CHAPTER 6   Applying Evidence to Clinical Practice

This example, admittedly, presented a clean illustration for using EBP to guide clinical decisions. In some cases, it won’t be as easy as using the ASHA Evidence Maps as your only method for locating systematic reviews. There may not be a systematic review available on your topic, requiring you to consult primary research; even then, there may not be evidence that is both high level and high quality available. Also, in this case, the parent was enthused about being directly involved in the intervention and had flexibility in her schedule to attend sessions. This might not be the case for all families. Also, in the example, Ronny quickly made significant gains. Often, your client will not show significant improvement in a short amount of time. If treatment gains are not made, you will need to decide if you should modify the treatment and, if so, how. This will likely require you to revisit the EBP steps outlined in Table 6–1.

The Future of Evidence-Based Practice The fields of speech-language pathology and audiology are relatively young with much yet to be discovered regarding how to best assess and support communication-based conditions. Nonetheless, the amount of research guiding clinical practice in these areas is certainly increasing, as is the quality of the research. Early studies very much relied on observational and case studies; today, RCTs and systematic reviews are much more commonplace. While each evidence level serves an important purpose, advancements in study designs, implementation, and analyses have allowed researchers to conduct more rigorous studies. This in turn allows clinicians to have more confidence in application of study results. To further advance the external evidence base for clinicians, future studies will likely increasingly focus on better serving the individual by understanding for whom an intervention or assessment is appropriate and under what conditions. This follows current precision medicine trends in health care that advocate for using an individual’s genomic sequence, environment, and lifestyle to guide clinical practice (National Library of Medicine, 2022). This means that not only will study participants be more specifically described, they will also include individuals with diverse racial, linguistic, cultural, neural, sexual, gender, and physical profiles to allow clinicians to offer the highest quality services regardless of a client’s background or profile. Additionally, advancements and increased focus in implementation science will further support clinicians’ use of EBP to ensure they are meeting their clients’ needs to the best of their ability.

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Throughout this chapter, we encouraged you to think about how you as the clinician will need to understand and evaluate the quality of evidence. As access to artificial intelligence (AI) continues to increase, clinicians may seek out tools such as ChatGPT or other large language models as a method to answer their PICO questions. There is nothing inherently wrong with using such tools; however, the clinician then becomes responsible for evaluating the quality of the evidence and answers provided by the AI tool used. When initially released, ChatGPT was found to include false references when answering questions (Anderson et al., 2023). Additionally, these tools may not include the most up-to-date research findings. Clinicians may use ChatGPT as one source of evidence, but will still need to critically evaluate the validity of that information just as with any other source of evidence. Currently, tools such as ChatGPT have the most promise in assisting with finding and synthesizing external evidence. Although the technology behind AI is likely to change rapidly, the integration of all three aspects of EBP — external evidence, clinical expertise, and client perspectives — to answer a specific clinical question for a specific client is still a task that clinicians are more successful at than AI. AI does not (yet, perhaps) have the ability to determine a client’s perspective on which treatment goals are most immediately meaningful to them, nor can it replace a clinician in implementing assessments or interventions; clinical expertise is still best left for clinicians to self-evaluate.

Summary The ASHA Code of Ethics states, “Individuals who hold the Certificate of Clinical Competence shall use independent and evidence-based clinical judgment, keeping paramount the best interests of those being served” (ASHA, 2023a). Therefore, it is essential for you, as a professional, to continually engage in identifying and evaluating the evidence for all of your clinical decisions. Using a focused approach to evaluate evidence will help ensure you meet this ethical obligation in an efficient manner. The EBP model can serve as a reminder that evidence can and should come from multiple sources: external, scientific evidence; your own clinical expertise; and the client’s perspective. Developing a PICO question and answering it by systematically addressing all three components of the evidence-based approach to clinical decision making will focus your evaluation of the evidence in a way that will result in the best outcome for the client. When evaluating clinical evidence for selecting specific assessment procedures, determining the reliability

and validity of the assessment is the foundation for deciding whether to use that assessment. Validity can only be evaluated in the purpose you have for choosing that assessment. If your purpose is to diagnose a disorder, measures of diagnostic accuracy should be used to document validity. For treatment evidence, a PICO question can help identify the specific type of evidence needed to evaluate the impact an intervention might have. When evaluating the quality of research evidence, it is important to determine what level of evidence a treatment study provides and the quality of the study methodology. Systematic reviews that include high-level, large-scale RCTs are considered the most useful evidence, assuming the researchers used rigorous methodology.

References Alsayedhassan, B., Banda, D. R., & Griffin-Shirley, N. (2016). A review of picture exchange communication interventions implemented by parents and practitioners. Child and Family Behavior Therapy, 38(3), 191–208. American Speech-Language-Hearing Association. (2023a). Code of ethics. http://www.asha.org/policy/ American Speech-Language-Hearing Association. (2023b). Evidence maps. https://www.asha.org/ Evidence-Maps/ Anderson, N., Belavy, D. L., Perle, S. M., Hendricks, S., Hespanhol, L., Verhagen, E., & Memon, A. R. (2023). AI did not write this manuscript, or did it? Can we trick the AI text detector into generated texts? The potential future of ChatGPT and AI in sports & exercise medicine manuscript generation. BMJ Open Sport & Exercise Medicine, 9, 1–4. https://doi.org/10.1136/bmjsem-2023-001568 Bettany-Saltikov, J. (2010). Learning how to undertake a systematic review: Part 2. Nursing Standard, 24(51), 47. Council on Academic Accreditation in Audiology and Speech-Language Pathology of the American Speech-Language-Hearing Association. (2023). Standards for accreditation of graduate education programs in audiology and speech-language pathology. https://caa.asha.org/siteassets/files/accreditationstandards-for-graduate-programs.pdf Crowe, M., Sheppard, L., & Campbell, A. (2011). Comparison of the effects of using the Crowe Critical Appraisal Tool versus informal appraisal in assessing health research: A randomised trial.



CHAPTER 6   Applying Evidence to Clinical Practice

International Journal of Evidence-Based Healthcare, 9(4), 444–449. Fey, M. E., & Finestack, L. H. (2009). Research and development in children’s language intervention: A 5-phase model. In R. G. Schwartz (Ed.), Handbook of child language disorders. Psychology Press. Finestack, L. H., & Fey, M. E. (2017). Translation and implementation research in the development of evidence-based child language intervention. In R. G. Schwartz (Ed.), Handbook of child language disorders (2nd ed.). Psychology Press. Gillam, S. L., & Gillam, R. B. (2006). Making evidence-based decisions about child language intervention in schools. Language, Speech, and Hearing Services in Schools, 37(4), 304–315. Guyatt, G. H., Haynes, R. B., Jaeschke, R. Z., Cook, D. J., Green, L., Naylor, C. D., . . . Evidence-Based Medicine Working Group. (2000). Users’ guides to the medical literature: XXV. Evidence-based medicine: Principles for applying the users’ guides to patient care. JAMA, 284(10), 1290–1296. Guyatt, G., Oxman, A. D., Akl, E. A., Kunz, R., Vist, G., Brozek, J., . . . Jaeschke, R. (2011). GRADE guidelines: 1. Introduction — GRADE evidence profiles and summary of findings tables. Journal of Clinical Epidemiology, 64(4), 383–394.

Howlin, P., Gordon, R. K., Pasco, G., Wade, A., & Charman, T. (2007). The effectiveness of Picture Exchange Communication System (PECS) training for teachers of children with autism: A pragmatic, group randomised controlled trial. Journal of Child Psychology and Psychiatry, 48(5), 473–481. National Library of Medicine. (2022). MedlinePlus: What is precision medicine? https://medlineplus​ .gov/genetics/understanding/precisionmedicine/ definition/ Oxford Centre for Evidence-Based Medicine. (2009). Oxford Centre for Evidence-Based Medicine: Levels of Evidence. https://www.cebm.ox.ac.uk/resources/ levels-of-evidence/oxford-centre-for-evidencebased-medicine-levels-of-evidence-march-2009 Plante, E., & Vance, R. (1994). Selection of preschool language tests: A data-based approach. Language, Speech, and Hearing Services in Schools, 25(1), 15–24. Porzsolt, F., Ohletz, A., Thim, A., Gardner, D., Ruatti, H., Meier, H., . . . Schrott, L. (2003). Evidencebased decision making — The 6-step approach. ACP Journal Club, 139(3), A11–A12. Robey, R. (2004). Levels of evidence. The ASHA Leader, 9(7) 5. https://doi.org/10.1044/leader.FTR2.0907​ 2004.5

Guyatt, G. H., Oxman, A. D., Vist, G. E., Kunz, R., Falck-Ytter, Y., Alonso-Coello, P., & Schünemann, H. J. (2008). GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. British Medical Journal, 336(7650), 924–926.

Robey, R., Apel, K., Dollaghan, C., Ellmo, W., Hall, N., Helfer, T., . . . Lonsbury-Martin, B. (2004). Report of the joint coordinating committee on evidence-based practice. https://www.asha.org/​ siteassets/uploadedfiles/jccebpreport04.pdf

Guyatt, G., Rennie, D., Meade, M. O., & Cook, D. J. (2008). Users’ guides to the medical literature: Essentials of evidence-based clinical practice (2nd ed.). McGraw-Hill.

Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence-based medicine: How to practice and teach EBM (2nd  ed.). Churchill Livingstone.

Haynes, R. B., Sackett, D. L., Guyatt, G. H., & Tugwell, P. (2006). Clinical epidemiology: How to do clinical practice research (3rd ed.). Lippincott Williams & Wilkins.

Salvia, J., Ysseldyke, J. E., & Witmer, S. (2013). Assessment in special and inclusive education (13th ed.). Cengage Learning.

Hollis, S., & Campbell, F. (1999). What is meant by intention to treat analysis? Survey of published randomised controlled trials. British Medical Journal, 319(7211), 670–674.

Schünemann, H., Brożek, J., Guyatt, G., & Oxman, A. (Eds.). (2013). The GRADE Working Group. GRADE handbook for grading quality of evidence and strength of recommendations. https://gdt.grade​ pro.org/app/handbook/handbook.html

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Employment Issues

7 Workforce Issues and Finding Employment Mark DeRuiter and Cathy DeRuiter

Introduction The needs of a population as large and diverse as that of the United States should be reflected in its workforce. Audiologists (AuDs), speech-language pathologists (SLPs), and communication sciences and disorders (CSD) faculty scholars and researchers contribute to the services and economy of our nation. This chapter addresses the current demographics and employment characteristics, including job and career satisfaction and salary information of those in our professions, with a focus on those who affiliate with the American Speech-Language-Hearing Association (ASHA). The chapter then moves into your personal search for your first clinical job in the field and covers different strategies for being successful in that endeavor. The country is constantly evolving. Changes in the political climate, advances in medical and technological fields, and world events affect the global economy and can significantly impact the job market. This chapter is rich with data and many references are provided so that readers can seek and find updated information as needed. The information presented will be useful as you consider your search for initial employment.

The Current Workforce ASHA is the professional, scientific, and credentialing association for more than 223,000 members and affiliates made up of audiologists; SLPs; speech, language, and hearing scientists; audiology and speech-language pathology support personnel; and students (ASHA, n.d.-a). ASHA’s Certificate of Clinical Competence (CCC) is an internationally recognized voluntary professional credential for audiologists and SLPs. Students will likely have heard about this credential, and many may be striving to earn it. If you are a professional, you likely work alongside many colleagues who hold the credential. Additionally, ASHA now has an assistant’s certification program, wherein you might work along with or even supervise one of these professionals at some point in your career. One advantage to a national association for membership and certification is that a great deal of data is available to you to 123



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learn about the demographics of your own discipline on the national level. The following sections on workforce issues are largely drawn from various ASHA reports. This chapter is a one-stop shop for general information about your discipline. Note, however, that things are subject to change, so it is important to monitor trends at the national, state, and local levels.

ASHA Membership and Affiliation Data At the end of each year, ASHA completes a membership and affiliation count. The data above is taken from this report and is shared here to help the reader understand what type of information is available and accessible online at https://www.asha.org. Not only does ASHA compile information on member data (member and affiliate profile trends — typically across a 20-year span, membership and affiliation counts archive — typically for a 10-year comparison), but it also shares state-level data, multilingual service provider information, and PhD holder demographic and employment data. These reports can assist audiologists, SLPs, new graduates, and employers in making informed decisions on how to move forward within the profession. In fact, you might be able to apply some of this information as you consider the second half of this chapter. At the end of 2021, ASHA represented 223,456 members and affiliates including audiologists; SLPs; speech, language, and hearing scientists; support personnel; and undergraduate, graduate, and doctoral students in CSD who had membership in the National Student Speech Language Hearing Association (NSSLHA; ASHA, 2022c). These numbers were determined through either membership, certification, or both. Breaking down this total into its component parts, there were 193,799 SLPs, 13,910 audiologists, 707 dually certified members holding certification in both audiology and speech-language pathology, 3,721 members in process of completing their certification, 354 members only (do not hold certification), 541 international affiliates from 61 countries outside the U.S., 446 certified assistants (23 in audiology, 354 in speech-language pathology, and 69 who have started but not yet completed the assistants certification program), 135 associates (support personnel; the associates program sunset as of December 2022 due to the initiation of the assistants certification program in 2021), and 10,341 national NSSLHA members (ASHA, 2022c). Overall, both audiology and speech-language pathology have continued to grow. However, the percentage of 10-year growth appears greater for SLPs than audiologists (ASHA, 2022c).

Employment Characteristics Where you work and how many hours you work per week are considerations for anyone in the profession. There are a wide range of environments and populations served by SLPs and audiologists. The data below are summarized from various reports on the national level. The following section summarizes data from ASHA regarding employment characteristics as reported by its membership/certificate holders and uses the association’s terms and structure. At the close of 2021, the majority of ASHA’s membership and affiliation were employed full-time (73.3%), whereas 17% were employed on a part-time basis (ASHA, 2022c). Less than 1.5% were unemployed and seeking employment. This number is below the December national unemployment rate of 3.7% reported by the U.S. Bureau of Labor Statistics (U.S. Department of Labor, Bureau of Labor Statistics [BLS], 2022).

Where audiologists and SLPs work is another important variable that can be impacted by a variety of factors discussed in this book. In 2021, the majority of audiologists (74.6%) were employed in health care settings, including nonresidential health care settings (46.4%), hospitals (27.5%), and residential health care settings (0.8%). Approximately one-quarter of audiologists (25.2%) were employed in full- or part-time practice in a private physician’s or audiology office or a speech and hearing center, and the remainder were employed in the educational setting (14%) including schools (7.7%) and higher education institutions (6.4%; ASHA, 2022c).

The percentages of SLPs employed across different settings vary from audiology. In 2021, the majority of SLPs, more than half (53.5%) were employed in educational settings including schools (50.9%) and higher education institutions (2.6%). Health care settings made up 39.4% of the employment sites of SLPs, including nonresidential health care settings (18.6%), hospitals (12.2%), and residential health care settings (8.6%). A smaller percentage of SLPs worked in private physician offices (0.2%), audiology or speech-language pathology offices (2.1%), or a speech and hearing center (1.3%), although SLPs did engage in full- or part-time employment in private SLP practices (22.4%) as well (ASHA, 2022c).



CHAPTER 7   Workforce Issues and Finding Employment

In 2021, the majority of audiologists (78%) reported their primary work role as a clinical service provider with 7.4% holding an administrative position (e.g., executive officer, department chair, or supervisor; ASHA, 2022c). A small percentage (5.1%) held a teaching position (0.5% held special education teacher roles and 4.6% were college or university professors), 2.1% were consultants, and 1.8% were researchers. Similar to audiologists, most SLPs (75.1%) reported their main work responsibility as a clinical service provider. In contrast to audiologists, more than one-tenth (11.2%) held a teaching position (9.4% were special education teachers and 1.8% were college or university professors) and 6.4% held administrative positions. Only 1.4% were consultants and 0.3% were identified as researchers. These percentages are consistent across the last several years (ASHA, 2022c).

Salary Salary is an area where students have a great deal of interest. However, it is important to remember that salary is not the only factor in a satisfying career. Additionally, salary is a complex issue and depends upon many factors such as part- versus full-time employment, benefits eligibility, and differences based on the region of the country and cost of living factors in given geographic areas. The following section summarizes data from ASHA regarding salary as reported by its members and uses the association’s terms and structure. Salaries of Audiologists: 2021 Data. In 2021, ASHA conducted a survey of audiologists aimed at gathering information about salaries, working conditions, and service delivery. There were 1,487 respondents to the ASHA 2021 Audiology Survey (excluding audiologists who worked in schools as they were included in the Schools Survey, which is described later in the chapter). The majority of audiologists (76%) were paid an annual salary; 22% were paid on an hourly basis and 3% were paid via commission (ASHA, 2022a). The majority of these respondent audiologists worked full-time (93%) primarily in nonresidential health care facilities (41%), hospitals (39%), higher education institutions (12%), industry (7%), or audiology franchises or retail chains (3%). The reported median full-time annual salary was $87,822 excluding bonuses and commissions. The median amount of a bonus was $2,500 for audiologists who earned a bonus. For those who received an annual commission, the median amount was $20,000 based on a median percentage of commission on product sales of 10%. The median commission was $14,000 for those receiving pay through an hourly wage and $50,000 (25% commission on product sales) for those who

worked primarily for commission. The median salary was $95,000 for those who received combined pay for their annual salary and earned commission. The median hourly wage was $45 excluding bonuses and commissions for those who worked up to 28 hours per week and $43.34 for individuals who worked more than 28 hours weekly. Audiologists who worked for hourly pay who also had a bonus received a median amount of $1,399. Of those hourly employees who received a commission, the median amount was $14,000. More than half (57%) of the audiologists who earned an hourly wage worked part time (ASHA, 2022b). Earnings can be affected by many different variables including primary work setting and role, highest academic degree, years of experience in the profession, geographic region, and type of community (e.g., metropolitan/urban, suburban, or rural). Audiologists who worked more than 28 hours/week in the hospital setting earned $48.55/hour, while audiologists working more than 28 hours/week in nonresidential health care facilities earned $40/hour (ASHA, 2022b). Other factors that can impact earnings for audiologists include: n

Audiologists who served as administrators earned a median calendar-year salary of $123,600 compared with $85,000 for clinical service providers.

n

The median calendar-year salary of audiologists holding a PhD was $114,000, compared with $86,000 for those who hold the clinical doctorate (AuD) and $85,000 for those with a master’s degree (ASHA, 2022a).

There were 230 audiologists who responded to the 2022 survey related to employment within the school setting (ASHA, 2022e). The majority indicated they were paid an annual salary (89.1%) with the remainder (10.9%) being paid on an hourly basis. The median academic year (worked 9–10 months) salary was $76,000, with the median calendar-year (worked 11–12 months) salary reported as $84,000. The majority of respondents described their primary work function as that of a clinical service provider (76.5%) and that although they worked for 9–10 months, they were paid over a 12-month period (84.5%). Salaries of Speech-Language Pathologists: 2021 Data.  Data from 2021 indicate that more than half (54%) of SLPs in health care settings (general medical, Veterans Affairs, military, long-term acute care or

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university hospitals, home health agencies or individuals’ homes, outpatient clinics or offices, pediatric or rehabilitation hospitals, and skilled nursing facilities) were paid an hourly wage (ASHA, 2021b) versus approximately one-third (36%) who were paid an annual salary (ASHA, 2021a). Across the 1,671 respondents, 72% worked full-time (ASHA, 2021a) yet of those who earned an annual salary, 92% worked full-time (ASHA, 2021a) versus 64% of hourly wage earners who worked full-time (ASHA, 2021b). One-tenth (10%) were paid per home health visit, with a median home visit wage of $65 (ASHA, 2021b). In 2021, the median hourly wage was $42 for full-time SLPs and $48 for part-time SLPs in health care settings (ASHA, 2021b). The median annual salary in health care was $80,000 (ASHA, 2021a). Like audiology, numerous factors affect earnings for SLPs in health care: n

SLPs in home health settings reported a higher median hourly wage ($65) than those in other practice settings (ASHA, 2021b).

n

Administrators, supervisors, and directors earned a median annual salary of $105,000, whereas clinical service providers earned $78,000 (ASHA, 2021a).

n

The median annual salary of SLPs was highest in the western United States ($90,000) and lowest in the northeast ($79,830; ASHA, 2021a).

In 2022, most SLPs in school settings (85%), essentially composed of special day/residential schools, preschools, elementary schools, secondary schools, and administrative offices, were paid an annual salary; the remaining 15% were paid an hourly wage (ASHA, 2022f ). These data are in contrast to SLPs who work in health care, where the majority received an hourly wage. A large majority (92%) of school-based SLPs worked 9 or 10 months per year (academic year) with the remainder working 11 or 12 months (calendar year) annually. The median academic-year salary of SLPs in school settings was $69,000, whereas the median calendar-year salary was $80,000. A small percentage of SLPs (15%) worked for an hourly wage. The median hourly wage was $51 (ASHA, 2022f ). Numerous factors can impact the salaries of SLPs in school settings: n

SLPs in secondary schools had a somewhat higher median academic-year salary

($75,000) than those in other school settings (ASHA, 2022f ). n

SLPs with 25–31+ years of experience (either in years within the profession or years within the school setting) had a higher median academic-year salary than those just starting out with 1–5 years of experience ($80,000–85,000 and approximately $54,000, respectively; ASHA, 2022f ).

n

SLPs in city/urban and suburban areas had a higher median academic-year salary than those in rural communities ($70,000, $72,000, and $60,000, respectively; ASHA, 2022f ).

Salaries of Academic and Clinical Faculty in Colleges and Universities. The Council of Academic Programs in Communication Sciences and Disorders (CAPCSD) conducts a salary survey in higher education on a regular basis. Data are available on the CAPCSD website (http://www.capcsd.org) in a format enabling calculation and comparison of salaries by entering a year of interest (CAPCSD, 2018). The 9-month adjusted base mean salary for assistant professor academic faculty was $70,408 in 2018. Assistant professor clinical faculty earned a median salary of $58,756. CAPCSD is planning to release a new academic salary survey in 2023–2024. You are encouraged to view the resources at http://www​ .capcsd.org if you are interested in an academic position. A variety of factors influenced salaries in academia, regardless of professional area of focus. These included: n

highest academic or clinical degree earned,

n rank, n

tenure status,

n

type of institution (i.e., public or private),

n

Basic Carnegie classification of institution, and

n

geographic region of institution (as defined by the Federal Reserve Classification).

Shortage of PhD Students and Faculty in CSD Evidence-based practice is the foundation of clinical practice. Much of the evidence base for our disci-



CHAPTER 7   Workforce Issues and Finding Employment

pline has come from the research of faculty members appointed at universities throughout the country. Therefore, a sufficient pipeline of faculty and PhD students in CSD is critical. Over the past two decades, numerous reports have discussed the shortage of PhD students and faculty in CSD (ASHA, 2002, 2016, 2019; Madison et al., 2004; McNeil et al., 2013; Oller, 2003). However, in 2019, ASHA issued a report through its Academic Affairs Board examining the impact of plans to increase the student pipeline and workforce for PhD researchers and faculty researchers. The group had set targets relative to ASHA’s Strategic Pathway to Excellence (http://www​ .ASHA.org/about/). During the period from 2013– 2018 there was growth in the number of earned research doctorates granted annually. Additionally, the percentage of all PhD graduates in CSD who took research and academic appointments had grown beyond what was targeted. These efforts support a science base for the discipline and develop research scientists who will further support the foundation of scientific evidence in our field. This support is consistent with ASHA’s Strategic Pathway to Excellence (ASHA, 2019). Although there is some growth in the number of PhD degrees awarded in the discipline, the demand for prepared audiology and speech-language practitioners remains. There are more new accredited academic programs now than 20 years ago, and the number of programs continues to grow. Clinical Doctorates: Most audiology programs moved to the Doctor of Audiology degree as the entry-level degree for professional practice between 2005–2007. Speech-language pathology continues to require a master’s degree for entry-level practice at the time of this writing. However, there are clinical doctorate programs in the United States that have offerings for SLPs. In general, clinical doctoral degrees focus less on research than the PhD degree. Clinical doctorates may have appeal to a variety of clinicians, dependent upon career goals. You can see a list of clinical doctorate programs in speechlanguage pathology by using ASHA’s EdFind website (ASHA, n.d.-b).

The Future:  Factors Affecting Employment Starting your new career is exciting and rewarding. It is important to consider what the future may hold as far as the ability to remain meaningfully and gainfully employed. Topics covered in this textbook including

the projected demand for audiologists and SLPs from the Bureau of Labor Statistics, the aging and growth of diversity of the United States population noted in Chapter 1, as well as other areas addressed throughout the text (e.g., changes in technology, federal policy, reimbursement, and interprofessional practice) remind us that our fields are anything but static. Professionals within the discipline will therefore need to continually monitor the dynamic landscape of the professions on the local, state, and national levels to assert the knowledge, skills, and training earned to remain competitive within the marketplace. It is exciting to be part of a growing field with so many possibilities. But how will you get where you want to go? The next section of this chapter will give you some thoughts and ideas as you consider seeking employment.

Job Search As you think about job settings, you will need to consider the job search itself. Searching for a job will take time and energy. However, it is important because it is the first step in your career. In some instances, you may find employment through a current practicum or externship. However, in most cases, you will need to search for employment. On average, new graduates should plan on a minimum of a 90-day lead time when they seek employment. The most frequently used source for finding jobs is the internet. For example, you might use ASHA’s Career Portal, the HearCareers site from the American Academy of Audiology, or a variety of job-seeking sites such as Monster, ZipRecruiter, or Indeed.com. Additionally, positions may be posted on the human resources pages of school districts, health centers, hospitals, and other agencies. You may also find positions through social media sites such as Facebook and LinkedIn. What is most important to remember is that positions are fluid (particularly in health care) and you will need to continually check back for available positions. If you have the option to set alerts through a job search tool, you should do so. One word of caution involves posting your resumé on a website for many employers to see. Students often report that if they do this, they are inundated with erroneous calls for positions that do not fit their needs. Carefully consider where you post your resumé and what information you reveal about yourself. As you begin your search, think of some basic things: n

What environments and clinical populations interest you most?

n

Do you need to work full-time, or are you seeking part-time employment?

n

Is flexibility in scheduling critical to you?

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Although only you can answer these questions it is important to think about your needs while looking at postings. Other sections of this chapter will provide you with information that might shape your answers to the questions above.

Consider What Information Is Available About You Before you start officially applying for positions, you might want to consider your own electronic presence. Cotriss (2023) reports that employers expect to find information about you online, and employers may feel it is an appropriate way to vet a candidate. However, you should closely monitor what information is available about you because it could bias an employer negatively. Begin by searching your name in various search engines. Also, check your social media sites and determine what is public versus private information. Are there objectionable pictures or posts? Will you want to remove or edit information? Have you blogged on controversial topics, especially as they relate to your candidacy as an employee? A proactive step can be to create some professional social media pages highlighting your skills as a clinician and making your personal pages less easily accessible to an employer. ASHA has provided guidance to its membership regarding social media, how employers use this information, and how to build your online professional presence (ASHA, n.d.-c).

highlight your skills and achievements that meet the specific needs of the agency to which you are applying. These resumes could blend a variety of styles but emphasize highly specific skills relative to a given position (e.g., vestibular testing, pediatric feeding and swallowing). If you are working on a targeted resume, ask trusted mentors to look at your document to determine that the structure makes sense and is functional for the environment to where you are applying. A curriculum vitae (CV) is a long-form of a resumé typically seen in academic environments. When you consider your resumé, you should primarily think of displaying your competency and skills. When you consider a CV, you should think of displaying credentials, especially related to research and professional associations (Doyle, 2022). Most new graduates will use a one- to two-page resumé format.

Resumé Content Suggestions The following suggestions will help you move forward with an initial draft of your resumé. The example in Appendix 7–A will serve as a guide. However, note that the sample resumé is streamlined. Your final product may have more entries. n

Identification section:  This section of your resumé provides your name, address, and contact information. Keep your email address professional and make sure your outgoing voicemail message has a professional tone. If you are a student using a university email account, confirm with your university that you will have access to this email account after you graduate.

n

Job/career objective:  Advice varies on objective statements on resumés. An objective is an opportunity for you to state what you are seeking in employment. However, if the objective is obvious (e.g., “Obtain a clinical fellowship in a medical environment”), it may be best to leave it off. When in doubt, it is likely to your advantage to leave the objective statement off your resume.

n

Education:  List in chronological or reverse order your earned degrees, name of college or university where they were obtained, city and state, and dates. If you graduated with honors, you should state it. Audiology students seeking externships may be encouraged to include their GPA on the resumé. Other applicants may not need to include a GPA, as graduation from an accredited program is the most important element regarding education.

Resumé The resumé or curriculum vitae (CV) is a critical tool for marketing yourself to an employer. Resumés can be constructed in a variety of styles such as chronological, functional, targeted, or a combination of these styles. Chronological resumés are the most common. They display a reverse chronological order (most recent first) list of your education, employment/practicum experience, and other skills. A sample reverse chronological resumé is found in Appendix 7–A. Functional resumés separate your skills and accomplishments into categories that reflect your job objective. Often, functional resumés have education toward the end of the document because the assumption is that your educational credentials are the foundation of your skills. Functional resumés do not link skills to locations. Instead, all skills are defined in a broader skills section, typically at the beginning of the resume. However, you may list your practicum and employment sites later in the document. Combination resumés combine chronological and functional styles. Finally, targeted resumes



CHAPTER 7   Workforce Issues and Finding Employment

n

n

include this near your degree designator versus in this category. It may be better to keep your honors category for other honors and awards (e.g., honors fraternities, scholarships).

Certification and licensure:  State which certificates or licenses you hold. This will be a fast way for an employer to screen your application, should these credentials be required. You can state that you are “license eligible” if you believe you meet the requirements for a license in a given state. However, do not state that you hold any credentials that you cannot immediately provide to an employer at the start of your employment.

n

Presentations:  Include any professional presentations using APA format. Remember to include all authors.

n

Clinical experience history:  This section lists your practicum experiences. You will want to state the name and location of where you were placed. Then, include relevant points about the experience so the reader has a snapshot of what knowledge and skills you have gained at the rotation. Keep these entries fresh using action verbs wherever possible. A list of action verbs can be found in Table 7–1.

Professional affiliations:  This segment lists the names of any professional local, state, national, or international associations to which the applicant belongs (e.g., NSSHLA, ASHA, AAA). If you held a specific role (e.g., treasurer), make sure to state it here.

n

Continuing education:  This section is reserved for professionals who have participated in postgraduate training or education. A new applicant may also use it if they have gone above and beyond typical graduate training.

n

Publications:  Any published books, monographs, chapters, or articles should be included in American Psychological Association (APA) format. A dissertation or thesis can be included here as well.

n

References:  Include references on a separate page. Make certain to include all information, including degree designator and title. There is no reason to state “References available upon request” on your resumé.

n

Honors/awards:  Include any honors and awards in this category. If you graduated summa cum laude (or other honors), you might want to

n

Personal data:  Your professional resumé is not a place to include personal data regarding hobbies or interests.

Table 7–1.  Sample Action Verbs administered

enhanced

programmed

aided

established

provided

analyzed

evaluated

recommended

appraised

examined

rehabilitated

assessed

facilitated

researched

assisted

formed

stimulated

communicated

generated

submitted

counseled

implemented

supervised

created

lectured

taught

demonstrated

managed

tested

designed

measured

trained

developed

monitored

undertook

directed

observed

utilized

documented

organized

edited

performed

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The resume in the appendix contains an address. There is growing conversation about whether an address is a necessary element of your resume because it may already be collected in an employment portal. Address information can also introduce potential bias and may be used in identity theft (Malinsky, 2022).

Resumé Style Suggestions There are multiple ways your resumé can look its best. Consider the following: n

Do not use lines or pictures on your resumé.

n

Use professional-looking fonts (avoid Comic Sans or scripted fonts) and keep the font size between 10 and 14.

n

Make certain there is white space on the resumé so it does not look busy or overwhelming.

n

If printing your resumé, stick with standard white paper, 8.5 by 11 inches.

Stahl (2016) provides some resumé style tips that may be useful to you. These recommendations come from the business world. Therefore, always remember to have someone in your own discipline take another look at your resumé to make sure it fits with the discipline of communication disorders.

Completing Your Application Cover Letter Your cover letter should impress your reader and describe your value, fit, personality, and enthusiasm to an employer (Page, n.d.). A simple internet search will provide you with many examples of effective cover letters. Overall, consider a cover letter as a brief introduction of yourself, your interests in the position, and how you might move forward to schedule an interview. These considerations will assist you in structuring the content of the letter. The first paragraph should offer the reader information about you, how you found the position, and why you are interested in the opening. This paragraph can be relatively brief, containing about three or four sentences

total. Make sure this opening paragraph is tailored to the employer versus being generic in nature. If you have the name of a person you can address the letter to, go ahead and do this. It will be more personal than “To Whom It May Concern.” The second paragraph should discuss your fit for the position. It is important here that you do not overwhelm the reader by recasting your entire resumé. Instead, look at the position posting and draw out the information that is most relevant to the position at hand. If you have special skills or certifications, highlight them in this section. The third paragraph will be your closing. Reiterate your interest and indicate your desire to engage in an interview. Remember, you will want to learn things about the employer, just as the employer will want to learn about you. It is appropriate to state when you are typically available and that you will follow up within a given period of time. Monitor your tone in this paragraph to sound enthused yet professional. You should use a block-style format for the cover letter and keep the tone of the letter appropriately assertive and positive. If possible, you might want to create a .jpeg file of your signature to give the letter a personal touch with an imported original signature.

Email Style Issues Emailing cover letters and resumés is common. Make sure to follow any directions you are given for emailing your resumé and cover letter. This includes any file-naming conventions that may be required by an employer. Avoid using an ambiguous subject line and consider sending a resumé and cover letter with a read receipt where possible. Keep the text of the email formal and make sure to address the recipient in a professional manner, using their name and title. Often new job seekers will ask if they should copy the contents of their cover letter into the body of the email. Although this is not forbidden, it might be wise to send a briefer email that outlines your interest with the cover letter attached to the email as a formal application document. This way your documents can be forwarded without any concern about changes in format.

Web-Based Applications Most employers will require you to fill out an application online. This can feel like a redundant task after you have worked diligently on your resumé. You might be tempted to fill in the fields with “See resumé” with the hopes that you will be able to attach a resumé at the end of the process. However, demonstrating that you can complete an entire application helps your future



CHAPTER 7   Workforce Issues and Finding Employment

employer to see how you pay attention to detail and how you value their time in the review of your application materials. Complete these applications carefully and cut and paste where appropriate!

Letters of Recommendation/ Verbal References Put together a list of recommenders who can provide information about you in the search process. Usually, three to five people are sufficient. Considering that most of the positions you will be applying for are clinical in nature, you should find people who can speak to your clinical skills. These can be preceptors, supervisors, and university faculty. Avoid people who can only serve as a personal reference. When asking for a reference, attempt to do it in a face-to-face meeting. You are asking for a serious commitment from someone, and you should demonstrate that you respect their time and energies. Provide the recommender with a resumé, sample cover letter, list of classes taken, and any other information you feel would be helpful to them should they need to write a letter or speak with an employer on the phone. You should also provide a recommender with your targeted list of job locations and job descriptions if you have them. Your job search may be a fluid process. Do not forget to keep your recommenders up to date as to where you are applying. Additionally, if you find that you are changing your search or job interests, make certain that recommenders are aware of these changes and your rationale.

Mode of the Interview The global pandemic has encouraged all of us to be more flexible. It is very possible that your first opportunity to interview might be online, even if you are close to the job location. If you are going to be screened for a first interview or offered a second interview online, make sure that the date and location work and that you will have a sufficient broadband signal and a quiet place in which to speak. Online interview tips: n

If you need to use specific software for the employer, download it early and work with the settings. If technical support is available to you, don’t be afraid to use it.

n

Check your lighting to make sure your interviewers can see your face.

n

Angle your camera slightly above your face for a pleasing view.

n

Look at yourself on camera and notice the surroundings behind you. Is there clutter? Are there items that might be distracting? Clear out your interview space or consider a virtual or blurred background.

n

Test your audio settings and consider wearing a headset with a good-quality microphone.

n

Interviewing Success

Close unnecessary browser pages and applications.

n

You have searched for the perfect position and applied to postings that might launch your career. Now you have been invited to the interview. How do you prepare? This section provides you with tips for success. First, consider the following suggestions as you move forward with your job search.

Eye contact is a challenge in an online/ video interview. Try and look at the camera as often as you can and avoid looking at yourself for long periods in the interview (some will even turn off any view of themselves to avoid a distraction).

n

Remain Flexible

Keep the area where you will be interviewing as quiet and distraction free as possible.

n

Technical problems always seem to happen when the stakes are high. Keep smiling and remember to breathe through any technical difficulties that might arise.

n

You can make a few sticky notes and put them around the edges of your monitor — ​ this can be a great way to remember which tests you’ve given, what hearing aid manufacturers you are familiar working with, and so on.

Being asked to interview for a position is a privilege, not a right. You should remain as flexible as possible when scheduling an interview. This will be your future employer’s first glimpse into your willingness to adapt and consider the needs of others. While you should remain flexible in your timing, also be mindful of your needs. For instance, do not schedule an interview for a time when you know the timing will be tight for you to commute to the site or when you know you need to leave the interview at a very specific time.

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n

You might think about formally dressing from the waist up for these interviews. However, always remember there could be a possibility where you might need to move about the room (e.g., a problem with lighting, you need to stop something that is making noise, a technical issue with your computer). If you’re fully dressed, you won’t need to worry about any last-minute needs to move about the space.

smoking cessation technique will be very helpful to you on your interview day. n

Avoid excessive jewelry, makeup, or nail polish colors that might be distracting to your interviewer.

n

An institution may have a policy about hair color, stating this needs to be a hair color typically found in nature. Your safest bet is to have a natural hair color.

n

Consider covering tattoos. Your interviewer may have an implicit bias against applicants with tattoos. Although this may not seem fair, it could stand between you and the position you desire.

n

Wear contact lenses or glasses if you need them. You may be looking at documents or websites with the employer or a human resources representative. You should be able to see them!

n

Look at yourself from all angles in a full-length mirror or have a friend or family member give one last look. Make certain all tags are removed from your clothing, no details have been missed (e.g., belt loops, collars are flat), and your clothing fits appropriately.

Looking the Part This will vary dependent upon the location and population you might potentially serve. Arriving underdressed conveys an image that you don’t care and arriving very overdressed states that your expectations might be overwhelming. You also might have different ways that you wish to express yourself in what you wear and how you look. For some larger organizations you might be able to find dress code information through a simple online search. For other organizations it might be harder to find this information. Below you will find a list of conservative approaches to appearance that can get you to your interview. Once you are engaging with an interviewer, you can consider asking more about dress code policy. n

Think about the position. If it is in a school, consider what you might wear if you were already working in that environment and the superintendent asked you to lunch. You would likely dress up for that occasion, right? You should treat the situation similarly for the interview. You can consider the same general rule in a medical setting; however, some medical settings may have a day-to-day dress code available to you with a basic internet search, or they might require scrubs, which are not recommended for an interview.

n

Women may wish to consider skirts or dresses; men should wear long-sleeved collared shirts with a tie. All clothes should be clean and pressed, and clothes should fit appropriately. Often suits and jackets are best.

n

Closed-toe shoes are a must, because they are often required in a medical facility. Socks or other hosiery are recommended.

n

Arrive clean and showered. Avoid excessive perfumes or colognes. If you are a smoker, do not smoke after showering. A patch or other

There are items to bring to your interview and items to avoid. Many applicants will bring a small folio to the meeting. This simple system can contain a few extra printouts of your resumé, a pad of paper, and a working pen. When you consider the folio, a basic black or brown color is best. A simple pen with no logo is also recommended. This way you avoid any bias that an interviewer might have regarding affiliations you might display. Other items that might be useful in your folio include lists of assessments you are familiar with, populations served, or hearing aid manufacturer programming software you are comfortable using. You should also have a written list of questions for your employer. You might also consider taking something to read to the interview. This can be useful should there be downtime and it may look more professional than engaging text messaging, email, or social media. You might want to print pages from the organization’s human resource manual or other industry-related materials to look at while waiting. Finally, having the contact information for your references can be handy if you have not already submitted them to the employer. If you bring your smartphone to the interview, it is best to have it turned completely off during the interview process. Phones that vibrate or light up are a distraction,



CHAPTER 7   Workforce Issues and Finding Employment

as well as smart watches that send messages directly to your wrist. If you forget and your device makes a sound, do not look at the device. Looking at who is calling or texting conveys one distinct message: There is someone else more important than your interviewer. Occasionally you may need to keep your phone and its notifications turned on (e.g., a sick child or elderly parent at home with a caregiver). Tell your interviewer that you may need to attend to a message at the beginning of the interview. If this is the case, silence all other notifications and only accept notifications from the one or two contacts who might reach out to you. If you make this type of request, you will have your first glimpse into how understanding a future employer might be in future situations.

tracted while talking with your interviewers. Avoid loud and public places for your interview and keep other distractions at a minimum.

Arriving at the Interview

The interview begins the moment you arrive or are visible on a screen. Remember to smile and greet your interviewer warmly. During an in-person interview, you might shake an interviewer’s hand, dependent upon any infectious disease protocol. Reach out with your right hand and grasp your interviewer’s right hand firmly. Prepare to engage in three up-and-down pumps of your hand while you say “Hello” to the interviewer. Maintain eye contact during the handshake and do not waiver in your eye contact or glance away. This is an appropriate time to state your name (especially if you use a name that is different from what is on your resumé. For instance, an applicant whose full name is Elizabeth may state, “Please feel free to call me Liz.” You can also clarify the pronunciation of your name, where appropriate). During the handshake, you might also state that it is your pleasure to meet the interviewer and that you are doing well and are enthused to be invited for a formal meeting. Remember, your ability to engage in an appropriate greeting is part of what your employer is evaluating. How will you interact with clients and families? Are you confident? Your handshake may be the first impression. One challenge point that occurs during the beginning for many new applicants is when you sit down with an interviewer and are asked, “Tell me a little bit about yourself.” Although this may seem like an easy task, it might be one where you get lost without practice. Try and keep this response brief — to about 100 words with three to four talking points that you will easily remember. If you are beginning this statement with a phrase like, “I was born in…,” you are likely going to provide far too much information. Instead, consider what brought you to this profession and why you are excited about today’s interview. Your “tell me a little bit” statement might vary slightly from interview to interview. This is acceptable as long as you are true to yourself.

Always arrive at least 10 to 15 minutes early to an inperson interview. For online interviews, log in at least 10 minutes before the interview and test your settings. If you are at risk of being late, make certain to call the employer and explain your situation and offer to reschedule the interview. If your reason for tardiness is a traffic incident, remember that these are easily verifiable online by the potential employer. Make certain that your reason is credible! When the interview starts, be friendly and professional with any staff who might check you in for your appointment or verify your equipment settings with you. Office staff are critical team members and may have more influence on the decision-making process than you know. A few kind words can go a long way. You may be offered water or coffee at in-person interviews. Water is always a safe bet because it is not likely to stain if you spill a bit and does not contribute to halitosis the way coffee might.

Things to Avoid Avoid chewing gum or candy. If fresh breath is a concern, consider small mouthwash packets that can be used during a restroom break or dissolvable freshening strips. As mentioned previously, best practice will be to leave your cell phone at home or turned completely off in a bag or folio. You will also want to do your best to leave your problems at home. Occasionally we may have challenges with spouses, significant others, or our own health. The interview is a time to keep things in the positive and avoid conversations regarding your personal problems. If you are engaging in an online interview, make sure notifications are turned off on your computer (e.g., email, social media, text messages) so you are not dis-

The Anatomy of an Interview Interviews are relatively simple in their structure. Like most things, they involve a beginning, a middle, and an end. It is the beginning and ending that pose unexpected challenges for those who are new to the interview process. Each of these sections will be discussed subsequently.

The Beginning of the Interview

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After you engage in a few pleasantries and a description of yourself, you will quickly move to the middle of the interview. Take some time to rehearse your “tell me a little bit about yourself ” statement. You might want to use an old-fashioned approach of writing out some brief topic areas on notecards that answer basic questions about yourself, your interest in the field, and how you learned about the position. You could consider how responses might vary depending upon where you are interviewing, the populations seen there, and what you know about the environment/organization.

The Middle of the Interview The middle of the interview is typically more technical and requires answers to specific questions. Here, your employer is looking for three “F”s: fit, flexibility, and how you function. When considering fit, the employer wants to understand how you meet the requirements of the position. Make sure you have studied the job description and posting well. Have examples ready! If the posting reads, “Competence with a wide range of hearing aid software,” be ready to state how you fit. Alternatively, if the posting is highly specific with a statement such as, “Experience with pediatric dysphagia a must,” you should be ready to describe your experiences in detail. You might also be asked some more technical questions about how you might address certain clinical cases to make sure your knowledge and skills are a fit for the position. Flexibility may be assessed by asking you general questions about what you enjoy about the environment where you are applying and what motivates you in your work. On a more specific level, an employer might look for confirmation regarding areas such as:

n

what you look for when working with a team, and

n

your aspirations for career advancement and leadership.

It is important to be honest regarding your flexibility with your employer. For instance, if you are not able to be flexible with your working hours, you should not state that staying later on a given day and coming in later the next works for you. Instead, you should state what flexibility you do have and where the challenges occur. For instance, you might state: “I can stay later on Tuesdays and Thursdays. However, the other days of the week are a challenge for me due to commitments after work.” This lets your potential employer know what you can do without interpreting your message as a complete “no.” Function is more critical to employers than most students or new graduates understand. You can be trained to perform assessments and use tools. However, how you function at work day to day may be less malleable. To get at function, employers will often ask questions using a behavioral event interview strategy. Here, the employer will ask questions, including how you have responded in the past. There is a simple formula for answering these questions called STAR: n S: situation n T: task n A: action n R: result

Think of this type of framework as you answer questions to make sure you cover all the elements. An example is provided in the box. When engaging in a STAR response, remember that you might want to avoid using the words “situation, task, action, result” repeatedly. This will give your answers some variety!

n

what management style you prefer,

STAR Interview Question Example

n

confirmation of the working hours at the facility and what you might expect,

n

commuting between facilities as appropriate,

n

how you might respond to interruptions during the day,

Imagine an interviewer asks you, “Tell me about a time you worked with a team and you handled conflict.” Your response can be framed using the STAR format.

n

your preferences for workspace and collaboration,

n

how you might respond to changes in your caseload as appropriate,

S:  “On one occasion at City Hospital, I was working with an interprofessional team. A situation evolved where we developed scheduling problems for the inpatients who needed our services. There were significant



CHAPTER 7   Workforce Issues and Finding Employment

delays moving patients from room to room for the different treatments they needed. It appeared that the staff responsible for patient transport were challenged in moving patients in a timely way.” T:  “Our task was to meet as a team, both the providers and the transport staff, and have a productive conversation about the needs and limitations for the patients we served.”

n

Tell me about a time you helped build a team.

These statements may seem somewhat similar (e.g., handling conflict or disagreement). It is important to listen closely to the question at hand and answer as specifically as possible, using examples from clinical work wherever possible.

A:  “My supervisor and I were called to action and scheduled a meeting with all of us at lunch. Of course, not everyone could make it, but more than 90% of the team arrived because we all knew we were getting frustrated by the day-to-day problem. My supervisor and I led a guided conversation to determine where the bottlenecks and challenges fell in the process. It was important that everyone in the room used positive and nonblaming language. We made that one of our commitments to the conversation at the outset.”

Again, it is critical to remember that there will be many areas of your position where you can be trained (e.g., administering a new assessment or operating new equipment). What is harder for your employer to change is your fit, flexibility, and function. What may seem like a dream job on paper may not be feasible for you because of the three “F”s. It is better to know this before accepting a position versus setting yourself up for failure on your very first job. Learning that a job is not a fit before you accept the position is a win for both you and the employer!

R:  “We found three bottlenecks in patient transport as well as our inpatient rehab scheduling. We worked with the managers of our units to change scheduling and our process. It took about three working days, but soon we worked out the kinks and had a better experience for the patients.”

The End of the Interview

Note how the example above uses the STAR format and avoids negative language or any strong focus on negatives, and does not overstate the role the student may have played in the situation.

Other STAR-based questions you might be asked include:

You will likely feel the interview turning back to you at a certain point, signaling the final phase of the process. Visual clues might be observing the interviewer looking at their watch or a clock on the wall. Verbal cues include the employer asking questions such as, “So, what questions do you have for me?” or, “Is there anything you feel I should know about you and your application?” These types of questions signal that your interviewer is nearing the end and wants to be certain that no questions are left unanswered should they move to make you an offer. Typical questions to ask toward the end of an interview include, but are not limited to: n

What assistance will I have for completing licensure and certification requirements and applications?

Tell me about a time you had many tasks to complete with similar deadlines.

n

Who will mentor my first year of employment?

n

Tell me about a time you addressed an unhappy patient or family.

n

Where will I work? (if more than one clinical site)

n

Tell me about a time you failed to meet an obligation.

n

What materials, tests, and equipment will be available to me?

n

Tell me about a time you made a mistake in your work.

n

What opportunities are there for continuing education?

n

Tell me about a time you handled conflict or disagreed with your direct supervisor.

n

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n

What assistance is there for relocation?

n

Is it acceptable if I am late on Tuesdays?

n

How and when will my performance be evaluated?

n

If I take this job, may I leave early on Fridays?

n

Can you tell me more about the current staff who work here?

n

What is the exact salary?

n

Are there materials for me to review regarding benefits?

Be sure to write down the answer to the questions and thank the interviewer for providing responses. The end of your interview is a great time to go back to a list of questions you have prepared. What is left unanswered? What would you need to make your decision, aside from salary information? You may have questions about benefits, and many employers may direct you to a manual or website rather than engage too deeply at this point in the conversation. This is normal. As you close the interview, wrap up your final questions and make a positive statement about the interaction or organization. Even if the position is not the right fit for you, remember that the people at this organization are your professional colleagues. Often, you wrap up the final moments of an in-person interview with a handshake. It is appropriate to thank the interviewer for their time and ask if they can tell you more about the decision timeline at this point. A simple “Can you tell me more about your timeline for hiring?” is appropriate. Avoid any statements that put pressure on the interviewer at this point, such as, “I’ve got several good offers, so I really need to know soon.” A statement about these needs is better left to a follow-up call or email. Closing a virtual interview will have many of the same steps, without the handshake. Sometimes signing off virtually can feel awkward because you may not feel certain you should log off at a given moment. An appropriate way to handle this is to state your farewell, that you are signing off, and that you look forward to hearing from the interviewer/hiring committee in the last moments of your time together. By sandwiching your verbal intention to sign off between the farewell and final phrase about the future, you give the interviewer an extra moment to interject should they not want you to log off from the meeting at that moment.

These types of questions signal to the employer that you are focused more on time away than time on the job, and how much you will get paid. Of course, there may be times when this information is critical to you (e.g., you are responsible for picking a child up from childcare on Wednesdays and cannot be late). A question regarding this type of situation is best left to the final negotiation process.

Telephone Interview Tips Employers (or a designee) might screen candidates using phone calls before engaging with virtual or in-person interviews, or they might conduct an entire interview by phone. Conducting interviews this way can be efficient for all parties involved. If you are asked to conduct a telephone interview, remember several things: n

Screening interviews are typically brief calls to determine if you meet minimum qualifications and should move to a next round of interviews. Don’t be disappointed if the interviewer moves the call along, quickly seeking information.

n

Telephones can fail. At the outset of the call, determine who will return the call if the call drops.

n

Conduct a phone interview in a quiet, distraction-free space. If your interviewer discovers you are multitasking, it sends a message that this job is not important to you.

n

Speak clearly and ask for confirmation that everyone can hear you if there is more than one other person on the call.

n

Interviewers cannot see your facial expressions. You may need to tell your interviewer “That makes me smile” or “Your question is causing me to pause a bit and think of possibilities” so that you avoid any misunderstandings.

n

Consider turn taking during the call. Your interviewer won’t have visual cues regarding when you are ready to move on from your

Questions you should consider avoiding in the first interview: n

When can I take my first vacation day?

n

When am I eligible for sick time?



CHAPTER 7   Workforce Issues and Finding Employment

answer. You can wrap up with summary statements such as, “Those are my thoughts on that question. What other questions do you have for me?” n

If you are being interviewed by a group, be certain to write down names and do your best to confirm who you are speaking to on the call. For instance, imagine an audiologist and a hiring manager are in the room. There could be instances where you change your language (either more or less technical) depending on the person who asks you a specific question.

n

Maintain your sense of humor. If you make a mistake and call someone by the wrong name, apologize and move on. If the technology poses a challenge, acknowledge that the best-laid plans sometimes fail.

Meal Interviews Interviews may include breakfast, lunch, or dinner with your primary interviewer and possibly a panel of other employees. Use your best etiquette at these meals and consider ordering foods that are easy to eat. If you need resources regarding etiquette, check with your university placement office; they may have workshops available to you. Another option is to search online resources and books. Be mindful of your food order so you do not appear overly difficult to please with a long list of changes to menu items. Your interviewer will likely have many different questions during the meal, so, you can expect to spend a lot of time talking versus eating. Avoid criticizing the food or being rude if the service is inadequate. However, it is acceptable to be appropriately assertive should there be a problem with your meal. Follow the lead of your interviewer and other guests before ordering any alcohol. Most experts do not recommend ordering alcohol, even if your host elects to have a drink. At the conclusion of the meal, thank the host. Also, determine if the restaurant environment was not conducive for you to talk with each member of the group (perhaps it was too noisy or the table was too long). If so, personally interact with each person immediately after the meal, thanking them for their time. This will provide your other tablemates with an opportunity to ask any last questions.

Second Interviews Some employers might invite you to a second interview. Second interviews often signal that the employer is very

interested in you and is seeking an opportunity for one last look or that there is a short list of candidates and there is desire to make a ranked list of candidates who might receive an offer. Second interviews are often conducted in person; however, this is not a requirement. You may not know exactly what your situation is; however, you might get hints by closely listening to the employer’s invitation. Phrases such as, “We want you to have a chance to meet the team” or “We want to take a little more time to talk about the schedule and what the day to day might look like” are very positive signs. Phrases such as, “We’ve entered the second phase of the interviews and we’d like to spend more time with you” may signal that you are one of a few applicants invited to come back to the site. The main issue about second interviews is this: If you have no intention of accepting a position, do not engage in a second interview. This wastes time and could damage your professional relationships. Instead, state that you are very flattered, but you are pursuing other opportunities. Prepare for the second interview just like you would the first. You will likely meet with different staff and be asked more detailed questions about yourself and your work style. Often second interviews focus on the “fit” portion of the three “F”s. They are often more relaxed than first interviews, but do not make any assumptions.

“Forbidden” Interview Questions Some interview questions are discriminatory and off the table during the interview process. These include questions related to age, race, color, gender/sex/sexual orientation, national origin, religion, marital/family status, arrest records, and disabilities. There are several options you have if you are asked one of these questions. n

Answer the question. This decision is entirely up to you. However, you may sense that the employer is not asking the question in a discriminatory manner. Instead, it is an error. For example, you might discover your interviewer attended the same high school as you. If they ask, “What year did you graduate?” this could be taken as a method to determine your age. However, if you sense that it stems from a friendly and positive conversation, you could choose to answer it.

n

Decline to answer the question and/or redirect the conversation. Perhaps your interviewer queries you about your plans to have a family. One option is to state, “I am not comfortable discussing my family planning in a job interview.” Another that moves to redirection

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might be, “I’m reflecting on the posting for this job. The job posting deals with working as a pediatric audiologist. Let’s talk about that.” Making this form of statement tips your hand to the employer that you understand forbidden questions, but it keeps the conversation going and helps you redirect the discussion. (Note: You will have to determine whether you wish to engage with any offer from this employer.) n

If you are deeply concerned or offended, close the interview with a polite but meaningful statement: “Thanks for taking the time to meet with me today. I’m uncomfortable discussing questions regarding my sexual orientation in this setting. I wish you the best in your search process.” This form of statement closes your time together in a polite way. You can then decide which, if any, further action you would like to pursue with the organization.

result of this call could be that you are offered a position. This will be covered later in the chapter.

Considering the Benefits That Might Be Available to You You have done your homework and you are hoping for an offer! However, before moving to the specifics of receiving the offer, you should consider what types of benefits may be provided. Some of this information might be available through an employee handbook or a website from the organization. Reviewing these benefits early, before receiving a final offer, can help you with your selection process in weighing the pros and cons of positions when you receive an offer or multiple offers.

Salary and Benefits Salary

Postinterview Follow-Up Plan to follow up with your interviewer within 2 days with a thank-you letter or email. This gives you a chance to express your appreciation for the interview, renew interest in the position, briefly restate major qualifications, and explain any unresolved issues raised during the interview. Be sure to proofread any correspondence before sending it. You could also send a handwritten thank-you card if you believe that a card fits the culture of the institution. After you have sent your thank-you note, spend some time waiting. Reflect on what the employer told you about the timeline when you closed the interview. Give the employer an extra 24 hours after this timeline for follow-up. If you have not heard after waiting this period of time, it is appropriate to follow through with an email or phone call. Remember to keep your tone positive and upbeat during any follow-up interaction. Odds are your potential employer is very busy and there may be many demands on their time. Start any contact by briefly reminding the employer who you are, when you interviewed, and that you are following up to determine any next steps regarding the position. There are several outcomes of this phone call. One is that the potential employer will state that they need more time to make the decision. You could then learn an approximate timeline for a decision. Another outcome could be that the potential employer has filled the position with another candidate. Although this may be disappointing to you, make sure to thank the potential employer for their time and energies. Also, it is reasonable to ask if they will keep you in mind for other opportunities. Another potential

Salary is often the focus for most people when they consider a job. Salary is important; however, you should consider salary in the context of many other factors such as cost of living, job satisfaction, work/life balance, and other benefits. The latter is very important. You might trade away a higher salary for a benefit that could be very important to you, simply because you are not examining all the details carefully. Always look thoroughly at a benefits package and make comparisons where you can if you have multiple job offers on the table. Students are often primarily concerned about salary. Reliable information about salary exists at the Bureau of Labor Statistics. Other resources include salary surveys from the ASHA (reviewed earlier in this chapter) and the American Academy of Audiology (AAA). ASHA has sources that are specific to regions and practice locations that many students find helpful. It is important to remember, however, that most new graduates may not start at a median salary simply due to a lack of experience. Within salary, you need to consider the type of job for which you are applying. Some positions offer a higher salary with limited or no benefits. Other positions offer a full complement of benefits. What is important to you, and why? Always remember, forgoing benefits for more pay may sound like a good idea in the moment. However, could there be instances where you need these benefits? Consider your future carefully. Another important factor is to consider where you will live. A given salary in the Midwest will require a significant adjustment if you are moving to a state like California or New York. There are several different salary tools available online to help you calculate differences



CHAPTER 7   Workforce Issues and Finding Employment

across the country. Students are wise to check these, especially if you are conducting a national search for a position. Another factor to consider is how your salary breaks down to an hourly rate. A common misconception is that a clinician who works 9 to 10 months in a school but is paid over 12 months is paid to work in the summer. This is not the case. Instead, this clinician is electing to be paid during the summer for work already performed during the school year. This could mean that a clinician on a 9- or 10-month appointment may actually earn more per hour than their colleague who works in a setting who is paid a similar salary for working all 12 months. You will note that salary is considered in this chapter as something you will discuss after the first interview. However, you may find times that an employer will ask you about salary expectations in the first interview. You should study the aforementioned sites, confer with colleagues and university faculty, and use broad data from the Bureau of Labor Statistics in providing a salary range (www.bls.gov). Also, demonstrate your flexibility if you find an employer balks at your salary demand. A simple statement of, “I’m interested in this salary range; however, I am willing to negotiate for the right position” may keep you in the conversation longer than being very rigid.

Health Care Insurance For many new applicants, the health care market can be a challenging maze of information. Before you begin looking at health care options, consider your current health and any chronic conditions you may have. Do you require frequent physician visits, or are you in good health? Do you have a spouse and children who may need health benefits? Are you planning to have a family in the near future? All these decisions may impact your decisions around health care. Small employers may have one option for health care while larger employers may have several different plans to choose from, depending upon your needs. In most instances (but certainly not all), employees subsidize some portion of the health insurance cost that is provided through the employer. This means you are paying for part of the plan each month, and you may have to pay copays and other out-of-pocket costs as you use the health care system. Some broad examples of these plans include: High-deductible plans:  These plans may have lower costs to you monthly. However, should you need health care, you may pay a large portion of the cost up front as you use care. In these plans, you might pay for entire visits and procedures until you reach a set limit (e.g., $10,000 annually). Highdeductible plans require an analysis on your part.

How much care will you require? If you have a catastrophic need (e.g., accident or emergent health condition) can you afford to cover the deductible in a given calendar year? Health Maintenance Organizations (HMOs):  These plans typically require you to establish a primary physician who will manage your health care. This means that referrals to other providers come through your primary care physician after you have seen this provider and been triaged for care. HMOs typically have a network of physicians and facilities that are your first point of referral. This means that you are restricted to these providers to receive the lowest cost of care out of pocket. Copays and deductibles may still be required; however, the deductibles are usually lower than a high-deductible plan. Preferred Provider Organizations (PPOs): These plans have published providers where you may not require a referral like an HMO. Often, if you use the providers in the network, you do not need to see a primary care physician for each referral to a specialist. Again, deductibles and copays may be required. Additionally, your portion of the subsidy for the cost of this type of plan is typically higher than the aforementioned plans. Open-access plans:  These plans may be highly desirable, but costly. These plans give patients the widest range of options; however, copays and deductibles may still exist. Because these plans offer access to many providers, your portion of the cost of these plans may be very high. WebMD offers resources that further describe health care plans. A link to this information can be found in the Resources section of this chapter. Remember, health care is fluid and subject to change in the United States. Also, some benefits may vary by the state or region of the country you live in. When in doubt, check with your employer and the associated health plan. Remember that you will typically make a choice about a health care plan with your employer at the time you start working and then annually thereafter. This means that you will need to stay with whatever choice you make for 12 months at a time. If you experience the birth of a child or other significant change in your life status (e.g., marriage, divorce, adopting a child) you may also have a window in which to make changes to your health care plan. You will want to look carefully at documentation from your employer regarding any changes you might make to your health care plan.

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Retirement and Other Incentives

Look to answer questions about PTO such as:

You should also consider retirement options with any employer. 401(k):  These retirement plans involve you providing a portion of your salary (often pretax) and a complementary percentage paid by your employer as a match. For instance, your employer may match up to 5% of your net salary that you invest in a 401(k) plan. These plans are typically investment accounts where you make choices about the level of risk you are willing to accept and the amount of return you expect on the investment of your salary. It is important to understand that many of these plans are not guaranteed retirement plans. Instead, they depend upon how the accounts where they are invested perform in the financial markets. You could lose all or a portion of your money if the market is not doing well. Defined contribution pension plans:  These plans are difficult to find, but they may exist in jobs that are funded as public service. For instance, some schools, universities, and other public positions may have this type of benefit. In these plans, you contribute to the retirement plan and work a given number of years until you are vested. If you have worked the appropriate number of years and contributed appropriately, you will have a predictable income when you retire at the age stipulated by the plan. You will want to examine the terms of this type of plan carefully to make sure you meet the requirements for the benefit. Profit-sharing, commission, or bonus plans: Some companies may have profit sharing or commission plans that are available to you based on company or personal performance. This type of plan may pay out monthly or annually, often at the close of the calendar year. As an employee and clinical service provider, you will want to confirm that these types of incentives do not compromise your ability to make ethical decisions when treating patients or administrating in your role.

Paid Time Off (PTO) Paid time off is something that many new employees are excited to learn about. This time is vacation pay or sick pay that the employee may earn where they are paid while not at work. You will want to look at an organization’s PTO plan very carefully.

n

How much PTO do you earn? Is there a differential based on your years of service? Often, PTO is earned based on the number of hours you have worked in a given pay period. Some organizations may reward employees who have been working with them for multiple years with more PTO accrual than newer employees.

n

When may you use your first days off? Some organizations will have a waiting period.

n

What notice must you give for PTO? How is it reported? Is it approved first-come, first-served? Is it based on seniority? This could impact your time away during peak vacation times, especially early in your career.

n

Does your PTO expire? Alternatively, may any unused PTO be rolled into another year or period?

n

May you donate PTO to another employee who is going through a hardship?

n

Are personal days offered? These may be offered aside from vacation or sick time.

n

The intention of these days is to give you time to conduct your personal matters.

Other Time Off Confirm with your employer what policies exist for other forms of time off. Different forms of PTO in this category might include: n

Bereavement time

n

Any policies related to the birth of children or adoption (some organizations may be more liberal than any required federal policies). Remember, being paid for maternity/paternity leave is not a requirement.

n

PTO for professional development, including time spent furthering your education, which may be necessary for licensure and any certificates you may hold

n

Any other policies an organization might have regarding time off, such as jury duty or other time away from work



CHAPTER 7   Workforce Issues and Finding Employment

Other Perks

Receiving the Offer

Sometimes it may be easy to overlook other perks an organization might have. However, these can add up. In some instances, a perk may be offered to you tax free, and the advantage to you is that these benefits are not taxed as you earn them (of course, always check carefully).

You have engaged in the interview and reviewed potential benefits. Now your future employer contacts you to discuss the terms of an employment offer. This can be an exciting but stressful time. Maintaining a clear mind during this process is critical.

Other perks to consider: n

Parking:  Always verify parking costs and whether they are subsidized in any way by the employer. Parking can be costly for those who commute to work daily. Alternatively, some large organizations might incentivize you to use public or other forms of transportation through other compensation or reward plans.

n

Business partnerships:  Some organizations may have relationships that offer you discounts on gym memberships (these could be linked to the health plan that you choose), cell phone costs, tax preparation, and more. Check to see what benefits might exist by looking at the organization’s benefits manual.

n

Professional fees/continuing education/ licensing:  Your new employer might be willing to cover some or all of the costs for professional credentialing and continuing education. You should examine these policies to determine how much funding is offered, how it is requested, and how long you need to be with an organization to earn this type of benefit.

n

Employee assistance programs: Some employers may have programs to assist you and your family members with mental health, parenting skills, substance abuse, financial matters, or even adoption. Although this is not guaranteed, you should look at a benefits package carefully to determine whether these benefits exist and if they might be useful to you.

n

Educational assistance programs: You might want to determine if an employer supports furthering your education. This might be in addition to funding your continuing education for licensing. In this case, perhaps an employer pays a portion of an additional degree, coursework, or certification you might seek. This could have a great payoff for your future!

The First Contact Many employers will contact you via telephone/teleconference to formally offer you a position. Be certain you are in a place where you can take the call and focus on the conversation. Be ready to take notes and have any final questions answered. You should have these questions written down and readily available. Remember, you are a professional interviewing and accepting a job in the real world. Although support from a parent or friend is comforting, asking for a third party to be present during the offer reveals you are not ready to handle the responsibilities of a clinician who needs to make independent decisions every day. Take this call independently, knowing you will gather all the information without making a decision during the call. There are many areas to consider: n

Remain enthused. Your future employer is moving forward with a big step for both of you. You may not be sure of the fit as you listen to the terms of the offer. Make sure to listen to the entire offer before being too negative or too positive. Avoid statements such as, “I can’t believe this is happening!” or “Is that all?” or “Thank goodness, because I don’t have any other offers.” Statements such as these may limit your negotiating power with the future employer.

n

Be mindful of your own research and how it fits the offer. It might be tempting to tell an employer about all the research you have done and how you believe the offer you are receiving can be better. However, your statements might be off-putting to the potential employer who may have this same information but have limitations. Determine what is most important to you versus passing along a vast amount of confusing information.

n

Receiving an offer is a confidence booster; be careful. You want to remain sensible during the call with an offer. Although receiving an offer is an affirmation for you, now is not the time to let your head get too big. Be mindful and considerate as you negotiate with a future employer.

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n

If you want to move forward, ask your future employer if you will receive the offer in writing or if it is a verbal offer. If the offer will be provided in writing, always ask for more time to review the written terms before saying yes. If the offer is verbal, take detailed notes and ask your employer for the time you need to consider the offer. Written offers are always desirable over verbal offers. Note that the offer may expire. Some employers may give you a week; others may have a shorter term. If a future employer demands you make the decision on the spot, consider what working with this employer might be like in the future. Is this the type of pressure you prefer? Most employers will give you at least 24 hours if you confirm your interest and state clearly why you need a little time to consider the situation. If you have a spouse or significant other, stating that you would like to confirm the offer with your family is a reasonable first step.

slightly higher than what they require to land somewhere in the middle. Often employers will negotiate for one round. This means you need to negotiate all at once instead of moving the process across multiple days. So, if you are seeking to negotiate around salary and funding for continuing education, you need to do so all in the same negotiation discussion. n

Remember that some elements of a position may be established around policy. For instance, if a large employer has a policy in place regarding vacation, it might not be malleable due to parity with other employees in the organization. Consider the size of your employer. Sometimes a small business may have more flexibility than a larger corporation or agency.

n

Think back to your conversations with your potential employer. Did they provide you with any clues? For instance, hearing something like, “We’ve been waiting to fill this position for quite a while now” may reveal that you have additional bargaining power. In contrast, if you know that you are one of many applicants, your ability to negotiate may be reduced.

n

Finally, think about your special knowledge and skills. Do you bring something to the table that others do not? Highlighting this during the interview and negotiating process is important!

Negotiating On some occasions, you will look at the offer and possibly wish for something better. Consider the following tips: n

n

n

n

If you have another offer that appears better to you, consider talking about how the other meets your needs without conveying an attitude that educates your future employer about the competitive market. Instead, state why the other offer you have may be a good fit for you and determine how the employer can meet your needs. If you have solid data (i.e., Bureau of Labor Statistics, cost of living calculators) and wish to further negotiate salary, let your future employer know where you are drawing your information from during the conversation. Some positions will have little room for negotiation. An example might be positions where there are published salary schedules/ negotiated contracts such as public schools. In these instances, attempting to make large demands regarding salary negotiation will reveal your naiveté more than anything else. In rare instances, you may be able to start higher on a published salary schedule, such as in the public schools, as an employer may award experience for previous externships, placements, or related work evidence. Be clear about your requirements for the position. Many applicants are advised to aim

Intangible factors when considering an offer: n

Does the staff work as a team or independently?

n

Can I see myself making friends here?

n

Is there someone who could be a good mentor for me?

n

Is the supervisor someone I can trust? Do they demonstrate good leadership?

Making the Decision As you prepare to accept a position, confirm with your employer what the final terms of the employment will look like. Will you be signing a contract, or will you be giving your word? If there is a contract to sign, always read it carefully. There may be hidden elements in a contract that require further legal review before you sign. This is particularly true of noncompete clauses, which may state that you will either not take patients with you



CHAPTER 7   Workforce Issues and Finding Employment

should you accept a different position or that you will not accept a position within a given radius of your current employer. Look closely at noncompete clauses to avoid legal headaches down the line. It is best to have noncompete clauses reviewed by a lawyer.

Is This Where I Want to Work? Although it may seem that an interview is one sided and the interviewee is the only person being judged, an interview ought to allow an applicant to judge the qualities of the organization that will influence his or her determination of “is this where I want to work”? (Golper & Brown, 2004). When determining where you want to work, consider factors such as the following: n

What is the reputation of this program? Will I be proud to say I work here?

The interviewer challenges you rather than inviting your responses.

n

The interviewer takes numerous calls or accesses media during your interview without apologizing.

n

You need to find your own clinical fellow (CF) or fourth-year experience mentor.

n

The salary is comparatively higher than you would expect for your experience and for the position for no clear reason.

n

The person who previously worked in the position left after a very short time.

n

You are not invited to speak with current employees or given other access to them.

n

You are asked to take a personality assessment before you are allowed to interview for the position.

Weigh all red flags carefully and determine whether the position is the right fit for you. Occasionally, positions that may appear the most prestigious or offer the highest salary may not be the best fit for you.

n

What is the financial stability of the program?

n

What are the program’s vision, mission, and values?

n

Is the facility clean and well maintained?

Getting Started

n

Are there sufficient supplies and materials?

n

Will I have my own computer?

n

Will I have sufficient privacy to do my desk work?

n

Do people seem happy?

n

What is the staff turnover?

n

Are the support and clinical staff friendly, respectful, and welcoming?

Once you have made your decision and signed any necessary contracts, it is time to make sure you are fully credentialed and ready to begin your new job. This will involve providing all elements necessary to start work, such as copies of transcripts/diplomas, licensure, payer credentials, background clearances, and fingerprint studies. Remember, your employer is monitoring you and your enthusiasm for the job, even before you start your clinical work. Make sure to comply with credentialing and paperwork requirements diligently.

n

Do people appear to behave and dress in a manner that is important to me?

n

Are there others in the program who are a part of my ethnic or cultural group?

Red Flags While you are interviewing or considering the offer, you may get a feeling that this job has problems. Common red flags may include: n

n

The interviewer is rude, abrupt, or ignores staff as you visit the agency.

Your employer may contact you for information well before your first day on the job. This may be to get you credentialed with different payers so that you can see patients/clients at the site as soon as possible. Check your email regularly and respond to employer requests quickly to avoid any delays in your future employment. Another responsibility you’ll have before starting in your position will be to obtain any necessary licenses and clearances to practice. Start on this process early and be tenacious with follow-up. Your employer cannot control your license/clearance status; this will be your sole responsibility.

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Check your mail, email (including spam), and any licensing and background clearance portals regularly to make sure you are moving forward with this process as quickly as possible. Some employers will not allow you to be at the work site unless you can demonstrate that you are appropriately licensed and have passed the necessary background studies.

Summary The focus of this chapter has been on the workforce and securing employment. Key concepts can be summarized in single words: research, networking, preparation, practice, style, and follow-up. Finding employment can feel stressful. However, the rewards are great with thoughtful and detailed preparation. Remember that your role as an employee starts upon submitting your accurate credentials upon application to the job. Chapter 8 continues with how to build your career once you have secured employment.

References American Speech-Language-Hearing Association. (n.d.-a). Quick facts. https://www.asha.org/about/ press-room/quick-facts/ American Speech-Language-Hearing Association. (n.d.-b). ASHA EdFind. https://find.asha.org/ ed/#sort=relevancy American Speech-Language-Hearing Association. (n.d.-c). What employers are finding on social media. https://careers.asha.org/getting-the-job/ what-employers-are-finding-on-social-media/ American Speech-Language-Hearing Association. (2002). Crisis in the discipline: A plan for reshaping our future. https://www.asha.org/siteassets/reports/ crisisinthediscipline.pdf American Speech-Language-Hearing Association. (2016). PhD programs in communication sciences disorders: Innovative models and practices. https:// academy.pubs.asha.org/wp-content/uploads/2019​ /05/2016-PhD-Programs-in-CSD-Report.pdf American Speech-Language-Hearing Association. (2019). Report of the 2013–2018 Academic Affairs Board (AAB) strategic plan to increase the student pipeline and workforce for phd researchers and facultyresearchers. https://www.asha.org/siteassets/reports/ academic-affairs-board-report-of-phd-shortageplan-2013-2018.pdf

American Speech-Language-Hearing Association. (2021a). ASHA 2021 SLP health care survey: Annual salary report. https://www.asha.org/siteassets/ surveys/2021-slp-hc-survey-annual-salaries.pdf American Speech-Language-Hearing Association. (2021b). ASHA 2021 SLP health care survey: Hourly and per-home-visit wage report. https://www.asha​ .org/siteassets/surveys/2021-slp-hc-survey-hourlywages.pdf American Speech-Language-Hearing Association. (2022a). ASHA 2021 audiology survey: Annual salaries. https://www.asha.org/siteassets/ surveys/2021-audiology-survey-annual-salaries.pdf American Speech-Language-Hearing Association. (2022b). ASHA 2021 audiology survey: Hourly wages. https://www.asha.org/siteassets/ surveys/2021-audiology-survey-hourly-wages.pdf American Speech-Language-Hearing Association. (2022c). 2021 member and affiliate profile. https:// www.asha.org American Speech-Language-Hearing Association. (2022d). 2021 member and affiliate profile trends: 2001-2021. https://www.asha.org/siteassets/ surveys/2021-member-affiliate-profile.pdf American Speech-Language-Hearing Association. (2022e). 2022 Schools survey. Survey summary report: Numbers and types of responses, educational audiologists. https://www.asha.org/research/ memberdata/schools-survey/ American Speech-Language-Hearing Association. (2022f ). 2022 schools survey report: SLP annual salaries and hourly wages. www.asha.org/Research/ memberdata/Schools-Survey/ Cotriss, D. (2023, May 11). Keep it clean: Social media screenings gain in popularity. Business News Daily. https://www.businessnewsdaily.com/2377social-media-hiring.html Council of Academic Programs in Communication Sciences Disorders. (2018). 2018 salary survey. https://www.capcsd.org/academic-and-clinicalresources/ Doyle, A. (2022). The difference between a resumé and a curriculum vitae. https://www.thebalancecareers​ .com/cv-vs-resumée-2058495 Golper, L., & Brown, J. (Eds.). (2004). Business matters: A guide to business practices for speechlanguage pathologists. ASHA Publications. Madison, C. L., Guy, B., & Koch, M. (2004). Pursuit of the speech-language pathology doctorate: Who,



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areas, or on the department’s social media. Check your local communication disorders department for such information.

why, why not. Contemporary Issues in Communication Sciences and Disorders, 31, 191–199. Malinsky, G. (2022, December 12). Don’t include your full address on your resume: Here’s why. CNBC. https://www.cnbc.com/2022/12/12/dont-includeyour-full-address-on-your-resume-heres-why.html McNeil, M. R., Nunez, L., Armiento-DeMaria, M. T., Chapman, K. L., DiLollo, A., . . . Robertson, S. (2013). Strategic plan to increase the student pipeline and workforce for PhD researchers and faculty researchers. ASHA. Oller, D. K. (2003). The PhD shortage in communication science disorders. ASHA Special Interest Division 10, Perspectives on Issues in Higher Education, 6(1), 2–3. Page, M. (n.d.). How important is a cover letter? https:// www.michaelpage.com/advice/career-advice/ cover-letter-and-resume-advice/how-important-​ cover-letter Stahl, A. (2016, February 8). 8 resumé style mistakes you’re probably making. Forbes. https://www.forbes​ .com/sites/ashleystahl/2016/02/08/8-resume-stylemistakes-youre-probably-making/?sh=34d50e06​ 562d U.S. Department of Labor, Bureau of Labor Statistics. (2022). TED: The economics daily. https://www.bls​ .gov/opub/ted/2022/245-areas-had-december2021-unemployment-rates-below-the-u-s-rate-of3-7-percent.htm

Resources Securing Employment n

n

n

American Academy of Audiology. In addition to job listings and opportunities for interviews at the annual convention, check for current job listings at http://www.audiology.org

n

Local libraries and bookstores. Check your local library or online bookstore for the section on employment or business. There are dozens of texts on topics such as interviewing, resumé preparation, and follow-up methods.

n

State-level professional organizations and conventions. Check state and national conventions and websites for placement and networking opportunities.

n

United States Department of Defense. See the contact information at https://www.usa.gov/ federal-agencies/u-s-department-of-defense for positions and requirements related to the Department of Defense.

n

U.S. Department of Veterans Affairs Careers. You can learn how to launch a career with the VA at https://www.va.gov/jobs/

Benefits n

WebMD provides information regarding health plans at https://www.webmd.com/healthinsurance/types-of-health-insurance-plans#1

n

Money Magazine provides general information about retirement accounts at https://money​ .usnews.com/money/retirement/articles/ retirement-accounts-you-should-consider

n

Vacation Counts offers considerations for paid time off at https://www.vacationcounts.com/ vacation-days-paid-time-off-work-policies-top10-questions-ask-hr/

Other Internet Sources Allied Healthcare Professionals:  http://www.Allied​ VIP.com Career OneStop:  http://www.jobsearch.org

ASHA publications and website. The monthly publication The ASHA Leader has a section on employment opportunities. The ASHA Career Portal (https://www.asha.org/careers/) has numerous resources for job tips, finding jobs, resumé writing, interviewing, and salary negotiations. You may also post a job resumé and search available jobs online.

Audiology Online:  http://www.audiologyonline​ .com

College department listings. Most college or university departments receive notices of job vacancies. These may be posted or available in a department administrator’s office or in student

HearCareers*:  https://hearcareers.audiology.org/ jobseekers/  *also a useful site to search for audiology externships

ASHA:  http://www.asha.org/careers/

CareerBuilder:  http://www.careerbuilder.com iHireTherapy:  http://www.ihiretherapy.com

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Monster:  http://www.monster.com Rehabworld:  http://rehabworld.com SpeechPathology:  http://www.speechpathology.com Therapy Jobs:  http://www.therapyjobs.com

Interview and Resumé Resources Best Interview Strategies:  http://www.bestinterview-strategies.com/questions.html Indeed:  https://www.indeed.com/career-advice/ interviewing/how-to-prepare-for-a-behavioralinterview

CollegeGrad:  http://www.collegegrad.com/ jobsearch/ Hloom’s Resumé Builder:  https://www.hloom.com My Perfect Resumé:  https://www.myperfectresume​ .com/

State and Local Association Resources Contact your state or local professional association to determine if it has a job listing or matching service. For state association contact information, visit ASHA’s website, https://www.asha.org



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Appendix 7–A Sample Resumé Samuel Smith

123 Harbor Lane Lakeville, KY 23414 [email protected] (555) 555-5555

EDUCATION University of the Lakes, Lakeville, KY Master of Arts in Speech-Language Pathology, Speech-Language Pathology Outstanding Student Scholarship 2019

May 2022

Hope College, Holland, MI Bachelor of Arts in Communications, Summa Cum Laude, Phi Beta Kappa

May 2020

PRACTICUM EXPERIENCES Graduate Student Clinician Lakeville Elementary School, Lakeville, KY

January–May 2022

• Provided assessment and treatment services to children with speech, language, fluency, voice, and literacy disorders • Led social thinking group for children with autism in 4th and 5th grades • Conducted hearing screenings for K–5th grades, directed parent volunteers • Documented services, wrote Individualized Education Plans (IEP), attended IEP meetings Mooresville Hospital, Mooresville, KY

August–December 2021

• Assessed and treated a variety of patients with speech, language, and swallowing disorders secondary to stroke, neurodegenerative conditions, and traumatic brain injury • Conducted supervised bedside and videofluoroscopic swallow evaluations and provided appropriate recommendations • Engaged in group treatment with patients with a variety of types of aphasia as well as cognitive communication disorders • Documented all services using electronic medical records system University of the Lakes Speech & Hearing Clinic, Lakeville, KY

September 2020–August 2021

• Provided comprehensive diagnostic and treatment services for patients with fluency, voice, motor speech, and phonological disorders • Conducted hearing screenings for all pediatric patients upon intake to the clinic • Participated in 4-week augmentative and alternative communication (AAC) camp for children using a variety of high-tech devices continues

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Appendix 7–A.  continued

VOLUNTEER Washington Elementary School, Ames, IA • Literacy Buddy for 8–9-year-old children in a 9-week intensive program

June–August 2021

PRESENTATION Smith, S. (2022). Providing literacy enhancement in the group setting. Paper presented at the annual convention of the Kentucky Speech, Language, and Hearing Association, Lexington, KY

SPECIAL ABILITIES/CERTIFICATIONS • Conversational fluency in Spanish and American Sign Language • CPR and Healthcare BLS Certified

8 Building Your Career Shari Robertson and Marva Mount

Introduction Congratulations on landing your first job! You should be justifiably proud of having accumulated the knowledge and clinical skills required to begin your career as an independent professional. We are delighted to have you as our colleague. Earning your degree is an important milestone; however, moving from student to practicing professional is a major paradigm shift. Your days — and the tasks that fill them — are no longer dictated by the demands of your professors and program requirements. There are no assignments, and no one is monitoring your progress to ensure you are successful. This chapter is designed to provide new professionals with a road map toward establishing and growing successful careers — from the nuts and bolts of navigating the first weeks and months of a new job to the application of career-advancing skills, practices, and strategies that are predictive of long-term success and job satisfaction. We will also discuss professional engagement and responsibilities, such as volunteering for your professional associations, and finish with career considerations that include promotion and advancement and strategies for changing employment.

Getting Off to a Good Start The first weeks and months of your first professional position can be as stressful and overwhelming as they are exciting. Fortunately, in addition to hanging your diploma and organizing your new office or treatment space, you can begin to lay the foundation for long-term success from the very first day. When you have the relevant information, you can more easily navigate expectations and responsibilities associated with your new role and prevent problems that could arise from a lack of knowledge and/or experience.

Roles and Responsibilities Now that you are no longer a student, you will be expected to be ready to go with little supervision. This can feel a little overwhelming, but you can smooth your transition from student to practicing professional by educating yourself about your new role and responsibilities. 149



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Begin by familiarizing yourself with your state’s laws regarding the professional credential requirements specific to your profession and your work setting. These may include (but are not limited to) licensure, educational certification, insurance credentials, professional liability insurance, professional scope of practice, and obtaining or maintaining your American SpeechLanguage-Hearing Association (ASHA) Certificate of Clinical Competence. Because there is no longer a clinic director reminding you to renew your credentials, insurance, and so forth, you will need to get into the habit of keeping track of these important professional documents and protections. It can be tempting to forgo certain credentials because they are not required in your current setting. However, since it is unlikely that you will remain in the same position or work setting throughout your entire career, you will want to carefully consider your current options regarding licensure and certification. It is typically much easier to obtain these credentials at the time you graduate because your degree-granting institution has ensured your preparation meets the current credentialing standards. It is not uncommon for people who wait to apply at a later time — even just a few years — to find they must take additional courses, accrue more clinical hours, or retake tests to meet new requirements. See Chapter 3 for more information. If you are a candidate for ASHA certification, this is also the time to arrange a meeting with your mentor or preceptor to discuss the plan to meet those requirements, including documentation of on-site visits and timely completion of required forms. Further discussion regarding the benefits of mentorship is provided later in this chapter. You may also see Chapter 22 for more information. Invest time into finding out everything you can about your new employer, including the employer’s philosophy or mission statement, goals and strategic plans, and corporate structure or staff roster. Review your employer’s policies and procedures manual, which may include topics such as attendance and punctuality, discrimination, sexual harassment, confidentiality, disability accommodations, conflict of interest, substance abuse, misconduct regarding technology (including the use of email and social media), and federal and state laws and regulations such as FERPA, IDEA, HIPAA, and Medicaid. Spend some quality time reviewing your schedule, specific responsibilities, materials, equipment, computing and communication systems, and anything else that will help you get started. Take a look at sample diagnostic protocols and reports, observe others working, and get a real feel for what the job entails. If telepractice is included in your job description, clarify the expectations, procedures, and policies specific to this service

delivery model. Seek out the other professionals with whom you will be working and introduce yourself to administrative/support staff so you know who can help you when you inevitably have questions. The saying “you get one chance to make a good first impression” holds true as you navigate the first few weeks of employment. During this time, consider how your actions and behaviors might be interpreted by people who do not yet know you well. Do your best to make a positive, lasting impression. Spend more time observing than offering opinions. There will be plenty of opportunities for you to demonstrate your talents, skills, and personality attributes. Similarly, spend more time planning than acting.

Organization Skills Did you know the average person loses an hour per day due to poor organizational skills? That is more than 2 weeks per year! Take a moment and think about what you could do with that amount of time. Travel, spend time with family, participate in your favorite leisure activities, read all the Harry Potter books in order cover to cover, or maybe even write your own. You can smooth your path to a successful career by cultivating habits that help you manage your space, materials, and energy efficiently and effectively. Good organizational skills streamline your days so you can focus more of your attention and energy on helping your clients, patients, or students achieve positive clinical outcomes. There are personal benefits as well. Developing and using an effective system of organization increases your feelings of control, thereby reducing stress, calming mental clutter, and freeing time and cognitive resources for you to work on your personal and professional goals. As with most any undertaking, there is no right or wrong way to organize your professional environment. Finding organizational systems that work well for you may take some trial and error initially, and systems that work well for someone else may not work well for you. Silber (2004) suggests there is a correlation between personality type and how we organize time, space, and materials. Specifically, some people like to feel in control of everything, particularly the environment around them. They are linear and structured and must compartmentalize to feel organized. Tasks must be completed in a timely fashion and things must be put away to achieve a sense of accomplishment (“a place for everything and everything in its place”). These individuals thrive using traditional organizational strategies. On the other end of the spectrum are people who are creative and visually oriented, with a need to see things to make sense of them. They can be easily caught up in the moment and completely lose track of time. They are



comfortable with a certain amount of clutter. In fact, rather than enhancing efficiency, filing papers and clearing desk space may cause them to feel they are being suffocated and that their creativity is stifled. Unfortunately, most work environments value and reward those whose outward behaviors reflect more linear, structured, organized personalities, such as those described in the previous paragraph. So, those who operate from this more creative, big-picture paradigm may need to experiment with a variety of strategies to find which ones can help them function efficiently in a professional work environment. Regardless of the strategies used for organization, you must commit to using them routinely on an ongoing and daily basis. Routines eventually become habits, providing the structure that is key to streamlining your day and helping you meet deadlines, responsibilities, and personal and professional goals. For example, you may want to establish the routine of checking emails and other digital correspondence at the beginning of the day and at the end of the day to remain on track for tasks that are a priority. It is extremely easy to get sidetracked by a request from a colleague that should not take priority or time at the moment and lose your focus on the task at hand. Another helpful routine is to identify specific places where items are always kept and are therefore easily accessible to you. Even if the rest of your workspace does not fit the criteria of “neat as a pin,” ensuring you have easy access to information and materials that you use daily will save you time, energy, and frustration. Routine use of your calendar has a big influence on your ability to manage your daily tasks. It can provide a clear picture of the tasks you must complete — those that are daily and those that are not — so you keep them in your sights. You may wish to complete certain tasks at specific times of the day, which can minimize distractions and ensure the task is not overlooked, avoided, or not completed. You can always be flexible and adjust your daily calendar as needed, but blocking off time for specific tasks will help you understand how much time each task may take, allowing you to plan accordingly. Task prioritization is a critical skill for managing your cognitive, energy, and time resources. Many people suggest you tackle the most important or resource-consuming task first when you have more energy and focus. This is often referred to as the “eat the frog” technique, so named (Tracy, 2017) after a vivid piece of advice from Mark Twain, in which he suggested that “eating the frog” was best done first thing in the morning, and if you had to eat more than one frog, it was best to eat the big one first. Using the “eat the frog” strategy helps us resist distractions, both internal (your ways of procrastinating)

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and external (demands from other sources) and prioritize tasks that bring us closer to our goals. It also ensures you are setting your own agenda rather than, by default, allowing someone else to do it for you. There will always be someone who needs something from you — a colleague, a student, a parent, a spouse, a child. When you set and prioritize your own agenda, you control the pace and direction of your day. It is very common to overestimate what can be accomplished in one day, particularly when tackling new tasks and those for which we may have no concept of the time needed to complete them. Another benefit of “eat the frog” is that it forces you to focus on less, even when you think you can or should be able to do more. Doing the big things first ensures that you focus on required, meaningful tasks so that you achieve small victories and build momentum that will carry on throughout your day. Do not underestimate the power of small successes! Procrastination can be a substantial challenge to our professional success as well as being a source of frustration and stress. While most people procrastinate occasionally, avoiding or delaying tasks that require attention on a regular basis leads to multiple negative consequences, such as preventing us from enjoying our personal time or impeding our progress on our goals, because we are paralyzed with inaction. So, why do we do it? Usually, we procrastinate because we are overwhelmed, because we do not correctly estimate the amount of time a project will take us, because we would much rather be doing something else, because we fear failure or the inability to complete a task, or because we are driven to perfectionism. Procrastination does not equate to laziness. Lazy people do nothing and are not bothered by it. Procrastinators find all sorts of other things to do — engage in social media, clean their closets, talk to a colleague — except the task they are avoiding. The longer this goes on, the more difficult it is to begin the task that is being avoided, creating a negative spiral of stress and self-incrimination. You can overcome procrastination! The first step is to acknowledge that you are avoiding a specific task. Then, ask yourself what is the underlying reason for avoiding the task and be honest with yourself in terms of the reason. Then make a plan to tackle it. Create a timeline with small, achievable steps (see the Creating a Career Path section in this chapter for more information about goal setting). Set aside a time and place where there will be no distractions and don’t let yourself leave until the job is started — or even completed. You can sweeten the antiprocrastination pot by promising yourself some sort of reward — your favorite coffee (with whipped cream), a phone call with a cherished friend, or a walk to the nearest shoe store. One of the most effective ways to kickstart yourself out of a procrastination episode is to have

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someone else hold you accountable and give them permission to enforce it! But don’t procrastinate about dealing with procrastination. The time and energy resources you will regain are worth the effort of kicking the procrastination habit to the curb. Once you have initiated an organizational system that meets your needs and works for you, make a concentrated effort to maintain that system so it becomes a routine part of your professional practice. In the long run, you will reap the benefits of working smarter, not harder.

Professional Ethics ASHA (2023b) states that a code of ethics is the fundamental principles and rules considered essential for the preservation of the highest standards of integrity. Adherence to any codes of ethics under which you practice is both obligatory and disciplinary. Therefore, it is imperative that you are familiar with the ethical standards that govern your practice, including the ASHA Code of Ethics (2023b), the American Academy of Audiology (AAA) Code of Ethics (2021), the ethical code and rules established for the state in which you work, the ethical code of conduct required for your place of employment, and any other professional association with which you are affiliated. Unfortunately, both new and not-so-new professionals can find their careers in serious jeopardy for violating ethical standards of practice, even unintentionally. Sanctions such as termination of employment, reprimand or censure by your professional association, and revocation or suspension of professional certification and/or association membership are major roadblocks toward growing a successful career. If you are serious about professional success, set aside time to thoroughly review all of the codes of ethics that apply to you at the beginning of your career and at least yearly to ensure you are always practicing within ethical parameters. ASHA Certification Maintenance Standards require that all certificate holders (CCC-A and CCC-SLP) must accumulate 30 professional development hours (PDHs; formerly certification maintenance hours [CMHs]) during each 3-year certification maintenance interval to maintain their ASHA Certificates of Clinical Competence (CCC). There are directives for hours as well, such as the current 2 hours required in the areas of cultural competency, cultural humility, culturally responsive practice, or diversity, equity, and inclusion (DEI). There is also a directive for at least 1 hour to be in the area of ethics (ASHA, n.d.). Likewise, state licensing agencies will have specific guidelines on your continuing education requirements

for the states in which you are licensed to practice. Your professional organizations, including your state association, are wonderful resources for continuing education courses. Conferences and conventions are also unique opportunities to learn from experts in the field, acquiring many hours of content in one location, with the bonus of being able to interact with your professional colleagues in person. You may also choose to follow other professionals in the field of speech-language pathology and audiology by joining a special interest group or on social media (e.g., Facebook groups, Instagram, LinkedIn) as additional sources of information on continuing education courses that may interest you. See Chapter 4 for more information.

Creating a Career Path Building a successful professional career doesn’t just happen. Setting personal and professional goals is key to both career success and satisfaction. If you were to ask a successful audiologist or speech-language pathologist (SLP) what practice or skill they would recommend to a new professional, setting and systematically working toward self-identified goals would most certainly be part of that discussion. While it might seem an odd undertaking at this early stage of your professional journey, mindfully mapping out a career plan is a proven way to help you build your career and enhance your job satisfaction. During your preprofessional training, it’s likely that most everyone had very similar goals — first to get into grad school, then to graduate, pass the Praxis, and get a job. Successful completion of your preceptor or clinical fellowship experience is undertaken at the appropriate juncture, depending on whether you are an audiologist or an SLP and your aspirations to obtain your Certificate of Clinical Competence. These are big life goals and you should be very proud of accomplishing them. However, life isn’t a fairytale, so riding off into the sunset and living happily ever after doesn’t really happen (nor would you want it to). Once you begin your professional career, it is very easy to get bogged down in day-today tasks that can leave you feeling busy all the time, but not like you have accomplished anything. Like a hamster on a wheel, you work hard and with all of the right intentions, but never feel like you are getting anywhere. This not only can leave you feeling unsatisfied and resentful, but also opens the door to stress and burnout — a topic that will be addressed later in this chapter. Identifying challenges and new goals will keep you energized, engaged, and growing your career from the earliest days and throughout your professional journey.



Just like a therapy plan, a career plan includes long-term goals and short-term objectives and serves as a road map toward where you want to go and how to know when you get there. Of course, no one is expecting you to have the entirety of your professional career mapped out from the beginning, but having some big milestone goals helps keep you motivated and moving ahead. Perhaps you want to eventually pursue a doctoral degree or move into leadership or supervisory roles. Maybe you are interested in obtaining board certification in a special area of expertise. Goals don’t have to be big and soaring. You may also set a goal of improving your organization skills, increasing your professional network, or submitting a paper to a state or national conference. All these goals are attainable; you just have to be committed to them by identifying how you will get from where you are to where you want to be. Once you have identified some long-term goals, prioritize one or two. For instance, you may identify writing a children’s book as a career goal, but not as a “right now” goal. That doesn’t mean you abandon it, you just keep it on your long-term list and focus on a higher-priority goal — that is, one more apt to be achievable and applicable given your current circumstances. It might be more reasonable at this early stage of your career to pick a goal that can improve your performance within your new employment setting, such as improving your professional communication skills or enhancing your emotional intelligence (EQ; see information later in this chapter related to these topics). However, your goals are yours. You are the final authority in deciding which are more appropriate for you and your professional aspirations. Once you have identified one or two long-term goals as your “right now” targets, create a plan of action by identifying benchmarks milestones; then, identify several easily managed action steps to move toward achievement of each milestone. Add these action steps to your to-do list to keep you focused, motivated, and accountable. Consider using the SMART (specific, measurable, achievable, realistic, and timely) method to create appropriate and measurable benchmarks toward your goal. Take time, at appropriate intervals, to review both where you have been (and celebrate those successes!) and where you are going. You may find that your goals change as you progress through your career. This is not only perfectly acceptable, but also to be expected. Career paths should be flexible and built on your current circumstances, skills, and aspirations. The more you learn about yourself and the career you have chosen, the more your ideas for professional growth and development will coalesce.

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Your First Mentor As you begin your career in the field of speech-language pathology or audiology, you will require the support and guidance of a mentor or preceptor as you work toward establishing yourself as an accomplished professional and, if you so choose, as a requirement for certification. Your mentor or preceptor serves as a coach or guide, employing less of a hands-on approach than you experienced as a student clinician. Effective mentors/preceptors provide a support system during this and other critical stages of career development. They are good listeners, knowledgeable, nonjudgmental, candid, and honest. They provide constructive feedback and resources and open the doors to professional networks that can assist you with gaining personal success. Finally, they are willing and able to devote the time required to develop skills in others while being eager to learn themselves. A mentor may be assigned to you within your work setting, or you may be required to identify one. The ASHA website (www.asha.org) has information on how to find a mentor, if necessary. (Note that the ASHA website provides information on mentorship in a general sense, since preceptorship in audiology is negotiated by the university program.) A mentor or preceptor is typically a more senior, respected professional in your field who will take a personal interest in your career development. It is important that you establish a good working relationship with your mentor or preceptor to gain the maximum benefit from this experience (ASHA, 2008a). You and your mentor/preceptor should discuss how often you will communicate and what modes of communication work best for each of you. Frequent contact, at least initially, is important to build trust and establish an effective, collaborative mentoring relationship, which will facilitate mutual respect of the experiences and views of one another, even when not in agreement. It will also establish the relationship as a two-way street to promote flexibility and enjoyment. At the first meeting, you and your mentor/preceptor will work together to establish goals that offer you a challenge as you grow professionally (sound familiar?). As you tackle these goals together, ASHA (2008b) recommends that you describe and measure your own progress and achievement to promote independence and confidence in your work. You may need to develop a tool for self-assessment to serve this purpose, or there may be a ready-made tool available from your employer or professional organization. The focus of the relationship with your mentor/ preceptor will be on sharing information. This requires

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critical thinking while maintaining an open line of communication. For instance, you could discuss how you might take better data, what strategies you could utilize to improve client outcomes, or how to engage with your professional association. Both you and your mentor/preceptor must be committed to using good interpersonal communication skills and openly sharing ideas, suggestions, and concerns. Be vigilant that there are no hidden agendas or insincerities in your oral and/or written communication with your mentor/preceptor or a mismatch between your verbal and nonverbal message. At times, you may need to engage in a difficult or uncomfortable conversation with your preceptor/mentor. For instance, you may feel that your preceptor is interfering during your diagnostic sessions, causing you to feel inadequate in front of your patients. Or, your mentor may voice that an aspect of your clinical treatment is inadequate. While these kinds of conversations may be uncomfortable, the worst thing you can do is avoid them. One of the hallmarks of an effective professional is being able to manage difficult situations so that both parties feel heard and respected, ensuring the relationship is maintained and even strengthened rather than damaged. If conflict occurs, seek to engage in a collaborative conversation so you will be genuine in learning what gave rise to the concern and committed to working together to solve the problem. See the section titled Professional Communication in this chapter for more information. Your relationship with your mentor/preceptor sets the stage for your professional growth as a clinician and as a leader in your chosen profession. Take advantage of the opportunity to learn from their guidance. Embrace constructive feedback and use it to become better at your chosen profession. Respect their time, but don’t be afraid to seek advice or ask questions. Your relationship will evolve over time as you become more proficient and move from a novice to a proficient audiologist or SLP. Eventually, the formal mentorship will come to an end. However, don’t be surprised if your first mentor remains a cherished professional guide and resource throughout your career. See Chapter 22 for more information.

Professional Skills That Foster Success As a newly minted audiologist or SLP, you typically use a large amount of your available cognitive resources learning how to be an independent professional. This is an important early step. However, there are several professional skills and personal paradigms common to people who are successful and satisfied in their chosen careers. While these skills are typically not taught in grad school,

they can be learned and applied across multiple work settings and job descriptions and are applicable at all stages of your career.

Professional Communication As a communication professional, you may question why communication leads off this discussion of critical professional skills. However, understanding communication styles — how they are used (and abused) — is an important component of your personal and professional success. During any given interaction, people use one of four communication styles: assertive, aggressive, passive, or passive-aggressive. Unfortunately, the latter three styles are a poor choice for communicating in any setting, let alone a professional one. These three styles are manipulative, stress producing, immature, and counterproductive to building positive relationships (Robertson, 2018). On the other hand, assertive communication relies on honesty, openness, and a sense of shared responsibility for a positive outcome. When you consistently communicate assertively, you build mutual trust with your colleagues, clients, students, patients, and/or family members. They feel good when they interact with you because they know there are no hidden agendas —  what you say is what you mean, and you mean what you say. You feel good because you know your message is getting across to the other person. Professionals who communicate assertively state their opinions respectfully, acknowledging that others may see a situation from a different perspective. Assertive communicators also listen attentively — seeking first to understand before being understood. They use appropriate eye contact and other nonverbal behaviors that match their verbal messages. Note that assertive communication does not mean saying whatever is on your mind. There are times when compassion and good judgment may require that you temper your message to spare the feelings of others; however, at no time is it appropriate to attempt to manipulate them, as is the case for the other three styles. Aggressive communicators use hurt, anger, guilt, and fear to attempt to sway people to do what they want them to do or to get their way. They may be rude, abrasive, sarcastic, and/or whiney. They look for other people to blame, consider themselves victims, and raise their voices in an attempt to control situations. Passive communicators, on the other hand, do not put any effort into communicating. They try to please everyone, agreeing to all requests and demands, even unreasonable ones, rather than risk speaking up. Those who habitually use passive communication do themselves, and those with whom they communicate, a great disservice. Coworkers have to guess what they are thinking; clients, who are



relying on their expertise, may receive the wrong message resulting in poor outcomes. A passive-aggressive communication style is perhaps the most detrimental to building both trust and your career. It is the exact opposite of communicating assertively — a combination of wanting to avoid confrontation (passive communication) and the desire to get one’s own way at all costs (aggressive communication). Passiveaggressive communicators use the silent treatment as a weapon, try to get people to take sides against each other, and engage in gossip, tattling, and other behaviors that require someone else to lose for them to win. This is the most damaging of all the communication styles and should have no role in the professional interactions of communication professionals. Using assertive communication, both when you initiate conversations and in response to other people, can be learned and honed. When you become aware that someone is trying to manipulate you by using communication that is anything other than assertive, you can neutralize the negative aspects of the interaction with an assertive response. For instance, if a colleague attempts to engage you in gossip or hearsay about a coworker or client (or anyone else), an assertive response similar to, “Until we have the facts, I would prefer not to talk about this situation” (and then not doing it) will shut down such an interaction that is unhealthy for you and for the culture of your workplace. Similarly, if you find yourself slipping into a less than open and honest communication style, you can correct yourself and steer toward a better course. This will eliminate the need to go back and repair relationships damaged by the erosion of trust that comes from engaging in nonassertive communication. Consistently using assertive communication in professional interactions requires mindfulness, courage, and persistence; however, open and honest communication enhances your professional reputation and opens doors to future career opportunities.

Emotional Intelligence (EQ) EQ is the ability to identify one’s own emotions, the self-regulation of those emotions, and the use of this knowledge to successfully solve problems and manage relationships. It focuses on skills in four distinct parameters or quadrants: (a) self-awareness, (b) selfmanagement, (c) social awareness, and (d) relationship management. Studies have shown that the correlation between high IQ and real-world success may be as small as 4%–10% (Goleman et al., 2002). Similarly, Goleman (1998) proposed that IQ or technical expertise merely accounts for a threshold level of performance on a job. EQ has been linked to success in a wide variety of areas such

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as leadership, communication, self-improvement, child raising, medicine, and corporate development. For audiologists and SLPs, the difference between clinicians who excel and those who do not often lies not in technical expertise, but rather in their ability to relate to others, understand their own strengths and weaknesses, and use this knowledge to advance the clinical relationship to the benefit of their clients (Robertson, 2007). The importance of EQ is well-demonstrated by an investigation involving individuals who suffered brain damage that resulted in an inability to experience emotion but whose cognitive abilities were intact (Damasio, 1994). Although they retained the technical knowledge to perform a job, they were found to be poor planners and poor decision makers. In fact, they had difficulty making even trivial decisions and experienced substantial social and professional problems in their vocational settings. These findings support the notion that what you know may help you get a job, but EQ helps you succeed at it. Fortunately, while some people have naturally higher levels of EQ than others, the skills associated with EQ can be learned. Self-Awareness. The first critical skill to developing EQ is to learn to consciously recognize one’s own emotions and the ways we express them to others so that we are sending the messages that we mean to send. Self-awareness includes your understanding of self-confidence, the awareness of your own emotional state, recognizing how your behavior affects others, and paying attention to how another person can influence your emotional state. Facial expressions, body language, choice of words, and tone of voice communicate emotions to others. Once clinicians have developed an awareness of their emotions, they can learn to use this awareness to manage their emotional responses. Self-Management.  If we send clients the wrong signals, even inadvertently, the damage to the clinical relationship may be difficult or even impossible to repair. Consequently, the ability to regulate one’s emotions (not just be aware of them) is a critical skill in developing clinical excellence and professional success. People who self-manage their emotions think before they act. They don’t allow their emotions to control their behaviors. They don’t make impulsive, careless decisions. Characteristics of self-management are thoughtfulness, comfort with change, integrity, and the ability to say no. Social Awareness/Empathy.  The ability to pay close attention to the signs and signals our clients give us to show their underlying emotions is critical to facilitating effective clinical relationships and good clinical outcomes. Social awareness is the ability to identify with

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and understand the wants, needs, and viewpoints of those around you — even when those feelings may not be obvious. We know that persons with communicative problems experience a variety of emotions such as anxiety, fear, anger, depression, frustration, loss, guilt, shame, and/or grief (Flasher & Fogel, 2004). Sometimes it can be difficult to determine the underlying emotion associated with a particular behavior. For example, tears might signal sadness, frustration, relief, or even happiness. Similarly, what might be perceived as a lack of effort may reflect less on motivation than on the underlying emotional state of a particular client. However, true feelings may show through posture, body movements, and tone of voice. Empathetic, socially aware people are usually excellent at managing relationships, listening, and relating to others. They avoid stereotyping and judging too quickly, and they live their lives in a very open, honest way. Relationship Management.  The final step in developing EQ is to consciously employ the previous three skills in combination to successfully manage clinical relationships. However, how we interact with others is heavily influenced by our personal view of the world and our own cultural background. Because of our tendency to assume that our values, or the values of our culture, are the most appropriate, we may subconsciously impose our value systems onto our clients. Clinicians who are truly tuned into their own emotions and those of their clients will likely be much more successful in communicating clearly, managing potential conflicts, and facilitating positive change. Learning to identify emotional cues and effectively manage clinical relationships is a dynamic process that takes time, practice, patience, and true commitment to valuing our clients, students, and patients and their families. Clinicians who wish to increase their EQ learn from each interaction with their clients and use this information to fine tune their management of clinical relationships. See Robertson, 2007, for a more thorough discussion of EQ as it relates to audiologists and SLPs.

Banish Burnout Burnout (often termed “professional fatigue”) was originally defined in1974 by American psychologist Herbert Freudenberger as physical and/or mental collapse caused by overwork and excessive/chronic stress (NIH, 2020). You may wonder why we are discussing burnout in a chapter aimed at early-career professionals; however, burnout affects people at all stages of their careers and in extreme cases can, sadly, result in a decision to pursue a different career path or drop out of the professional community altogether (Robertson, 2022).

Interestingly, burnout is virtually exclusive to highachieving, intelligent, emotionally aware people who care about what they do and the people in their care — making those in helping professions such as audiology and speech-language pathology at an increased risk. Fortunately, cultivating a healthy personal and professional mindset from the start of your professional journey can help you stay energized and charged throughout your career and avoid ending up as a smoking pile of ashes. As mentioned previously, moving from student to practicing professional is a major paradigm shift. Your days — and the tasks that fill them — are no longer dictated by the demands of your professors and program requirements. No matter how rigorous your graduate preparation, nothing can really simulate what it is like to be the professional in charge of all aspects of identification, assessment, and treatment of your patients, students, or clients. Scheduling, planning, completing paperwork, attending parent conferences, and learning the culture and expectations of your employment setting — in addition to managing your personal life — can overwhelm you before you even get started. Burnout is the result of unrelenting stress, but stress and burnout are different things. Stress is meant to be a short-term solution to an immediate problem, which can be good for us in small doses — helping us to meet deadlines, deal with traumatic events, or problem solve in a crisis situation. Stress stimulates the amygdala (the reptilian part of the brain) to release hormones for a fightor-flight response to a threat. In the short term, stressed people can still function professionally and personally. Even when aware that they are under too much stress, they can be creative, solve problems, and imagine a time when they get things back under control. In a nutshell, stress involves “too much”— too many pressures demanding too much of your time, attention, and energy. Conversely, burnout is about “not enough”— not enough time, not enough self-care, not enough resources. It is a cumulative process resulting from self-inflicted, long-term exposure to stress hormones that are intended, biologically, to solve short-term problems. Despite sending distress signals such as pain, fatigue, and unhappiness, we keep pushing through until all the body’s resources are consumed. Often described as “tired but wired” due to the effects of the constant bath of stress hormones on our bodies and psyche, burned-out people are in a state of negative energy. They feel empty, physically exhausted, mentally numb, unmotivated, and beyond caring. They do not see any hope in their situation changing. They are just done (Gentry & Dietz, 2020). Contrary to popular belief, burnout is not the result of hating your job. In fact, there is very little correlation between a person’s work environment and professional fatigue. Burned-out individuals can be found in fantas-



tically positive and psychologically safe workplaces as well as in more challenging environments. Although it may sound counterintuitive, the vast majority of people who find themselves burned out actually love their jobs! They just haven’t learned how to protect themselves from professional fatigue. When the crash comes, they may or may not have the capacity to reclaim their career. However, this catastrophic outcome — both for you personally and for the profession as whole — can be managed. You can learn to avoid or even reverse the trend toward professional collapse by implementing strategies to reduce stress and nurture your mind, body, and spirit. In her book, Burnout to Badass: Elea’s Stress Conquering Method for Getting Your Life Back When Work Burns You Out (2017), Elea Faucheron describes the importance of cultivating professional habits and a personal lifestyle that result in the production of good energy, which is generated when you get more energy out of what you do than you put in. Conversely, bad energy is the result of putting in tons of effort, but getting poor results (i.e., more energy goes in than is generated), leaving you tired but wired. She stresses the importance of committing to habits and professional practices that reduce stress, generate good energy, and protect you from burning out. To that end, we will discuss three of the most powerful stress-busting strategies as they apply to early-career professionals who are seeking to build success in both the short and long term. 1. Manage your energy. Staying organized, remaining on task, and battling procrastination are important skills for busy professionals. As such, there are many resources that provide suggestions, strategies, and advice regarding time management. However, time is a fixed commodity — we all get 60 minutes in an hour and 24 hours in a day and, unfortunately, it is far too easy to learn to abuse time by trying to cram as much work as possible into this finite resource. To preserve our psychological and physical health in the long term, we need to reframe our thinking from time management to energy management (Grossman, 2020). Science tells us that working every second is not efficient. In fact, we are more productive and less stressed when we schedule (and take) regular breaks that give our bodies, minds, and spirits time to recover. As an example, think about holding a glass of your favorite beverage at arm’s length, straight out from your shoulder. It does not feel very heavy. It’s kind of nice to look at. But, how long can you hold it there? Thirty seconds? No problem. A minute? Maybe your shoulder is beginning to feel a little fatigued. Two minutes? By now, your whole arm is probably

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shaking. If you make it to 5 minutes, it is most likely only by gritting your teeth and using sheer willpower. However, if you stop every 30 seconds and let your arm rest for a bit, you can probably reach 5 minutes of beverage holding time with little or no stress. The same principle holds true for you. It is important that you break big tasks into smaller chunks by taking regular breaks to allow yourself to recover and recharge. These small recovery rituals (e.g., a short walk, a cup of coffee, a few minutes of stretching) are critical to keeping you motivated and on task as well as contributing to a higher quality of work. 2. Resist perfectionism. Perfectionistic tendencies are consistently identified in research as a strong precursor to burnout. In other words, nearly everyone who has experienced burnout has expended huge amounts of energy striving for an impossible-to-achieve perfect standard. As professionals, we are, of course, expected to do our best to provide high-quality services for our clients, patients, and students. However, we are human — and we are not perfect. When we nitpick about every aspect of our lives, when 99% of what we do is fantastic but we can only see the 1% that is not, when we voluntarily put ourselves into the perfect trap and throw away the key, we waste our precious energy resources and get nothing good back in return (a classic example of negative energy as described above). Perfectionism gives us increased levels of stress, anxiety, depression, and the risk of burnout. Unfortunately, the rigors of many preprofessional training programs in audiology and speech-language pathology produce graduates who have perfected their perfectionism. This is unsustainable in the long run and can lead to serious negative personal and professional consequences. Fortunately, success doesn’t require perfection. So, we suggest you set a new standard: Strive to be awesome, not perfect! 3. Put yourself first. Taking good care of your mental and physical health is critical to career success. Just as small breaks help you be more efficient and productive, it is important to cultivate nonwork recovery rituals as well. Getting adequate sleep, engaging in meaningful leisure activities, socializing with others, and cultivating a mindset that you must take care of yourself before you can take care of others are keys to reducing stress, preventing burnout, and setting the stage for professional and personal success. Give yourself

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permission to be as kind to and supportive of yourself as you would to someone else (remember, you are awesome, not perfect). The editors of this text take stress and burnout very seriously. You are reading about it here in this chapter, and you will learn about other elements of stress and burnout in Chapter 24.

Impostor Syndrome Another source of self-imposed anxiety and stress is an underlying, but unsupported, fear of inadequacy and unworthiness related to your professional skills and accomplishments. Typically referred to as impostor syndrome, there is a mismatch between your self-perception and how others view you. Even as you are praised for your contributions and expertise, you don’t believe you are worthy of recognition. In fact, you may fear that other people will eventually realize that you are not what you seem (Bravata, 2019). Although the exact cause of impostor syndrome is unknown, there is general agreement that impostor syndrome, which disproportionately affects women and persons of color, has at least some of its roots in perfectionism (McGregor et al., 2008). Feeling inadequate can result in high levels of anxiety and stress, causing you to overcompensate by working harder and longer in an attempt to live up to what other people think about you. Alternately, you may experience a drop in motivation and decreased work productivity. If you harbor feelings of professional inadequacy, you might be surprised to learn that you are not alone. In fact, you are in very good company. People whom you might never have suspected to experience impostor syndrome — Michelle Obama, Tina Fey, Natalie Portman, Facebook COO Sheryl Sandberg, Supreme Court Justice Sonia Sotomayor, Lady Gaga, and Tom Hanks — have all shared that they have felt like impostors (Feenstra et al., 2020). Paradoxically, if you were to name a common characteristic of these individuals, it would most likely be that they are incredibly successful at what they do. In fact, some experts argue that feeling like an impostor may actually be a sign of eventual extraordinary success. You cannot grow your career without getting out of your comfort zone — where you naturally feel less confident of your skills and abilities (Rodionova, 2016). Thus, these feelings are to be expected and embraced as a sign of a high achiever rather than of impending failure. The strategies discussed previously in regard to burnout, managing your energy, getting a handle on perfectionism, and being kind to yourself can also help mitigate the negative personal and professional effects of impostor syndrome. In addition, make a conscious

and concentrated effort to shift your mindset away from a focus on failure to a focus on positive progress and outcomes and celebrate your strengths and successes (Eruteya, 2022). Your career map is an excellent tool in combating impostor syndrome because it provides concrete and visual proof of your progress toward your professional goals. Take time to reflect on the challenges you have overcome while acknowledging that the road to success will be littered with missteps and you will most certainly slip and fall at times if you are ever going to truly find your footing. Create a portfolio of your accomplishments so that during times of stress and doubt you are able to reflect on all the good that you have achieved. Separate fact from feelings. Recognize when those feelings of self-doubt creep into your thinking and be ready to neutralize them. Simply observe and be mindful of when and how they show up. Remind yourself that just because thoughts of inadequacy are there does not make them true. Be prepared to use positive self-talk to override negative thoughts; tell yourself that you do know what you are talking about, that you know much more than you think you do in that moment, and that you are willing and able to learn new things if need be. Stop comparing yourself and your journey to someone else. Comparison is the stealer of joy and contentment. It is a trap for feeling like you do not measure up. Your journey is your own; different from that of anyone else and not comparable because you cannot see the hard work behind it. If you must compare your progress to another, compare yourself to the person you were last month, or last year, or 5 years ago. That is the comparison that actually matters in your equation and one that will make the most difference to you in overcoming any feelings of inadequacy you may experience. Finally, don’t keep your feelings of self-doubt, which can be overwhelming and paralyzing, to yourself. You can mitigate these unhelpful feelings by taking action to help you get unstuck and move forward. Seek out trusted colleagues, friends, mentors, and/or therapists and share your feelings about your perceived inadequacies. You will most likely find many of them harbor similar feelings, opening the door for mutual support and collaboration and strengthening workplace relationships. Keep in mind that a large percentage of high-achieving people suffer from impostor syndrome; consequently, your feelings of inadequacy actually suggest you are not only capable, but also likely destined for remarkable success.

Teamwork Audiologists and SLPs who want to grow their careers must be able to perform well not only as an individual,



but also as an effective member of a variety of teams. Depending on the task or role, we may team up with other audiologists and/or SLPs, our clients/patients/ students, family members, related professionals, support staff, consultants, and more to ensure our services are appropriate, relevant, and effective. You are also a member of the entire group of people that make up your workplace. Consequently, your ability to work with and within a team isn’t just a good skill to have, it is a required component of professional success regardless of your work setting. In a classic experiment of team functioning, Skillman (see Coyle, 2018) discovered that the best predictor of team success was not the task assigned, but rather the way in which the members of the team interacted with one another. In direct opposition to everything we think we know, results revealed that teams of kindergarteners consistently outperformed groups of college-level business management students. Skillman concluded that, in contrast to the business students, the kindergartners didn’t waste the bulk of their time negotiating who was in charge or competing for a leadership role. Rather, they immediately started to experiment with possible solutions, took risks, and noticed outcomes, which guided them to an effective solution in a short amount of time. In a nutshell, the kindergartners did not succeed because they were smart, but because they worked together in a smarter way (Coyle, 2018). In today’s complex work environments, people must be able to think strategically, laterally, and creatively and adapt quickly to change. Like kindergarteners, successful workplace teams focus their efforts on solutions rather than the status or power levels of themselves or any of the others in the group. High-functioning, productive teams are thriving ecosystems where members feel safe to take informed risks, offering their ideas, insights, and expertise to the rest of the team. Members of the group act as a cohesive unit with shared values and a shared vision, generating ideas, inspiration, and energy. In healthy workplace teams, “anyone can speak to anyone and everyone has everyone’s back” (Coyle, 2018) while holding each other accountable to a high standard of excellence. Results of another classic experiment related to team functioning revealed that the presence of a single person (a “bad apple”) who demonstrated negative behaviors could disrupt team functioning, reducing performance by 30% to 40% (Felps et al., 2006). (Interestingly, it was very common for other group members to begin to demonstrate some of the same negative behaviors as the bad apple — an actor that had been hired to play the role of a jerk, a slacker, or a downer.) Consequently, it is critical that all members of a team be committed to behavior that supports positive team functioning.

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Specifically, they fulfill their role on the team effectively and efficiently, ask good questions, contribute thoughtful ideas based on their expertise, meet deadlines without fail, and are open to learning and feedback. Team members are committed to empowering, coaching, and rewarding themselves as well as their colleagues for a job well done (and to honest discussions among team members when they don’t). Teams made up of individuals who are willing to embrace these ideals are able to maintain positive energy even when dealing with unexpected, unpredictable, challenging, and complex circumstances (Coyle, 2018). As a new member of a team, your willingness to listen, observe, avoid unproductive interactions, discourage gossip, and show consideration for others will go far in demonstrating your willingness to contribute to a positive team culture. Show your creative talents, demonstrate your willingness to experiment, and take advantage of opportunities to participate in seminars, training events, and classes. Request constructive feedback from colleagues as you complete tasks together and keep a positive attitude when that feedback is provided. Your efforts will contribute not only to a positive workplace culture for everyone, but also to your own professional satisfaction and long-term success.

Curiosity A prescribed body of knowledge is necessary to be effective and competent in our chosen professions. Knowledge such as this is measurable and finite, stemming from outside sources such as coursework, studying, books, and/or hands-on experience. But without curiosity, our collective knowledge base is stagnant and backward looking. Every single new idea, innovation, or breakthrough in our profession, or any profession, is the result of someone who, not content to accept the status quo, had the curiosity and courage to ask “What if?” Human beings are hard wired to prefer routine; however, rather than clinging to what is comfortable and familiar, we have a professional responsibility to engage our curiosity to facilitate increases to our collective professional knowledge as we seek to improve clinical outcomes for patients, students, and clients. There is a robust body of research regarding the substantial benefits of cultivating curiosity in the workplace, which has been described as the most critical determinant of employee performance (Hamilton, 2020). For audiologists and SLPs, these include (but are not limited to) facilitating innovation in your clinical practice, increasing your ability to manage professional roadblocks by seeing them as opportunities rather than obstacles, and decreasing your chances of falling prey to confirmation bias (i.e., making broad judgments based

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on personal paradigms). Being curious not only opens up new worlds and new possibilities but is also positively correlated with a reduction in personal stress and conflict in the workplace. Overall, curious professionals perform better both individually and in teams. Not surprisingly, studies confirm that if you want a prosperous and rewarding career, find ways to increase your curiosity and creativity (Berger, 2015). Anyone who has ever interacted with children knows that they are naturally curious. Their brains are full of questions and they are unafraid to experiment with creative problem solving. Unfortunately, our innate curiosity diminishes as we mature. Most of us learn to censor our own creativity as we enter education and the workforce, where we are less apt to be rewarded for engaging in wild flights of fancy. Instead of learning to be more creative as we age, we tend to excel at forgetting how to be curious. Experts in developing curiosity stress that being stuck in regular, routine practices stifles curiosity and creative thinking (Gino, 2018). To mitigate this, we need to push ourselves out of our comfort zones so we do not become cognitively lazy and professionally stagnant. Further, we must be open to learning, unlearning, and relearning things we think we already know, understanding that what we have taken for granted might not be the best solution. We can encourage our brains to be more curious by exploring new subjects, engaging in new experiences, diving into diverse reading material, and seeking out other curious people. We must ask the right questions of ourselves and others, with the understanding that we might receive unexpected answers that compel us to change. Alternately, we must be open to encouraging others to ask questions of us — even if that means they are challenging our assumptions, views, and interpretations. The world, including our professional world, will continue to change and evolve. Without professional curiosity, ear horns would still be the preferred method of sound amplification and Augmentative and Alternative Communication (AAC) devices would be the size of suitcases. Luckily, audiologists and SLPs were willing to challenge the status quo, resulting in massive improvements in outcomes for people with communication challenges. Imagine what we could accomplish if we harnessed our collective professional curiosity on behalf of those we serve.

Professional Engagement and Responsibilities One of the biggest missteps to growing a career is maintaining a narrow focus on your immediate work setting. True professionals understand that they have both

a responsibility to participate in their profession on a larger scale and the opportunity to grow their leadership skills and network within their larger professional community.

Professional Associations Audiology and speech-language pathology are memberled professions. That means we are only as strong as our collective willingness to share the responsibilities that come along with self-governance. It is not uncommon to hear people ask what their national, state, or even local associations are doing on their behalf, assuming that payment of their dues entitles them to sit back and let other people do the work of leading and growing our professions. This is actually backward thinking. The question should be, “What are you doing for your association?” There is no ASHA or AAA or PSHA (Pennsylvania) or TSHA (Texas) without volunteers who are willing to share their time and talents to benefit their colleagues. Dues help support association infrastructures such as certification, continuing education, and financial and convention management. But without engaged members, associations wither and our professions suffer. Being a member of a professional association is not a luxury cruise where your only responsibility is to decide which deck gets the most sun for tanning. Rather, it is like a windjammer cruise where everyone has a responsibility to help sail the ship. Some may take turns at the rudder, some trim the sails, some navigate, some scan the horizon to look out for nasty sea monsters. If everyone decides they are too busy to pitch in and help sail the ship, it won’t sail, and then no one gets anywhere. There are countless advantages to joining, supporting, and volunteering for your professional organizations. You get the chance to focus your energies on making something about your job, profession, or world better. You gain insight about the scope of your profession, build knowledge in new areas, have input in decision making and public policy, learn from one another, hone leadership skills, and find abundant opportunities for career growth. There are so many ways you can engage and contribute! Start by adding your association’s email to your safe list so you receive important communications. (Professional associations consciously limit email communications to only the most important messages so you do not need to fear for your inbox.) Next, familiarize yourself with their websites. You will most likely be surprised at the treasure trove of information you can find there. (For instance, if you aren’t familiar with the ASHA Practice Portal, stop reading and go there now. It’s an incredible resource for both audiologists and SLPs. https://www​ .asha.org/practice-portal/). While you are there, sign up to receive email alerts. Then, respond to a call to review



a document, contact a government representative, or to comment on newly written or revised guidelines. Take the initiative to vote in association elections, give input on the public policy agenda (ASHA, 2023a), or volunteer for a focus group. Also, set aside time to read association newsletters, magazines, and other publications. Professional associations work hard to keep their members informed, but, as we know, it takes two to communicate! Maxwell (2022) argues that, regardless of your profession, “how well you lead determines how well you succeed.” Put another way, your ability to lead is the lid on your potential for success. Maxwell also asserts that true leadership emerges in volunteer leadership positions. Given this, it is not surprising that volunteer association leaders are the superstars of our professions. They are genuinely committed to moving our professionals forward and are willing to share their time and talents to make that happen. You can raise your leadership lid by volunteering to join these movers and shakers on a wide variety of committees, boards, and councils of your professional associations. State associations are a great place to begin your leadership journey as they are typically looking for members to step up into leadership positions and will provide guidance and support as you grow your skills. The benefits of this level of professional engagement are numerous and invaluable. Not only will you gain lifelong friends, mentors, and role models, you will also find yourself energized, inspired, and grateful to be part of the synergy generated when dedicated people join forces to do amazing things. Take a look at Chapter 17 to learn more about this important topic!

Networking You have heard the expression, “It’s not what you know, it’s who you know.” This mentality is especially true regarding opportunities for career advancement and success, particularly in today’s culture in which we are connected to one another in so many ways. Networking may be best described as “professional relationship building” as it is, at its heart, about meeting people within your profession and building a relationship with them. Of course, we are not limited to networking exclusively within the bubble of audiology and/or speech-language pathology; in many instances, networking with people in related professions can also yield positive benefits as you grow your career. Genuine professional relationships offer numerous perks. When you are at the beginning of your career, tips and insights from those who have already been there and done that can be priceless. You have the opportunity to learn about professional opportunities (e.g., jobs, promotions, new roles) that may not be advertised. If

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you have already established a relationship with someone connected to this opportunity, you give yourself the best chance to be considered. Networking can also help you keep up to date on new research, trends, and best practice and is a tremendous source of inspiration, new perspectives, and fresh ideas to help you improve your clinical and professional skills. Your place of employment and your professional associations offer some of the best opportunities for you to develop your professional networking skills. In your workplace, you expand your network (and contribute to a positive work environment for everyone) by attending staff meetings and informal get-togethers, eating lunch in the employees’ break room, and seeking out people that appear open to building a relationship with you. When you volunteer within and for your professional associations, your knowledge, interests, skills, and talents will be more quickly recognized by your colleagues. There are also opportunities for networking within your university alumni associations, religious groups, civic associations, political organizations, and special interest/hobby clubs, to name a few. These can serve as excellent opportunities for you to meet and establish relationships with individuals with whom you share common interests that extend beyond the workplace, while enabling you to practice your networking skills. Social networking sites such as Facebook, Instagram, and LinkedIn provide additional ways to network with fellow professionals. ASHA and several other professional organizations have a strong presence on these networking sites, so take advantage of following them and interacting, as appropriate. Keep in mind that a purely online connection isn’t likely to be as strong as a relationship that has benefitted from at least some amount of face-to-face interaction. These sites are most effective as a means to stay in touch with people you already know and want to get to know better. Alternately, when you make connections online, consider how you might be able to strengthen the relationship in person. Finally, be aware that when you take advantage of these sites for the purpose of networking, your communication exchanges should only reveal information about you that is appropriate for all readers. Be vigilant in maintaining confidentiality (particularly when it relates to your patients, clients, or students), your choice of topics, language style, and photos to project a professional image. Many audiologists and SLPs have used networking to improve or supplement their ability to do things well and to expand their careers in directions that go beyond the clinical setting. ASHA members may join one or more of the special interest groups (SIGs) for specialized networking opportunities. SIGs also provide access to educational programs, research, publications, and dialogue with members with similar interests. There are 20 special interest groups that address the diverse areas of

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language learning, neurogenic disorders, voice disorders, fluency disorders, orofacial disorders, hearing research and diagnostics, aural rehabilitation, hearing conservation, hearing disorders in childhood, issues in higher education, administration and supervision, augmentative and alternative communication, swallowing and swallowing disorders, communication issues in culturally and linguistically diverse populations, gerontology, school-based issues, global issues, telepractice, speech science, and counseling (ASHA, 2022). When done properly, networking can open a wide variety of professional doors to help you grow and thrive in your chosen career. However, remember that networking is a two-way street. When you are willing to help others by sharing your time, talents, and experiences, there’s a strong chance they’ll help you right back. Embrace this philosophy and your networking efforts can lead to, well, pretty much anything!

Advocacy Advocacy may be a new concept for you because it is not typically included in graduate education curriculum. However, advocating for our clients, patients, and students, and for our profession as a whole, is an important role of a responsible professional. If we don’t advocate for the needs of our clients, our role in the community, and our professional roles and responsibilities within our work environment, who will? Even more concerning, if we aren’t involved in decisions that affect us, we are essentially abdicating decision making to people who may or may not have our best interests at heart. (A common quote that demonstrates the importance of advocacy is, “If you aren’t at the table, you might well be on the menu.”) Growing a successful career is much more likely when we help others understand the key role we play in the quality of life of those we serve as well as the kinds of policies, procedures, and laws that are conducive to helping them find success. Advocacy at the local level may include regular conversations with decision makers such as a school principal or administrator, an insurance company, or a supervisor (especially if your supervisor is not an audiologist or an SLP). State and federal legislators also need to hear from you. Your state association and ASHA have staff and lobbyists who monitor proposed legislation and identify lawmakers who are open to championing causes important to our profession. Every year ASHA identifies top priorities, as noted by input solicited from members, for advocacy efforts on Capitol Hill. (Find the annual public policy agenda at https://www.asha.org/advocacy/) But lawmakers need to hear directly from their constituents and, as a professional in the field, your input is critical for advocacy efforts to be successful.

There are numerous ways you can engage in advocacy. Start by visiting the ASHA Take Action Advocacy webpage (https://www.asha.org/advocacy/takeaction) and sign up for alerts. You will also find a wealth of information here on current federal and state campaigns, surveys on issues that are important to you, and how you can contact your elected officials, including prewritten messages on key issues that are automatically sent to your representatives in Congress once you fill in your name and address. You can also visit your state and federal representatives in person and let your voice be heard. Professional associations often sponsor “Hill Days” to raise our profile, build relationships with legislators, and help them understand why we do what we do. Be aware that ASHA cannot directly advocate for issues that are decided at the state level such as caseload size and licensure requirements. Similarly, state associations cannot advocate effectively on local issues. In each case, we need to be willing to engage with the appropriate decisions makers and raise our individual and collective voices on issues that are important to us and those we serve. See Chapter 25 for more information.

Continuing and Advanced Education Your education does not stop once you are employed. Keeping abreast of advances and changes within your profession is critical to growing your career as well as a professional responsibility. Your employer will expect you to have the latest assessment and intervention skills and use evidence-based practice. Maintenance of certification and licensure will also require documentation of continuing education (CE) throughout your career. Be sure to know the requirements that apply to you, which can vary depending on your certification, job settings, and/or your maintenance interval. You do not want to jeopardize your credentials because you did not fulfill continuing education mandates. Your employer may offer on-site educational opportunities, or you may participate in local, state, or national conferences that provide recorded and/or live, on-site CE sessions. There are also several online CE programs available, many with minimal cost. Regardless of where you obtain your CE, it is important to keep a log of your CE activities and proof of completion and attendance. The CE register on the ASHA site is an easy way to keep track of your progress toward the 30 Continuing Education Units (CEUs) required during each maintenance interval (3 years). Your employer may contribute to the cost of required continuing education, but in all cases, you should keep receipts for reimbursement or tax purposes. In addition to the continuing education requirements for maintenance of licensure and certification,



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you may want to consider developing your expertise in a specific area and seek formal recognition of your advanced skill and knowledge. AAA, ASHA, and other professional organizations have created specific credentials that recognize specialized areas of practice. Such a credential demonstrates your advanced expertise and will likely set you apart from your colleagues in the eyes of both employers and consumers. The websites of your professional association can provide specific information on obtaining specialty recognition. If you are considering advancing your education by obtaining a PhD, there are several considerations to take into account. The structure of a PhD degree program focuses on preparation for careers in research, teaching, and other scholarly activities. Therefore, the majority of people in communication sciences and disorders (CSD) who have a PhD pursue a career within a college or university. CSD programs are currently experiencing a shortage of people with PhDs to assume faculty positions, so there are many employment opportunities should you decide to earn your PhD. In addition to opportunities within a college or university, individuals with PhDs may be employed as clinical researchers in hospitals and clinics. PhD audiologists may be employed in industry ​ — for example, by hearing aid companies for product research and development (ASHA, 2019). If you expect to continue your career exclusively in clinical practice, you may wish to consider a SLP-D (Doctor of Speech-Language Pathology) to advance your knowledge in areas such as leadership in health care and education, supervision, and advance evidence-based practice. There is more information about obtaining the PhD and SLP-D on the ASHA website as well as on university websites that offer these degrees.

education. Increasingly, programs have career ladders intended to foster staff development and leadership and provide opportunities for new challenges without employees having to be promoted to a supervisory position. Advancement both vertically and laterally can be challenging and contribute to a more fulfilling career. Before advancement, some basic questions arise. What duties does the new position entail? What are prerequisite technical and personal skills and credentials for fulfilling the position? Will the new responsibilities be challenging or constitute a professional or personal burden? Will the prestige or financial reward be adequate to compensate for new responsibilities? For example, if promotion entails increased travel, is this possible with your current lifestyle? What personal accommodations, such as the need for childcare, would be required? A major difference in seeking an advanced position within a present organization is that the interview will be with familiar individuals. However, careful preparation is no less important for a longtime employee. In some cases, a current employee may be competing with individuals from both within and outside the organization whose credentials and experiences are equal or superior to their own. If you decide to apply for advancement within your present organization, you need to be prepared psychologically for a rejection. Some individuals may perceive this as an overwhelming personal rebuff by colleagues, and it may affect their ability to work productively in that setting. This is an important concept to consider as you apply for promotions within your setting. Having a positive support network is vital to helping you cope if such a rejection occurs. While rejection does not usually mean your current position is in jeopardy, this may be a good time to reevaluate your goals and have a frank discussion with trusted colleagues about your options at this time.

Career Considerations

Changing Employment

Promotion and Advancement

An employee may change employment settings for any number of reasons. These reasons include job loss, relocation, unreasonable demands in the current position, lack of opportunities for professional growth, infrequent raises, boredom or burnout, lack of employer appreciation, or readiness to assume new or increased responsibilities associated with a different position. Regulatory policies pertaining to reimbursement for long-term care and outpatient rehabilitation services have significantly affected employment in medical settings. Thus, some professionals may change jobs by choice, whereas others will find this an unwelcome event in their lives. The new job search may begin while you are currently employed, or the process may begin after resignation or termination from a position. Securing a

Once employed, you may find opportunities for advancement within the current program, within the larger organization, or even within other settings. Individuals become aware of available positions through professional publications, networking, or direct solicitation to apply for a position. Advancement can take the form of moving upward to positions of more direct program responsibility such as supervisory roles, or it can take place laterally with the individual remaining in a similar position but assuming new responsibilities or a new type of caseload. For example, in some programs, individuals may become team leaders or have special duties such as coordinator of quality improvement or continuing

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new position while currently employed presents some challenges. If you are currently employed, you may not want your employer to know that you have begun a job search. If the job search becomes public, how will this knowledge affect your current position? How available can you be for interviews? If you do not want your current employer to know about a potential move, you will need to change options for references. You also must be prepared to take time off from work to attend interviews, either on the phone or in person. In the case of relocation or a mutually agreeable job change, your current employer will be the best possible reference in securing new employment. If your position ends before you begin a job search, you again have to evaluate the helpfulness of a former employer. Targeted employers will want to know the circumstances of why you left the last position and generally will want some reference from that employer. It is important to consider that a current employer is the most important reference for the future; therefore, conditions under which the applicant leaves should be positive —“a graceful exit” (Kroner, 1989). When an employee leaves, employers are sometimes asked to indicate on the termination documentation if they would or would not rehire this individual. That is a question often asked by future employers when calling for references on a terminated employee. An ungraceful exit, such as leaving without reasonable notice for your employer to find a replacement, or leaving without completing required paperwork, is not likely to get a “would rehire” response. Before you resign from a current position, be sure to have the new offer in writing. Check your current employer’s policies and procedures manual for contractual information on what time period constitutes sufficient notice of termination. Your present employer must then receive notification of your intended departure. Include in this letter your exit date, the title of your new position and employer, and the last date of work. It is also dignified to inform your boss before telling coworkers and meet with this person in a formal exit interview. Exit interviews should be positively focused on making an orderly and courteous transition between you and your replacement (Kennedy, 1998). Before leaving a current position, all work should be summarized for a successor and all required paperwork must be updated, completed, and filed. Some employers will require you to help train a replacement, so an overlap time may be necessary. How a departure is handled can positively or negatively affect the tone of future references from the employer. Many SLPs and audiologists have felt the impact of changes in Medicare and other insurance reimbursement in medical settings. Some have lost their jobs while others have had positions changed or hours reduced. Although this is likely to be a time of anger, despair, and frustration, it is also an important time to know what

your options are financially and vocationally. Be sure to consider psychological support during this time of unwelcome transition. Some human resources departments will have such support available to assist you.

Financial Considerations If you are faced with an impending loss of a job, as a result of changing employment or otherwise, it is critical to plan for the time when you may be without a regular income. To be prepared: n

Know your financial assets and monthly expenses and make a realistic financial plan.

n

Reduce all unnecessary expenses.

n

Build a 3- to 6-month cash reserve.

n

Reduce debt.

n

Know the rules regarding any 401(k) or retirement plans to which you have contributed.

n

Discuss mortgage and insurance coverage with qualified professionals.

n

Investigate your agency’s severance package options and negotiate the best one.

n

Plan for health insurance while unemployed (e.g., COBRA option).

n

Claim your unemployment benefits.

The Interval Between Jobs It may take more time than you had anticipated to find new employment. While this can cause an increased level of anxiety, you can also view this as an opportunity to upgrade skills, volunteer, and engage in self-care. It is also prudent to maintain your professional certification, licensure, and continuing education requirements during any extended periods from active work. For applicants who have been unemployed for an extended time, the prospective employer will most likely inquire how you have ensured that your professional skills are up to date. You can handle this by providing clear, concise, and honest answers while emphasizing your interest in, and qualifications for, the present position.

Summary Growing your career doesn’t happen in a day, but it is nurtured daily. The decisions you make at the beginning stages of your career can have a lasting impact, positively or negatively, on your professional success and career satisfaction.



CHAPTER 8   Building Your Career

Take the time you need to be thoroughly familiar with the policies, procedures, and expectations of your new workplace. Identify your career path and set achievable goals to help you move forward on your professional journey. Establish yourself as a team player who meets deadlines, uses assertive communication, and adheres to the codes of ethics established by your employer and your relevant professional associations. As your career advances, consider the importance of building skills in emotional intelligence, managing stress to prevent burnout, and confronting your inner impostor. Engaging with your professional associations, developing your professional networks, and finding ways to advocate for your clients, students, and patients as well as for the profession as a whole will open up numerous opportunities for personal and professional growth. Take advantage of learning opportunities through continuing and advanced education and leverage them as appropriate when changing employment. You are the CEO of your life and your career. Now is the time to take the reins as you build your career with confidence, competence, and success.

American Speech-Language-Hearing Association. (2023a). 2023 ASHA public policy agenda. https:// www.asha.org/siteassets/advocacy/2023-ashapublic-policy-agenda.pdf

References

Eruteya, K. (2022, January 3). You’re not an imposter. You’re actually pretty amazing. Harvard Business Review. https://hbr.org/2022/01/youre-not-animposter-youre-actually-pretty-amazing

American Academy of Audiology. (2021). Code of ethics of the American Academy of Audiology. https:// www.audiology.org/wp-content/uploads/2021/05/​ 201910-CodeOfEthicsOf-AAA.pdf American Board of Audiology. (2011). Board certification in audiology. http://www.boardofaudiology.org/​ board-certified-in-audiology/ American Speech-Language-Hearing Association. (n.d.). Three-year certification maintenance intervals. https://www.asha.org/certification/certmaint​ intervals/ American Speech-Language-Hearing Association. (2008a). Clinical supervision in speech-language pathology [Technical report]. https://www.asha.org/ policy/ps2008-00295/ American Speech-Language-Hearing Association. (2008b). Knowledge and skills needed by speech language pathologists providing clinical supervision. https://www.asha.org/policy/ks2008-00294/ American Speech-Language-Hearing Association. (2018). ASHA membership and certification handbook. https://www.asha.org/certification/ American Speech-Language-Hearing Association. (2022). Special interest groups. https://www.asha​ .org/SIG/About-Special-Interest-Groups/

American Speech-Language-Hearing Association. (2023b). Code of ethics. http://www.asha.org/policy/ et2016-00342/ Bravata, D. M., Watts, S. A., Keefer, A. L., Madhusudhan, D. K., Taylor, K. T., Clark, D. M., . . . Hagg, H. K. (2019). Prevalence, predictors, and treatment of impostor syndrome: A systematic review. Journal of General Internal Medicine, 35, 1252–1275. ncbi.nlm .nih.gov/pmc/articles/PMC​7174434 Berger, W. (2015, September 11). Why curious people are destined for the C-suite. Harvard Business Review. https://hbr.org/2015/09/why-curious-people-aredestined-for-the-c-suite Coyle, D. (2018). The culture code: The secrets to highly successful groups. Bantam. Damasio, A. D. (1994). Descartes’ error: Emotion, reason, and the human brain. Putnam.

Faucheron, E. (2017). Burnout to badass: Elea’s stress conquering method for getting your life back when work burns you out. Move, Think, Smile Publisher. Feenstra, S., Begeny, C. T., Ryan, M. K., Rink, F. A., Stoker, J. I., & Jordan, J. (2020). Contextualizing the impostor “syndrome.”  https://ncbi.nlm.nih.gov/ pmc/articles/PMC7703426/ Felps, W., Mitchell, T. R., & Byington, E. (2006). How, when, and why bad apples spoil the barrel. Negative group members and dysfunctional groups. Research in Organizational Behavior, 27, 181– 230. Flasher, L., & Fogel, P. (2004). Counseling skills for speechlanguage pathologists and audiologists. Thompson. Gentry, J. E., & Dietz, J. D. (2020). Forward facing professional resilience: Prevention and resolution of burnout, toxic stress, and compassion fatigue. Outskirts Press. Gino, F. (2018). Why curiosity matters. Harvard Business Review, (Sept–Oct), 48–57). Goleman, D. (1998). Working with emotional intelligence. Bantam.

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Goleman, D., McKee, A., & Boyatzis, R. (2002). Primal leadership: Realizing the power of emotional intelligence. Harvard Business Review. Grossman, S. (2020). The 7E solution to burnout. Warrior Publishing. Hamilton, D. (2020, April 3). How to instill curiosity in the workplace. Forbes Coaches Council. https:// www.forbes.com/sites/forbescoachescouncil/2020/​ 04/03/how-to-instill-curiosity-in-the-workplace/​ ?sh=42c8614f42e2

right 2025. Plural Publishing, Inc. rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

Heathfield, S. (2011). Performance development planning (PDP). LiveAbout. http://humanresources​ .about.com/cs/perfmeasurement/a/pdp.htm Kennedy, J. L. (1998, September 12). When it’s time to resign, do it with savvy. Buffalo News, A14. Kroner, K. (1989). Take the gamble out of changing jobs. Nursing, 20, 111–118. Maxwell, J. (2020). The 21 irrefutable laws of leadership. Harper Collins. McGregor, L. N., Gee, D. E., & Posey, K. E. (2008). I feel like a fraud and it depresses me: The relationship between the imposter phenomenon and depression. Social Behavior and Personality International Journal 36, 43–48. https://doi.org/​ 10.2224/sbp.2008.36.1.43 NIH: National Library of Medicine (2020). Depression: What is burnout? https://www.ncbi.nlm.nih.gov/ books/NBK279286/

Raudsepp, E. (1990). Knowing when to look for a new job. Nursing, 20, 136–140. Robertson, S. (2007). Got EQ? Increasing cultural and clinical competence through emotional intelligence. Communication Disorders Quarterly, 29(1), 14–19. Robertson, S. (2017). I used to have a handle on life, but it broke. Dynamic Resources. Robertson, S. (2022). Beyond burnout: From charred to recharged. ASHA. Rodionova, A. (2016, February 2). Why impostor syndrome could be a sign that you are truly great. The Independent. https://www.independent.co.uk/ news/business/news/why-impostor-syndrome-couldbe-a-sign-that-you-are-truly-great-a6849126​.html Rosenberg McKay, D. (2010). Make a good impression at your first job. LiveAbout. http://careerplanning​ .about.com/cs/firstjob/a/first_job.htm Schwartz, I., Horner, J., Jackson, R., Johnstone, P., & Mulligan, M. (2007). Eligibility requirements and essential functions. Council of Academic Programs in Communication Sciences and Disorders. Silber, L. (2004). Organizing from the right side of the brain: A creative approach to getting organized. St. Martin’s Press. Tracy, B. (2017). Eat that frog: 21 great ways to stop procrastinating and get more done in less time (3rd ed.). Berrett-Koehler Publishers.

Pavlina, S. (2007). Personal development for smart people. http://www.stevepavlina.com/

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9 Assistants in Audiology and Speech-Language Pathology Diane Paul, Tricia Ashby-Scabis, and Lemmietta G. McNeilly

Introduction Many individuals support the work of audiologists and speech-language pathologists (SLPs) including families, administrators, teachers and instructional aides, psychologists, social workers, other professional staff, interns, and volunteers. This chapter focuses specifically on individuals hired in a professional capacity who have training and supervision to extend audiology and speech-language pathology services. They perform services as assistants that are prescribed, directed, and supervised by licensed and/or certified audiologists or SLPs. The chapter will also include information about credentialing of audiology and speech-language pathology assistants (SLPAs) at the national level. Support personnel in audiology and speech-language pathology have been employed in a variety of work settings since the 1960s. They are support staff who extend and expand clinical services; they do not substitute or replace qualified audiologists or SLPs. Several terms are used in different states to designate individuals who provide support services in audiology and speech-language pathology (e.g., “aides,” “assistants,” “extenders,” “paraprofessionals,” “technicians”). States may have different tiers of support personnel depending on the assigned responsibilities. The American Speech-LanguageHearing Association (ASHA) uses the term and offers credentialing for “assistants” (ASHA, n.d.-a). The employment of assistants has been a topic of debate, particularly in speech-language pathology, with passionate views on both sides. Those favoring the use of support personnel, or more specifically audiology assistants and SLPAs, believe that access to care is improved, frequency and efficiency of service are increased, and the skills of clinicians are better used. From this perspective, the judicious use of assistants facilitates practice at the top of the license for clinicians. Those opposing the use of assistants in clinical practice argue that the quality of care may be compromised and the services of audiologists and SLPs may be devalued. Proponents say the use of assistants is in the best interest of consumers; opponents say consumers may be misled (Breakey, 1993; Werven, 1993). Consumers may mistakenly think that assistants have the education and training to provide all services or may not realize they are working with an assistant who has a more limited scope of practice. The dynamics of the service delivery system, in tandem with cost controls and personnel needs, have led to the development of new and changing state and national policies related to the training, 167



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supervision, credentialing, and responsibilities of assistants in audiology and speech-language pathology (American Academy of Audiology [AAA], 2010a, 2010b, n.d.; ASHA, 1992, 1998, 2004g, 2013, 2022a, 2022b, 2022f, 2022g, n.d.-a, n.d.-b, n.d.-c, n.d.-g, n.d.-i, n.d.-j, n.d.-k). See Table 9–1 (pp. 171–173) for a chronology of policies related to assistants in audiology and speech language pathology. In many health care and school settings across the country, audiologists and SLPs are experiencing personnel shortages, sometimes in conjunction with high caseload/workload sizes, large amounts of paperwork, and budget constraints (ASHA, 2021a, 2022a, 2022b, 2022c). In response, some health care facilities and school districts have chosen to employ assistants to support their clinical staff. The purpose of this chapter is to provide information about the training, responsibilities, supervision, and effectiveness of assistants in audiology and speechlanguage pathology. Specifically, the chapter includes information on the rationale, challenges, professional policies, state regulations, current use, training recommendations, national credentialing, supervision requirements, job responsibilities, payment, research, and future directions related to assistants in audiology and speech-language pathology. A glossary of key terms used in this chapter is provided in Appendix 9–A.

Rationale for Use of Assistants Service delivery for individuals with communication disorders continues to evolve. When audiologists and SLPs practice at the “top of the license,” an essential option includes using extenders to participate in the service delivery process. Assistants who are educated to participate in the service delivery process are supervised by audiologists and SLPs who are competent to design intervention plans that include extension of their services with the engagement of assistants. The audiologists and SLPs are qualified and competent to assess the communication functioning of individuals; they also design intervention plans, monitor the individual’s progress, and make decisions regarding entry and exit from treatment. Assistants can provide guided practice of targeted behaviors, document progress of functional goals, and select therapeutic resources. The intervention plan for a patient/student/client is the responsibility of the audiologist or SLP. Practicing at the top of the license means that the audiologist and the SLP are engaging in those activities that require their level of expertise and skills. Appropriately delegating activities to assistants, monitoring the progress on functional goals, and intervening

periodically are effective options for practicing at the top of the license (McNeilly, 2018). The demand for services at a time when the need for audiologists and SLPs is high (Bureau of Labor Statistics, 2022a, 2022b) is one of the converging factors leading to the use of assistants. Other influences include facilitating practice at the top of the license, federal legislation sustaining the education rights of students with disabilities, the Individuals With Disabilities Education Improvement Act of 2004 (IDEA, 2004), including the right of students to be assessed in their native language and increasing caseloads due to (a) recognition of the value and need for early intervention services (ASHA, n.d.-f; Guralnick, 2011, 2019; Joint Committee on Infant Hearing, 2007); (b) aging of the population with concomitant health needs (Administration for Community Living, 2022; National Academies of Sciences, Engineering, and Medicine, 2016); (c) the need to care for individuals with hearing loss resulting from occupational noise (AAA, 2003; ASHA, 2004a); and (d) expanding scopes of practice in audiology and speech-language pathology (AAA, 1997, 2004, 2023; ASHA, 2001, 2004d, 2004e, 2016b, 2018d). Thus, because of the growing need for services, combined with the rising health care and education costs and personnel shortages, some audiologists and SLPs have identified roles for assistants in the delivery of services for children and adults with communication disorders. First, we will consider the rationale for three of the assistant roles: participating in telepractice, serving as interpreters/translators in multilingual/multicultural environments, and working on collaborative teams in classrooms. Following the discussion of these roles, we will address policy, practice, training, and research issues related to the use of assistants in audiology and speech-language pathology.

Role of Telepractice Telepractice is an appropriate model of service delivery for both audiologists and SLPs (ASHA, n.d.-l, n.d.-m). The use of telepractice increased by necessity during the COVID-19 pandemic, particularly for SLPs. Research demonstrates some parameters for the use of support personnel in telepractice. Coco et al. (2021) suggest that accessibility of services and delivery of care by a community health worker (CHW) assisting in remote service delivery via teleaudiology is “feasible, accessible and effective” if appropriate training and supervision are ensured. Also needed is a clear scope of practice, are conjunction with knowledge of the service area licensure or legal regulations. There is research on CHWs in Greenland by Demant et al. (2019) where the data suggest it is not effec-



CHAPTER 9   Assistants in Audiology and Speech-Language Pathology

tive to use nonspecialist health workers when working with a specific type of video otoscope used exclusively for video­recording otoscopy for otitis media. The videos were not sufficient for proper identification of pathology, and the researchers stress the importance of training for these support health workers. SLPs engaging in telepractice can train and use assistants appropriately to deliver services. Assistants can work with clients/patients/students in their homes, classrooms, or other settings while the SLP supervises either synchronously or asynchronously. State licensure laws must be adhered to for telepractice within states or across state lines (ASHA, n.d.-l, n.d.-m). The federal regulations and state regulations changed during the pandemic and public health emergency (PHE), which expired May 11, 2023.

Roles of Assistants: Interpreters/Translators The need to use multilingual/multicultural assistants in audiology and speech-language pathology may increase as the United States population continues to diversify with respect to language and culture (U.S. Census Bureau, 2021). Because only a small percentage of ASHA members and affiliates, most of whom are clinicians, selfidentify as nonwhite (8.7%), Hispanic or Latino (6.2%; ASHA, 2022d), and/or as a multilingual service provider (8.2%; ASHA, 2022b), it often is not possible to match a clinician to a client’s cultural and linguistic background (ASHA, 2004c, n.d.-e). Consequently, the assistance of professional interpreters and cultural brokers is often necessary to provide culturally and linguistically appropriate services (ASHA, 2004c, 2016b, n.d.-e; Lynch & Hanson, 2004). Executive Order 13166 that reinforces Title VI of the Civil Rights Act (U.S. Department of Justice, 2000) reminds facilities that receive any type of federal funds, including Medicaid/Medicare, that they must develop a plan to provide equal access to services for people with limited English proficiency. IDEA 2004 also requires that assessments be conducted in a child’s native language. Assistants who share the same language and/or culture with a client may be asked to fill these roles to help meet the needs of a multilingual population (ASHA, 1985a, n.d.-d, n.d.-e; Langdon & Cheng, 2002). However, the roles of an interpreter and assistant are decidedly different. Therefore, ongoing training, planning, and communication are needed. As discussed in the section titled “Challenges of Using Assistants,” adequate training for each role is critical when one person plays multiple roles. In the 2021 ASHA Survey of Audiology and Speech-Language Pathology Assistants (ASHA, 2021b), 20.2% of SLPAs indicated they serve

as an interpreter for clients/patients/students and families who do not speak English. About 22.3% of SLPAs indicated they provide services under an SLP’s supervision in another language for individuals who do not speak English and for English-language learners. The frequency with which they provide these services ranges from daily to less than monthly.

Roles of Assistants: Classroom Teams IDEA 2004 recognizes the use of paraprofessionals and assistants as adjuncts to the team of service providers in the schools. In accordance with state law, paraprofessionals and assistants who are appropriately trained and supervised may assist in the provision of special education and related services for children with disabilities. In addition, the state must adopt a policy that requires local educational agencies to recruit, hire, train, and retain highly qualified personnel, including paraprofessionals, to provide special education and related services to children with disabilities. Special education paraprofessionals who provide instructional support in Title I programs (Improving the Academic Achievement of the Disadvantaged) also must meet the requirements of the U.S. Elementary and Secondary Education Act (1965). The use of alternative service delivery models for SLPs in schools has also prompted the use of SLPAs. Although the prevailing speech-language pathology service delivery model in schools has been and continues to be a pull-out model (ASHA, 1995a, 2010, 2020b, 2020c, 2020d), it may not be the most ideal model for fostering natural, contextually-based communication interactions (ASHA, n.d.-h). The recognition of the need for more functional outcomes has led to an extension of service into the classroom (Cirrin et al., 2010; Paul-Brown & Caperton, 2001). The use of SLPAs who work directly in the classroom has been a means to integrate speech and language goals into the curriculum, generalize learned concepts, enhance carryover of functional skills, and reinforce SLP goals in the student’s natural setting (Gerlach, 2000; Goldberg & Paul-Brown, 1999; Pickett, 1999; Pickett & Gerlach, 1997). The appropriate use of trained, supervised, and lesscostly assistants may be one way to meet the growing service needs of persons with communication disorders and maintain the role of the fully qualified audiologist and SLP (Paul-Brown & Goldberg, 2001). The use of assistants in various roles (e.g., interpreters/translators, classroom collaborators) may provide a means to supplement services for a diverse population, extend services in natural settings, free clinicians to dedicate more time to individuals with more complex conditions, and fulfill increasing managerial responsibilities (ASHA, n.d.-a, n.d.-h).

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Challenges of Using Assistants Some audiologists and SLPs have expressed concerns about the impact of using assistants on service delivery. Some believe assistants (a) may be hired in lieu of qualified providers, (b) may be used to increase caseload size, (c) may be asked to provide services for which they are not trained, or (d) may receive inadequate supervision. Audiologists are concerned about otolaryngologists hiring support personnel, specifically otologic technicians (OTO techs), instead of hiring or referring to audiologists. In many school settings, demand for educational audiologists and SLPs (especially for SLPs) outweighs supply. Indeed, 25% of audiologists and 54.3% of SLPs responding to ASHA’s 2018 Schools Survey (ASHA, 2018b, 2018c) indicated that job openings were more numerous than job seekers in their type of facility and in their geographic area. According to ASHA’s 2022 Schools Survey, (ASHA 2022d, 2022e), 20.1% of audiologist respondents and 30.8% of SLP respondents indicated that personnel shortages were among their greatest challenges as school-based clinicians. Employers may be tempted to hire assistants to fill a persistent vacancy. There is a concern about quality of services when the motivation for using support personnel is to respond to a personnel shortage rather than to extend and enhance services (Paul-Brown & Goldberg, 2001). As ASHA recognized more than 30 years ago, “limited professional resources do not constitute a justification for applying lower standards in either the employment or utilization of supportive personnel” (ASHA, 1988, p. 56). Another area of concern is when a multilingual assistant is asked to work with clients without adequate supervision or support. Although using a multilingual assistant may be beneficial, there is potential for misuse or overuse if the assistant has not been trained appropriately or is asked to go beyond an assistant’s job responsibilities (e.g., inappropriately expected to conduct evaluations and create treatment plans for multilingual clients). Furthermore, the ability to speak a second language does not automatically qualify someone to be a translator or interpreter, nor does it mean the individual has the skills necessary to serve as an audiology assistant or SLPA (ASHA, 1985a, 2004c, 2013, n.d.-d, n.d.-e; Langdon & Cheng, 2002). Clearly, inappropriate use of assistants could have far-reaching and negative effects on the professions (ASHA, n.d.-a, n.d.-g). One way to ensure the quality of care is not compromised is for audiologists and SLPs to adhere to state and national laws and follow professional ethics statements and guidelines so that assistants receive appropriate training and supervision and only provide services within a limited scope of practice. Even in the absence of mandatory state requirements, audiologists

and SLPs are responsible for adhering to professional guidelines that delineate the appropriate use and supervision of assistants. Another way to promote the appropriate use of assistants is through education and awareness initiatives, such as providing information to administrators, principals, school boards, hospital boards, otolaryngologists, and others responsible for personnel or hiring decisions about the role of supervised assistants and their job responsibilities in comparison to the scope of practice of the supervising audiologists and SLPs. In 2009, ASHA established an affiliation category for support personnel in audiology and speech-language pathology to give ASHA and its members a stronger, more credible voice in explaining the proper use of assistants with defined boundaries for how they are used. ASHA supports the use of assistants to ensure both accessibility and the highest quality of care while addressing productivity and cost–benefit concerns. The professional continuum concept, affirmed by ASHA’s Board of Directors (BOD), includes SLPAs and master’s-level SLPs within the service delivery process. SLPAs can play a critical role in the service delivery process (McNeilly, 2009). Starting in 2011, ASHA began to offer associate status to assistants who work under the supervision of an ASHA-certified audiologist or SLP. Applicants were required to adhere to ASHA’s guidance for audiology assistants or SLPAs, perform only tasks that are appropriate for assistants, adhere to state laws and state licensure requirements for assistants, and pay the requisite annual fees (McNeilly, 2010). Benefits for associate status for assistants through ASHA were networking opportunities (e.g., joining special interest groups), continuing education programs, ASHA online and print resources, and participation on ad hoc committees. They were not able to vote or hold elected office within ASHA. More recently, ASHA has taken another step toward setting a national standard for the use of assistants in audiology and speech-language pathology, a credentialing program for assistants. In November 2017, ASHA’s BOD approved funding and implementation of an Assistants Certification program (ACP) for audiology assistants and SLPAs. In 2020, the Council for Clinical Certification in Audiology and Speech‐Language Pathology (CFCC) established standards for ASHA Audiology Assistants Certification and SLPA Certification programs that include an audiology assistant or SLPA national certification exam, respectively (CFCC. 2020). The ACP launched in December 2020 and the first certificate holders were awarded C-AA and C-SLPA certification in 2020. At year-end 2021, there were 446 assistants — 23 certified in audiology, 354 certified in speech-language pathology, and 69 who had started but not yet completed the ACP (ASHA, 2022d).



CHAPTER 9   Assistants in Audiology and Speech-Language Pathology

Evolving Professional Policies and Practices State licensure boards and professional organizations have responded to concerns about misuse of assistants by providing regulations, policies, and reports with specific guidance. ASHA (1998, 2004b, 2013, 2016b, 2018d, 2022f, 2022g, n.d.-a, n.d.-g), AAA (1997, 2006, 2010a), the Council for Exceptional Children (Consortium of Organizations on the Preparation and Use of Speech-Language Paraprofessionals in Early Intervention and Education Settings, 1997), and the National Joint Committee on Learning Disabilities (1998) are

among the professional organizations representing audiologists and/or SLPs that have developed documents to provide guidance for the appropriate use and supervision of support personnel in those education and health care settings in which they are employed. All the professional policies rely on the clinical judgment and ethics of qualified professionals. This includes decisions regarding the delegation of tasks and the amount and type of supervision to provide. Table 9–1 presents a chronology of the policies professional organizations have developed over the last 56 years to guide the practice and performance of support personnel in audiology and speech-language pathology.

Table 9–1. Chronology of Ethical and Professional Practice Policies Related to the Use of Assistants by Audiologists and Speech-Language Pathologists n

1967 — ASHA’s Executive Board established the Committee on Supportive Personnel.

n

1969 — ASHA developed the document Guidelines on the Role, Training, and Supervision of the Communicative Aide.

n

1973 — Council for Accreditation in Occupational Hearing Conservation started training and certifying hearing conservationists.

n

1979 — ASHA referenced supportive personnel in the Code of Ethics and issued an Issues in Ethics statement highlighting the professional and ethical responsibilities of the supervising professionals and emphasizing the dependent role of the communication aide.

n

1981 — ASHA revised its guidelines for supportive personnel.

n

1988 — ASHA developed a technical report about the use of support personnel in speech-language pathology with underserved populations.

n

1990 — ASHA revised the Code of Ethics and included a proscription about service delegation.

n

1992 — ASHA developed a technical report on issues and the impact of support personnel in audiology and speech-language pathology. The 1992 and 1994 revised Code of Ethics dealt with the delegation of support services.

n

1994 — ASHA approved a position statement supporting the establishment and credentialing of categories of support personnel in speech-language pathology.

n

1995 — ASHA approved guidelines for the training, credentialing, use, and supervision of SLPAs.

n

1996 — ASHA convened a consensus panel to develop a strategic plan for approving speech-language pathology assistant programs and credentialing SLPAs. The plan was used as a framework to develop a training approval process and credentialing process for SLPAs.

n

1997 — Consortium of Organizations on the Preparation and Use of Speech-Language Paraprofessionals in Early Intervention and Education Settings developed guidelines for three levels of paraprofessionals in education settings: aides, assistants, and associates. The assistant category paralleled the ASHA SLPA guidelines. Consortium organizations included ASHA; Council for Exceptional Children/Division for Children’s Communication Development and Division for Early Childhood; Council of Administrators of Special Education; and Council of Language, Speech, and Hearing Consultants in State Education Agencies.

n

1997 and 1998 — AAA and ASHA published separate position statements and guidelines for support personnel in audiology. continues

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Table 9–1.  continued n

1998 — National Joint Committee on Learning Disabilities developed a report on the use of paraprofessionals with students with learning disabilities.

n

2000 — Council on Academic Accreditation in Audiology and Speech-Language Pathology developed criteria and procedures for approving technical training programs for SLPAs, the Council on Professional Standards in Speech-Language Pathology and Audiology developed criteria for registering SLPAs, and the Council for Clinical Certification in Audiology and Speech-Language Pathology developed the implementation program.

n

2001 — ASHA revised its Code of Ethics, added the terms assistants, technicians, or any nonprofessionals to the term support personnel, and mandated informing persons served about the credentials of providers.

n

2002 — ASHA developed knowledge and skills statements for supervisors of SLPAs.

n

2002 — ASHA developed an approval process for SLPA training programs.

n

2003 — ASHA established a registration process for SLPAs.

n

2003 — ASHA voted to discontinue the approval process for SLPA training programs and the registration program for SLPAs as of December 31, 2003, due primarily to financial concerns.

n

2003 — ASHA revised its Code of Ethics and elaborated on delegation and supervision of support personnel.

n

2004 — ASHA issued a new Issues in Ethics Statement on support personnel.

n

2004 — ASHA revised its position statement for support personnel in speech-language pathology and its guidelines for SLPAs to remove references to SLPA credentialing.

n

2006 — AAA published a new position statement to define the function of the audiologist’s assistant.

n

2010 — ASHA revised its Code of Ethics and continued to set forth rules concerning accurate representation of credentials, delegation of tasks, and supervision for assistants, technicians, and support personnel.

n

2010 — AAA updated its position statement about the use of an audiology assistant. The rationale was provided in a 2010 task force report.

n

2011 — ASHA revised its guidelines for support personnel in audiology and speech-language pathology.

n

2011 — ASHA established an Associates Program for audiology assistants and SLPAs. The Associates Program provided an affiliation category entitling approved applicants access to ASHA benefits and discounts without full ASHA membership.

n

2012 — ASHA added provisions related to audiology assistants and SLPAs to its model bill for the state licensure of audiologists and SLPs. The model bill, updated in 2014, provides a prototype for state regulation of audiologists, SLPs, and audiology assistants and SLPAs. It is designed as an example to be modified to reflect individual states’ needs.

n

2013 — ASHA developed the Speech-Language Pathology Assistant Scope of Practice. The Speech-Language Pathology Assistant Ad Hoc Committee created the document to provide guidance for SLPAs and their supervisors about ethical considerations related to the SLPA practice parameters.

n

2013 — The ASHA Practice Portal pages launched with “audiology assistants” and “speech-language pathology assistants” listed as Professional Issues topics. These are updated approximately every 5 years. The document addressed how SLPAs should be used and what specific responsibilities are within and outside their roles of clinical practice

n

2014 — ASHA issued an Issues in Ethics statement on audiology assistants.

n

2014 — ASHA updated its Model Bill for State Licensure of Audiologists, Speech-Language Pathologists, and Audiology and Speech-Language Pathology Assistants.



CHAPTER 9   Assistants in Audiology and Speech-Language Pathology

Table 9–1.  continued n

2015 — ASHA Board of Directors (BOD) voted to make the Associates Program an ongoing program. ASHA approved a feasibility study regarding the potential of credentialing audiology assistants and SLPAs.

n

2016 — The Board of Ethics revised the ASHA Code of Ethics.

n

2017 — The Board of Ethics revised the Issues in Ethics: Audiology Assistants.

n

2017 — The ASHA BOD unanimously approved funding and implementation of the Assistants Certification Program.

n

2017 — The Board of Ethics revised the Issues in Ethics: Speech-Language Pathology Assistants.

n

2018 — ASHA published the Audiology Assistant Exam Blueprints and the Speech-Language Pathology Assistants Exam Blueprints to help identify core competencies for assistants.

n

2020 — ASHA developed an Assistants Code of Conduct. It provides a framework and guidance for clinical decision making pertaining to the conduct of assistants in audiology and speech-language pathology.

n

2020 — The Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC) established standards for ASHA Audiology Assistants Certification and SLPA Certification programs that includes an audiology assistant or SLPA national certification exam, respectively.

n

2021 — The American Academy of Audiology (AAA) updated its audiology assistants position statement. The updated position statement was created to provide current guidance on the role of assistants in supporting audiologists in the delivery of hearing- and balance-care services.

n

2022 — ASHA developed the Scope of Practice for Audiology Assistants as an ASHA policy document. The document provides guidance for audiology assistants and their supervisors regarding ethical considerations related to the audiology assistant practice parameters. The document addresses how audiology assistants should be used and the specific responsibilities that are within and outside their roles of clinical practice. Given that standards, licensure, and practice requirements vary from state to state, the document delineates ASHA’s policy for the use of audiology assistants.

n

2022 — ASHA updated its Scope of Practice for the Speech-Language Pathology Assistant (SLPA) as an ASHA policy document. The document provides guidance for SLPAs and their SLP supervisors regarding ethical considerations related to the SLPA practice parameters. It addresses how services performed by SLPAs should be used and the specific responsibilities that are within and outside their roles of clinical practice. Given that standards, state credentialing (e.g., licensure), and practice requirements vary from state to state, the document’s purpose is to provide information regarding ASHA’s guidelines for the use of SLPAs for the treatment of communication disorders across practice settings.

Chronology of Ethical and Professional Practice Policies Related to the Use of Assistants by Audiologists and SpeechLanguage Pathologists Ethical Responsibilities ASHA’s Code of Ethics and Issues in Ethics statements have provided a general framework for the supervision of support personnel in audiology and speech-language pathology. The first reference in the ASHA Code of Eth-

ics was in the 1979 Code, specifically, Principle of Ethics II, Ethical Proscription 4, which stated, “Individuals must not offer clinical services by supportive personnel for whom they do not provide appropriate supervision and assume full responsibility.” The first ASHA Issues in Ethics statements to address support personnel highlighted the professional and ethical responsibilities of the supervising clinicians and emphasized the dependent role of the communication aide (ASHA, 1979). The 1990 ASHA Code used the same language and had the first reference to delegation, with its proscription not to delegate any service. The 1992 ASHA Code and its revision in 1994 both dealt with the delegation of support

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services. The 2001 ASHA Code added terms (e.g., assistants, technicians) to the term “support personnel” and mandated that members had an affirmative requirement to “not misrepresent the credentials of assistants, technicians, or support personnel and shall inform those they serve professionally of the name and professional credentials of persons providing services.” The 2003 revision of the ASHA Code maintained this requirement pertaining to representation of credentials and added requirements pertaining to delegation of tasks and supervision (ASHA, 2003). The 2010 revision of the ASHA Code continued to set forth rules concerning accurate representation of credentials, delegation of tasks, and supervision. The 2016 and 2023 revisions of the ASHA Code continue to address representation of credentials, delegation of tasks, and supervision of assistants (ASHA, 2016a, 2023). ASHA Issues in Ethics statements discuss a variety of training options and tasks and indicate that support personnel should be supervised by ASHA-certified audiologists and/or SLPs (ASHA, 2017b, 2017c). The statements identify principles and rules in the code that are applicable to supervision in clinical practice and use of assistants. Consistent with its prior Code of Ethics (AAA, 2018), AAA’s current code (AAA, 2023) puts forth a rule pertaining to delegation and supervision of support personnel by its audiology members. Specifically, Rule 2d states, “Individuals shall provide appropriate supervision and assume full responsibility for services delegated to supportive personnel. Individuals shall not delegate any service requiring professional competence to unqualified persons” (AAA, 2023). ASHA created an Assistants Code of Conduct (ASHA, 2020a) to guide certified assistants in audiology and speech-language pathology. It provides a framework to help with clinical decision making and defines assistants’ roles. The Code of Conduct is based on principles in three areas: (a) responsibility to persons served professionally, (b) responsibility to the public, and (c) responsibility for professional relationships.

Chronology of Professional Practice Policies In addition to the policies related to ethical use of assistants and other support personnel, professional organizations developed documents to guide professional practice. In 1970, ASHA published its first professional practice guidelines on the use of support personnel in audiology and speech-language pathology. These guidelines, revised in 1981, delineated training needs, scope of responsibilities, and amount of supervision for support personnel in audiology and speech-language pathol-

ogy (ASHA, 1970, 1981). The following two sections address professional practice policies specific to either audiology or SLPAs.

Audiology Assistants Multiple professional organizations are involved in the use of audiology assistants and other support personnel. In 1997, a Consensus Panel on Support Personnel in Audiology convened with members of the Academy of Dispensing Audiologists, AAA, Educational Audiology Association, Military Audiology Association, and National Hearing Conservation Association and developed a position statement and guidelines (AAA, 1997). ASHA developed its own audiology support personnel position statement and guidelines (ASHA, 1998) that differed only in its requirement for supervisors to hold the ASHA Certificate of Clinical Competence in Audiology. ASHA currently outlines the duties, tasks, and steps performed by an audiology assistant in the Scope of Practice for Audiology Assistants (ASHA, 2022f ): Duty Area, Description A. Participate in patient/client/student care 1. Self-identify as audiology assistants to patients/ clients/students/families, staff, and others 2. Comply with all relevant laws, regulations, and local policies 3. Use standard precautions for infection control and safety standards 4. Prepare patient/client/student, materials, equipment, and room based on appointment type 5. Assist patients/clients/students and caregivers in completing case history or other relevant forms (e.g., questionnaires, outcome measures) 6. Assist with providing services (e.g., testing and telepractice) 7. Assist with fitting of hearing devices and accessories 8. Assist with intervention programs (e.g., auditory rehabilitation, tinnitus management, hearing loss prevention) 9. Perform nondiagnostic otoscopy 10. Conduct audiologic testing without clinical interpretation (e.g., hearing screening, pure-tone air conduction thresholds, newborn hearing screening, immittance screening, otoacoustic emission screening)



CHAPTER 9   Assistants in Audiology and Speech-Language Pathology

11. Document and report all patient/client/ student encounters — including interaction, services, and outcomes

3. Assist with activities such as research projects, in-service training, public relations programs, and marketing programs

12. Assist with educating patients/clients/students, families, and caregivers (e.g., communication strategies, hearing loss prevention)

4. Participate in community awareness, health literacy, education, and training programs

13. Assist with educating patients/clients/students, families, and caregivers about use and care of hearing devices, assistive listening devices, and alerting devices

AAA developed an audiology assistants position statement in 2006 to guide audiologists on the education and job responsibilities of an assistant in the delivery of hearing and balance care services; it was updated in 2010 and again in 2021 (AAA, 2006, 2010a, 2021). The AAA statement indicates that audiology assistants assigned duties should be based on the qualifications and competency of their supervisors and on the assistant’s training, supervision, and work setting (AAA, 2021). AAA continues, within the updated Position Statement for Audiology Assistants, to advise that the audiology assistant should have a minimum of “a high school diploma, or equivalent, and either formal educational training and/or competency-based training within the facility where they will be working” (AAA, 2021, p. 3). Additional comments in the AAA assistant position statement state the importance of understanding what assistant duties are allowed under state regulations for the state in which they are providing services. Audiology assistants and other support personnel are trained and used in a variety of employment settings, such as industry, schools, private clinics, and Veterans Administration hospitals and other military hospitals and medical centers. In industrial and military settings, assistants may help with the prevention of hearing loss resulting from noise. Occupational hearing conservationists have been trained and certified by the Council for Accreditation in Occupational Hearing Conservation (CAOHC) since 1973. They may be audiometric technicians, occupational health nurses, engineers, and others who do audiometric testing and help to fit hearing protection devices for employees (Suter, 2002). The CAOHC is an interdisciplinary group that currently includes representatives from nine organizations. Its mission is to provide education about noise in the workplace and to prevent noise-induced hearing loss in industry. The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) (see AAO-HNS, 2006) developed a certificate program for otolaryngology personnel (CPOP) to train otolaryngology office personnel to become OTO techs and conduct hearing testing. The program includes a self-study reading component, a 2½-day workshop, and 6 months of supervision by an otolaryngologist. The list of tasks delegated to an OTO tech closely matches the scope of practice of audiologists. Such overlap of responsibilities is a concern to professional audiology organizations such as AAA and

14. Advocate for patient/client/student needs B. Perform hearing device maintenance 1. Preset hearing aids, using initial fitting of the manufacturer software prior to a fitting appointment 2. Restore or verify previous patient/client/ student settings of hearing devices 3. Perform electroacoustic analysis of hearing devices 4. Perform listening checks and visual inspection of hearing devices and accessories 5. Perform troubleshooting and minor repairs of hearing devices, earmolds, and accessories 6. Perform minor modifications to earmolds, custom hearing devices, and custom products 7. Clean hearing devices, earmolds, and accessories 8. Send hearing devices and accessories for repair C. Maintain the audiology clinic or service setting 1. Assist with clerical duties (e.g., stocking of materials, recordkeeping, scheduling activities) 2. Verify the function and safety of the equipment routinely 3. Perform infection control 4. Maintain inventory of supplies 5. Communicate with hearing device manufacturers/suppliers 6. Order hearing devices, earmolds, and accessories D. Engage in professional activities and advocacy 1. Participate in professional organizations 2. Advocate for relevant public policies and resources at the local, state, and national levels

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ASHA about the blurring of professional and technical boundaries, particularly when otolaryngologists hire OTO techs rather than audiologists but bill for the services of audiologists. Those endorsing the use of OTO techs suggest their use can free up time for audiologists to perform more complex hearing and balance services. Some audiologists have argued that the move to the doctoral level for the profession of audiology may lead to increased use of audiology assistants to have a less costly option for the more technical aspects of the profession (Thornton, 1993). One of the reasons audiologists decided not to require a higher education degree or credential for audiology assistants is to have the educational level and scope of responsibilities as distinct as possible between technical- and professional-level personnel. Rather than have prescriptive policies related to education and tasks, audiologists prefer to determine independently what audiology assistants should do and how they should be trained.

Speech-Language Pathology Assistants In a 1995 position statement, ASHA endorsed the use of support personnel in speech-language pathology for the first time rather than only providing guidance for their use (ASHA, 1995b). In 1996, the earlier ASHA guidelines from 1981 were revised to address one category of support personnel, SLPAs, defined as “support personnel who perform tasks as prescribed, directed, and supervised by certified SLPs, after a program of academic and/ or on-the-job training” (ASHA, 1996, p. 22). SLP assistants were differentiated from SLP aides, who usually have a narrower training base and more limited responsibilities relative to the duties of assistants. Like the first two ASHA guideline documents, the 1996 guidelines specified a scope of responsibilities and outlined the type and amount of supervision required. Some of these decisions were influenced in part by the less restrictive policies developed by other professions with a longer history using support personnel, such as occupational therapy and physical therapy (ASHA, 1992). The ASHA guidelines were more prescriptive than those of the other professions to avoid the risk of assistants working outside of their limited scope of responsibilities or being hired in the place of SLPs (ASHA, 1996). The ASHA guidelines also called for training at the associate’s degree level rather than just on-the-job training and recommended a credentialing program for assistants and for assistant-level training programs. ASHA’s plan to credential SLPAs and approve training programs started with the 1995 position statement supporting the establishment and credentialing of categories of SLP support personnel (ASHA, 1995b). In 2000, criteria for approving technical training programs and

for registering SLPAs were developed by the Council on Academic Accreditation in Audiology and Speech-Language Pathology (CAA; ASHA, 2000a) and the Council on Professional Standards in Speech-Language Pathology, respectively (ASHA, 2000b). Recommendations for assistant-level tasks, knowledge required, and where this knowledge could and should be obtained were based in part on a job analysis of SLPAs conducted by the Educational Testing Service (Rosenfeld & Leung, 1999). ASHA established implementation dates of January 2002 for the approval process for training programs and January 2003 for the SLP assistant registry process (Mullins & Appler, 2002). The CAA was responsible for implementation of the technical training approval process and the CFCC was responsible for implementation of the assistant registration program. ASHA’s commitment to these programs was linked to the receipt of sufficient fees to cover administrative costs paid by training programs and individuals seeking registration. When those revenues fell well short of what was required, the decision was made to discontinue the approval process for SLPA training programs and the registration program for SLPAs as of December 31, 2003. In 2004, the ASHA position statement for SLP support personnel and guidelines for SLPAs were revised to remove references to SLP assistant credentialing. Relevant portions of the criteria for SLPA technical training programs and assistant registration related to training, use, and supervision were folded into the 2004 SLPA guidelines (ASHA, 2004b, 2004g). The guidelines documents were superseded in 2013 by the ASHA Scope of Practice for SLPAs and again in 2022 to provide guidance for SLPAs and their supervisors (ASHA, 2013, 2022g). Recognizing that standards, licensure, and practice requirements vary from state to state, the documents delineate specific responsibilities that ASHA considers to be within and outside an SLPA scope of clinical practice. If the SLPA has demonstrated the necessary competencies and the supervising SLP provides the appropriate amount and type of supervision, the SLPA may engage in or be assigned to perform the following tasks (ASHA, 2022g): Service Delivery n

Self-identify (e.g., verbally, in writing, signage, titles on name badges, etc.) as an SLPA to students, patients, clients, families, staff, and others.

n

Exhibit compliance with federal, state, and local regulations including: the Health Insurance Portability and Accountability Act (HIPAA), the Family Educational Rights and Privacy Act



CHAPTER 9   Assistants in Audiology and Speech-Language Pathology

(FERPA), reimbursement requirements, and state statutes and rules regarding SLPA education, training, and scope of practice. n

Administer and score screenings for clinical interpretation by the SLP.

n

Assist the SLP during assessment of students, patients, and clients (e.g., setting up the testing environment, gathering and prepping materials, taking notes as advised by the SLP, etc.).

n

Administer and score assessment tools that (a) the SLPA meets the examiner requirements specified in the examiner’s manual and (b) the supervising SLP has verified the SLPA’s competence in administration, exclusive of clinical interpretation.

n

Administer and score progress monitoring tools exclusive of clinical interpretation if (a) the SLPA meets the examiner requirements specified in the examiner’s manual and (b) the supervisor has verified the SLPA’s competence in administration.

n

Implement documented care plans or protocols (e.g., individualized education program [IEP], individualized family service plan [IFSP], treatment plan) developed and directed by the supervising SLP.

n

Provide direct therapy services addressing treatment goals developed by the supervising SLP to meet the needs of the student, patient, client, and family.

n

Adjust and document the amount and type of support or scaffolding provided to the student, patient, or client in treatment to facilitate progress.

n

n

Develop and implement activities and materials for teaching and practice of skills to address the goals of the student, patient, client, and family per the plan of care developed by the supervising SLP. Provide treatment through a variety of service delivery models (e.g., individual, group, classroombased, home-based, cotreatment with other disciplines) as directed by the supervising SLP.

n

Provide services via telepractice to students, patients, and clients who are selected by the supervising SLP.

n

Document student, patient, or client performance (e.g., collecting data and calculating percentages for the SLP to use; preparing charts,

records, and graphs) and report this information to the supervising SLP in a timely manner. n

Provide caregiver coaching (e.g., model and teach communication strategies, provide feedback regarding caregiver–child interactions) for facilitation and carryover of skills.

n

Share objective information (e.g., accuracy in speech and language skills addressed, participation in treatment, response to treatment) regarding student, patient, and client performance to students, patients, clients, caregivers, families, and other service providers without interpretation or recommendations as directed by the SLP.

n

Program augmentative and alternative communication (AAC) devices.

n

Provide training and technical assistance to students, patients, clients, and families in the use of AAC devices.

n

Develop low-tech AAC materials for students, patients, and clients.

n

Demonstrate strategies included in the feeding and swallowing plan developed by the SLP and share information with students, patients, clients, families, staff, and caregivers.

n

Assist students, patients, and clients with feeding and swallowing skills developed and directed by the SLP when consuming food textures and liquid consistencies.

Culturally Responsive Practices n

Adjust communication style and expectations to meet the needs of clients, patients, and students from different cultural groups and to provide services in a culturally responsive manner.

n

Provide information to families and staff regarding the influence of first language on the development of communication and related skills in a second language (under the direction of the supervising SLP).

n

Develop an understanding of the family dynamic from a cultural perspective to effectively engage in meetings surrounding intake, discussions of the therapy plan of care, and other communication scenarios surrounding practices for addressing communication concerns.

n

Engage in continuing education and training opportunities focusing on the assessment and intervention process when working with

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individuals from culturally and linguistically diverse backgrounds. Responsibilities for Practitioners Who Use Multiple Languages n

Assist the SLP with interpretation and translation in the student’s, patient’s, or client’s first language during screening and assessment activities exclusive of clinical interpretation of results.

n

Interpret for students, patients, clients, and families who communicate using a language other than English when the provider has received specialized training with interpreting skills in the student’s, patient’s, or client’s first language.

n

Provide services in another language for individuals who communicate using a language other than English or for those who are developing English-language skills. Such services are based on the provider’s skills and knowledge of the language spoken by the student, patient, or client.

n

Provide administrative support.

n

Assist with clerical duties and site operations (e.g., scheduling, recordkeeping, maintaining inventory of supplies and equipment).

n

Perform safety checks and maintenance of equipment.

n

Prepare materials for screening, assessment, and treatment services.

Prevention and Advocacy n

Present primary prevention information to individuals and groups known to be at risk for communication and swallowing disorders.

n

Promote early identification and early intervention activities.

n

Advocate for individuals and families through community awareness, health literacy, education, and training programs to promote and facilitate access to full participation in communication — including addressing the social determinants of health and health disparities.

n

Provide information to emergency response agencies for individuals who have communication, swallowing, and/or related disorders.

n

Advocate at the local, state, and national levels for improved public policies affecting access to services and research funding.

n

Support the supervising SLP in research projects, in-service training, marketing, and public relations programs.

n

Participate actively in professional organizations.

With respect to the training of SLPAs, several academic training programs for assistants have evolved (and continue to develop) over the years. ASHA has a self-reported list of 44 technical training programs for SLPAs (ASHA, n.d.-k). Additionally, the opportunities for training and lifelong learning for SLPAs do not end with the various degree programs available. Indeed, several learning opportunities, such as in-service seminars, are presented in various work settings. Similarly, as supervisors learn new techniques and practices in the profession evolve, supervisors can convey ideas and information on how their assistants can best work with them to ensure the highest quality outcomes for their clients/patients/students. ASHA has developed other documents and products over the years to assist SLPs who choose to employ assistants in various settings. These include a report on using support personnel with underserved populations (ASHA, 1988), knowledge and skills for supervising SLPAs (ASHA, 2002a), and practical tools and forms for supervising SLPAs (ASHA, 2009b) and for using and supervising SLPAs working in school settings (ASHA, 2000c).

State Regulations Assistants in audiology and speech-language pathology may or may not be regulated by state laws and regulations (ASHA, n.d.-a, n.d.-g). Supervising audiologists and SLPs are responsible for determining the applicable requirements in their state and work setting. Laws and regulations for assistants in audiology and speechlanguage pathology in educational and other practice settings vary from state to state. Differences may be reflected in a few requirements, including education, supervision, continuing education, titles used for assistants, and regulation or laws or lack thereof. State licensure boards and/or departments of education and ASHA provide current information about the requirements for specific practice settings and populations. As of February 2023, 45 states regulate (license, register, or certify) audiology and SLPAs in school settings and 43 states regulate (license, register, or certify) assistants outside of school settings. Of the states that regulate the use of assistants, a wide range of educational requirements is found. A few states have different



CHAPTER 9   Assistants in Audiology and Speech-Language Pathology

requirements for different levels of assistants, ranging from a high school diploma or equivalent to a bachelor’s degree in communication sciences and disorders (CSD) with enrollment in a master’s degree program. Continuing education for assistants is required in 20 states for those in school settings and in 25 states for those outside of school settings. A variety of titles are used to designate assistants in the professions, with assistant and aide being the most common. State agencies (licensure boards) currently regulating assistants also have a variety of differing supervision requirements (see ASHA’s website at https://www.asha.org/advocacy/state/ for state-specific information).

Supervisory Requirements To ensure assistants do not exceed the boundaries of their education and experience, most states that regulate assistants have imposed one or more supervision requirements. Some states limit the number of assistants that one licensed audiologist or SLP may supervise. Some states specifically prescribe the amount of direct and indirect supervision that a supervisor must provide to the assistant. Some states specifically define what activities assistants may or may not perform, and others simply provide a general statement that assistants are the responsibility of the licensed audiologist or SLP and should be appropriately supervised given their individual education and experience. In addition to state regulatory agencies, state education agencies may credential assistants to work solely in schools to support service delivery provided by qualified professionals. Some school districts hire assistants under the classification of teacher assistants. If a state regulates assistants (i.e., under the term of support personnel, assistant, aide, paraprofessional, or apprentice), individuals who wish to become employed in that state must meet the state requirements for practice under a licensed professional. ASHA also requires that audiologists and SLPs hold the Certificate of Clinical Competence to supervise assistants (ASHA, n.d.-a, n.d.-g). Information about the regulation of assistants in schools in all states and contacts for state licensure boards or departments of education is available at the ASHA website. State regulations may differ from ASHA’s standards and policies (e.g., in the number of hours of direct supervision required per week). In states where there is a conflict, members and certificate holders must abide by state requirements including applicable laws, regulations, and policies (ASHA, n.d.-a, n.d.-g). Generally, it is best to adhere to the strictest requirements to comply with the Code of Ethics, national certification standards, and state licensure.

Assistant Employment Trends Survey data were reviewed to determine the effects of using audiology assistants and SLPAs in educational, health care, and other settings. Having more time to work with clients/patients/students with more complex needs (71% of audiologists and 36% of SLPs) and having fewer clerical duties (64% of audiologists and 33% of SLPs) were two of the primary effects reported from the use of assistants (ASHA, 2009a). Other effects reported from using assistants included increased frequency or intensity of services and a response to personnel shortages. The main reasons reported for not using assistants were that they were not budgeted for or not needed. Also, approximately one-quarter of audiologists and SLPs indicated that larger caseloads or workloads were an effect of using assistants. Changes in the employment rates of assistants over time were explored for each profession and are discussed below.

Employment of Audiology Assistants Survey data have been collected to determine the percentage of audiologists who use assistants, the median number of assistants they supervise, and the tasks assistants perform. In the percentage of audiologists who employ assistants, a 2001 survey of audiologists showed that 45% hired assistants or previously hired assistants in their practices (Hamill & Freeman, 2001). A 2004 survey of AAA members showed that approximately 28.4% of audiologists employed assistants (AAA, 2006). A 2005 report from the United States Department of Veterans Affairs by Robert Dunlop revealed a 619% increase in the number of audiology support personnel in Veterans Administration hospitals from 1996 to 2004, with a decrease in the ratio of audiologists to support personnel from 24:1 in 1996 to 5.26:1 in 2004 (as cited in AAA, 2006). In a 2009 survey of ASHA members, 43% of audiologist respondents reported that their facility employed one or more audiology support personnel (ASHA, 2009a). In 2016, 2018, and 2021 ASHA surveys, audiologists were asked if they supervised audiology assistants. Of those who did, the median number they supervised was 1 (ASHA, 2016d, 2016e, 2018b, 2019, 2022a). As for the tasks that audiology assistants perform, Karzon et al. (2018) analyzed data from questionnaires to audiologists who employ assistants. Their data suggested the use of assistants to help with conditioned play audiometry, visual reinforcement audiometry, infection control, mail management, disposing of protected health information, ordering supplies, calling families, stocking supplies, troubleshooting equipment, and doing

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auditory brain stem response (ABR) screening. ASHA survey data from 2021 (ASHA, 2021b) showed that 89% of audiology assistants perform infection control duties daily and 79% clean hearing aids and other amplification devices daily. Other frequent activities include assisting audiologists with setup and technical tasks; instructing patients in the proper use and care of hearing aids and other amplification devices; packaging and mailing earmold orders, sending hearing devices for repair, and making manufacturer/lab returns; performing checks on hearing aids and other amplification devices; troubleshooting and making minor repairs to hearing aids, earmolds, and other amplification devices; maintaining inventories of supplies; and checking the function of equipment.

Employment of Speech-Language Pathology Assistants In a 2009 survey of ASHA members, 40% of schoolbased SLPs and 32% of health care-based SLPs reported that their facility employed one or more speech-language pathology support personnel (ASHA, 2009a). In a 2015 survey of ASHA members, school-based SLPs reported that their facility employed an average of 1.2 support personnel, while health care-based SLPs reported that their facility employed an average of 1.1 support personnel (ASHA, 2016c). In 2016 and 2018 ASHA surveys, school-based SLPs were asked if they supervised assistants. Of those who did, the median number they supervised was 1 (ASHA, 2016f, 2018c). In the surveys, SLPs were also asked whether supervising assistants affected their caseload or workload. In 2018, most SLPs indicated that it did. About 27% reported that supervising assistants increased their caseload, 36% reported that it decreased their caseload, 46% reported that it increased their workload, and 30% reported that it decreased their workload. These data are largely consistent with those from the 2016 survey. As for the tasks that SLPAs perform, ASHA survey data from 2021 (ASHA, 2021b) showed that 79% of SLPAs document client/patient/student performance and report this information to the supervising SLP daily. About 68% assist with clerical duties daily, such as preparing materials and scheduling activities, as directed by the SLP. Other frequent activities include assisting with departmental operations (e.g., recordkeeping and maintaining an inventory of supplies and equipment). Other less frequent — but no less important — tasks include providing guidance and treatment via telepractice and programming and providing instruction in the use of AAC.

Training for Assistants Assistants should not be permitted to work with individuals unless the supervising audiologists or SLPs are confident that the assistants have obtained a reasonable amount of training and possess appropriate skills (ASHA, n.d.-a, n.d.-g).

Training Audiology Assistants Audiology assistants are expected to have at least a high school diploma or equivalent and competency-based skills needed to perform assigned tasks (AAA, 2010a; ASHA, n.d.-b). The CFCC launched a new credential for audiology assistants in 2020. Candidates eligible to take the audiology assistants exam must complete one of three pathways that best fits their education and experiences. The need for three pathway options stems from the high variability in training for audiology support personnel. ASHA requires all applicants to complete the following (ASHA, n.d.-c): Education Option 1 n

Bachelor’s degree in CSD from an accredited institution

n

Fieldwork:  500 hours providing patient services within the Scope of Practice for Audiology Assistants (ASHA, 2022f ) under the supervision of an ASHA-certified audiologist*

*Fieldwork/clinical hours are verified as part of the online application process; no documentation needs to be submitted. Any hours completed January 1, 2020, or after must have been supervised by an ASHA-certified audiologist (see Standard III). Education Option 2 n

College degree (non-CSD), high school diploma, or GED from an accredited institution

n

Complete ASHA’s Online Audiology Assistant Education Modules or equivalent (i.e., associate’s degree or certificate program in becoming an audiology assistant)

n

Fieldwork:  1,000 hours providing patient services within the Scope of Practice for Audiology Assistants (ASHA, 2022f ) under the supervision of an ASHA-certified audiologist*

*Fieldwork/clinical hours are verified as part of the online application process; no documentation needs to be submitted. Any hours completed January 1, 2020, or



CHAPTER 9   Assistants in Audiology and Speech-Language Pathology

after must have been supervised by an ASHA-certified audiologist (see Standard III). Education Option 3 Military: Active Duty n

A military job series awarding certificate (audiology/ENT)

n

Provide a copy of:

n

n

service member training record

n

most recent annual performance evaluation

Complete the three 1-hour prerequisite courses

Military:  Veteran n

Honorable discharge

n

A military job series awarding certificate (audiology/ENT)

n

Provide a copy of:

n

n

military transcript

n

annual evaluation form of prior service obtained no more than 5 years prior to certification application submission

Complete the three 1-hour prerequisite courses

Prerequisites.  In addition to finishing all the requirements of the selected pathway option, applicants must also complete the following: n

A 1-hour ethics course*

n

A 1-hour course in universal safety precautions*

n

A 1-hour patient confidentiality training course (HIPAA, FERPA, etc.)*

*These three prerequisite courses must be completed no more than 2 years prior to application. These requirements may also be met as part of an academic course. Training programs for audiology assistants are harder to find. At the time of publication, Nova Southeastern University offered a self-paced distance learning program with training modules in testing and amplification. Students access a website for course materials, tests, and tutorials. Another successful training program is through the Audiology Academy, which offers an option to complete 10 online course modules (basic training focused on diagnostic training, amplification, infection control, and aural rehabilitation) or 15 online course modules (complete training focused on the aforementioned topics and including patient-centered care, communication etiquette and Hearing Instrument Test Box training,

and other responsibilities). Georgia State University launched an audiology assistant certificate program at the beginning of January 2023. It is expected that other programs will emerge with their own certificate programs in the coming years. CAOHC offers a training program for occupational hearing conservationists that involves successful completion of a practical and written exam after a 20-hour course on a variety of topics such as social and legal ramifications of noise on people and pure-tone audiometric procedures. CAOHC also offers an 8-hour recertification course; recertification is required every 5 years. CAOHC also certifies course directors, the majority of whom are audiologists (ASHA, 2004a).

Training Speech-Language Pathology Assistants Training requirements for assistants in speech-language pathology vary across the country. ASHA’s 2004 guidelines were developed to promote greater uniformity in training requirements across the country (ASHA, 2004b). The 2004 ASHA guidelines recommended completion of an associate’s degree from a technical training program with a program of study specifically designed to prepare the student to be an SLPA. The guidelines suggested SLPAs complete coursework, fieldwork, and on-the-job training. The ASHA Scope of Practice for SLPAs (ASHA, 2013) extended the training paths to include an associate’s degree in an SLPA program or a bachelor’s degree in a speech-language pathology or CSD program. ASHA’s updated Scope of Practice for the SLPA (ASHA, 2022g) includes information in three areas: (a) specific information regarding the use of appropriately trained SLPAs to screen feeding/swallowing in nonmedically fragile individuals; (b) assistance with administration of some standardized assessment tools based on the requirements stated in the examiner manual; and (c) parameters to guide SLPs as they determine the frequency and amount of direct supervision for SLPAs. The CFCC developed standards for the ASHA Speech-Language Pathology Assistants Certification that were effective July 1, 2020. The standards address the degree, education, supervised clinical experience, assessment, Assistants Code of Conduct, and maintenance of certification (CFCC, 2020). n

Applicants must: n

meet degree and education requirements,

n

pass a national examination, and

n

abide by the Assistants Code of Conduct.

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Eligibility Pathways To be eligible to take the SLPA certification exam, applicants for ASHA SLPA certification must complete one of three pathway options that best fits their education and qualifications. Education Option 1 n

2-year SLPA program degree from an accredited institution (e.g., associate’s degree from a community college or technical training program)

n

Complete the three 1-hour prerequisite courses listed below

n

Complete the clinical fieldwork requirement listed below

Education Option 2 n

Bachelor’s degree in CSD from an accredited institution

n

Complete ASHA’s online SLPA education modules or academic equivalent

n

Complete the three 1-hour prerequisite courses listed below

n

Complete the clinical fieldwork requirement listed below

Education Option 3 n

College degree (associate’s or bachelor’s) from an accredited institution

n

Complete an SLPA certificate program with equivalent coursework, or complete academic coursework from an accredited college institution, in the areas below: n Introductory or overview course in communication disorders n Phonetics n Speech sound disorders n Language development n Language disorders n Anatomy and physiology of speech and hearing mechanisms

n

Complete ASHA’s online SLPA education modules or academic equivalent

n

Complete the three 1-hour prerequisite courses listed below

n

Complete the clinical fieldwork requirement listed below

Prerequisites.  In addition to finishing all the requirements of the selected pathway option, applicants must also complete the following: n

A 1-hour of ethics course*

n

A 1-hour course in universal safety precautions*

n

A 1-hour patient confidentiality training course (HIPAA, FERPA, etc.)*

*These three prerequisite courses must be completed no more than 2 years prior to application. These requirements may also be met as part of an academic course. Applicants who have not had specific academic training in the roles and responsibilities of working as an assistant must also complete ASHA’s online education modules for assistants or an equivalent academic course.

Clinical Hours n

Clinical fieldwork (also called “clinical practicum” or “on-the-job” hours): A minimum of 100 hours, to include n 80 hours of direct patient/client/student services under the supervision of an ASHAcertified SLP* n 20 hours of indirect patient/client/student services under the supervision of an ASHAcertified SLP*

n

Hours may be completed via an academic practicum or on the job with a current/former CCC-SLP and may be no more than 5 years old at the time of application.

n

Observation and simulation hours cannot be used toward this requirement.

n

The supervisor will verify the clinical hours via the online application when submitted. No paperwork is required to be sent to ASHA.

*Any hours completed January 1, 2020, or after must have been supervised by an ASHA-certified SLP. Direct Clinical Contact.  Examples of direct clinical contact may include the following activities performed under the direction and supervision of the supervising SLP: n

Screening speech, language, and hearing

n

Assisting the SLP during assessment

n

Administering assessment tools within the ASHA Scope of Practice for the SLPA

n

Providing direct therapy services



CHAPTER 9   Assistants in Audiology and Speech-Language Pathology

Indirect Clinical Contact.  Examples of indirect clinical contact may include the following activities performed under the direction and supervision of the supervising SLP: n

Meeting with the SLP to review sessions and notes and to plan future services

n

Preparing materials and planning for clinical services

n

Attending consultations or team meetings with the SLP

n

Documenting screening/treatment results following services

n

Entering or recording data for billing purposes and/or code procedures following services

As of February 2023, ASHA is aware of 44 operational associate’s degree programs for SLPAs in 16 states (ASHA, n.d.-k). Some of these programs have training opportunities through distance learning and collaborations between community colleges and universities. The coursework and fieldwork experiences required in the SLPA training programs typically differ from those at the bachelor’s, preprofessional, or master’s professional levels. It is a challenge for SLPA training programs in community colleges to locate textbooks written specifically for SLPAs. Often the programs must use more advanced textbooks written for SLP students and omit the sections that do not apply, such as those related to assessment and diagnosis and detailed theoretical discussions. Assistant-level training programs are not specifically intended to be the start of a career ladder to audiology- or SLP-level positions; however, some programs lend themselves to such opportunities. Assistant training programs also may be another avenue for students, including multilingual and multicultural students, to seek their bachelor’s and master’s degrees in CSD. Universities do not always accept coursework from the SLPA training program to transfer to the bachelor’s degree programs. Knowledge and skills needed to be an SLPA are distinctly different from those needed to be an ASHAcertified SLP. Academic programs and institutions have the discretion to determine which academic coursework completed in technical training programs will be accepted for transfer to a bachelor’s degree program. Students interested in pursuing a career as an SLP are encouraged to verify the transferability of credits between assistant training programs and bachelor’s programs. Students also are encouraged to investigate the requirements of graduate educational programs to ensure basic science courses taken at the undergraduate level will be acceptable to the graduate program (ASHA, n.d.-k).

Credentialing Assistants ASHA’s national credentialing programs recognize that there are a variety of ways of transmitting knowledge and acquiring the knowledge, skills, and abilities for assistants. The credentials recognize multiple training paths to becoming an audiology assistant or an SLPA. Rather than expecting all assistants to have the same training or degree, the credentialing process instead expects applicants to pass a national exam to assess the acquisition of competencies related to practice as an assistant in audiology or speech-language pathology. In November 2018, the CFCC approved exam blueprints for audiology assistants and SLPAs (ASHA, 2018a, 2018e). The blueprints outline the duties and tasks and assign weighted percentages for the content. The national certification exams were completed in 2020. The certification exam for audiology assistants tests an applicant’s knowledge, skills, and abilities on tasks related to providing patient care, performing hearing device maintenance, and maintaining the audiology clinic. Tasks for SLPAs pertain to providing services, providing administrative support, and participating in prevention and advocacy activities. ASHA describes a variety of benefits for certifying assistants: aid assistants in maintaining current knowledge; enhance confidence that they have met nationally recognized standards; demonstrate professional commitment; and help potential employers, clients, and other professionals. Also, credentialing is expected to improve access to care by creating a cost-effective and reliable means of identifying qualified professionals who can provide the skills expected of a trained assistant (ASHA, n.d.-c, n.d.-j). National credentialing standards also may help states determine licensure standards without the costly burden of each state conducting independent job analyses and exams. Several states have passed laws and regulations accepting ASHA’s C-SLPA as an option for meeting some or all their licensing/credentialing requirements.

Supervision of Assistants Audiologists and SLPs may delegate services to assistants only with appropriate supervision (ASHA, 2016b, 2018d). It is essential that the supervising professional has the knowledge and skills needed to provide such supervision (ASHA, n.d.-a, n.d.-g). Supervisors who do not speak the same language as the assistant are still responsible for their supervision. Ideally an interpreter would be provided. Management and supervision skills are not synonymous with the skills needed to be a highly qualified

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audiologist or SLP. Many professionals have not received specific supervisory training during their preservice education programs. To become a competent supervisor and manager, professionals may consider taking continuing education courses that target these areas. The amount and type of supervision provided should be based on the skills and experience of the assistant, the needs of clients/ patients/students served, the service delivery setting, the tasks assigned, and other factors such as initiation of a new program, orientation of new staff, and change in client/patient/student status (ASHA, n.d.-a, g). The goal for the supervising professional is to ensure the assistant restricts their clinical activities to prescribed tasks, in contrast with the goal of independent clinical practice for supervision of students and clinical fellows (ASHA, 1985b; Paul-Brown & Goldberg, 2001). The supervising audiologist or SLP is responsible for the actions of assistants. Specifically, the supervisor would be held responsible and could be subject to sanctions if an assistant performs activities beyond the scope of their job responsibilities. Thus, any alleged violation of the code(s) of ethics governing the supervising professionals should be reported to the AAA Ethical Practices Board or the ASHA Board of Ethics for adjudication. ASHA members and certificate holders have a responsibility to ensure assistants under their supervision behave in an ethical manner (ASHA, 2017a, 2017b, 2017c). ASHA members and certificate holders are vicariously liable for the unethical conduct of assistants they supervise and can sanction them if they are found in violation. Assistants are also bound by an Assistants Code of Conduct (ASHA, 2020a). State laws pertaining to supervision vary and may differ from professional policies. This means audiologists and SLPs need to check specific state regulations to determine minimum amounts of supervision required and qualifications for supervisors of assistants in a particular state. Audiologists, SLPs, and assistants are legally bound to follow licensure laws and rules that regulate them and their practice in the state in which they work. Use of assistants is not permitted in every state. There is not a single entity responsible for oversight of assistants. The authority for practice regulations varies by state and work settings. It is necessary to check state laws and association standards. Currently, ASHA has direct oversight of the actions of ASHA-credentialed assistants in audiology or speech-language pathology.

Supervision of Audiology Assistants Neither ASHA nor AAA has prescribed supervisory requirements for training audiology assistants, nor are there professional policies that set a specific amount of

supervision after training or that specify a maximum number of audiology assistants that can be employed. The supervising audiologist has the responsibility for these decisions (AAA, 2021; ASHA 2022f, n.d.-b). Regarding supervision of occupational hearing conservation personnel, the Hearing Conservation Amendment (HCA), administered by the United States Department of Labor’s Occupational Safety and Health Administration (OSHA), specifies who may perform certain audiological procedures and indicates where the responsibility resides (U.S. Department of Labor, n.d.). Regarding supervision of OTO techs, an otolaryngologist is responsible for providing supervision during the 6-month portion of the training period. Thereafter, the OTO tech works loosely under the supervision of the physician. However, this is like a physician providing supervision to anyone in the physician’s office who provides patient care as governed by the state’s medical practices act. Presumably, a credentialed audiologist may also supervise the OTO tech consistent with the code(s) of ethics governing the audiologist, provided the physician accepts this role for the audiologist (AAOHNS, 2006).

Supervision of Assistants in Speech-Language Pathology ASHA does not specify an exact amount and type of supervision for SLPAs (ASHA, 2022g) but recommends a combination of direct and indirect supervised treatment based on client needs and assistant skill level. Direct supervision means “in-view observation and guidance while the SLPA is performing a clinical activity” (ASHA, 2022g) and includes supervision via telecommunication technology because the SLP can provide ongoing immediate feedback. Indirect supervision “may include (a) reviewing demonstration videos; (b) reviewing student, client, or patient files; (c) reviewing and evaluating audio or video recorded sessions; and/or (d) conducting supervisory conferences either in person or via telephone and/or live, secure virtual meetings” (ASHA, 2022g). The ASHA Scope of Practice for the SLPA recommends that an SLP supervise no more than two SLPAs at the same time (ASHA, 2022g). The supervising SLP has responsibility for establishing a means of documenting the supervision of the SLPA. Even when faced with time and workload pressures, the SLP is expected to adhere to these supervision guidelines. Although state and national guidelines are available to guide decisions about the amount of direct and indirect supervision, it remains the supervising SLP’s responsibility to determine the type and exact amount (beyond



CHAPTER 9   Assistants in Audiology and Speech-Language Pathology

the minimum) of supervision each SLPA requires. For example, some SLPAs may require more guidance and oversight to complete the required documentation. Another SLPA may need mentoring to ensure adherence to the rules and regulations of the facility. The SLP makes these decisions based on the SLPA’s individual strengths and technical proficiency. When asked how comfortable they felt to supervise SLPAs, 55% of SLPs in schools were very or extremely comfortable supervising assistants. The more years of experience SLPs had in the schools, the more likely they were to report that they were extremely comfortable with supervising assistants (ASHA, 2020c).

Job Responsibilities of Audiology Assistants The supervising audiologist is responsible for planning and delegating tasks an assistant may perform (ASHA, n.d.-b). Examples of tasks that have been delegated to assistants by supervising audiologists over the past 25 years include daily visual and listening checks on hearing aids and auditory trainers for children in public schools (Johnson, 1999); assisting with hearing screenings, hearing aid monitoring, and use of assistive listening devices in rehabilitation hospitals (Johnson et al., 1998); learning ways to optimize communication during interactions with persons with hearing loss (Johnson et al., 1998); and assisting with hearing conservation programs at work sites (ASHA, 2004a; Suter, 2002). The 2022 ASHA Scope of Practice for Audiology Assistants delineates services an audiology assistant may perform — if permitted by state law and after the assistant has demonstrated competence (ASHA, 2022f, n.d.-b). ASHA also provides a code of conduct (ASHA, 2020a) for those performing tasks as an audiology assistant and with the expectation that those supervising the assistant adhere to a professional scope of practice (ASHA, 2018d). The audiologist has exclusive responsibility for a variety of clinical activities. Audiology assistants may not interpret data; determine case selection; transmit clinical information, either verbally or in writing, to anyone without the approval of the supervising audiologist; compose clinical reports; make referrals; sign any formal documents without a signature from the supervising audiologist (e.g., treatment plans, payment forms, reports); discharge a patient/client from services; or communicate with the patient/client, family, or others regarding any aspect of the patient/client status or service without the specific consent of the supervising audiologist (ASHA, 2022f, n.d.-b).

Job Responsibilities of Assistants in Speech-Language Pathology Because assistants must be supervised by a licensed and certified SLP, it seems reasonable that the SLP should make decisions about the specific tasks and activities assigned to the SLPA (ASHA, 2022g). The SLP should advise the administrator of a facility or school principal that it is the supervising SLP’s responsibility to select the clients/patients/students, assign responsibilities, and determine the amount and type of supervision needed. Viewed collectively across states, assistants have a broad scope of responsibilities ranging from clerical duties to clinical activities. ASHA has delineated a restricted set of tasks in service delivery, administrative support, and prevention and advocacy, outlining which duties an SLP may delegate to an SLPA and which tasks only an SLP can provide (ASHA, 2022g). It is the responsibility of the supervising SLP to make sure SLPAs engage only in activities within their scope of practice. The SLP assigns clients/patients/students to an SLPA based on the student’s needs and the SLPA’s level of experience. The SLPA may be assigned to work with clients/patients/students on previously learned, less clinically challenging, or more rote or repetitive skills. For example, the SLP may assign an SLPA to work on increasing generalization after the SLP has worked with a student to establish a specific sound. Assistants also may work as members of a team in health care and education settings (Longhurst, 1997). In schools, IDEA has institutionalized the practice of using teams to determine the most appropriate course of action for each student and to collaborate and develop the IFSP or IEP.

Payment of Services Provided by Assistants Coverage and payment for services provided by assistants (often referred to as “support personnel”) depend on state laws and regulations and individual payer polices, which vary widely across the U.S. Federal law currently does not recognize assistants in audiology or speech-language pathology regardless of the level of supervision by an audiologist or SLP. An otolaryngologist, however, can bill Medicare for work performed by OTO techs under direct supervision. Private insurers and state Medicaid programs may cover licensed or registered audiology or SLP assistants. One must query each payer to verify coverage and supervision requirements. Private insurers who allow the provision of services by assistants may or may not provide a different rate of payment for services provided by an audiologist or SLP

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compared with an audiology assistant or SLPA. Most private insurers do not cover services that do not require the skills (directly or indirectly) of an audiologist or SLP. Each state has considerable latitude in administering its Medicaid program. Federal regulations indicate that services may be rendered “by or under the direction of ” a qualified audiologist or SLP, but a state may still prescribe the qualifications of the subordinate practitioners (Medicaid Program, 2004; Medicaid Assistance Programs, 2023).Therefore, one must verify Medicaid coverage of assistants/support personnel including supervision requirements, even if they are registered or licensed in the state. If an audiologist is employed by a Medicaid agency, clinic, or school, the federal regulations require that the audiologist’s employment terms allow for adequate supervision of support personnel who are “under the direction” of the qualified audiologist (Federal Register Medicaid Program; Provider Qualifications for Audiologists). The Medicaid Program Federal Register states that “under the direction of ” requires “services be provided by or under the direction of an audiologist for which a patient is referred by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law.” Additionally, the Federal Register states: n

“The qualified audiologist must see the beneficiary at the beginning of and periodically during treatment;

n

be familiar with the treatment plan recommended by a referring physician or other licensed practitioner of the hearing arts practicing under State law;

n

have continued involvement in the care provided;

n

and review the need for continued services throughout treatment.”

While the number of hours or ratio of supervision is not specifically outlined in the Federal Register, the audiologist must ensure their supervision meets the needs of the individual receiving services, in order for those services to be safe and effective. The support personnel working under the supervision of the audiologist must have a direct line of communication to the supervising audiologist for any necessary needs that arise during the course of treatment. Thorough documentation must be maintained by the support personnel, as well as the supervising audiologist. The key point with respect to payment for services provided by assistants in audiology or speech-language pathology is that for Medicaid and private insurers, each payer makes its own decisions about what is covered and

who is the qualified provider. For Medicaid, this varies by state and, with Medicaid Managed Care Plans, may even vary within a state depending on the specific plan and setting (e.g., school versus health care setting).

Research Related to Assistants To determine the effectiveness of using assistants to extend the clinical work of audiologists and SLPs, a systematic literature search of published English language studies through December 2022, was conducted searching electronic databases (the search methodology is available upon request of the first author). The studies, which spanned several decades, needed to be relevant to two clinical questions and contain original data or purport to be systematic reviews of the literature. A summary of the studies is provided below.

Have Any Studies Compared Audiology or Speech-Language Pathology Assistants With Audiologists or Speech-Language Pathologists? One study was identified that compared support personnel in audiology with nonspecialist health workers. Bright et al. (2019) found more than 90% accuracy in detecting the presence of hearing loss when comparing a trained audiologist, CHW, and a nurse in Malawi. However, when looking at otoscopy and determining middle ear issues, the CHW and nurse made more “dangerous errors” in their diagnoses in comparison to an ear, nose, and throat (ENT) physician (Bright et al., 2019). No studies were identified that compared support personnel in audiology with clinical service provision. Some studies compared treatment outcomes by support personnel and SLPs, primarily with elementary schoolchildren with articulation disorders and adults with aphasia. Studies With Children. A large-scale, blinded, randomized controlled trial was designed to compare language outcomes following direct versus indirect and individual versus group treatment for 161 children (6–11 years) with primary language impairment (Boyle et al., 2007; Boyle et al., 2009). The study also had a control group of children that received “usual levels of communitybased speech and language therapy.” The authors provided an intervention manual with suggested procedures and activities, which focused primarily on comprehension monitoring, vocabulary, grammar, and narratives (McCartney et al., 2004). Speech-language therapists conducted the direct interventions and speech-language therapy assistants conducted the indirect interventions



CHAPTER 9   Assistants in Audiology and Speech-Language Pathology

with individuals or small groups of children attending inclusive schools in Scotland. The study found no significant differences in language outcomes between direct and indirect treatment or between individual and group treatment based on postintervention testing. All groups showed short-term improvements in expressive language outcomes. Receptive language skills proved to be more intractable and did not show improvements regardless of the intervention group (Boyle et al., 2010). The authors suggested that the assistants acted effectively with these children because of the lack of differences in language outcomes across groups. Language outcomes did not improve for a cohort intervention group when school staff rather than SLPs or SLPAs conducted indirect, consultative language treatment (McCartney et al., 2011). A cost analysis of the different modes of treatment revealed that indirect assistant-led group therapy was the least costly option and therapist-led individual therapy was the costliest (Dickson et al., 2009). Additional studies involving children, most conducted in the mid-1970s, found no significant differences in the articulation outcomes of children with mild to moderate speech disorders when comparing treatment by trained paraprofessionals (also called supportive personnel or speech therapy aides) and professional clinicians; children in both groups showed improvements in articulation (Alvord, 1977; Costello & Schoen, 1978; Gray & Barker, 1977). Sounds that were not targeted for treatment showed no change for children in either the aide or clinician group (Gray & Barker, 1977). One study reported no significant differences between groups of children with learning disabilities with “perceptual deficits” treated by trained “perceptual aides” and “therapists” (including occupational, physical, recreational, and language); improvements were noted in motor skills, visual and somatosensory perception, language, and educations skills in children from both treatment groups (Gersten et al., 1975). One study reported that four out of five young children made more progress on computer-based language tasks when a parent volunteer provided the training compared with an SLP (Schery & O’Connor, 1997). Small sample size and lack of statistical comparison make these results difficult to interpret. A mother–child home program administered by paraprofessionals was compared with interventions by professionals that were tailored to the cognitive and language needs of 2-year-old children. Children in both groups showed similar improvements; however, the children were still delayed in cognitive and language functioning at age 4 in both groups (Scarr et al., 1996). Studies With Adults.  Studies comparing volunteers and professionals providing clinical services for adults

focused primarily on volunteers working with individuals with aphasia. Patients showed improvement in communication, and no differences were found in the amount of progress made for adults who received services from professionals compared with those receiving services from untrained volunteers (David et al., 1982; Meikle et al., 1979). In a study with trained volunteers, men with aphasia showed improvement in their communication during treatment but not when treatment was discontinued. These results were similar to patients with aphasia who received treatment from SLPs (Marshall et al., 1989). In a study that compared three different treatment approaches and a no-treatment condition, two of the treatments for patients with aphasia were administered by professionals and one was administered by “trained nonprofessionals” (Shewan & Kertesz, 1984). The two approaches administered by professionals showed significant differences compared with the nontreatment condition; the treatment method used by nonprofessionals approached significance. It is not possible to determine whether the difference in significance level was due to the treatment approaches themselves or to differences between nonprofessionals and professionals. In another study with patients with aphasia, comparisons were made among clinic treatment by an SLP, home treatment by a trained volunteer, and deferred treatment. No significant differences were found among the three groups after the deferred-treatment group received treatment by a professional (Wertz et al., 1986). In a study investigating the implementation of a SLPA’s role for swallowing screening and education in a multidisciplinary head and neck treatment clinic, SLPAs were specifically trained in feeding screening. Outcomes included optimal care compliance with both SLPs and SLPAs. Results revealed no increase in swallowingrelated admissions and a (nonsignificant) increase in patient satisfaction postimplementation, indicating no compromise to patient safety or satisfaction (Frowen et al., 2021). Studies Comparing Service by Audiologists or Speech-Language Pathologists and Assistants. Ideally, supervisors should only assign tasks to assistants that can be performed with the same level of quality as the clinicians. The studies available reveal no differences in treatment outcomes for children or adults when the services provided by support personnel in speechlanguage pathology are compared with those provided by clinicians. The consistency between outcomes for clinicians and support personnel is encouraging for those who employ or wish to employ assistants. Clearly, more research, with a large enough sample for adequate statistical power and sound methodology, is needed (see summary by Greener et al., 1999).

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Do Any Studies Show the Effectiveness of Audiology or Speech-Language Pathology Assistants? The studies described for the first clinical question (i.e., comparing clinical service by assistants with audiologists or SLPs) also address the second question of the effectiveness of assistants in audiology or speech-language pathology. All previously cited studies showed that children and adults made improvements when support personnel in speech-language pathology were used. Other studies have been conducted that show the effectiveness of support personnel in audiology or speech-language pathology but did not have a comparison group. Effectiveness of Assistants in Audiology. A study was identified that addressed the use of support personnel for individuals with hearing loss. A Canadian consumer organization trained seniors with hearing loss to serve as peer models and provide support for other seniors with hearing loss in long-term health care facilities or in the community (Dahl, 1997). The volunteers were trained to assist with hearing aid care, use of assistive listening devices, and strategies for coping with hearing loss. Within a 5-month period, the volunteers totaled 288 weekly half-day visits. The seniors receiving support found the visitor program to be helpful. An informal follow-up evaluation 1 year after the project showed continued visits by some of the volunteers and the addition of newly trained volunteers. A report by the National Academies of Sciences, Engineering, and Medicine (2016) suggested that CHWs could address issues surrounding access to hearing care. Audiologist-trained CHWs were used in two pilot programs focused on addressing the public health issue of hearing loss by providing access to services in underserved communities. A study by Mamo et al. (2019) was completed to identify whether CHWs might be accepted as extenders of audiology services and in what ways. Their study was not focused specifically on the effectiveness of a CHW, but it identified that audiologists’ involvement was necessary to recognize patient needs and to provide focused training for the CHWs. Additionally, use of CHWs allowed for improved efficiency for the audiologists and better access to services for those in communities lacking access to hearing care. Four studies were identified that addressed whether audiometric technicians could determine which patients could be fitted with a hearing aid without the need for a medical referral. One study was conducted to determine if “physiological measurement technicians” could safely prescribe hearing aids without medical supervision. The technicians reportedly failed to mention the presence of active inflammatory ear disease in the referral letter for

three of eight cases where middle ear disease was present. The authors concluded that review by ENT medical staff was needed before prescription of a hearing aid (Bellini et al., 1989). In the other studies, the authors concluded that the audiology technicians made accurate assessments of patients to determine if they required a hearing aid referral to an ENT (Koay & Sutton, 1996; Swan & Browning, 1994; Zeitoun et al., 1995). For example, a “senior audiology technician or higher grade” working in a general practitioner’s office determined that 23% of the 135 patients required medical referral before being fitted for a hearing aid. The ENT review of the same patients showed 100% agreement with the audiology technicians (Koay & Sutton, 1996). Additional data are available from De Wet Swanepoel, an audiologist using support personnel globally to aid in hearing care service delivery in underserved areas of South Africa. Swanepoel and Hall (2010) documented that the use of community-trained hearing support personnel within a telehealth service delivery model has yielded “clinically equivalent results for remote, telehealth-enabled tests compared to conventional faceto-face versions” (p. 187). Effectiveness of Assistants in Speech-Language Pathology.  The few studies conducted on the effectiveness of support personnel in speech-language pathology focus primarily on their use with children with articulation and expressive language disorders and adults with aphasia or dementia. Studies With Children.  Support personnel in speechlanguage pathology have conducted speech and language screening programs for children. In a pilot program, existing school personnel serving as aides were trained to screen the speech and language skills of elementaryage children. The aides were reported to administer the screening tests accurately to make appropriate referrals for those children with a high probability of having speech and language problems (Pickering & Dopheide, 1976). In another pilot screening program, paraprofessionals screened young children between 19 and 21 months during home visits for language delay. Screening data from the administration of a standardized screening test were found to be reliable, valid, and sensitive in identifying children for further assessment (Pickstone, 2003). Children with speech sound disorders showed improvement when they received speech services from SLP support personnel. A study of articulation treatment for elementary-age children by trained paraprofessionals reported that 83.5% of the treated sounds were used correctly in a conversational sample (Galloway & Blue, 1975). Improvements in speech production were reported for children treated by students (Hall & Knut-



CHAPTER 9   Assistants in Audiology and Speech-Language Pathology

son, 1978), communication aides (Van Hattum et al., 1974), and paid aides and volunteers (Scalero & Eskenazi, 1976). Studies focused on improving language skills in children also demonstrated improvements when services were provided by support personnel in speech-language pathology. A single-participant study reported increases in communication (e.g., percentage of correct information and words per minute) when a “nonprofessional” provided a structured maintenance program for an individual with epilepsy and language and cognitive impairments (Wright et al., 2003). Teachers in another study reported that 41% of their 22 kindergarten students showed improvement after receiving computer-aided language enrichment by volunteers, although the outcomes were not quantified (Schetz, 1989). “Nonprofessional tutors” were used to help first-grade children develop phonological and early reading skills (Vadasy et al., 2000). Tutors provided one-on-one instruction for 30 minutes, 4 days a week, for 1 school year in phonological skills, letter–sound correspondence, decoding, rhyming, writing, spelling, and reading. Tutored children received significantly better reading, spelling, and decoding scores than students who did not receive tutoring. The tutored children continued to do better than nontutored children in decoding and spelling after second grade. An exploratory study used specialist teaching assistants to conduct speech and/or language intervention for 35 children (4–6 years) for four 1-hour sessions over 10 weeks. The children, from an inclusive school in the U.K., showed improvement in targeted language outcomes and on a standardized language test. Differences also were noted on a questionnaire comparing speech and language performance at school and at home before and after intervention (Mecrow et al., 2010). A recent study involving parents and therapy assistants (McDonald et al., 2019) assessed the feasibility and outcomes with this mode of service delivery. However, there was no comparison group with clinician-administered interventions. The exploratory study included nine children between 26 and 31 months considered at risk for language difficulties. Following intervention, five of six children with expressive language delays at baseline demonstrated typical language skills. Three children with both receptive and expressive language delays at baseline did not make improvement as measured by the Words subscale of the Language Use Inventory. The authors concluded that the use of trained therapy assistants is feasible for either helping with expressive language skills or identifying 2-year-olds with more complex language needs. Another recent study (Towson et al., 2020), using a single-case, multiprobe design, examined whether paraprofessionals trained in dialogic reading could make a dif-

ference in the single-word receptive and expressive vocabulary of preschool children with language impairments. The study was not designed to make comparisons with clinicians. Results showed minimal gains in expressive language and no gains in receptive language skills. Study limitations, such as a one-time training for paraprofessionals, few subjects, no comparison group, and variable fidelity of paraprofessionals with implementation, make it difficult to draw conclusions about the feasibility of the use of paraprofessionals or the intervention used. Paraprofessionals’ role with children with complex communication needs (Cole-Lade & Bailey, 2020) was explored by comparing the extent to which teams integrated paraeducators. The study compared three educational teams that included general and special education teachers, paraeducators, SLPs, and parents. Using an instrumental, multiple-case study and qualitative research design, the study described how paraeducators were used across teams. Authors discussed the variability in the roles of the paraeducators and concluded that the team that fully integrated the paraeducators worked in a collaborative way to support children. Positive outcomes in speech and language were shown when children with severe disabilities received services from support personnel in speech-language pathology. In one study, two psychiatric aides who served as paraprofessional teachers were trained to use a structured language training program with children with severe disabilities. In this study, matched pairs of children were randomly assigned to an experimental or control condition. Results showed that the children in the experimental group who received language training by the aides for 2 months showed improvement in language (e.g., identifying and labeling objects) and social skills (Phillips et al., 1973). Another study trained undergraduate students to use behavioral principles to develop the verbal behavior of young children with severe disabilities with limited verbal repertoires (Guralnick, 1972). Five of the eight children showed progress in their development of communication skills (e.g., imitating sounds, sustaining eye contact, using gestures). Another article reported on the use of blind and partially sighted high school students who were trained and paid to serve as speech assistants in a residential school to provide extra class practice for younger children with visual impairments who had speech problems (Briggs, 1974). Although data were not collected on the speech outcomes of the students receiving services, the author reported that most appeared to benefit from the additional practice provided by the assistants. A systematic review of different service delivery models demonstrated that trained SLPAs could provide effective services for children with language disorders (Cirrin et al., 2010).

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Assistants also have been used with positive outcomes in countries and communities where speech-language pathology services are scarce. For example, speech assistants were found to be an efficient way to extend speech correction services for children with a cleft lip and palate in Thailand and other developing countries (Hanchanlert et al., 2015; Makarabhirom et al., 2015; Pradubwong et al., 2016). Supervised student speech-language pathology students worked in rural communities in Australia with school-age children who demonstrated improved communication skills (Kirby et al., 2018). Studies With Adults. Adults with aphasia showed communication improvements when treatment was provided by support personnel, including relatives (Lesser et al., 1986), untrained volunteers (Eaton Griffith, 1975; Griffith & Miller, 1980; Lesser & Watt, 1978), and community volunteers (Lyon et al., 1997). Similarly, adults with “communication handicaps” showed increased responsiveness, verbalizations, and social interactions when trained volunteers were used as an adjunct to professional treatment (Mueller, 1990). Trained volunteers were judged to be better conversational partners for adults with aphasia than were untrained volunteers (Kagan et al., 2001). The individuals with aphasia showed significant improvements in social skills and message exchange skills when interacting with volunteers who received supported conversation training. These changes were not seen in the adults with aphasia who interacted with the untrained volunteers. Community aphasia groups have been used as an extension of conventional speech-language pathology treatment to improve the well-being of adults with aphasia (Pettigrove et al., 2022). A systematic review was conducted to determine the nature and benefits of such groups. Although studies did not compare SLP-, peer-, or volunteer-led groups, it appears that the specialized training of the group leaders is pivotal to maximizing positive outcomes. Support personnel also have been used successfully with adults with dementia. One article described a partnered volunteering language and memory stimulation program for adults with Alzheimer’s disease. The study reported positive changes in language and memory on pre- and post-tests after two semesters of service by student volunteers from speech-language pathology or psychology (Arkin, 1996). Another study used nursing assistants to enhance the discourse skills of nursing home residents with dementia. In this study, one group of nursing assistants was trained and supervised using communication techniques and memory books with the residents. A control group paired nursing assistants with residents with dementia but did not use specific communication or memory tools. The conversational skills of residents in the treatment group were more coherent

and had fewer vague empty phrases compared with the no-treatment control group. The nursing assistants in the treatment group also used more facilitative discourse strategies (e.g., encouragement, cuing) than assistants in the control group (Dijkstra et al., 2002). Effectiveness of Assistants in Audiology and SpeechLanguage Pathology.  The effectiveness of assistants in audiology and speech-language pathology remains an open question. Only a few studies are available, and most studies were conducted in the 1970s and 1980s. The methodological quality of many of the studies was poor (e.g., no control group, few participants, no randomized groups, few statistical comparisons) or not accessible, with the exception of a more recent 2007 study (Boyle et al., 2007). Audiometric technicians appear capable of determining which patients need a medical referral before being fitted for a hearing aid. The available studies using support personnel in speechlanguage pathology appeared to show that they could be effective in improving speech production for children with articulation disorders or conversational skills for adults with aphasia or dementia. Support personnel also appear to have positive benefits in extending services in countries and rural communities where audiologists and SLPs are not widely available.

Future Research Issues In 1977, Gray and Barker wrote that “there is little substantive information about whether or not [aides] can reliably and effectively provide services” (p. 534). More than 45 years later, this same statement can still be made. There is a paucity of high-quality efficacy research on the use of assistants in audiology or speech-language pathology. Among the few studies conducted, there is some evidence of comparable outcomes between supervised SLPAs and SLPs, particularly when services are limited to more repetitive treatment activities. Although some studies demonstrate that support personnel in audiology and speech-language pathology can carry out assigned tasks, most are descriptive rather than empirical. Except for a controlled trial in the U.K. (Boyle et al., 2007), few research designs go beyond a low level of evidence, using case studies with no randomization or control group. Research also is needed pertaining to the optimal amount and type of supervision necessary for assistants with various amounts of experience and to determine the effectiveness of different types of assistant training programs. The use of appropriately trained, supervised, and credentialed assistants may be a viable option in some settings to enhance the frequency and intensity of service delivery in audiology and speech-language pathology.



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However, more evidence, and better-quality evidence, is needed before the value of assistants in audiology and speech-language pathology can be ascertained. Future research questions could address the value of using credentialed assistants, comparisons in efficacy in different work settings, and the benefits of using assistants in maintenance programs and highly scripted programs.

Summary The intended use of assistants is to supplement and extend the work of audiologists and SLPs. Audiology assistants and SLPAs may be hired to increase the frequency, intensity, efficiency, and availability of services by following a specific set of job responsibilities. However, the licensed and/or certified audiologist or SLP ultimately remains responsible for the training, selection, management, and supervision of the assistant. It is also the clinician’s obligation to inform the consumer of the level of training and expertise of the assistant so that at no time is the assistant represented as an audiologist or SLP. The clinician retains the legal and ethical responsibility for all services provided or omitted. The clinician and the assistant need to work as a team to support the communication needs of the individuals they serve. ASHA has in place a national credentialing program for assistants and numerous states regulate their use. In these states, the use of assistants can be monitored, ensuring the assistants are used legally in education and supervision. Adherence to professional guidelines also serves as a means of monitoring ethical clinical practice. The limited research available suggests that services provided by assistants are effective, although much more quality research is needed to determine the degree of effectiveness and optimal amount of supervision and to make comparisons with services by assistants and audiologists and SLPs. Additionally, studies are needed that involve audiologists and SLPs who are specifically educated to use assistants appropriately as an extension of their services. Acknowledgments.  The authors gratefully acknowledge the expertise, attention to detail, and care of the following ASHA National Office staff in the preparation of this chapter: Gail Brook, Eileen Crowe, Brooke Hatfield, Jessica Kuney, Andrea Moxley, Neela Swanson, Lisa Wolf, and Sarah Warren. The authors also extend their appreciation to Keegan Abernathy, Tracy Schooling, and Beverly Wang for their assistance with the literature review. Dedication. In loving memory of our dear friend, Steve Ritch (1964–2019), whose light, love, and joy touched everyone who knew him and whose dedica-

tion and commitment advanced the development of the ASHA Audiology Assistants and Speech-Language Pathology Assistants program.

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competence. https://www.asha.org/practice/ethics/ cultural-and-linguistic-competence/ American Speech-Language-Hearing Association. (2017c). Issues in ethics: Speech-language pathology assistants. https://www.asha.org/practice/ethics/ speech-language-pathology-assistants/ American Speech-Language-Hearing Association. (2018a). Audiology assistant exam blueprint 11-1-2018. https://www.asha.org/SysSiteAssets/ uploadedfiles/asha/associates/audiology-assistantexam-blueprint.pdf American Speech-Language-Hearing Association. (2018b). 2018 schools survey. Survey summary report: Numbers and types of responses, educational audiologists. https://www.asha.org/siteassets/surveys/ 2018-schools-survey-educational-audiolo​gists.pdf American Speech-Language-Hearing Association. (2018c). 2018 schools survey. Survey summary report: Numbers and types of responses, SLPs. American Speech-Language-Hearing Association. (2018d). Scope of practice in audiology. https://www​ .asha.org/policy/sp2018-00353/ American Speech-Language-Hearing Association. (2018e). SLPA exam blueprint 11-1-2018. https:// nmsha.net/wp-content/uploads/2019/01/SLPAExam-Blueprint-1.pdf American Speech-Language-Hearing Association. (2019). 2018 audiology survey. Survey summary report: Number and type of responses. https://www​ .asha.org/siteassets/surveys/2018-audiology-surveysummary-report.pdf

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and volunteers compared. Journal of Neurology, Neurosurgery, and Psychiatry, 45, 957–961. Demant, M. N., Jensen, R. G., Bhutta, M. F., Laier, G. H., Lous, J., & Homøe, P. (2019). Smartphone otoscopy by non-specialist health workers in rural Greenland: A cross-sectional study. International Journal of Pediatric Otorhinolaryngology, 126, 109628. https://doi.org/ 1016/j​.ijporl.2019.109​ 628 Dickson, K., Marshall, M., Boyle, J, McCartney, E., O’Hare, A., & Forbes, J. (2009). Cost analysis of direct versus indirect and individual versus group modes of manual-based speech-and-language therapy for primary school-age children with primary language impairment. International Journal of Language and Communication Disorders, 44(3), 369–381. Dijkstra, K., Bourgeois, M., Burgio, L., & Allen, R. (2002). Effects of a communication intervention on the discourse of nursing home residents with dementia and their nursing assistants. Journal of Medical Speech-Language Pathology, 10(2), 143–157. Eaton Griffith, V. (1975). Volunteer scheme for dysphasic and allied problems in stroke patients. British Medical Journal, iii, 633–635. Frowen, J., Hughes, R., & Kiss, N. (2021). Introduction of a speech-language pathology assistant role for swallow screening in a head and neck radiotherapy clinic. International Journal of SpeechLanguage Pathology, 23(4), 441–451. https://doi​ .org/10.1080/17549507.2020.1800818 Galloway, H. F., & Blue, C. M. (1975). Paraprofessional personnel in articulation therapy. Language, Speech, and Hearing Services in Schools, 6, 125–130. Gerlach, K. (2000). The paraeducator and teacher team: Strategies for success. Pacific Training Associates. Gersten, J. W., Foppe, K. B., Gersten, R., Maxwell, S., Mirrett, P., Gipson, M., … Grueter, B. (1975). Effectiveness of aides in a perceptual motor training program for children with learning disabilities. Archives of Physical Medicine & Rehabilitation, 56(3), 104–110. Goldberg, L., & Paul-Brown, D. (1999). Strategies for the effective use of speech-language pathology assistants in the classroom. Proceedings of the Seventh Annual Comprehensive System of Personnel Development Conference, National Association of State Directors of Special Education, Alexandria, VA.

Gray, B. B., & Barker, K. (1977). Use of aides in an articulation therapy program. Exceptional Children, 43, 534–536. Greener, J., Enderby, P., & Whurr, R. (1999). Speech and language therapy for aphasia following stroke. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD000425 http://doi.org/10.1002/1465​ 1858.CD000425 Griffith, V. E., & Miller, C. L. (1980). Volunteer stroke scheme for dysphasic patients with stroke. British Medical Journal, 281, 1605–1607. Guralnick, M. J. (1972). A language development program for severely handicapped children. Exceptional Children, 39, 45–49. Guralnick, M. J. (2011). Why early intervention works: A systems perspective. Infants and Young Children, 24(1), 6–28. Guralnick, M. J. (2019). Effective early intervention: The developmental systems approach. Brookes. Hall, P. K., & Knutson, C. L. (1978). The use of preprofessional students as communication aides in the schools. Language, Speech, and Hearing Services in Schools, 9, 162–168. Hamill, T., & Freeman, B. (2001). Scope of practice for audiologists’ assistants: Survey results. Audiology Today, 13(6), 34–35. Hanchanlert, Y., Pramakhatay, W., Pradubwong, S., & Prathanee, B. (2015). Speech correction for children with cleft lip and palate by networking of community-based care. Journal of the Medical Association of Thailand, 98(Suppl. 7), S132–S139. Individuals With Disabilities Education Improvement Act, Pub. L. No. 108-446, 20 U.S.C. § 1400 et seq. (2004). https://www.govinfo.gov/app/details/ PLAW-108publ446 Johnson, C. E. (1999). Dimensions of multiskilling: Considerations for educational audiology. Language, Speech, and Hearing Services in Schools, 30, 4–10. Johnson, C. E., Clark-Lewis, S., & Griffin, D. (1998). Experience, attitudes, and competencies of audiologic support personnel in a rehabilitation hospital. American Journal of Audiology, 7, 1–6. Joint Committee on Infant Hearing. (2007). Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs. https:// www.asha.org/policy/ps2007-00281/



CHAPTER 9   Assistants in Audiology and Speech-Language Pathology

Kagan, A., Black, S. E, Duchan, J. F., SimmonsMackie, N., & Square, P. (2001). Training volunteers as conversation partners using “supported conversation for adults with aphasia” (SCA): A controlled trial. Journal of Speech, Language, and Hearing Research, 44, 624–638. Karzon, R., Hunter, L., & Steuerwald, W. (2018). Audiology assistants: Results of a multicenter survey. Journal of the American Academy of Audiology, 29(5), 405–416. Kirby, S., Lyle, D., Jones, D., Brunero, C., Purcell, A., & Dettwiller, P. (2018). Design and delivery of an innovative speech pathology service-learning program for primary school children in Far West NSW, Australia. Public Health Research & Practice, 28(3), e28231806. Koay, C. B., & Sutton, G. J. (1996). Direct hearing aid referrals: A prospective study. Clinical Otolaryngology and Allied Science, 21, 142–146. Langdon, H. W., & Cheng, L. L. (2002). Collaborating with interpreters and translators. Thinking Publications. Lesser, R., Bryan, K., Anderson, J., & Hilton, R. (1986). Involving relatives in aphasia therapy: An application of language enrichment therapy. International Journal of Rehabilitation Research, 9, 259–267. Lesser, R., & Watt, M. (1978). Untrained community help in the rehabilitation of stroke sufferers with language disorder. British Medical Journal, ii, 1045–1048. Longhurst, T. (1997). Team roles in therapy services. In A. L. Pickett & K. Gerlach (Eds.), Supervising paraeducators in school settings: A team approach (pp. 55–89). Pro-Ed.

Mamo, S. K., Frank, M. R., & Korczak, P. (2019). Exploring community health worker (CHW) models for delivering audiology services. Hearing Review, 26(1), 12–17. Marshall, R. C., Wertz, R. T., Weiss, D. G., Aten, J. L., Brookshire, R. H., Garcia-Bunuel, L., . . . Goodman, R. (1989). Home treatment for aphasic patients by trained nonprofessionals. Journal of Speech and Hearing Disorders, 54(3), 462–470. McCartney, E., Boyle, J., Bannatyne, S., Jessiman, E., Campbell, C., Kelsey, C., . . . O’Hare, A. (2004). Becoming a manual occupation? The construction of a therapy manual for use with language impaired children in mainstream primary schools. International Journal of Language and Communication Disorders, 39(1), 135–148. McCartney, E., Boyle, J., Ellis, S., Bannatyne, S., & Turnbull, M. (2011). Indirect language therapy for children with persistent language impairment in mainstream primary schools: Outcomes from a cohort intervention. International Journal of Language and Communication Disorders, 46(1), 74–82. McDonald, D., Colmer, S., Guest, S., Humber, D., Ward, C., & Young, J. (2019). Parentimplemented language intervention delivered by therapy assistants for two-year-olds at risk of language difficulties: A case series. Child Language Teaching & Therapy, 35(2), 113–124. https://doi​ .org/10.1177/0265659019842244 McNeilly, L. (2009). Speech-language pathology assistants: Current state of affairs. Perspectives on School-Based Issues, 10(1), 12–18.

Lynch, E. W., & Hanson, M. J. (Eds.). (2004). Developing cross-cultural competence: A guide for working with children and their families (3rd ed.). Brookes.

McNeilly, L. (2010, November 1). ASHA will roll out associates program in 2011. The ASHA Leader, 15(14). https://doi.org/10.1044/leader​ .AN1.15142010.7

Lyon, J. G., Cariski, D., Keisler, L., Rosenbek, J., Levine, R., Kumpula, J., . . . Blanc, M. (1997). Communication partners: Enhancing participation in life and communication for adults with aphasia in natural settings. Aphasiology, 11, 693–708.

McNeilly, L. (2018). Using the International Classification of Functioning, Disability and Health Framework to achieve interprofessional functional outcomes for young children: A speech-language pathology perspective. Pediatric Clinics of North America, 65(1), 125–134.

Makarabhirom, K., Prathanee, B., Suphawatjariyakul, R., & Yoodee, P. (2015). Speech therapy for children with cleft lip and palate using a communitybased speech therapy model with speech assistants. Journal of the Medical Association of Thailand, 98(Suppl. 7), S140–S150.

Mecrow, C., Beckwith, J., & Klee, T. (2010). An exploratory trial of the effectiveness of an enhanced consultative approach to delivering speech and language intervention in schools. International

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Journal of Language and Communication Disorders, 45(3), 354–367. Medicaid Program; Provider Qualifications for Audiologists, 2004. Volume 69, Fed. Reg. 30580–30586. May 28, 2004. Medical Assistance Programs (Medicaid), 42 C.F. R. § 440.110 (2023). Meikle, M., Wechsler, E., Tupper, A., Benenson, M., Butler, J., Mulhall, D., & Stern, G. (1979). Comparative trial of volunteer and professional treatments of dysphasia after stroke. British Medical Journal, 2, 87–89. Mueller, P. B. (1990). A volunteer speech-language facilitation program for communicatively handicapped elders in long-term care facilities. Adult Residential Care Journal, 4, 217–225. Mullins, J., & Appler, K. (2002). Assistance on assistants: ASHA’s registration program for speech-language pathology assistants. Perspectives: Administration and Supervision, 12(3), 12. https:// doi.org/10.1044/aas12.3.12 National Academies of Sciences, Engineering, and Medicine. (2016). Hearing health care for adults: Priorities for improving access and affordability. The National Academies Press. https://nap.national​ academies.org/catalog/23446/hearing-health-carefor-adults-priorities-for-improving-access-and National Hearing Conservation Association. (2018). Working together to prevent noise induced hearing loss (NIHL). http://www.hearingconservation.org/ National Joint Committee on Learning Disabilities. (1998). Learning disabilities: Use of paraprofessionals. In Collective perspectives on issues affecting learning disabilities (2nd ed., pp. 79–98). Pro-Ed. Paul-Brown, D., & Caperton, C. J. (2001). Inclusive practices for preschool children with specific language impairment. In M. J. Guralnick (Ed.), Early childhood inclusion: Focus on change (pp. 433– 463). Brookes. Paul-Brown, D., & Goldberg, L. R. (2001). Current policies and new directions for speech-language pathology assistants. Language, Speech, and Hearing Services in Schools, 32, 4–17. Pettigrove, K., Lanyon, L. E., Attard, M. C., Vuong, G., & Rose, M. L. (2022). Characteristics and impacts of community aphasia group facilitation: A systematic scoping review. Disability and

Rehabilitation, 44(22), 6884–6898. doi10.1080/09 638288.2021.1971307 Phillips, S., Liebert, R. M., & Poulos, R. W. (1973). Employing paraprofessional teachers in a group language training program for severely and profoundly retarded children. Perceptual and Motor Skills, 36, 607–616. Pickering, M., & Dopheide, W. R. (1976). Training aides to screen children for speech and language problems. Language, Speech, and Hearing Services in Schools, 7, 236–241. Pickett, A. L. (1999). Strengthening and supporting teacher/provider–paraeducator teams: Guidelines for paraeducator roles, supervision, and preparation. City University of New York Graduate Center. Pickett, A. L., & Gerlach, K. (Eds.). (1997). Supervising paraeducators in school settings: A team approach. Pro-Ed. Pickstone, C. (2003). A pilot study of paraprofessional screening of child language in community settings. Child Language Teaching & Therapy, 19, 49–65. Pradubwong, S., Prathanee, B., & Patjanasoontorn, N. (2016). Effectiveness of networking of Khon Kaen University community-based speech model: Quality of life. Journal of the Medical Association of Thailand, 99(Suppl. 5), S36–S42. Rosenfeld, M., & Leung, S. (1999). A job analysis of speech-language pathology assistants: A study to aid in defining the job of speech-language pathology assistants. A job analysis study conducted on behalf of the American Speech-Language-Hearing Association. Educational Testing Service, Education Policy Research Division. Scalero, A. M., & Eskenazi, C. (1976). The use of supportive personnel in a public school speech and language program. Language, Speech, and Hearing Services in Schools, 7, 150–158. Scarr, S., McCartney, K., Miller, S., Hauenstein, E., & Ricciuti, A. (1996). Evaluation of an islandwide screening, assessment and treatment program. Early Development & Parenting, 3, 199–210. Schery, T., & O’Connor, L. (1997). Language intervention: Computer training for young children with special needs. British Journal of Educational Technology, 28, 271–279. Schetz, K. F. (1989). Computer-aided language/ concept enrichment in kindergarten: Consultation



CHAPTER 9   Assistants in Audiology and Speech-Language Pathology

program model. Language, Speech, and Hearing Services in Schools, 20, 2–10. Shewan, C. M., & Kertesz, A. (1984). Effects of speech and language treatment on recovery from aphasia. Brain and Language, 23, 272–299. Suen, J. J., Bhatnagar, K., Emmett, S. D., Marrone, N., Kleindienst Robler, S., Swanepoel, D. W., . . . Nieman, C. L. (2019). Hearing care across the life course provided in the community. Bulletin of the World Health Organization, 97(10), 681–690. https://doi.org/10.2471/BLT.18.227371 Suter, A. H. (2002). Hearing conservation manual (4th ed.). Council for Accreditation in Occupational Hearing Conservation. Swan, I. R., & Browning, G. G. (1994). A prospective evaluation of direct referral to audiology departments for hearing aids. Journal of Laryngology and Otology, 108, 120–124. Swanepoel, D. W. (2020). E-health technologies enable more accessible hearing care. Seminars in Hearing, 41(2), 133–140. https://doi.org/10.1055/s-0040-​ 1708510 Swanepoel, D. W., & Hall, J. W., III. (2010). A systematic review of telehealth applications in audiology. Telemedicine Journal and E-Health, 16(2), 181–200. https://doi.org/10.1089/tmj.2009.0111 Thornton, A. (1993). The Cheshire profession. American Journal of Audiology, 2, 5. Towson, J. A., Green, K. B., & Abarca, D. L. (2020). Reading beyond the book: Educating paraprofessionals to implement dialogic reading for preschool children with language impairments. Topics in Early Childhood Special Education, 40(2), 68–83. https:// doi.org/10.1177/0271121418821167 U.S. (1965). Elementary and Secondary Education Act of 1965: H. R. 2362, 89th Cong., 1st sess., Public law 89-10. Reports, bills, debate and act. U.S. Govt. Print. Off. U.S. Census Bureau. (2021). 2020 census illuminates racial and ethnic composition of the country.

https://www.census.gov/library/stories/2021/08/ improved-race-ethnicity-measures-reveal-unitedstates-population-much-more-multiracial.html U.S. Department of Justice, Civil Rights Division. (2000). Executive Order 13166, Title VI of the Civil Rights Act of 1964 (Title VI): Improving access to services for persons with limited English proficiency. http://www.justice.gov/crt/about/ cor/13166.php U.S. Department of Labor. Occupational Safety and Health Administration. (n.d.). Occupational noise exposure. regulations/standardnumber/1910/​ 1910.95/ Vadasy, P. F., Jenkins, J. R., & Pool, K. (2000). Effects of tutoring in phonological and early reading skills on students at risk for reading disabilities. Journal of Learning Disabilities, 33, 579–590. Van Hattum, R. J., Page, J. M., Baskervill, R. D., Duguay, M. J., Conway, L. S., & Davis, T. R. (1974). The Speech Improvement System (SIS) taped program for remediation of articulation problems in the schools. Language, Speech, and Hearing Services in Schools, 5, 91–97. Wertz, R. T., Weiss, D. G., Aten, J. L., Brookshire, R. H., Garcia-Buñuel, L., Holland, A. L., . . . Goodman, R. (1986). Comparison of clinic, home, and deferred language treatment for aphasia. A Veterans Administration cooperative study. Archives of Neurology, 43, 653–658. Werven, G. (1993). Support personnel: An issue for our times. American Journal of Speech-Language Pathology, 2(2), 9–12. Wright, H. H., Shisler, R. J., & Rau, B. (2003). Maintenance of communication abilities in epilepsy: A clinical report. Journal of Medical Speech-Language Pathology, 11, 157–167. Zeitoun, H., Lesshafft, C., Begg, P. A., & East, D. M. (1995). Assessment of a direct referral hearing aid clinic. British Journal of Audiology, 29, 13–21.

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Appendix 9–A Assistants in Audiology and Speech-Language Pathology: Key Word Definitions student, client, or patient files; (c) reviewing and evaluating audio- or video-recorded sessions; and/ or (d) conducting supervisory conferences either in person or via telephone and/or live, secure virtual meetings.

Aides:  Support personnel who have a narrower training base and more limited responsibilities relative to the duties of assistants. Assistants:  Support personnel who perform tasks as prescribed, directed, and supervised by certified and licensed (where applicable) professionals after a program of academic and/or on-the-job training. Cultural broker:  A person who is knowledgeable about the client’s/patient’s culture and/or speech community and who provides this information to the clinician for optimizing services. Also referred to as cultural guides, cultural informants, or cultural-linguistic mediators. Direct supervision:  In-view observation and guidance while the assistant is performing a clinical activity. This may include the supervisor viewing and communicating with the assistant via telecommunication technology as the assistant provides clinical services. Indirect supervision:  Does not require the supervisor to be physically present or available via telecommunication while the assistant is providing services. Indirect supervisory activities may include (a) reviewing demonstration videos; (b) reviewing

Interpreter:  Individual who conveys information from one language to another for oral messages. Support personnel:  Provide activities adjunct to the clinical efforts of certified and licensed (where applicable) professionals with appropriate training and supervision. Telepractice types: n

Asynchronous services (store and forward): Images or data captured and transmitted for viewing or interpretation by a professional.

n

Synchronous services (client interactive): Services are conducted with interactive audio and video connection in real time to create an in-person experience similar to that achieved in a traditional encounter.

Translator:  Individual who conveys information from one language to another for written messages.

SECTION III

Setting-Specific Issues

10 Health Care Legislation, Regulation, and Financing Jeffrey P. Regan

Introduction The political environment of the United States has become complex due to several factors, such as enduring hyperpartisan gridlock, sharpening ideological division (both between and within the political parties), and never-ending election and campaign fundraising cycles. Within this environment the foundational institutions of governing and policy making are being stretched and challenged. Consequently, legislative and regulatory processes — both in Washington and in state capitals nationwide — have acquired a degree of uncertainty. Despite the current political environment, health care legislation and regulation have had a profound impact on audiology and speech-language pathology. This impact has been chiefly caused by the paradigmatic shift underway in health care payment policy. Over the past decade the United States has slowly moved away from provider-centered payment models that are based on service volumes and fragmented care toward patient-centered payment models that incentivize health outcomes and highquality coordinated care. More recently, the COVID-19 pandemic and its impact on audiology and speech-language pathology have affected public policy, especially in telehealth utilization. This emerging policy landscape offers both challenges and opportunities for audiologists and speech-language pathologists (SLPs) in the years ahead. This chapter begins by providing an overview of Medicare, Medicaid, and private health insurance — the three major drivers behind health care payment policy for audiologists and SLPs. Next, the chapter provides an overview of coding systems, which collectively form the bedrock for payment policy. Finally, the chapter discusses six recent health care legislative and regulatory issues of particular importance to audiology and speech-language pathology. Questions that facilitate further thinking and discussion are provided at the end.

Medicare Established in 1965 as Title XVIII of the Social Security Act, Medicare is federal health insurance principally for individuals 65 years or older and is managed by the Centers for Medicare and Medicaid Services (CMS). Medicare currently has four parts that provide specified benefits. 203



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Medicare Part A provides hospital and medical benefits. Certain audiology and speech-language pathology services provided in inpatient hospital, skilled nursing facility (SNF), home health, and hospice settings are covered by Part A and included in the facility payment. Medicare Part B provides supplemental medical insurance. Part B is optional and includes a monthly premium. Certain audiology and speech-language pathology services provided in outpatient hospital and noninstitutional settings, including private practice settings, are covered by Part B. Part B also covers services provided in inpatient hospital and SNF settings when a Medicare beneficiary is determined ineligible for Part A or has exhausted Part A benefits. Audiologists who bill under Medicare Part B may require a physician referral prior to diagnostic testing. SLPs who bill under Medicare Part B must have a physician approve a plan of care within 30 days of the beneficiary’s first visit. Audiology and speech-language pathology services covered by Part B (excluding audiology services provided in hospital outpatient settings) have payment rates set annually by the Medicare Physician Fee Schedule. Audiology services provided in hospital outpatient settings have payment rates set annually by the Outpatient Prospective Payment System. Medicare Part C, or Medicare Advantage, provides supplemental medical insurance through private managed care organizations (MCOs), which must offer benefits and coverage at least on par with Medicare Part B. Audiologists and SLPs may contract directly with MCOs. Medicare Part C currently covers more than 20 million Medicare beneficiaries and is expected to grow further. Medicare Part D provides a prescription drug benefit. Offered under both traditional Medicare and Medicare Advantage, Part D plans vary significantly in coverage and cost. Medicare is locally administered by Medicare administrative contractors, or MACs. There are currently 16 MACs nationwide. MACs are private entities responsible for processing claims and issuing payments under Parts A and B, as well as for durable medical equipment. Each MAC develops and disseminates local coverage determinations, or LCDs, for selected services. LCDs are based on national coverage policies issued by CMS and are designed to clarify coverage and coding procedures to providers, including audiologists and SLPs. In addition to MACs, recovery audit contractors review claims for inappropriate payments or fraud. Medicare only covers diagnostic testing provided by an audiologist. As of January 2023, certain diagnostic testing services may be provided without a physician order (or nonphysician practitioner order in certain

states) under the following conditions: (a) a Medicare beneficiary presents with nonacute hearing loss and (b) services have not been provided to a Medicare beneficiary within the past 12 months from the date of service. If these conditions are met, an audiologist may bill for services rendered using the appropriate current procedural terminology (CPT) code and a special “AB” modifier to indicate that the service was provided without an order. If these conditions are not met, an audiologist may provide and bill for services only when a physician (or nonphysician practitioner in certain states) orders the testing for the purpose of informing the physician’s diagnostic medical evaluation or determining appropriate medical or surgical treatment. Treatment services, rehabilitation services, hearing aids, and other neurologic assessments are not currently covered by Medicare when performed independently by an audiologist (Federal Register, 2022). Audiology services recognized in the Medicare Benefit Policy Manual at Chapter 15, Section 80.3, include evaluation of the cause of disorders of hearing, tinnitus, or balance; evaluation of suspected change in hearing, tinnitus, or balance; determination of the effect of medication, surgery, or other treatment; reevaluation to follow up regarding changes in hearing, tinnitus, or balance that may be caused by established diagnoses that place the patient at probable risk for a change in status, including but not limited to otosclerosis, atelectatic tympanic membrane, tympanosclerosis, cholesteatoma, resolving middle ear infection, Meniére’s disease, sudden idiopathic sensorineural hearing loss, autoimmune inner ear disease, acoustic neuroma, demyelinating diseases, ototoxicity secondary to medications, or genetic vascular and viral conditions; failure of a screening test (note that the screening test itself is not covered); diagnostic analysis of cochlear or brain stem implant and programming; and audiologic diagnostic tests before and periodically after implantation of auditory prosthetic devices. Medicare currently covers medically necessary assessment and treatment services provided by an SLP when a physician (or nonphysician practitioner in certain states) approves a plan of care within 30 days of a beneficiary’s first visit. Speech-language pathology services provided under Part B are subject to special requirements designed to ensure medical necessity. When the cost of speech-language pathology and physical therapy services combined reaches $2,040, a special modifier must be used to justify the medical need for continued services. When the cost of speech-language pathology and physical therapy services combined reaches $3,000, a targeted medical review by CMS may occur. Services may continue beyond the $3,000 threshold provided there is documented justification for why such services are medically necessary.



CHAPTER 10   Health Care Legislation, Regulation, and Financing

Medicaid Established in 1965 as Title XIX of the Social Security Act, Medicaid is an initiative funded in partnership between the federal government and states to provide medical care to individuals who meet defined low-income or disability thresholds. The federal government establishes broad guidelines for the program while states have significant latitude to establish eligibility requirements, service coverage, and payment rates. Each state is required to submit a State Medicaid Plan, which must be approved by CMS. Federal guidelines do not require that audiology and speech-language pathology services be covered by Medicaid for individuals 21 years of age or older; however, most states provide some coverage of services. For individuals under the age of 21, federal guidelines mandate comprehensive audiology and speech-language pathology services through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program. EPSDT services include identification of children with speech or language impairments, diagnosis and appraisal of specific speech or language impairments, referral for rehabilitation of speech or language impairment, provision of speech and language services, and hearing aids and augmentative and alternative communication (AAC) devices when deemed to be medically necessary. Federal guidelines require that audiologists and SLPs meet certain qualifications to receive payments under Medicaid. Under the Code of Federal Regulations, Title 42, Section 440.110, a “qualified audiologist” means an individual with a master’s or doctoral degree in audiology who maintains documentation to demonstrate that they meet or exceed state licensure requirements, and that the individual is licensed by the state as an audiologist to furnish audiology services. In states that do not license audiologists, or if an individual is exempted from state licensure based on practice in a specific institution or setting, the individual must meet one of the following conditions: maintains Certificate of Clinical Competence in audiology granted by the American Speech-LanguageHearing Association (ASHA), successfully completes a minimum of 350 hours of supervised clinical practicum, performs at least 9 months of full-time audiology services under the supervision of a qualified master’s- or doctoral-level audiologist after obtaining a master’s or doctoral degree in audiology or a related field, or successfully completes a government-approved national examination in audiology. Federal guidelines define a “speech-language pathologist” as an individual who must meet one of the following conditions: maintains a Certificate of Clinical Competence (CCC) from ASHA, successfully completes

the equivalent educational requirements and work experience necessary for the certificate, or successfully completes the academic program and is acquiring supervised work experience to qualify for the certificate (Code of Federal Regulations, n.d.). Federal guidelines grant significant latitude to states in determining payment rates and payment methodologies, which vary widely. Rates must be adequate to support enough participating providers so that Medicaid beneficiaries have appropriate access to Medicaid services. What constitutes appropriate access is not defined explicitly in federal law or regulation. Both payment rates and payment methodologies must be included in each state’s Medicaid plan.

Private Health Insurance Private health insurance plans offer coverage of audiology and speech-language pathology services, but coverage varies significantly. Inpatient services are often included in basic hospital coverage. Outpatient services are often covered with utilization restrictions. Coverage varies for early intervention, prevention, wellness, and hearing aid services. Payment rates and methodologies for audiology and speech-language pathology services vary widely between private health plans. Private insurers generally set rates using a market-driven approach, a relative value approach, or a combination of the two. Market-driven approaches tie payments to service delivery or utilization trends in local areas or regions. Relative value approaches tie payments to the provider’s competence, time, and risk for each procedure. Payment methodologies may include fee for service, discounted fee for service for patients enrolled in a health plan, or capitation, in which fixed payments are made in advance on a per patient, per unit of time basis.

Coding Systems Appropriate coding forms the bedrock of health care payment policy. Audiologists and SLPs utilize coding systems when submitting claims to Medicare, Medicaid, or private health plans. Codes specifically identify what diagnoses are made, what procedures are performed, and what devices are supplied by a provider. Appropriate coding ensures audiologists and SLPs are accurately paid for time given and services rendered. There are currently two coding systems commonly used by audiologists and SLPs: Healthcare Common Procedures Coding System (HCPCS) and ICD-10

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(International Classification of Diseases, 10th Revision, Clinical Modification). The HCPCS was first established in 1978 to standardize the delivery of health care procedures and devices. Managed by CMS, HCPCS currently has two distinct levels of codes. Level I of HCPCS comprises the CPT codes maintained by the American Medical Association (AMA). The CPT codes capture a wide array of health care procedures and services across six separate categories. The CPT editorial panel is responsible for making sure the codes and accompanying information are updated annually to comport with current practice standards and evidence-based care. The CPT editorial panel is composed of physicians and two nonphysician providers who convene annual meetings during which health care providers, device manufacturers, and other stakeholders comment on new codes or changes to existing codes. The CPT editorial panel is supported by the CPT advisory committee, which is also composed of physicians and nonphysician providers. The process of approving new codes or changing existing codes is highly structured. Medical societies and nonphysician provider associations, such as ASHA, play important roles in the CPT process. These roles include proposing new codes or changes to existing codes and preparing audiologists and SLPs to serve as designated CPT advisors. Once the CPT editorial panel makes decisions on new or existing CPT codes, AMA’s Specialty Society Relative Value Scale Update Committee (RUC) meets and recommends CPT code valuations to CMS, which are set using relative value units, or RVUs. Most RUC members are physicians. The RUC is supported by a larger RUC advisory committee, which is composed of physicians and nonphysician providers. A core component of the RUC’s work is collecting survey data on the CPT codes under review for valuation. This data is used to develop recommendations to the RUC. The RUC’s recommendations, in turn, are forwarded to CMS’ medical officers and contractor medical directors for final review. CMS may elect to accept or reject the RUC recommendations. Ultimately, CMS’ reviews of the RUC recommendations are contained in the annual Medicare Physician Fee Schedule, which finalizes RVUs for each CPT code. As with the CPT process, medical societies and nonphysician provider associations, such as ASHA, are critical to the RUC process. Their duties include conducting code surveys, compiling survey data, making valuation recommendations to the RUC based on the survey data, and preparing audiologists and SLPs to be designated RUC advisors. Level II of the HCPCS comprises codes that capture devices, supplies, and other equipment provided to patients, as well as a small number of health care

procedures. These code sets are updated annually and administered by CMS in cooperation with private insurers, medical societies, and nonphysician provider associations. HCPCS Level II includes codes for speechgenerating devices, AAC devices, voice amplifiers, voice prosthetics, and hearing services (excluding services related to hearing aids). The ICD-10 is the current revision of the International Classification of Diseases coding system used by the United States. ICD is managed globally by the World Health Organization; the Centers for Disease Control and Prevention (CDC) and the National Center for Health Statistics have joint responsibility for maintaining ICD in the United States. ICD codes principally capture diagnoses, disorders, conditions, symptoms, and morbidities. Audiologists and SLPs are required to use ICD-10 codes when billing Medicare, Medicaid, or private health plans for payment. Revisions to the ICD codes happen relatively infrequently; however, when new revisions take place, they are often significant in scope and require a lengthy period of transition for providers, manufacturers, and payers alike.

Key Health Care Legislative and Regulatory Issues Health care coverage and payment policy remains of utmost importance to audiology and speech-language pathology. With the move toward patient-centered payment models, this policy has undergone a paradigmatic shift over the past decade that has significantly impacted our professions and the 40 million Americans who have communication disorders. There are six legislative and regulatory issues currently of key importance to audiology and speech-language pathology: the Affordable Care Act, the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act, the Patient-Driven Payment Model, the Medicare Audiologist Access and Services Act, coverage and payment of audiology and speech-language pathology services provided via telehealth, and the Audiology and Speech-Language Pathology Interstate Compact. However, it is important to note that these are not the only important public policy issues impacting the professions in health care. Several other issues in the areas of coverage, payment, licensure, professional practice, workforce, and diversity, equity and inclusion (DEI) require active engagement by the professions each year. Professional associations such as ASHA develop, disseminate, and maintain extensive information on legislative and regulatory issues impacting the professions, as well as opportunities for audiologist and SLP members to become actively engaged as advocates.



CHAPTER 10   Health Care Legislation, Regulation, and Financing

Affordable Care Act The Patient Protection and Affordable Care Act (P.L. 111-148), or ACA, is fundamentally designed to reduce the number of uninsured Americans and curtail the rising cost of health care. Enacted into law in 2010, the ACA accomplishes its objectives in four principal ways. First, it mandates that Americans obtain health insurance at the risk of a tax penalty and facilitates the sale of private health plans on regulated state-based exchanges. Second, it mandates that private health plans cover preexisting conditions. Third, it mandates that private health plans cover 10 so-called essential health benefits (those specifically pertaining to speech-language pathology and audiology services are further explained below) without any annual or lifetime caps on coverage. Finally, it requires states with limited federal assistance to expand state Medicaid programs by raising income-based eligibility thresholds. The ACA has been politically controversial since its enactment. During the administration of President Barack Obama, Republicans in Congress made numerous unsuccessful attempts to repeal the ACA or replace it with weaker coverage mandates. In 2012 the Supreme Court upheld most of the law in the landmark decision in National Federation of Independent Business v. Sebelius (567 U.S. 519). The court found that the individual mandate to purchase health insurance was an appropriate exercise of Congress’ taxing power; however, the requirement to expand Medicaid was an inappropriate exercise of Congress’ spending power. During the administration of President Donald Trump, Republicans in Congress — even while enjoying a majority in both the Senate and House of Representatives — failed to secure sufficient support to repeal or replace parts of the ACA. However, in late 2017, Republicans were successful in repealing the individual mandate and its associated tax penalty. Of particular relevance to audiologists and SLPs are the ACA’s essential health benefits. Habilitative and rehabilitative services and devices must be covered by health plans sold on state-based exchanges. The terms “habilitation” and “rehabilitation” have been defined in federal regulations since 2016 using language initially recommended by the National Association of Insurance Commissioners (HealthCare.gov, n.d.). Habilitation is defined as “Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings” (HealthCare.gov, n.d.).

Rehabilitation is defined as “Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings” (HealthCare.gov, n.d.). Habilitative services establish skills that have not yet been acquired at an age-appropriate level. Rehabilitative services and devices help individuals reestablish skills that were acquired at the appropriate age but have been lost or impaired. For example, speech-language treatment for a child with autism spectrum disorder is habilitative; speech-language treatment for an adult with aphasia following a stroke is rehabilitative. A child born with severe to profound hearing loss who is fit with hearing aids receives audiologic habilitation to develop speech and language skills. An adult with hearing loss and tinnitus who is fit with hearings aids equipped with sound generators receives audiologic rehabilitation to improve listening skills and to cope with tinnitus. Identifying habilitative and rehabilitative services and devices as essential health benefits under the ACA has clearly improved patient access to services provided by audiologists and SLPs. However, two recent regulatory developments have threatened to undermine the progress gained by the ACA. The first development concerns state flexibility in defining essential health benefits. In 2020, states gained the authority to change or modify the list of services and devices covered under each essential health benefit category. States also have the authority to substitute benefits both within and between essential health benefit categories provided such substitutions cause no change in value to the overall benchmark plan (i.e., the model benefit that serves as a standard for health plans sold on a state’s ACA exchange). This development essentially puts each essential health benefit category in competition with each other and may weaken covered habilitation and rehabilitation services in coming years, especially if states grapple with budgetary shortfalls or other fiscal challenges. The second development concerns short-term limited duration (STLD) plans. STLD plans are primarily designed to provide basic levels of coverage to individuals transitioning between health plans. As such, they provide far less robust coverage and are exempt from coverage mandates promulgated by the ACA, such as covering preexisting conditions and essential health benefits. In the wake of the Congressional repeal of the ACA’s individual mandate in 2017, former President Trump issued an executive order that directed the Department of Health and Human Services (HHS) to expand the

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availability of STLD plans. This action clearly indicated a desire of the president to encourage more Americans to purchase STLD coverage instead of insurance coverage under the ACA-regulated state exchanges. In 2018 the HHS issued a final rule that expanded STLD coverage to a maximum of 12 months, with an option to renew for an additional 36 months. These changes may also reduce coverage for habilitation and rehabilitation services.

Medicare Access and CHIP Reauthorization Act The Medicare Access and CHIP Reauthorization Act (P.L. 114-10), or MACRA, makes sweeping changes to health care payment policy. Enacted into law in 2015, MACRA is a principal driving force behind the shift from provider-centered payment models toward patientcentered payment models. MACRA established a new policy framework called the Quality Payment Program that sets Medicare payments under Part B to physicians and specified nonphysician providers in outpatient and nonfacility settings based on high-quality and coordinated care. There are two components to the Quality Payment Program: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPMs). MIPS is Medicare’s provider reporting system on high-quality and coordinated care. It consolidates three previous reporting systems: the Physician Quality Reporting System (reports quality of care), the ValueBased Payment Modifier (reports cost of care), and Meaningful Use (reports utilization of electronic health records). It also adds a new reporting activity on practice improvement. All physicians and specified nonphysician providers, including audiologists and SLPs, are required to report into MIPS if they meet certain patient volume thresholds (see below). Providers may report into MIPS as individuals or as part of a group in a variety of ways, including claims, a qualified clinical data registry, and electronic health records. Each year, reports generate a score for the quality, cost of care, interoperability, and practice improvement categories. These scores are subsequently combined and weighted to create a final score that is measured against a performance threshold. This determines a positive or negative payment adjustment. The maximum positive and negative payment adjustments are 9% beginning in 2021. Payment adjustments are distributed on a sliding scale and must remain budget neutral. The adjustments are applied 2 years after the performance score. In other words, scores achieved by providers in 2021 determine payment adjustments made in 2023. Reporting into MIPS may be involuntary or voluntary. As of 2023, involuntary or required report-

ing applies to physicians and nonphysician providers, including audiologists and SLPs, who bill $90,000 or more to Medicare annually, treat 200 or more distinct Medicare beneficiaries annually, and provide 200 or more distinct procedures annually. This current threshold excludes nearly all audiologists and SLPs from involuntary reporting; however, it remains possible that this threshold could be progressively lowered in the coming years. Audiologists and SLPs who meet one or two of the threshold criteria may voluntarily report into MIPS and compete for payment adjustments. Others who meet none of the criteria may voluntarily report into MIPS but are ineligible for any payment adjustment. As of 2023, audiologists and SLPs only report into the quality and practice improvement categories. AAPMs compose the second component of MACRA’s Quality Payment Program. AAPMs are Alternative Payment Models (APMs) endorsed by Medicare that seek to enhance quality and value of services. AAPMs may include several existing and emerging APMs, such as Accountable Care Organizations (ACOs), PatientCentered Medical Homes (PCMHs), and episode-based bundled payments. To qualify as an AAPM under Medicare, an APM must demonstrate utilization of quality measures comparable to measures under MIPS, utilization of certified electronic health record technology, and assumed financial risk. Audiologists and SLPs are eligible to participate in AAPMs as qualifying or partially qualifying participants. As of 2023, physicians and nonphysician providers must receive at least 50% of payments under Medicare Part B through the AAPM or see at least 35% of Medicare beneficiaries through the AAPM to be designated as qualifying participants. Eligible providers may be considered partial qualifying participants if they receive at least 40% of payments under Medicare Part B through the AAPM or see at least 25% of Medicare beneficiaries through the AAPM. Qualifying participants are exempt from MIPS reporting requirements. Partial qualifying participants may voluntarily report into MIPS and compete for payment adjustments. Qualifying participants of a successful AAPM receive an annual 5% lump sum bonus until 2024. Partial qualifying participants will receive a 0.75% positive payment adjustment beginning in 2026.

Patient-Driven Payment Model APMs are not just limited to Medicare Part B. Efforts to identify innovative ways to improve the quality of care and reduce costs are taking place across the public and private payment landscape. Notably, the ACA supports the development of APMs, such as ACOs and PCMHs. Audiologists and SLPs can participate in ACO entities



CHAPTER 10   Health Care Legislation, Regulation, and Financing

and PCMH practices as ancillary providers. To date, the overall effectiveness of APMs in achieving quality and cost targets has been mixed. Some APMs have successfully improved health outcomes while lowering overall costs relative to fee-for-service payment models, while others have not. Professional associations such as ASHA are leading efforts to identify what APMs are most suitable for audiologist and SLP participation. One APM with significant impact to speech-language pathology services is the Patient-Driven Payment Model (PDPM). Developed by CMS, the PDPM radically changes how speech-language pathology services are paid for in SNFs. Prior to October 2019, speech-language pathology services, along with occupational and physical therapy services, were paid under the Resource Utilization Group, Version IV (RUG-IV). RUG-IV was a prospective payment system that based payments on a case-mix model that favored volume and quantity of services over value and quality. CMS determined that RUG-IV was providing inappropriate financial incentives to SNF providers by not considering a patient’s unique clinical characteristics, needs, or goals. The PDPM was consequently developed to remove this incentive and improve the overall value and quality of care. As an APM, the PDPM bases payments on a patient’s unique clinical characteristics. Payments for patients who demonstrate a need for speech-language pathology services are based on the presence of five case-mix factors: the patient’s primary diagnosis, the presence of at least one of 10 identified comorbidities, a mechanically alternated diet, a swallowing disorder, and a cognitive impairment. These case-mix factors are used in part to score the patient. A patient who meets the criteria for all five factors receives a higher score than a patient who meets the criteria for three factors, and so forth. The higher score translates into higher payments for speechlanguage pathology services. The PDPM model also addresses the provision of concurrent (i.e., treatment of two patients at the same time) and group therapy (i.e., treatment of at least four residents at the same time) in SNFs. Under the RUGIV model, the amount of group therapy provided to a patient was capped at 25% per discipline while there was no cap on the provision of concurrent therapy. The PDPM model retains the 25% cap on group therapy and applies a 25% cap on concurrent therapy. This cap is designed to ensure individualized therapy is appropriately provided to patients when deemed clinically appropriate. The PDPM promises to improve the overall quality and value of services provided to SNF patients. More data is needed over time to gauge the long-term success of the model. Nevertheless, it is critical that SLPs

remain employed by SNFs to provide services. It is equally important that the PDPM ensures the provision of speech-language pathology services that are both clinically necessary and appropriate to the patient.

Medicare Audiologist Access and Services Act As identified above, Medicare currently covers only diagnostic testing provided by an audiologist. Treatment services, rehabilitation services, hearing aids, and other neurologic assessments are not currently covered by Medicare when performed independently by an audiologist. While audiology treatment services are covered by some state Medicaid programs and private health plans, coverage is inconsistent. The lack of Medicare coverage across the audiologist’s full scope of practice arguably represents the largest challenge to the profession going forward and is the principal barrier to the profession reaching its full potential in serving individuals with hearing loss. Recognizing the critical importance of expanded Medicare coverage of audiology services, the American Academy of Audiology, the Academy of Doctors of Audiology, and ASHA joined efforts in supporting bipartisan legislation known as the Medicare Audiologist Access and Services Act. Initially introduced in 2019, this legislation has three principal components. First, it expands Medicare coverage to include both diagnostic and treatment services provided by an audiologist. Second, it eliminates the physician order requirement and allows audiologists to practice independently. Third, it reclassifies audiologists as practitioners under Medicare. This classification would, among other things, allow audiologists to furnish services via telehealth permanently. Since its introduction, the Medicare Audiologist Access and Services Act has gained greater bipartisan support, as well as the support of key allied stakeholders such as the Hearing Loss Association of America and the Hearing Industries Association. Passage and enactment of this bill will remain a top advocacy priority for the profession.

Coverage of Audiology and Speech-Language Pathology Services Provided via Telehealth The pandemic had a paradigmatic impact on how audiologists and SLPs practice, especially in the utilization of telehealth. Since the height of the pandemic in 2020, the public policy framework regulating the use of telehealth as an appropriate service delivery model has been inconsistent across the country, as well as between public and private payers.

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Medicare currently defines audiologists and SLPs as “suppliers.” This definition by statue excludes both professions from being paid for services rendered via telehealth. However, Congress granted CMS the authority under the Coronavirus Aid, Relief, and Economic Security Act (P.L. 116-136) to waive this exclusion and allow audiologists and SLPs to be paid for services delivered via telehealth. The waiver was tied to the federal COVID-19 public health emergency (PHE). Upon the expiration of the PHE (which occured on May 11, 2023), Congress granted a 2-year extension of temporary telehealth authority under the Consolidated Appropriations Act of 2023 (P.L. 117-328). This 2-year extension will be a critical time for both professions to gather utilization and health outcomes data to advocate to Congress and CMS for permanent telehealth authority under Medicare. Medicare policy continues to influence state Medicaid programs and private payers. Therefore, it is appropriate to speculate that obtaining permanent Medicare coverage of audiology and speech-language pathology services provided via telehealth at pay parity with services provided in person will bring more consistency to the broader public policy framework regulating telehealth. In the meantime, audiologists and SLPs should ensure any services provided and billed utilizing telepractice are done in full accordance with current applicable laws, regulations, and guidance. Professional associations, such as ASHA, provide updated compliance information to members.

Audiology and Speech-Language Pathology Interstate Compact The rise of health technology coupled with workforce shortages in underserved areas and events such as the COVID-19 pandemic demonstrate the need for audiologists and SLPs to engage in interstate practice at the discretion of the clinician. The 2020s promise to be a transformational decade during which interstate practice of audiology and speech-language pathology moves from idea to reality. The Audiology and Speech-Language Pathology Interstate Compact (ASLP-IC) is a contractual agreement between states that allows for qualified audiologists and SLPs residing in a compact state to apply for a compact privilege to provide services in other compact states with their home state license. The ASLP-IC offers benefits to both providers and patients, including but not limited to, enhanced access to care, continuity of care, and strengthened collaboration on best practices. States become members of the compact by enacting model legislation. The model legislation was first shared broadly with state legislators in 2021. As of January 2023, 23 states have adopted the ASLP-IC: Alabama, Colorado, Dela-

ware, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Mississippi, Missouri, Nebraska, New Hampshire, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee, Utah, West Virginia, and Wyoming. Additional states are expected the adopt the compact in the coming years. Furthermore, the ASLPIC Commission’s executive committee is currently working to establish the operational parameters of the compact. It is anticipated that qualified audiologists and SLPs residing in a compact state may begin to apply for a compact privilege to practice before the end of 2023. The ASLP-IC promises to transform both audiology and speech-language pathology and access to services.

Summary The political environment of the United States has become complex and uncertain. Despite the current political environment, recent health care legislation and regulations, particularly around coverage payment policy, have had a profound impact on audiology and speech-language pathology, chiefly due to the transformation from provider-centered payment models based on service volumes and fragmented care toward patient-centered payment models that incentivize health outcomes and high-quality coordinated care. This shift is most apparent in Medicare, Medicaid, and private insurance. More recently, the COVID-19 pandemic and its impact on the practice of audiology and speechlanguage pathology have affected public policy, especially in telehealth utilization. The ACA, the Medicare CHIP Reauthorization Act, the PDPM, the Medicare Audiologist Access and Services Act, coverage of audiology and speech-language pathology services provided via telehealth, and the ASLP-IC are six legislative and regulatory issues important to audiologists and SLPs and to how the professions provide and bill for health care services. Ongoing work is needed to ensure audiology and speech-language pathology services are appropriately delivered and properly valued in these emerging health care delivery and payment services.

References and Resources Agency for Healthcare Research and Quality (n.d.). Patient-centered medical home. https://pcmh.ahrq​.gov/ American Medical Association (n.d.). https://www.amaassn.org/ American Medical Association (n.d.). Current procedural terminology (CPT). https://www.ama-assn.org/ amaone/cpt-current-procedural-terminology



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American Medical Association (n.d.). RVS update committee (RUC). https://www.ama-assn.org/about/ rvs-update-committee-ruc American Speech-Language-Hearing Association (n.d.). Advocacy. https://www.asha.org/advocacy/ American Speech-Language-Hearing Association (n.d.). Billing and reimbursement. https://www.asha​ .org/practice/payment/ American Speech-Language-Hearing Association (n.d.). Telepractice. https://www.asha.org/practiceportal/professional-issues/telepractice/ American Speech-Language-Hearing Association (n.d.). Value-based care: Alternative payment models. https://www.asha.org/advocacy/Value-Based-Care/ America’s Health Insurance Plans (n.d.). https://www​ .ahip.org/ Audiology and Speech-Language Pathology Interstate Compact (n.d.). https://aslpcompact.com/ Center for Consumer Information and Insurance Oversight (n.d.). Information on essential health benefits (EHB) benchmark plans. https://www.cms​ .gov/cciio/resources/data-resources/ehb.html Centers for Disease Control and Prevention (n.d.). ICD-10. https://www.cdc.gov/nchs/icd/icd-10-cm​ .htm Centers for Medicare and Medicaid Services. (n.d.). Accountable care organizations. https://innovation​ .cms.gov/initiatives/aco/ Centers for Medicare and Medicaid Services. (n.d.). Early and periodic screening, diagnostic, and treatment. https://www.medicaid.gov/medicaid/benefits/ epsdt/index.html Centers for Medicare and Medicaid Services. (n.d.). Healthcare common procedure coding system. https:// www.cms.gov/medicare/coding/medhcpcsgeninfo/ index.html Centers for Medicare and Medicaid Services. (n.d.). ICD-10 (specific to Medicare and Medicaid). https:// www.cms.gov/medicare/coding/icd10/ Centers for Medicare and Medicaid Services. (n.d.). Local coverage determinations. https://www.cms.gov/ Medicare/Coverage/DeterminationProcess/LCDs​ .html

Centers for Medicare and Medicaid Services. (n.d.). What’s a MAC. https://www.cms.gov/Medicare/ Medicare-Contracting/Medicare-AdministrativeContractors/What-is-a-MAC.html Centers for Medicare and Medicaid Services. (n.d.). Medicare benefit policy manual. https://www.cms .gov/Regulations-and-Guidance/Guidance/ Manuals/Internet-Only-Manuals-Ioms-Items/ Cms012673.html Centers for Medicare and Medicaid Services. (n.d.). Medicare physician fee schedule. https://www.cms​ .gov/medicare/medicare-fee-for-service-payment/ physicianfeesched/ Centers for Medicare and Medicaid Services. (n.d.). Quality payment program. https://www.cms.gov/ Medicare/Quality-Payment-Program/QualityPayment-Program.html Centers for Medicare and Medicaid Services. (n.d.). Patient-driven payment model. https://www.cms .gov/Medicare/Medicare-Fee-for-Service-Payment/ SNFPPS/PDPM.html Centers for Medicare and Medicaid Services. (n.d.). Medicare fee for service recovery audit program. https://www.cms.gov/Research-statistics-data-andsystems/monitoring-programs/medicare-FFScompliance-programs/recovery-audit-program/ index.html Code of Federal Regulations. § 440.110 Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (2022). https://www.ecfr.gov/current/ title-42/chapter-IV/subchapter-C/part-440/ subpart-A/section-440.110 Consolidated Appropriations Act. Pub. L. No. 117-328 H.R. 2617 (2022). https://www.cbo.gov/publication/ 58901 Coronavirus Aid, Relief, and Economic Security Act. Pub. L. No. 116-136, 134 Stat. 281(2020). https:// www.congress.gov/116/plaws/publ136/PLAW116publ136.pdf Families USA. (n.d.). https://familiesusa.org/

Centers for Medicare and Medicaid Services. (n.d.). Medicaid. https://www.medicaid.gov/

Federal Register (2022, November 18). The federal register. https://www.federalregister.gov/documents/​ 2022/11/18/2022-23873/medicare-and-medicaidprograms-cy-2023-payment-policies-under-thephysician-fee-schedule-and-other

Centers for Medicare and Medicaid Services. (n.d.). Medicare. https://www.medicare.gov/

HealthCare.gov (n.d.). Glossary. https://www.health​ care.gov/glossary/

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Henry J. Kaiser Family Foundation. (n.d.). https:// www.kff.org/ Medicare Access and CHIP Reauthorization Act of 2015. Pub. L. No. 114-10, 129 Stat. 87 (2015). https://www.congress.gov/114/plaws/publ10/ PLAW-114publ10.pdf Medical Billing and Coding Certification. (n.d.). https://www.medicalbillingandcoding.org/ National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012). https://supreme​ .justia.com/cases/federal/us/567/519/

Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111–148, 124 Stat. 119 (2010). https://www.congress.gov/111/plaws/publ148/ PLAW-111publ148.pdf U.S. Department of Health and Human Services. (n.d.). Affordable Care Act overview. https://www​ .hhs.gov/healthcare/index.html U.S. Department of Health and Human Services. (n.d.). Affordable Care Act essential health benefits. https://www.healthcare.gov/glossary/essentialhealth-benefits/

11 Service Delivery in Health Care Settings Jeffrey P. Johnson, Christine T. Matthews, and Alex F. Johnson

Scope of Chapter This chapter addresses key professional issues that affect speech-language pathologists (SLPs) and audiologists in health care settings. Professionals from these disciplines serve patients with a variety of health conditions, lead and teach other practitioners and learners, promote best and evidence-based practice, advocate for patients and their discipline, and deal with a variety of unique ethical and regulatory issues. At the center of the various activities associated with service delivery in health care settings is the primary responsibility of the clinician to provide excellent, safe, affordable care. Beyond the core commitment to the patient are collaboration with the health care team and service to the profession. The first section of this chapter summarizes the various locations and settings in which health care is delivered: acute care, rehabilitation, specialty hospitals, extended care, and outpatient settings. Because the nature of the work and its primary focus and goals change by setting, it is important for current and future practitioners to understand these differences. Much of the information provided applies to both SLPs and audiologists. The second part of the chapter summarizes several complex yet established foci of modern health care, including patient safety, documentation, supervision of trainees and new professionals, interprofessional responsibilities, and health literacy. These foundational topics have a significant impact on the way providers in health care settings engage with and provide care to patients and interact with colleagues in the communication sciences and other professions. Finally, the last section of the chapter examines dynamic trends that are likely to have a growing impact on service delivery in health care settings moving forward. Preparation of competent and qualified clinicians, degree status and certification programs, and advancements in alternative (i.e., non-face-to-face) service delivery methods are some of the topics briefly discussed with the emerging professional in mind.

Health Care Settings and Key Responsibilities The American Speech-Language-Hearing Association (ASHA) reported that in 2021, 39% of SLPs and 75% of audiologists were employed in health care settings. An additional 22% of SLPs and 31% 213



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of audiologists worked in private practice, and it can be assumed that a sizable portion of those individuals also provided inpatient and outpatient services to patients in health care settings on a contractual basis (ASHA, 2022a). For the individual unfamiliar with the continuum of health care settings, several key characteristics are provided in Table 11–1. A key point for consideration here is appreciation of the unique purpose of each setting within the overall health care enterprise. A secondary point is consideration of the skill and/or knowledge set that may be most useful in each type of setting. It is important to note that experience in one setting may not serve as adequate preparation for another setting. Clinicians who move across the continuum need significant flexibility, extensive and appropriate background preparation, and essential orientation and competency in each setting to be effective and successful.

Acute Care Settings Acute care hospitals can be differentiated across several criteria that are important for prospective clinicians to understand. In general, acute care hospitals are hospitals in which patients are admitted for care (typically short term) for an acute illness or injury or for management of problems of such complexity that they cannot be diagnosed or treated in outpatient or other settings. Within the broad category of acute care, several additional descriptors can be helpful in appreciating various roles and differences. Some acute care hospitals provide the most advanced levels of life support, procedures, and surgeries and can handle patients with the most complex diagnoses. These tertiary care hospitals are usually located in large metropolitan areas, may be university affiliated (i.e., academic medical centers), have a significant physician education component, and are staffed and technologically designed to handle the most complex medical cases. Typically, these hospitals have a staff of SLPs who are employed to handle the volume of inpatients and outpatients. When otolaryngology, neurology, or neurosurgery are key specialty components, audiologists may also be employed to provide inpatient and outpatient hearing assessment, vestibular testing, and/or intraoperative monitoring, as well as habilitation/ rehabilitation of hearing. A second type of acute care hospital is the more general community or rural hospital. General hospitals vary in size depending on the geographic area and population served. They may emphasize some aspects of specialty care, are more likely to be staffed by primary care physicians and general surgeons, and have a number of specialists on call. The emergency departments of these hospitals are designed to manage common illnesses and traumas and are typically not organized to

receive the most complex cases. A common staffing pattern for speech-language pathology in this setting would be one or two staff SLPs (more in larger institutions). Audiologists may also be on staff to provide assessment and rehabilitation services, often on an outpatient basis. Another example is the long-term acute care hospital (LTACH). These hospitals are designed to provide specialty care to patients with acute illnesses who require a longer stay (more than 25 days) than the average of 4 to 5 days typical of many tertiary care hospitals. Many of these specialty hospitals focus specifically on two populations of great interest for SLPs: ventilator-dependent individuals and those who have sustained traumatic brain injury. When these are predominant patient populations, SLPs with specialized training and skills are required to assist in dysphagia and communication management and rehabilitation. Two more types of acute specialty hospitals should be mentioned: pediatric specialty hospitals and designated cancer hospitals. Most pediatric specialty hospitals in the United States operate in a manner similar to the tertiary care hospitals described previously, serving acute patients with complex diseases and staffed by a variety of specialists. Pediatric hospitals also have the specific mission of being child and family centered. They are particularly attuned to the illnesses of childhood and the stressors that are common when a child is ill, and usually have programs and staff customized to address this very important group of patients and their families. Because of the common intersection of communicative/swallowing disorders with childhood illness and disease, it is common for SLPs and audiologists to be employed as part of a large outpatient or inpatient service in this setting. A second setting, designated cancer hospitals, provides care to patients with focus on treatment, management, and end-of-life issues associated with cancer. The federal government has designated a number of cancer centers throughout the country, and it is common for these to be associated with other large medical institutions. SLPs in these settings are typically employed to serve patients with head and neck cancer, brain tumors, or other cancers that affect communication or swallowing in children and adults. Additionally, audiologists may be required to assist in monitoring hearing for ototoxicity.

Postacute Settings Several postacute settings may also employ SLPs and audiologists. These include rehabilitation hospitals, where patients typically have a short postacute period of rehabilitation, as well as skilled nursing facilities, where patients may receive rehabilitation but with less intensity.

n

Hospitalization for management of complex medical problems n Requires specialized medical, nursing, surgical, and extensive availability of other services

n

Acute care

Inpatient rehabilitation

Hospitalization for immediate posthospital rehabilitation needs n At least 3 hours per day of rehabilitation treatment provided

Brief Description

Setting Respiratory diseases (21.7%) Cerebrovascular diseases (16.3%) n Occlusion/transient ischemic attack (4.9%) n Central nervous system (CNS) diseases (4.6%) n Head injury (3.6%)

(Source:  ASHA, 2019b)

Cerebrovascular diseases (28.2%) n Respiratory diseases (9.5%) n Mental disorders (8.8%) n CNS diseases (7.9%) n Head injury (5.7%)

n

(Source:  ASHA, 2019a)

n

n

Most Common SLP Caseload Medical Diagnosis

Table 11–1.  Unique Characteristics of SLP Practice by Health Setting

(Source:  ASHA, 2019b)

disorder (66.5%) n Dysphagia (46%) n Dysarthria (13.6%) n Aphasia (13.4%) n Voice disorder (3.3%) n Apraxia (3.3%)

n Cognitive-communication

(Source:  ASHA, 2019a)

n

disorder (24.7%) Aphasia (9.3%) n Dysarthria (6.6%) n Voice disorder (4.1%) n Apraxia (1.6%)

Dysphagia (82.4%)

n Cognitive-communication

n

Most Common SLP Diagnoses

Differential diagnosis Interpretation of medical information on communication disorders n Advanced interprofessional skills n Consultative communication skills n Competency in MBS, FEES, trach/ vent management skills, bedside language, speech, voice assessment

continues

Comprehensive assessment and treatment skills n Skills in outcomes and change measurement n Management of complex language, cognitive, and dysphagia disorders n Family and team communication skills n Advanced collaboration and interprofessional skills n Postdischarge planning and management skills

n

n

n

Essential Clinical Skills

CHAPTER 11   Service Delivery in Health Care Settings 215

n

SLP services are provided in the patient’s home where they often feel most comfortable n Allows for highly tailored and functional treatment tasks given the treatment setting

n

n

Home care

Outpatient

Skilled nursing

Offers subacute rehabilitation services for patients with complex medical conditions who are unable to tolerate more intensive rehabilitation n At least 1–2 hours of daily rehabilitation treatment

Variety of settings including hospitals, clinics, medical offices, and independent private SLP practices

Brief Description

Setting

Mental disorders (17.8%) Cerebrovascular disease (15%) n Respiratory diseases (14.4%) n CNS diseases (12.9%) (Source:  ASHA, 2019d)

n

n

(Source:  ASHA, 2019c)

Cerebrovascular disease (27%) n CNS diseases (13.1%) n Head injury (8.9%) n Respiratory diseases (6.9%)

n

(Source:  ASHA, n.d.-c)

Cerebrovascular disease (63%) n CNS diseases (8%) n Respiratory diseases (5%) n Hemorrhage/injury (3%) n Other neoplasm (2%)

n

Most Common SLP Caseload Medical Diagnosis Dysphagia (54%) Aphasia (37%) n Motor speech (29%) n Memory (15%)

(Source:  ASHA, 2019d)

n

disorder (49.5%) Aphasia (6.5%) n Dysarthria (5.3%) n Voice disorder (2.1%)

Dysphagia (59.7%) n Cognitive-communication

n

(Source:  ASHA, 2019c)

disorder (40.6%) n Aphasia (23.6%) n Dysphagia (21.6%) n Voice disorder (21.1%) n Dysarthria (17.1%) n Apraxia (5.4%)

n Cognitive-communication

(Source:  ASHA, n.d.-c)

n

n

Most Common SLP Diagnoses Long-term patient management skills Educating, counseling, and following up with families n Outcomes measurement n Efficiency in management of therapy termination n Business-related skills, especially in private practice Long-term patient management skills Additional skills in both group and individual therapy n Skills in educating, counseling, and following up with families n Outcomes measurement n Efficiency in management of therapy termination n Business-related skills, especially in private practice See Inpatient Rehabilitation skills (above) n Communication and advocacy skills focused on elderly persons n Competence in independent clinical decision making n Ability to deal with larger corporate structures

n

n

n

n

n

Essential Clinical Skills

216

Table 11–1.  continued

SECTION III   Setting-Specific Issues

n

n

Hospice/ palliative care

Veterans Health Administration: n Acute care n Inpatient rehabilitation n Skilled nursing n Outpatient n Hospice/ palliative n Home care (Source:  Veterans Health Administration, 2023)

Top 5 most common VA SLP caseload medical diagnoses: n Stroke n Parkinson’s disease (PD) n Traumatic brain injury (TBI) n Amyotrophic lateral sclerosis (ALS) n Post-traumatic stress disorder (PTSD)

n  Any severe or chronic    condition that affects       communication of basic    needs or swallowing,       particularly after medical       treatments have been       decreased or stopped

Most Common SLP Caseload Medical Diagnosis

(Source:  Veterans Health Administration, 2023)

Top 5 most common SLP diagnoses: n Cognitive-communication disorder n Dysphagia n Dysphonia n Dysarthria n Aphasia

Neurogenic language or speech disorders n Cognitive disorders

n

n Dysphagia

Most Common SLP Diagnoses

Differential diagnosis Knowledge of anatomy, physiology, and general medical information n Competency in MBS, FEES, trach/ vent management, TEP voice restoration, assistive technology, aphasia, fluency, speech, voice, cognitive-communication and swallowing management across care settings n

n

Application of ethical and clinical reasoning n Ability to adapt tools and resources to achieve maximum functionality with least patient/family effort n Use of communication technologies n Adaptive feeding/swallowing skills

n

Essential Clinical Skills

Note:  Acronyms and abbreviations: CNS: central nervous system; FEES: fiberoptic endoscopic evaluation of swallowing; MBS: modified barium swallow; TEP: tracheoesophageal prosthesis.

Five levels of complexity across 171 medical centers n Over 100 community living centers where inpatient rehabilitation, skilled nursing, respite, and inpatient hospice care are provided n 1,113 outpatient sites of care

Addresses either end-oflife or quality-of-life issues in persons with severe or terminal illnesses

Brief Description

Setting

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In each of these settings, SLPs and audiologists may be involved in assessment and treatment, although audiologists are less likely to be included, while SLPs are almost always utilized to help patients restore function. These settings can be described along continua of acuity, complexity of cases, and prognosis. For example, patients admitted from the acute care setting to the rehabilitation hospital will have significant remaining complications, may have multiple problems needing skilled rehabilitative and medical/nursing care, and will have a prognosis that is more positive, even when it is not for full recovery. When patients cannot tolerate the required 3 hours per day of rehabilitation, or if they have factors that negatively contribute to their prognosis but could still benefit from rehabilitation, they are typically admitted to a skilled nursing setting that has a rehabilitation component, including speech-language pathology services. It is rare for audiologists to have a full-time appointment in this setting, although contractual arrangements may be in place for individual patient consultation. Patients in skilled nursing settings are seen for postacute convalescent recovery, with a plan for discharge to home or for transfer to a long-term care environment. In these settings, rehabilitation activities may be less intense than in the rehabilitation hospital, but this is not necessarily the case and the goals of treatment, as always, are based on the patient’s personal goals and capacity. A larger number of patients in these settings are likely to have dementia, and many will have dysphagia and its associated complications with nutrition and feeding. Another location of postacute care that is quickly growing is home care. Now, more than at any time in the past, clinicians can serve patients in the home who are more ill or have complex illnesses. Through the use of new protocols and with advanced technology, patients are being discharged from the hospital earlier than ever. Many SLPs now work primarily in the home setting. Home care organizations may be aligned with specific hospitals or may be independent and accept referrals from many acute or rehabilitation settings. SLPs are frequently employed by these agencies as either independent contractors or employees who provide skilled rehabilitation in the home. It is not uncommon for SLPs in this environment to also be required by the employing home health agency to provide some routine health services (e.g., blood pressure monitoring, suctioning). A final postacute setting is hospice care. Hospice is provided for patients for whom the goals have changed to comfort rather than cure or prolongation of life. Most hospice care is provided in the patient’s home or assisted living facility, but about 18% is provided in inpatient settings, including nursing and inpatient hospice facilities (National Hospice and Palliative Care Organization, 2020). The role of SLPs or audiologists in hospice

is limited since rehabilitation is not a goal. However, given that comfort and quality of life are particular foci in hospice, the SLP or audiologist has a role in ensuring that communication is maintained with family and staff via external supports and technology, that caregivers understand helpful ways to communicate with the patient, and that the eating process is comfortable and safe. Family and staff may also need education about communication and/or swallowing. A review by Chahda and colleagues is a good source for original research on the SLP’s role in palliative care (Chahda et al., 2017), while recommendations and guidelines for SLPs and audiologists working in this setting can be found in the peer-reviewed and broader literature (e.g., Pollens, 2004, 2012, 2020; Shaw, 2015; Vescovich, 2015; Weinstein, 2015).

Outpatient Settings The third general category of care is the outpatient setting. Patients may be seen as outpatients after hospitalization if further inpatient care is no longer indicated. Commonly, the SLP or the audiologist may see patients with clinical conditions that do not require hospitalization for evaluation and treatment. Examples include patients with a variety of conditions, such as dementia, head injury, voice disorders, and neurodegenerative diseases. Some outpatient settings are multidisciplinary, rehabilitationfocused programs, while others have services limited to speech-language pathology or audiology. In these outpatient settings, it is possible for services to be delivered via a hospital or agency where the clinician is an employee or by a private practitioner who is self-employed. A unique health care system exists in the United States and its territories that spans the full range of settings described above, from the highest complexity acute care hospital to home and outpatient care. The Veterans Health Administration (VHA) is the largest integrated health care system in the U.S. and, given the unique needs of veterans, SLPs and audiologists provide care at many of the nearly 1,300 VHA facilities throughout the country (U.S. Department of Veterans Affairs, 2023). The VHA is the largest employer of and the largest training site for graduate and postgraduate SLPs and audiologists. As of early 2023, there were 1,350 audiologists, 355 audiologist assistants, and 475 SLPs providing care in VHA. With respect to audiological services, tinnitus and hearing loss are among the most common military service-connected conditions treated in VHA (U.S. Department of Veterans Affairs, 2021), while dysphagia management accounted for approximately 48% of SLP services in 2022 and the full range of communication and cognitive services composed the other 52% (Veterans Health Administration, 2022b).



CHAPTER 11   Service Delivery in Health Care Settings

Regardless of the physical setting where the patient is seen, it is likely that every SLP or audiologist will see patients with communication disorders that are health related. Frequently, an assumption is made that school-age children have communication disorders that are educationally relevant and that health concerns are handled by the medical SLP. In recent years, however, school-based SLPs have seen increased school participation by children with serious health-related conditions (Ballard & Dymond, 2018; Lefton-Greif & Arvedson, 2008). Thus, all SLPs need to develop expertise in serving individuals with health-related communication disabilities, regardless of the setting of their employment. This role is not new for school-based clinicians; however, the increased frequency and complexity of children with health concerns places considerable demands on the work of already-busy SLPs in school settings. It is incumbent on clinicians from medical settings to ensure school-based SLPs have access to necessary information and resources to support the children they serve.

Routine Considerations for Speech-Language Pathologists and Audiologists in Health Care As noted previously, individuals with health-related conditions that affect communication and swallowing may be seen in any of the settings in which clinicians practice. There is a specific set of considerations that impacts the way SLPs and audiologists can and should practice. This section focuses on these concerns and their effect on the nature of service delivery in the health care setting.

Health Status of the Patient For every patient seen in a given health care setting, the primary concern is physical and mental health status of the patient. When a patient comes for diagnostic services, accurate and timely diagnosis is critical in managing the patient’s condition. When a patient comes for audiology, speech, language, or swallowing treatment, the clinician should ensure the patient is safe, make note of any significant changes in behavior that could have medical significance, and be cognizant of the overarching medical diagnosis and understand its implications for rehabilitation. The general medical diagnosis and prognosis are key factors in determining the purpose of the evaluation or treatment referral and contribute to decision making about the nature of any approach to intervention. For example, the young patient with a traumatic brain injury or poststroke aphasia may be an excellent candidate for rigorous rehabilitation provided

by the SLP. In contrast, a different approach focused on palliative care may be appropriate for the individual with progressive deterioration in neurological function. Thus, the SLP is obligated to understand the effect that the actual medical conditions and prognoses have on the patient’s health status as well as on communication and swallowing function to determine the potential benefits of rehabilitation.

Safety A second issue of great concern in all health settings today is patient safety (World Health Organization [WHO], 2017). The implications of speech-language or hearing disorders on patient safety are not well documented and additional research in this area is necessary (Hemsley et al., 2016). Likewise, the effects of language impairment and cognitive, perceptual, or sensory difficulties on compliance with medical or nursing instructions remain undocumented with specific regard to patient safety issues. A growing literature summarizes the effect of low health literacy on patient compliance with such tasks as following medication instructions or other directions from care providers (Davis et al., 2007). It has been estimated that about one-third of adult Americans have limited health literacy, disproportionately impacting vulnerable populations such as the elderly, disabled, ethnic minorities, those with limited English proficiency, those with limited education, and lower socioeconomic status (Schillinger, 2020). A logical extension of this literacy concern suggests that the SLP or audiologist should ensure patients understand and can participate in decision making about their own care. This is especially important in inpatient settings where the pace can be fast and a patient’s misunderstanding or lack of hearing can be misinterpreted as cognitive impairment. In these situations, SLPs and audiologists should provide assistive devices to augment communication or hearing, and advocate for patients under their care. When patients are knowledgeable about their condition and can obtain the information needed for informed decision making, they are safer. Woods (2006) argues that communication is the root of most patient safety breakdowns and cites six factors that make communication challenging for patients: gender, cultural/ethnic factors, health literacy level, socioeconomic factors, time/urgency factors, and personality/behavioral factors. Certainly, the nature and severity of the communication disorder represents an additional critical factor for those in the care of an SLP or audiologist. Another obvious area of safety concern for the clinician occurs when invasive procedures are necessary or certain patient risk factors are present. Examples of invasive procedures provided by SLPs include videostroboscopy,

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insertion and removal of tracheoesophageal prostheses, and a number of swallowing procedures. Audiologists may engage in procedures such as ear canal irrigation during vestibular testing, cerumen removal, and making impressions of the ear. Additionally, some SLPs and audiologists are involved in intraoperative monitoring during laryngeal, otologic, or neurosurgical procedures. When involved in these types of activities, clinicians should have demonstrated competence in carrying out the task, have documented institutional authorization, and be aware of any risks associated with the procedure. Appropriate precautions and personnel should be available in case of complications. Competency for these higher-risk tasks can be established in several ways, including demonstration and observation over repeated opportunities, clinician testing and interviewing, simulation tasks, case studies, or written examinations. ASHA provides resources to assist members involved in performing these tasks. It is important that those who are engaged in highrisk professional activities (or supervising others) have validated, clearly documented competence. This protects the practitioner and the institution from unnecessary complications if an adverse event occurs. Most important, it protects the patient from incompetent or inexperienced practitioners, increasing the probability of a safe and satisfactory clinical outcome.

Infection Control Clinicians in all settings should be knowledgeable experts in all aspects of infection control, ensuring they have minimized patient (and staff ) risk for exposure to infection. Appropriate procedures for cleaning or disposing of equipment and supplies that have been exposed should be established and followed. All clinicians should know procedures for airborne and contact isolation precautions, hand hygiene, cleaning and disinfection of reusable medical equipment, and medical waste disposal. All hospitals require employees to be knowledgeable in this area and are required to provide necessary training. Prevention of disease transmission should be a consideration with every professional interaction. See Chapter 18 for more information. Requirements for best practice regarding safety standards are generated by a number of sources, including state and local health departments, The Joint Commission (formerly JCAHO), the Occupational Safety and Health Administration (OSHA), the Centers for Disease Control and Prevention (CDC), and the Office of Inspector General (OIG) for Veterans and Federal Health Care Facilities. In most institutional settings, all providers of health care are required to demonstrate knowledge of safety requirements. In general, The Joint

Commission, an accrediting body, reviews compliance with institutional safety and quality standards on a regular basis and provides recommendations for improvement when needed. ASHA has a webpage with links to resources provided by The Joint Commission (ASHA, n.d.-e). These resources include information about patient safety issues, performance measures and accreditation, and sentinel events (i.e., safety events resulting in patient death or serious injury). OSHA (https://www.osha.gov) focuses on protection of workers. Thus, clinicians who are exposed to risk from radiation or infectious material should be familiar with OSHA standards. The CDC is concerned with preventing and managing general health concerns in the United States. Clinicians with concerns about disease outbreaks or specific information about various conditions can find a variety of alerts and general content on the CDC website (https://www.cdc.gov). Many readers in the United States are probably quite familiar with the CDC due to its prominent role in distributing information over the course of the COVID-19 pandemic. Given the health, safety, social, and psychological implications of the pandemic, it should come as little surprise that COVID-19 had a dramatic effect on the provision of speech-language pathology and audiological services, as described in the box below.

The COVID-19 global pandemic has changed the face of health care delivery. This evolving health crisis necessitated new personal protective equipment (PPE) recommendations and increased innovation and utilization of alternative modes of service delivery (primarily telehealth/virtual care options) that have changed the practice patterns of SLPs and audiologists. SLPs and audiologists provide care to patients who are acutely infected with COVID-19 and treat those suffering from the postinfectious sequelae of the virus. During the acute infectious period, providers utilize N-95 respiratory masks, eye protection, gowns, and gloves to reduce their risk of transmission. The virus has also changed PPE recommendations for patients who are not ill with COVID-19, given the risk of asymptomatic transmission. Wearing a surgical mask during inperson patient encounters has become the norm in many health care settings, and this can certainly degrade the quality of interactions with individuals with hearing and other communication disorders. However, clinicians should be aware that the expanded use of PPE has resulted in low rates of COVID-19 transmission for our professions while still allowing for provision of critical in-person ser-



CHAPTER 11   Service Delivery in Health Care Settings

vices. As noted above, the pandemic also resulted in rapid growth in the use of telehealth for speechlanguage pathology and audiology services. While most services in speech-language pathology and audiology can be completed using video-based telehealth platforms, telehealth is not without limitations. Certain therapeutic tasks are challenging to administer over a computer and sessions are dependent on the quality of users’ internet signal. As such, now more than ever, SLPs and audiologists must be creative, flexible, and prepared to implement strategies to overcome or mitigate limitations associated with masks, telehealth, and other consequences of the pandemic to deliver high-quality patient care.

Measuring Change, Progress, and Outcomes General principles and specific practices associated with assessment and diagnosis in health care settings are beyond the scope of this chapter. Typically introduced in graduate curricula and practica, lifelong learning of clinical skills is the goal of every competent practitioner in speech-language pathology and audiology. These essential skills are covered comprehensively in common texts used in graduate education. A topic sometimes overlooked in disorder-specific discussions is measurement of change over time, which may indicate progress, deterioration, or plateauing. These observations are critical to decisions about the patient and their plan of care. The benefit to the patient and the family is the centerpiece of all work in communication and swallowing disorders. Benefit (or lack of it) can be measured from multiple perspectives along a continuum from shortterm behavioral change to significant change in health status, participation in functional activities, or overall quality of life. In the various health care settings, early changes in communication, cognition, or swallowing can signal the very beginning of recovery. Intermediate levels of progress are seen in recovery of functional skills in listening, attention, understanding, reading and writing, and conversation. The most desired and challenging stages of communication progress are observed when patients’ functional abilities are either restored or maximized so their participation in life activities is enabled rather than disrupted by their communication, hearing, or swallowing abilities. It is worth noting that rarely are these changes attained in a simple, orderly manner. Patients may show progress in one domain of communication while experiencing little gain in another aspect. Thus, to document and measure change across the con-

tinuum of health care settings (and patient acuity), many different tools and approaches may be necessary. Measurement is important to everyone involved in the care process. Evidence of change and outcome are the bases for decisions related to reimbursement and provide guidance for the clinician as to whether treatment is beneficial and should be continued. Conversely, measurement provides support for the decision to stop treatment when minimal benefit is documented (even when ongoing adjustments to the plan of treatment were made to optimize gain). Measures of change or outcome are usually based on assessments of the patient’s perceived benefit, the clinician’s judgment of change, and/ or objective measures of communication performance. Patient Reported Outcomes.  Patients are often the best judges of the benefits of services received. Table 11–2 lists several tools developed to help clinicians reliably quantify benefit and/or change from the patient’s perspective. Most of these tools are designed to measure the patient’s view of the degree of functional impairment or progress, as opposed to improving understanding of the underlying causative mechanisms. In general, the assessment of outcomes and progress should include the patient’s perspective, ensuring the clinician and patient agree on the benefit of treatment or other interventions. In some cases, if a patient cannot independently respond to the demands of the task, a family member or other caregiver may need to assist with collection of the measurements. While this approach compromises the validity of some assessment tools, it may nevertheless provide a useful perspective from the view of the patient or the patient’s proxy. Furthermore, some instruments, such as the Communicative Effectiveness Index (CETI; Lomas et al., 1989), have been expressly designed to capture the caregiver’s or loved one’s perspective of the patient’s functioning. Eadie et al. (2006) provide a critical review of the psychometric properties of several self-report instruments used in speech-language pathology, and Cohen and Hula (2020) offer a more recent appraisal of patient-reported outcome measures, as well as key considerations related to their expanded use in the field. Performance-Based Measurement Tools. Numerous outcomes tools have been developed for measuring patient progress in various settings. Many of these tools are based on the WHO International Classification of Functioning, Disability, and Health (ICF; WHO, 2001), which classified key factors associated with functioning and disability. The ICF classification is based on various categories of body functions and structures, as well as associated activity limitations, impairments, or participation restrictions. ASHA has adopted the ICF model as

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Table 11–2. Sampling of Speech-Language-Hearing Patient Self-Assessment Tools Used in Health Care Settings Focus

Instrument Title

Author

Communication

ASHA Quality of Communication Life Scale

Paul et al., 2004

Hearing

Hearing Handicap Inventory for Adults (HHIE)

Newman et al., 1990

Stroke/Aphasia

Burden of Stroke Scale (BOSS)

Doyle et al., 2004

Aphasia

Assessment of Living With Aphasia (ALA)

Simmons-Mackie et al., 2014

Aphasia

Aphasia Communication Outcome Measure (ACOM)

Hula et al., 2015

Parkinson’s disease, ALS, MS

Communicative Participation Item Bank (CPIB)

Baylor et al., 2013

Head and neck cancer/dysphagia

M.D. Anderson Dysphagia Inventory (MDADI)

Chen et al., 2001

Dysphagia

Swallowing Quality of Life (SWAL-QOL)

McHorney et al., 2000

Voice

Voice Handicap Index (VHI)

Jacobson et al., 1997

foundational to scopes of practice in both audiology and speech-language pathology. In essence, the ICF model focuses on the person, their abilities, and any limitations to carrying out basic bodily functions (e.g., swallowing, breathing, hearing) and activities (e.g., talking, reading, writing, comprehending) or participating in important life activities (e.g., social relationships, work, school, community). The ICF is designed to encompass all aspects of human function and participation across the life span. It also considers how an individual’s environment impacts health, functioning, and human performance. Thus, the ICF provides a model that allows practitioners from across various fields to consider priorities, goals, and desired outcomes for various treatment and/or rehabilitation activities. SLPs and audiologists can use the ICF as a tool to assist with clinical decision making and goal setting for their clients/patients. One of the most widely used general measures in rehabilitation settings is the Functional Independence Measure (FIM; Keith et al., 1987). The FIM is a descriptive measure completed by the clinician and designed to measure change in a number of areas including communication. Because the FIM provides a global measure

of communication in the context of other areas of function (e.g., walking, eating), there has been interest in the development of communication-specific tools that provide a more detailed focus on a variety of components of speech-language and swallowing. One set of measures, Functional Communication Measures (ASHA, 2022b), is now part of ASHA’s National Outcomes Measurement System. Use of these measures for communication and swallowing allows for assessment of the benefit of treatment services for a given patient while also measuring the effectiveness of a particular program or service to a group of patients. Thus, the outcomes obtained from these analyses allow for a clinical service to be modified or improved based on results. As part of their professional preparation, all professionals in speech-language pathology and audiology have been exposed to dozens of specific measurement approaches for diagnosis and assessment. Many of these tools (e.g., standardized tests of language or speech, the modified barium swallow, audiometric testing, vestibular studies, oral mechanism examination) provide a valuable window to selected functions, allowing careful description of behaviors and some underlying mechanisms as



CHAPTER 11   Service Delivery in Health Care Settings

well. While these tools are essential for diagnosis and assessment, they are not always the best measures for studying patient change and progress, especially when the outcome is a change in function rather than specific physiologic, cognitive, or linguistic change. Thus, it is best to use valid and integrative measures and include the combined perspective of the clinician and the patient to assess and document progress.

Documentation SLPs or audiologists should address any questions and concerns raised by the referring provider. Responses to referral sources should be clear, direct, timely, and accurate. Good guidelines for report writing and consultation can be found in a number of sources; however, only a few such sources focus on writing reports and notes specifically for health settings (ASHA, n.d.-b; Kummer et al., 2007). Johnson and Jacobson (2016) have also written about the errors in patient care attributed to poor or incomplete documentation. Several examples of errors associated with documentation are summarized in Table 11–3. Documentation, as provided by the SLP, serves a variety of priorities, including (a) educating and informing the referral source and other providers, (b) documenting progress toward goals and additional behavioral/clinical observations, (c) reporting on any adverse events or outcomes, and (d) ensuring information required for compliance or reimbursement is available.

As the first priority, documentation that educates and informs the referral source and others involved in the care of the patient is a critical component of the care process for all patients. Most important, initial speechlanguage-swallowing-hearing consultations should address the question of the referral source. Conley et al. (2009) reported that 25% of referral notes do not contain a clear question, so SLPs completing initial consultations should be sure to obtain clarity before proceeding with evaluation or treatment. Numerous publications describe good report writing guidelines, and novice SLPs should review these. In health settings, especially in hospital documentation, reports may be produced using an electronic medical records system that does not allow for the type of writing recommended in common speech-language pathology texts. Regardless of the format required, notes should be concise and clear, avoid speech-language pathology terms the referral source might not know and use only approved medical abbreviations, and add information that will be helpful in subsequent decision making and patient care. Second, when the patient is being seen for treatment beyond the initial consultation, it is important to document the goals and the response to treatment. Again, the approach to doing this will be setting dependent; however, many SLPs use the principles of the SOAP approach (subjective, objective, assessment, plan) in clinical settings. The SOAP approach, introduced by Weed (1971), has been adapted to many clinical disciplines and is well understood within the health care

Table 11–3. Ten Examples of SLP or Audiology Communication or Documentation Errors   1. Failure to report results of high-risk or invasive procedures with accuracy or timeliness.   2. Failure to document sufficiently for others to provide necessary follow-up.   3. Failure to document supervision of nonlicensed (or noncertified) personnel.   4. Failure to document results from evaluations that could have diagnostic significance or could change the medical plan of care.   5. Failure to document observation of changes in patient behavior that could signal altered medical or psychological status.   6. Failure to document appropriate informed consent for any research activities that include the patient.   7. Producing diagnostic statements or interpretations outside the scope of practice or not substantiated with data or observations.   8. Failure to ensure confidentiality of patient information.   9. Failure to communicate beyond the written record (e.g., call attention to significant findings) when timing or urgency are important factors. 10. Failure to communicate clearly and appropriately with patients and their caregivers.

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enterprise. This method is familiar to colleagues in medicine, nursing, and other health fields. It allows for easy retrieval of relevant information, elimination of irrelevant observations, and clear statement of next steps, an area that is frequently of great interest to those involved in managing hospital stays for patients. Table 11–4 offers some brief guidance for writing SOAP notes. Chapter 16 discusses documentation issues in more detail. Electronic medical records (EMRs)/electronic health records (EHRs) are widely used in health care systems across the country (Alpert, 2016). Indeed, by 2015, 84% of nonfederal acute care hospitals had adopted basic EHR systems for use in note writing, and 96% had an EHR system that met requirements established by the U.S. Department of Health and Human Services (Henry et al., 2016). The use of this technology has had a profound effect on health care delivery across settings. All providers who document in the medical record must learn to enter information using these new technologies. There is minimal documentation, if any, in the literature about the specific opportunities and challenges associated with EHRs as reported by audiologists and SLPs.

While detailed discussion of this trend is beyond the scope of this chapter, practitioners and academics are encouraged to become aware of specific institutional requirements and the opportunity to prepare for full utilization of information in these systems. Practitioners across health settings should consider two points: (a) clinical administrators should ensure key information required for management of patients with communication disorders is included in the various templates in their particular EHR system and (b) clinicians should highlight critical and timely information (e.g., questions, clarifications, recommendations) so it is clear for the rest of the health care team.

Continuing Professional Development For the clinical practitioner in the health setting, nothing is more critical than continuous professional education and development. This concept entails going beyond the more traditional approach to continuing education as attendance at workshops and conferences or occasional reading. Every practitioner should devote a

Table 11–4. What Are SOAP Notes? Comment Type

Description

SLP Example

Subjective

Describe patient’s emotional, physical, cognitive status; include general observations about patient’s mood, appearance, attitude, or conduct.

The patient was lethargic.

Summarize data related to stated goals; include measurable information. Compare data from current session to previous sessions.

The patient was able to accurately repeat 20 out of 30 multisyllabic words today; yesterday he was able to repeat eight words.

Interpret the data and observations that have been noted in the current session and provide a speech-language pathology or audiology diagnosis.

The patient’s performance on the oral motor exam showed increased strength.

Based on the assessment of what has occurred, describe the next steps. Changes in goals or recommended activities, changes in therapy scheduling or frequency, and any needed referrals might be included. Also, document any recommendations for family members.

The patient should be referred for laryngological examination.

Objective

Assessment

Plan

The patient refused to cooperate with the examination.

The patient was able to sustain vocalization for 12 seconds.

The patient’s scores on the test are supported by the increase in intelligibility noted in conversational speech.

The patient should be considered for discharge from treatment. The patient’s family should be encouraged to converse with the patient several times per day, focusing on current events.



CHAPTER 11   Service Delivery in Health Care Settings

significant amount of time to learning new approaches, technologies, or delivery models that address the issues of cost–benefit to the patient and the system, improving safety for the patient, and enhancing quality of health and life. Some state licensure laws even require continuing education in specified areas such as prevention of medical errors for SLPs to maintain licensure. Access to such professional development activities is readily available online, in some university-affiliated hospitals, major health care systems, through a number of continuing education centers and offerings, and through ASHA, the American Academy of Audiology, and other professional organizations. When considering various professional development programs to improve one’s current practice, it can be helpful to use a series of self-guided questions to direct selection of activities and information. Here are some questions for choosing health-related continuing education programs in communication sciences and disorders (CSD): n

Are there skills and knowledge that need to be developed to provide services to a specific patient population in a specific setting?

n

For the patient populations being served:

n

n

What is the core understanding of any disease processes, common symptoms and medications, typical and atypical communication, and swallowing issues needed to best manage this group of patients?

n

What are the resources available to guide best practice in managing this group of patients?

n

Are there special technical procedures or skills that need to be verified before serving this patient population?

n

What are the expected effects of treatment with this patient population and the range of outcomes that have been reported in the literature?

For the specific health setting (e.g., nursing home, acute care): n

What are the service models, regulatory issues, and reimbursement constraints that impact care in this environment?

n

What are the documentation requirements and what technical or other skills are needed to complete documentation?

n

What are the collaborative (interprofessional) skills required to work in this setting?

n

What are the specific desired systematic outcomes associated with this setting? (For

example, in acute care, the goals may be rapid assessment, short-term consultation and intervention, and planning for transfer. In hospice care, the goals may be comfort, nutrition, reduced communication effort, and maintaining interaction with caregivers.) Using these basic questions, a clinician can identify areas of skill and knowledge needed to function as an expert in a given health setting. The clinician can then acquire the information needed through reading, formal education, mentored hands-on experience in the clinical setting, and workshop/conference attendance. As technology for content delivery has advanced, so has the number of opportunities for delivery of continuing education. While attendance at conferences continues, the number of web-based available mechanisms for continuing education is ever-increasing. In these activities, prospective attendees should use the same questions and clarifications regarding evidence, quality, and currency of the information being presented. Increasingly, information is available regarding potential conflicts of interest on behalf of those presenting continuing education. Learners should always ask themselves if there is a product or service being sold or advanced. If so, the same high standards of evidence should be applied in evaluating potential benefit for patients. Another aspect of continuing professional development focuses on the education of other professions about communication and swallowing disorders. SLPs and audiologists are always part of a team with the common goal of improving the health and function of the patient. Learning from and with these other professions is critical to good patient care. One piece of this professional exchange is to share knowledge of how individuals’ communication disorders affect their progression with other members of the health care team. For example, when a patient has a hearing loss and is hospitalized, it may be necessary to give support to the staff providing care regarding use of amplification and communication strategies. A broader discussion of interprofessionalism occurs later in this chapter, and Chapter 19 of this book addresses the issue of interprofessional practice more comprehensively.

Supervision of Others SLPs and audiologists have long been involved in the supervision and mentoring of new professionals in the field. The current educational pathway typically begins in the university clinic and extends to various off-campus practicum and internship experiences and finally to a clinical fellowship in speech-language pathology or a

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fourth-year externship in audiology. Accrediting bodies and certification boards ensure these clinical experiences are valid, rigorous, and comprehensive. There is a body of literature that addresses the topic of clinical supervision, focusing primarily on the student–clinical instructor/preceptor relationship. Examples of this body of knowledge come from the work of early leaders such as Jean Anderson (1988), who proposed a continuum/ developmental model of supervision with an ongoing goal of encouraging the independence of the supervisee. McCrea and Brasseur (2003) continued Anderson’s themes. Their work provides a rich discussion of the importance of the supervisory process to the development of professional competence in assistants, in new and advanced students, and in the early years of professional experience. In their book, McCrea and Brasseur encourage a change from the term “supervision” to “clinical education” and refer to the instructional role as “clinical educator.” Moving the focus of discussion to teaching and learning is key to the ongoing development of professionals, especially as they move to levels of advanced practice. Regardless of the terminology, professional leaders and associations acknowledge that skills and knowledge are required to deliver education to others. ASHA’s Practice Policy webpage (https://www.asha.org/policy/) provides reports, position papers, and other resources that specify general approaches and best practices for training and supervising assistants, students, and clinical fellows (see ASHA, 1985, 2008, for examples). Guidance on more advanced professional development relevant to health care settings can be attained from two sets of resources. First, ASHA consensus documents are available for a number of focused practice areas. For example, resources on feeding/swallowing services for patients in neonatal intensive care units (ASHA, 2004) and audiologic services for infants and young children (ASHA, 2006) can aid supervisors in planning and providing clinical training in these specialized settings. A second set of resources that may be useful to those practicing and leading in health settings can be found in literature from other disciplines, such as physical therapy, medicine, nursing, and occupational therapy. Many disciplines have struggled with the same issues that have been challenging for those in communicative disorders, including teaching clinical problem solving and reflection, learning clinical procedures and psychomotor skills, applying evidence-based approaches, using simulation tasks and/or simulated patient scenarios, and practicing interdisciplinary communication. It is beyond the scope of this chapter to review this literature, but a survey of educational approaches from other disciplines will be enlightening and helpful to those charged with

the education of others. See Chapter 22 for a further discussion of supervision and mentoring.

Quality and Compliance With Regulatory Processes The ethical, legal, and other regulatory processes that impact service delivery in the health setting are extensive. In essence, all these regulations have been put into place to protect patients and institutions, to ensure best practices are established and used, and to reduce costs. Despite their respectable intent, these goals are, in some ways, in competition with each other and produce demands for productivity reports, paperwork, meetings, documentation, and site visits by accreditation programs. The work associated with compliance is a significant component of delivering modern health care in the United States, and those who choose to work in this setting should understand that their role includes this demanding and sometimes frustrating intrusion into clinical or research goals. Providers in hospitals, nursing homes, health care, and outpatient settings are affected by these various requirements. Administrators in these settings typically provide support for clinicians by completing required paperwork and other activities so that access to service for patients is accomplished most efficiently. Additionally, through its Practice Management website, ASHA provides resources on billing and reimbursement, practice policies, ethics, licensure, and other topics that will help providers navigate the myriad responsibilities associated with compliance (ASHA, n.d.-d).

Interprofessional Responsibilities and Competencies Interprofessional practice and collaboration has been an evolving area of discussion in the discipline for years. Within the national health care scene, there is widespread interest in the potential impact and professional benefit of interprofessional practice on quality of care, safety, and patient satisfaction. In a recent report, the Interprofessional Education Collaborative (2016) outlined an important discussion from a number of health-related professional organizations representing the disciplines of osteopathic and allopathic medicine, nursing, pharmacy, dentistry, and public health. This document presents four major domains for interprofessional practice, including values and ethics, roles/responsibilities, interprofessional communication, and teams/teamwork. The increased prevalence of this topic in the professional literature and in the educational curricula of medical and nursing schools suggests that health professionals from a variety of disciplines, including speech-language



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pathology and audiology, should become familiar with the language and culture of interprofessionalism. Furthermore, it is important that professionals in CSD understand their role in interprofessional issues and collaboration. Within the values domain, it is incumbent upon the SLP or audiologist to articulate and advocate respectfully for the communication rights and independence of all patients while also inviting and expressing respect for input from other members of the interdisciplinary team. Under the domain of roles and responsibilities, helping colleagues develop a realistic and clear picture of the role of the SLP or audiologist is critical. Similarly, SLPs and audiologists need to work diligently to ensure their understanding of the roles and contributions of other providers is clear. The last two factors — communication and teamwork — are also very important to all professionals caring for a patient. Tools and strategies for effective performance on teams are widely available. These capabilities should become part of the education and practice pattern of every SLP and audiologist who anticipates a successful career in the health care environment. Historically, speech-language pathology and audiology associations and professionals have worked to establish autonomy in their care of patients and to achieve recognition for their distinctive contributions to the health care field. Given the number of unique disciplines represented in health care, it is not surprising that others have challenged these attempts and that occasional turf wars have emerged across disciplines that have common patient interests. Despite occasional disagreements with colleagues from medical and other health disciplines, the clinical arm of speech-language pathology and audiology has flourished over the past two decades. It is common for these fields to be listed as desirable occupations, with demand for speech-language pathology projected to grow by 21% through 2031 and for audiology by 10% (Bureau of Labor Statistics, U.S. Department of Labor, 2022). These predictions for growth exceed the national averages for other occupations. Society, particularly in North America, has become familiar with the knowledge and care provided by certified and licensed SLPs and audiologists and, in turn, continues to expect expert service from these providers. The recognition and status of speech-language pathology and audiology appear to be moving in the desired direction. The simultaneous desire for autonomy and interprofessional collaboration may seem incongruent. This is not the case. Autonomy in decision making about communication and swallowing disorders and about the training and education needed to serve patients is essential to good care. The SLP or audiologist has the capacity to describe, measure, and prognosticate regarding

the patient’s communication or swallowing disorder. In interprofessional contexts, the SLP or audiologist delivers the information about the patient’s communication and/or swallowing to the larger discussion of the total care, medical condition, follow-up planning, social and emotional status, and desired outcomes. The assumption is that the patient and the system will be best served when all providers bring their distinctive contributions to the discussion in a respectful manner with an open mind. Conversely, it is essential that the SLP or audiologist receive and appreciate the impact of shared information from others involved in the care of the patient and consider the ways in which that information is beneficial in treating the patient’s communication disorder.

Multicultural Issues and Health Disparities SLPs and audiologists are well aware of how diverse their patients are. Educational programs require the development of knowledge and skills around multicultural issues as they affect communication and its disorders. Respect for cultural differences lies at the heart of being engaged with others in the clinical environment. Thus, skilled clinicians need the interpersonal skills to approach each situation with respect and without judgment. Additionally, differences in behavior or language that are representative of a specific culture should not be treated as abnormal or disordered. Clinicians need to learn about and use appropriate tools for assessment and intervention with an understanding of the influence of culture on communication and health practices as a prominent feature of their patient interactions. Chapter 21 in this text discusses the broad range of issues that come into play when we consider culture in clinical practice settings, and clinicians may find this review helpful as they consider their own background and knowledge in this area. One area of concern to those who work in the health care environment is that of disparities in access and quality for certain populations. The CDC has described health disparities as “preventable differences in the burden of disease, injury, violence or opportunities to achieve optimal health that are experienced by socially disadvantaged populations” (CDC, 2020). Populations at documented risk are those defined by race, ethnicity, income, disability, geographic location, or sexual orientation. Disparities are believed to result from poverty, environmental trends, educational inequalities, or inadequate access to health services. While the topic of disparities is a major area of concern in general, especially as the distribution of health care is redefined through health reform in the United States, there are specific concerns related to the practice of speech-language

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pathology or audiology in health settings that should be considered. See Chapter 10 for more information.

Health Literacy Low health literacy, or the ability to find and understand health information and services and make informed decisions about one’s care, affects health outcomes. According to an analysis of the 2003 National Assessment of Adult Literacy, only 12% of American adults had proficient health literacy (Kutner et al., 2006). Fifty-three percent had intermediate health literacy, and 36% — or more than one-third of adults — had basic or below basic health literacy. Given that a patient’s health literacy is likely to interact with their communication disorder or difference, SLPs and audiologists should be particularly concerned about their patients’ ability to understand and comply with instructions (written or spoken) and access the health system for needed services. Every clinician should learn how to respectfully use appropriate levels of communication and utilize feedback to ensure patients and/or caregivers understand necessary instructions. With the use of media and individualized communication content and methods, there is ample opportunity to ensure that this occurs. Also, when the SLP or audiologist suspects that the patient may be having difficulty accessing the broader health system due to communication disability or other language differences, it will be useful to assist the patient to ensure needs are met. More recently, there have been focused efforts to reduce health care system complexities and to provide health professional education aimed at improving health literacy for patients (Nutbeam & Lloyd, 2021). In cases where these efforts fall short, it is likely that many of the tools and approaches used by SLPs and audiologists in their treatment of people with communication disorders would be helpful in addressing low health literacy. Given that so much of health improvement requires compliance with written, oral, and digital information, interprofessional communication and collaboration among the provider, the patient, and the specialist in CSD is imperative to bridging the gap for those with low health literacy. Communication Disorders as Risk Factors for Reduced Health Literacy.  Many people with language or other communication disorders have difficulties with health literacy. Beyond their ability to understand and/or comply with clinical instructions regarding selfcare or prescriptions, patients with communication disorders are at additional risk. Much of the access to the health care system is driven by patients’ perceived health concerns and their ability to ask for assistance. When symptoms are not obvious, or if patients do not have

a reliable caregiver (spokesperson), they may be unable to communicate concerns, particularly patients with aphasia, traumatic brain injury, deafness, or another major communicative difference that limits expression. Clinicians should advocate for the health needs of their patients when significant communication deficits are an issue. Studies are badly needed to document the occurrence of preventable illness and mental health problems, and access to preventive care for those with communication disorders. This is an area where SLPs and audiologists have a significant opportunity to influence primary care for their patients. Establishing reliable, basic communication strategies and tools for communication between patient and provider, preparing patients for visits with their primary care provider or specialty physician, and following up after appointments to ensure patients understand and can comply with directives can add value to the scope of care provided by the clinician specializing in communication disorders.

Dynamic Considerations for Speech-Language Pathologists and Audiologists in Health Care In this last section of the chapter, we consider several changing and developing topics that impact speech-language pathology and audiology in health settings.

Health Reform and Cost Control In 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) with the reported intent of making health care more accessible to everyone and reducing barriers for individuals who were previously ineligible for insurance coverage. In the years following the implementation of the ACA, active political debate has continued regarding further expansion of health coverage. Some political leaders have advocated for reversing or eliminating this law, while others have argued for continued expansion of health benefits for all Americans. Thus, although the ACA is now in its second decade, the health care landscape in the U.S. may continue to evolve, depending on the posture of the government and its associated policies and objectives. Federal and state governments have also worked to expand the primary care workforce by providing loan repayment programs for health care professionals, including SLPs and audiologists. Specifically, the Public Service Loan Forgiveness (PSLF) program provides a portion of student loan debt relief for professionals who work for a period of time in public health and certain other settings (https://studentaid.gov/pslf/), and recent legislative



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efforts have focused on disease prevention, with particular attention to children and to senior citizens on Medicare. Like the ACA, debt relief and related programs that affect health care professionals are subject to change, so SLPs and audiologists who are enrolled or interested in enrolling are advised to stay informed. In summary, clinicians in health care settings face broad challenges in light of the implications of the recent and evolving health reform and cost-containment efforts described above. SLPs and audiologists need to constantly address the issue of treatment efficiency, ensuring that costs are under control without compromising the quality of care and that patients (and referral agencies) are receiving the most value. The long-term and specific implications of health care reform and its effect on service delivery, education, and reimbursement in speechlanguage pathology and audiology remain to be seen.

Trends in Education for Health Settings Preparation of the next generation of practitioners is always on the minds of those who teach and those who employ new graduates. Education, especially higher education, is a dynamic process that has many stakeholders: students, the public, state and federal government, employers and, of course, patients. Entry-level graduate programs in the health professions are commonly heavily regulated by many different agencies. All universities participate in regional accreditation, and each of the health professions is subject to specialized accreditations that specify the content and the expected outcomes for graduates. To address the need for rapid learning and evidence-based care in an interprofessional environment, several new educational approaches are emerging in health professions education. While not typically utilized at this time in most CSD programs, they hold promise for providing interesting and helpful solutions to learning integrated clinical skills. Three of these approaches — dedicated education units, clinical simulation, and standardized patients — can address interdisciplinary educational needs and core content in the discipline, and are described below. Dedicated (Collaborative) Education Units (DEUs). These hospital-based units are designed with two goals in mind: excellent patient care and student-focused education. DEUs developed primarily out of the field of nursing for the purpose of changing the standard approach to nursing education. In this model, faculty members work with staff in the hospital to develop their role as clinical educators. Students are assigned in teams to the unit, in which opportunities for education, discussion,

and reflection are included as part of the core operation of the unit (Moscato et al., 2007). Recently, at least one graduate program, the MGH Institute of Health Professions, implemented an interprofessional DEU model in an acute care setting with representatives from several disciplines, including speech-language pathology, nursing, physical therapy, and occupational therapy (Banister et al., 2020). An important goal of this model is the development of knowledge of and appreciation for the work of each participating discipline in addressing the patient’s health concerns. Thus, speech-language pathology students may learn, in some detail, how nurses and physicians use medication to promote stabilization and recovery, how physical therapists address safety issues related to transfers and patient mobility, and how occupational therapists implement strategies for optimal patient positioning and orientation. As these models expand and become more common, practitioners in health care settings may find themselves called upon to train and educate students from a variety of disciplines. Furthermore, as professionals trained in these models join the workforce, the culture and expectations related to service delivery in health care settings is likely to evolve. Clinical Simulation.  The use of simulation as a tool for building clinical skills and problem-solving abilities is expanding rapidly in clinical education in the health professions. Simulation allows no-risk practice in aspects of care that previously could only be experienced with live patients (Ziv et al., 2003). The literature on use of simulation for learning procedures in surgery, emergency medicine, anesthesia, and other technically demanding areas of medicine is quite extensive. Additional applications of simulation for situations that rely heavily on problem solving, decision making, and communication across disciplines are emerging (DeVita, 2005). These multidisciplinary approaches rely on clinical scenarios to elicit complex problems that require communication among professionals, an application that will likely be developed to include SLPs in rehabilitation or pediatric settings. Simulation has been used successfully in audiology settings to teach technical audiology skills in assessment and in amplification (Zurek & Desloge, 2007). Additionally, a task force of the Council of Academic Programs in Communication Sciences and Disorders (CAPCSD) recently produced a summary of best practices guiding the use of simulation in CSD (Dudding et al., 2019). This area is likely to develop in response to the demand for expanded or alternative clinical practicum experience and the need for exposure to patient populations that are sometimes inaccessible. One area of simulation that has significant promise for the health fields is virtual reality (VR). As the technology for this approach becomes more fluid and

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more “real,” it is likely that virtual speech clinics and virtual patients will be readily accessible. Williams (2006) reported on a prototype project in which a virtual immersion center was developed to provide interactive simulation with students or clients in a CSD program at Case Western Reserve University. In this VR setting, students could interact with patients in a 3D environment and the instructor could control the patients’ responses. This example provides a model for clinical education, though its exact replication may be limited by the need for a full-room environment and considerable technology support. On the other hand, new technological advances and applications for smartphones, tablets, and computers make virtual reality models for simulated clinical experiences, patient/clinician interactions, and interprofessional problem-solving activities a realistic goal for the educational environment. There are several commercially available and university-based virtual platforms designed to enhance clinical education for speech-language pathology and audiology students. While such platforms have been available for a number of years, simulation became even more attractive during the height of the COVID-19 pandemic, when access to certain patient populations and clinical environments was limited. Regardless of the source and design of simulation experiences, they should ideally include a broad range of simulated clinical cases with varying etiologies, severities, and concomitant impairments or comorbidities to afford the learner opportunities to practice a variety of necessary clinical skills, including clinical interviewing, differential diagnosis, treatment planning and implementation, and counseling. Standardized Patients.  Another emerging approach to the development of patient interaction and assessment skills is the use of standardized patients (SPs). These “patients,” portrayed by trained actors, provide a special type of simulation. Their use in medicine and nursing education programs is extensive. Several reports in the literature describe the use of SPs in speech-language pathology. Zraick et al. (2003) report on the use of SPs to teach interpersonal skills to new graduate students in speech-language pathology, and English et al. (2007) describe a similar application to evaluating students’ abilities in counseling the parents of newly identified deaf children. Interestingly, a recent study has demonstrated that actors can be trained to believably portray aphasia and dysarthria (Baylor et al., 2017). Moreover, evidence indicates that speech-language pathology students trained with simulated (i.e., standardized) patients during the middle third of their academic programs demonstrated similar clinical skills competence as those receiving traditional clinical education (Hill et al.,

2021). Thus, the use of SPs in clinical education and training is likely to continue to expand. These three approaches to clinical development — ​ DEUs, clinical simulation, and SPs — will need careful evaluation in the coming years to determine their effectiveness in preparing clinicians to face the real world. However, if it is demonstrated that valuable skills can be acquired efficiently and effectively with generalization to clinical practice, their use will be invaluable as a cost-effective measure for instruction. Additionally, students in early stages of education will be able to benefit from simulated real-world problem solving, integration of clinical and theoretical skills, and risk-free feedback on errors or alternative approaches. While these simulated environments using technology or actors may never fully parallel real-world clinical interactions as an effective teaching modality, they do provide a potential bridging experience that new clinicians or those learning advanced skills will find beneficial.

Entry-Level and Advanced Degrees for Practice An additional concern for the future of the disciplines is the change in requirements for the entry level to practice. Since the mid-1990s, entry requirements for audiology have evolved from a master’s degree to a professional doctoral degree, the Doctor of Audiology (AuD). The profession of audiology is not alone in making these entry-level changes; professional doctorates are well established in physical therapy (Doctor of Physical Therapy, DPT), psychology (Doctor of Psychology, PsyD), and pharmacy (Doctor of Pharmacy, PharmD). In all of the disciplines mentioned, the PhD (rather than the practice degree) remains the entry-level degree for scientific/research work and academics. The field of advanced practice nursing, which includes the nurse practitioner role, has designated the Doctor of Nursing Practice (DNP) as a “practice doctorate” in nursing, and the profession of occupational therapy has identified an advanced model of education that terminates with the Occupational Therapy Doctorate (OTD). Thus, there are two major types of degree levels for practicebased professions. The predominant model, entry-level doctoral education, is required in medicine, dentistry, physical therapy, audiology, and pharmacy. The alternative, professional doctoral education after entry into the field (i.e., after basic licensure and certification requirements are established) is found in nursing and occupational therapy. Some anticipate that in these latter cases, postentry advanced degrees will evolve to entry-level requirements, but this is speculative at this time. In the 1960s, speech-language pathology and audiology were two of the first nonphysician health professions



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to require a master’s degree for entry-level practice and professional certification. Two to three decades ahead of colleagues in other disciplines, CSD has long been a standard bearer for advancing the highest levels of education and practice. Now, with the entry level as a professional practice doctoral degree in audiology, a significant disparity exists between speech-language pathology and audiology, which are part of the same intellectual and disciplinary heritage. There has been considerable discussion over the years regarding the role of professional doctoral education in speech-language pathology, especially in health care settings. In 2003, Lubinski summarized the arguments for and against the professional doctorate — which date back to at least the mid-1980s — and proposed the development of innovative models to support its implementation (Lubinski, 2003). Conversations on this topic continued and, in 2015, ASHA produced Guidelines for the Clinical Doctorate in Speech Language Pathology (ASHA, 2015). This document provides guidance for organization of programs and highlights four domains for advanced study: depth of knowledge and advanced skill development in select areas of practice; critical thinking and problem solving; clinical education, teaching, supervision, and mentorship; and expertise in interpreting and applying clinical research. At the time of this writing, there are eight active postprofessional clinical doctoral degree programs in speech-language pathology (ASHA, n.d.-a): Kean University, Loma Linda University, MGH Institute of Health Professions, Northwestern University, Nova Southeastern University, Rocky Mountain University of Health Professions, University of Kansas, and Valdosta State University. As these and other programs expand and graduate more SLPs with advanced training, practitioners in health care settings may observe or experience changes in expectations or responsibilities assigned to SLPs, as well as the growth of new opportunities for leadership, mentorship, and innovation.

a growing area of interest in the field for some time. Recent studies in the U.S. and abroad have investigated the use and effectiveness of telehealth by audiologists and SLPs (Eikelboom & Swanepoel, 2016; Molini-Avejonas et al., 2015; Speyer et al., 2018) and demonstrated its application for management of such conditions as Parkinson’s disease (Stegemöller et al., 2020), head and neck cancer (Collins et al., 2017), dysphagia (Morrell et al., 2017), aphasia (Choi et al., 2016; Pitt et al., 2019), and hearing loss (Hatton et al., 2019). The advantages of telehealth were undoubtedly best demonstrated by its rapid adoption and widespread use during the recent COVID-19 pandemic. Telehealth technology allowed primary care and specialty service providers to treat and manage patients while limiting the exposure and direct contact that come with traditional face-to-face care. During the first 7 months of the pandemic, the rates of practitioners in health care settings who routinely provided telehealth services increased from 3% to 19% for audiologists and 2.5% to 32% for SLPs (ASHA, 2020). It is probable that those rates continued to grow over the course of the pandemic and, though telehealth use may fluctuate in accordance with COVID-19 case rates, it will likely remain an important tool for clinicians working in health care. In 2022, for example, more than one-quarter of all speech-language pathology encounters and more than 10% of all audiology encounters across the Veterans Health Administration were conducted virtually, demonstrating the maintenance of this service delivery modality following the resolution of the initial pandemic restrictions (Veterans Health Administration, 2022a). Furthermore, as technology advances and becomes more accessible and new research confirms the efficacy of telepractice for a broader array of communication disorders, the demand for clinicians who are tech savvy and experienced in telehealth practice can be expected to grow. Longer-term research evaluating the costs and benefits to patients and payers will likely also contribute to the adoption of telehealth in health care and other settings.

Telehealth Telehealth is the use of a variety of telecommunication technologies such as telephones, smartphones, and web-based video platforms to deliver care and health education. Some health care providers have employed telehealth for years. Using platforms originally designed for social and business interactions or those developed specifically for health care, providers can offer a range of services to patients who live in remote locations, have limitations associated with physical mobility or transportation, or face other obstacles. The use of telehealth for the provision of speechlanguage pathology and audiologic services has been

Summary This chapter addresses practice issues related to speechlanguage pathology and audiology in health settings. First, distinctive characteristics of the various health settings across the continuum of care were reviewed. Next, the critical issues of compliance, documentation, patient safety, and development of clinical skills were discussed as core to the role of the practicing clinician. Finally, exploration of several emerging topics, including health reform, evolving professional entry models, and telehealth technologies, were also considered.

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The health care continuum offers a vibrant and dynamic professional setting for the skilled SLP or audiologist. The demand for individuals to join this practice setting with a commitment to excellent patient care and innovation is evident. Advances in technology and practice offer solutions to current disparities in access and quality and address the ever-present need for cost containment.

References Alpert, J. (2016). The electronic medical record in 2016: Advantages and disadvantages. Digital Medicine, 2(2), 48. https://doi.org/10.4103/22268561.189504 American Speech-Language-Hearing Association. (n.d.-a). ASHA EdFind. https://find.asha.org/ed/ American Speech-Language-Hearing Association. (n.d.-b). Documentation in health care. https:// www.asha.org/Practice-Portal/Professional-Issues/ Documentation-in-Health-Care/ American Speech-Language-Hearing Association. (n.d.-c). Getting started in home health. https:// www.asha.org/slp/healthcare/start_home/ American Speech-Language-Hearing Association. (n.d.-d). Practice management for audiologists and speech-language pathologists. https://www.asha.org/ practice/ American Speech-Language Hearing Association. (n.d.-e). Joint Commission resources for SLPs. https:// www.asha.org/slp/healthcare/jointcommission​ resources American Speech-Language-Hearing Association. (1985). Clinical supervision in speech-language pathology and audiology. https://www.asha.org/ policy/tr2008-00296/ American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speechlanguage pathologists providing services to infants and families in the NICU environment. https://www​ .asha.org/policy/ks2004-00080/ American Speech-Language-Hearing Association. (2006). Roles, knowledge, and skills: Audiologists providing clinical services to infants and young children birth to 5 years of age. https://www.asha​ .org/policy/ks2006-00259/ American Speech-Language-Hearing Association. (2008). Knowledge and skills needed by speech-

language pathologists providing clinical supervision. https://www.asha.org/policy/ks2008-00294/ American Speech-Language-Hearing Association. (2015). Guidelines for the clinical doctorate in speechlanguage pathology. https://www.asha.org/policy/ gl2015-00341/ American Speech-Language-Hearing Association. (2019a). National outcomes measurement system: Adults in healthcare-acute hospital national data report 2019. https://www.asha.org/siteassets/ uploadedfiles/ASHA/NOMS/Adult-NOMS-AcuteHospital-Data-Report.pdf American Speech-Language-Hearing Association. (2019b). National outcomes measurement system: Adults in healthcare-inpatient rehab national data report 2019. https://www.asha.org/siteassets/ uploadedfiles/asha/noms/adult-noms-inpatient-​ data-report.pdf American Speech-Language-Hearing Association. (2019c). National outcomes measurement system: Adults in healthcare-outpatient national data report 2019. https://www.asha.org/siteassets/uploaded​ files/asha/noms/adult-noms-outpatient-data-report​ .pdf American Speech-Language-Hearing Association. (2019d). National outcomes measurement system: Adults in healthcare-skilled nursing facility national data report 2019. https://www.asha.org/siteassets/ uploadedfiles/ASHA/NOMS/Adult-NOMSSkilled-Nursing-Facility-Data-Report.pdf American Speech-Language-Hearing Association. (2020). ASHA COVID-19 survey results — October 2020. http://www.asha.org/research/memberdata/ covid-19-tracker-survey/ American Speech-Language-Hearing Association. (2022a). 2021 member and affiliate profile. http:// www.asha.org American Speech-Language-Hearing Association. (2022b). ASHA’s national outcomes measurement system (NOMS) clinician user guide: SLP healthcare. https://www.asha.org/siteassets/uploadedfiles/ ASHA/NOMS/NOMS-SLP-Clinician-User-Guide​ .pdf Anderson, J. L. (1988). The supervisory process in speech-language pathology and audiology. CollegeHill Press. Ballard, S. L., & Dymond, S. K. (2018). Inclusive education for secondary age students with severe disabilities and complex health care needs.



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Intellectual and Developmental Disabilities, 56(6), 427–441. Banister, G., Portney, L. G., Vega-Barachowitz, C., Jampel, A., Schnider, M. E., Inzana, R., . . . Knab, M. (2020). The interprofessional dedicated education unit: Design, implementation and evaluation of an innovative model for fostering interprofessional collaborative practice. Journal of Interprofessional Education & Practice, 19, 100308. https://doi.org/10.1016/j.xjep.2019.100308 Baylor, C., Burns, M. I., Struijk, J., Herron, L., Mach, H., & Yorkston, K. (2017). Assessing the believability of standardized patients trained to portray communication disorders. American Journal of Speech-Language Pathology, 26(3), 791–805. https://doi.org/10.1044/2017_AJSLP-16-0068 Baylor, C., Yorkston, K., Eadie, T., Kim, J., Chung, H., & Amtmann, D. (2013). The communicative participation item bank (CPIB): Item bank calibration and development of a disorder-generic short form. Journal of Speech, Language, and Hearing Research: JSLHR, 56(4), 1190–1208. https://doi​ .org/10.1044/1092-4388(2012/12-0140) Bureau of Labor Statistics, U.S. Department of Labor. (2022). Occupational outlook handbook. https:// www.bls.gov/ooh/healthcare/ Centers for Disease Control and Prevention. (2020). Health disparities. https://www.cdc.gov/ healthyyouth/disparities/ Chahda, L., Mathisen, B. A., & Carey, L. B. (2017). The role of speech-language pathologists in adult palliative care. International Journal of SpeechLanguage Pathology, 19(1), 58–68. https://doi.org/​ 10.1080/17549507.2016.1241301 Chen, A. Y., Frankowski, R., Bishop-Leone, J., Hebert, T., Leyk, S., Lewin, J., & Goepfert, H. (2001). The development and validation of a dysphagia-specific quality-of-life questionnaire for patients with head and neck cancer: The M. D. Anderson dysphagia inventory. Archives of Otolaryngology–Head & Neck Surgery, 127(7), 870–876. Choi, Y.-H., Park, H. K., & Paik, N.-J. (2016). A telerehabilitation approach for chronic aphasia following stroke. Telemedicine and E-Health, 22(5), 434–440. https://doi.org/10.1089/tmj.2015.0138 Cohen, M. L., & Hula, W. D. (2020). Patientreported outcomes and evidence-based practice in speech-language pathology. American Journal of Speech-Language Pathology, 29(1), 357–370. https://doi.org/10.1044/2019_AJSLP-19-00076

Collins, A., Burns, C. L., Ward, E. C., Comans, T., Blake, C., Kenny, L., . . . Best, D. (2017). Homebased telehealth service for swallowing and nutrition management following head and neck cancer treatment. Journal of Telemedicine and Telecare, 23(10), 866–872. https://doi.org/10.1177/135763​ 3X17733020 Conley, J., Jordan, M., & Ghali, W. A. (2009). Audit of the consultation process on general internal medicine services. Quality and Safety in Health Care, 18(1), 59–62. https://doi.org/10.1136/qshc​ .2007.025486 Davis, R. E., Jacklin, R., Sevdalis, N., & Vincent, C. A. (2007). Patient involvement in patient safety: What factors influence patient participation and engagement? Health Expectations, 10(3), 259–267. https://doi.org/10.1111/j.1369-7625.2007.00450.x DeVita, M. A. (2005). Improving medical emergency team (MET) performance using a novel curriculum and a computerized human patient simulator. Quality and Safety in Health Care, 14(5), 326–331. https://doi.org/10.1136/qshc.2004.011148 Doyle, P. J., McNeil, M. R., Mikolic, J. M., Prieto, L., Hula, W. D., Lustig, A. P., . . . Elman, R. J. (2004). The Burden of Stroke Scale (BOSS) provides valid and reliable score estimates of functioning and well-being in stroke survivors with and without communication disorders. Journal of Clinical Epidemiology, 57(10), 997–1007. https://doi.org/​ 10.1016/j.jclinepi.2003.11.016 Dudding, C. C., Brown, D. K., Estis, J. M., Szymanski, C., & Zraick, R. (2019). Best practices in healthcare simulations: Communication sciences and disorders. Council of Academic Programs in Communication Sciences and Disorders. Eadie, T. L., Yorkston, K. M., Klasner, E. R., Dudgeon, B. J., Deitz, J. C., Baylor, C. R., . . . Amtmann, D. (2006). Measuring communicative participation: A review of self-report instruments in speech-language pathology. American Journal of Speech-Language Pathology, 15(4), 307–320. https://doi.org/10.1044/1058-0360(2006/030) Eikelboom, R. H., & Swanepoel, D. W. (2016). International survey of audiologists’ attitudes toward telehealth. American Journal of Audiology, 25(3S), 295–298. https://doi.org/10.1044/2016_ AJA-16-0004 English, K., Naeve-Velguth, S., Rall, E., UyeharaIsono, J., & Pittman, A. (2007). Development of an instrument to evaluate audiologic counseling

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skills. Journal of the American Academy of Audiology, 18(08), 675–687. https://doi.org/10.3766/jaaa​ .18.8.5 Hatton, J. L., Rowlandson, J., Beers, A., & Small, S. (2019). Telehealth-enabled auditory brainstem response testing for infants living in rural communities: The British Columbia Early Hearing Program experience. International Journal of Audiology, 58(7), 381–392. https://doi.org/10.10​ 80/14992027.2019.1584681 Hemsley, B., Georgiou, A., Hill, S., Rollo, M., Steel, J., & Balandin, S. (2016). An integrative review of patient safety in studies on the care and safety of patients with communication disabilities in hospital. Patient Education and Counseling, 99(4), 501–511. https://doi.org/10.1016/j.pec.2015.10.022 Henry, J., Pylypchuk, Y., Searcy, T., & Patel, V. (2016). Adoption of electronic health record systems among U.S. non-federal acute care hospitals: 2008–2015 (No. 35; ONC Data Brief ). Office of the National Coordinator for Health Information Technology. Hill, A. E., Ward, E., Heard, R., McAllister, S., McCabe, P., Penman, A., . . . Walters, J. (2021). Simulation can replace part of speech-language pathology placement time: A randomised controlled trial. International Journal of SpeechLanguage Pathology, 23(1), 92–102. https://doi.org/ 10.1080/17549507.2020.1722238 Hula, W. D., Doyle, P. J., Stone, C. A., Austermann Hula, S. N., Kellough, S., Wambaugh, J. L., . . . St. Jacque, A. (2015). The Aphasia Communication Outcome Measure (ACOM): Dimensionality, item bank calibration, and initial validation. Journal of Speech, Language, and Hearing Research, 58(3), 906–919. https://doi.org/10.1044/2015_JSLHRL-14-0235

Keith, R. A., Granger, C. V., Hamilton, B. B., & Sherwin, F. S. (1987). The functional independence measure: A new tool for rehabilitation. Advances in Clinical Rehabilitation, 1, 6–18. Kummer, A., Johnson, P., & Zeit, K. (2007). Clinical documentation in medical speech-language pathology. In A. F. Johnson & B. H. Jacobson (Eds.), Medical speech-language pathology: A practitioner’s guide (2nd ed.). Thieme. Kutner, M., Greenberg, E., Jin, Y., & Paulsen, C. (2006). The health literacy of America’s adults: Results from the 2003 National Assessment of Adult Literacy. National Center for Education Statistics. Lefton-Greif, M. A., & Arvedson, J. C. (2008). Schoolchildren with dysphagia associated with medically complex conditions. Language, Speech, and Hearing Services in Schools, 39(2), 237–248. https://doi.org/10.1044/0161-1461(2008/023) Lomas, J., Pickard, L., Bester, S., Elbard, H., Finlayson, A., & Zoghaib, C. (1989). The Communicative Effectiveness Index: Development and psychometric evaluation of a functional communication measure for adult aphasia. Journal of Speech and Hearing Disorders, 54(1), 113–124. https://doi.org/​ 10.1044/jshd.5401.113 Lubinski, R. (2003). Revisiting the professional doctorate in medical speech-language pathology. Journal of Medical Speech-Language Pathology, 11(4), lix–lxiii. Gale Academic OneFile. McCrea, E. S., & Brasseur, J. A. (2003). The supervisory process in speech-language pathology and audiology. Allyn & Bacon.

Interprofessional Education Collaborative. (2016). Core competencies for interprofessional collaborative practice: 2016 update. https://ipec.memberclicks​ .net/assets/2016-Update.pd

McHorney, C. A., Bricker, D. E., Kramer, A. E., Rosenbek, J. C., Robbins, J., Chignell, K. A., . . . Clarke, C. (2000). The SWAL-QOL outcomes tool for oropharyngeal dysphagia in adults: I. Conceptual foundation and item development. Dysphagia, 15(3), 115–121. https://doi.org/10.1007/s004​ 550010012

Jacobson, B. H., Johnson, A., Grywalski, C., Silbergleit, A., Jacobson, G., Benninger, M. S., & Newman, C. W. (1997). The Voice Handicap Index (VHI): Development and validation. American Journal of Speech-Language Pathology, 6(3), 66–70. https://doi.org/10.1044/1058-0360.0603.66

Molini-Avejonas, D. R., Rondon-Melo, S., de La Higuera Amato, C. A., & Samelli, A. G. (2015). A systematic review of the use of telehealth in speech, language and hearing sciences. Journal of Telemedicine and Telecare, 21(7), 367–376. https:// doi.org/10.1177/1357633X15583215

Johnson, A. F., & Jacobson, B. H. (2016). Medical speech-language pathology: A practitioner’s guide (3rd ed.). Thieme.

Morrell, K., Hyers, M., Stuchiner, T., Lucas, L., Schwartz, K., Mako, J., . . . Yanase, L. (2017). Telehealth stroke dysphagia evaluation is safe



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and effective. Cerebrovascular Diseases, 44(3–4), 225–231. https://doi.org/10.1159/000478107 Moscato, S. R., Miller, J., Logsdon, K., Weinberg, S., & Chorpenning, L. (2007). Dedicated education unit: An innovative clinical partner education model. Nursing Outlook, 55(1), 31–37. https://doi​ .org/10.1016/j.outlook.2006.11.001 National Hospice and Palliative Care Organization. (2020). 2020 edition: Hospice facts and figures. www.nhpco.org/factsfigures Newman, C. W., Weinstein, B. E., Jacobson, G. P., & Hug, G. A. (1990). The Hearing Handicap Inventory for adults: Psychometric adequacy and audiometric correlates. Ear and Hearing, 11(6), 430–433. https://doi.org/10.1097/00003446199012000-00004 Nutbeam, D., & Lloyd, J. E. (2021). Understanding and responding to health literacy as a social determinant of health. Annual Review of Public Health, 42(1), 159–173. https://doi.org/10.1146/ annurev-publhealth-090419-102529 Paul, D. R., Frattali, C. M., Holland, A. L., Thompson, C. K., Caperton, C. J., & Slater, S. C. (2004). Quality of communication life scale. American Speech-Language-Hearing Association. Pitt, R., Theodoros, D., Hill, A. J., & Russell, T. (2019). The development and feasibility of an online aphasia group intervention and networking program — TeleGAIN. International Journal of Speech-Language Pathology, 21(1), 23–36. https:// doi.org/10.1080/17549507.2017.1369567 Pollens, R. (2004). Role of the speech-language pathologist in palliative hospice care. Journal of Palliative Medicine, 7(5), 694–702. https://doi​ .org/10.1089/jpm.2004.7.694 Pollens, R. (2020). Facilitating client ability to communicate in palliative end-of-life care: Impact of speech-language pathologists. Topics in Language Disorders, 40(3), 264–277. https://doi​ .org/10.1097/TLD.0000000000000220 Pollens, R. D. (2012). Integrating speech-language pathology services in palliative end-of-life care. Topics in Language Disorders, 32(2), 137–148. https://doi.org/10.1097/TLD.0b013e3182543533 Schillinger, D. (2020). The intersections between social determinants of health, health literacy, and health disparities. Studies in Health Technology and Informatics, 269, 22–41. https://doi.org/10.3233/ SHTI200020

Shaw, G. (2015). Dying to be heard: Hearing health­care at the end of life. The Hearing Journal, 68(1), 18. https://doi.org/10.1097/01.HJ.0000459739​ .71381.16 Simmons-Mackie, N., Kagan, A., Victor, J. C., Carling-Rowland, A., Mok, A., Hoch, J. S., . . . Streiner, D. L. (2014). The assessment for living with aphasia: Reliability and construct validity. International Journal of Speech-Language Pathology, 16(1), 82–94. https://doi.org/10.3109/17549507​ .2013.831484 Speyer, R., Denman, D., Wilkes-Gillan, S., Chen, Y., Bogaardt, H., Kim, J., . . . Cordier, R. (2018). Effects of telehealth by allied health professionals and nurses in rural and remote areas: A systematic review and meta-analysis. Journal of Rehabilitation Medicine, 50(3), 225–235. https://doi.org/10.23​ 40/16501977-2297 Stegemöller, E. L., Diaz, K., Craig, J., & Brown, D. (2020). The feasibility of group therapeutic singing telehealth for persons with Parkinson’s disease in rural Iowa. Telemedicine and E-Health, 26(1), 64–68. https://doi.org/10.1089/tmj.2018.0315 U.S. Department of Veterans Affairs. (2021). VA research on hearing loss. Office of Research & Development. https://www.research.va.gov/topics/ hearing.cfm U.S. Department of Veterans Affairs. (2023). Veterans health administration. https://www.va.gov/health/ Vescovich, M. (2015). 3 questions that could change how you provide end-of-life care: How can we best support those with advanced illness? Ask yourself these questions to grow your treatment skills. The ASHA Leader, 20(7), 38–39. https://doi​ .org/10.1044/leader.OTP.20072015.38 Veterans Health Administration. (2022a). Data on telehealth use by VHA audiology and speechlanguage pathology providers in 2022 [Unpublished raw data]. Veterans Health Administration. (2022b). Most common speech-language pathology services in 2022 [Unpublished raw data]. Veterans Health Administration. (2023). Data on most common diagnoses among patients receiving speechlanguage pathology services [Unpublished raw data]. Weed, L. L. (1971). Medical records, medical education and patient care: The problem oriented record as a basic tool. Press of Case Western Reserve University.

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Weinstein, B. E. (2015). Palliative care: Defining the role of the audiologist. The Hearing Journal, 68(1), 23. https://doi.org/10.1097/01.HJ.0000459740​ .48510.d0 Williams, S. L. (2006). The virtual immersion center for simulation research: Interactive simulation technology for communication disorders. Presence2006, Proceedings of the 9th Annual International Workshop on Presence (9th ed.) Cleveland, Ohio: Humanity and Social Science, 124–127. Woods, M. S. (2006). The DUN factor: How communication complicates the patient safety movement. Patient Safety & Quality Healthcare E-Newsletter. https://www.psqh.com/mayjun06/dun.html World Health Organization (WHO). (2001). International classification of functioning, disability and health (ICF).

World Health Organization (WHO). (2017). Patient safety: Making health care safer. https://apps.who.int/​ iris/handle/10665/255507 Ziv, A., Wolpe, P. R., Small, S. D., & Glick, S. (2003). Simulation-based medical education: An ethical imperative. Academic Medicine, 78(8), 783–788. Zraick, R. I., Allen, R. M., & Johnson, S. B. (2003). The use of standardized patients to teach and test interpersonal and communication skills with students in speech-language pathology. Advances in Health Sciences Education, 8(3), 237–248. https:// doi.org/10.1023/A:1026015430376 Zurek, P. M., & Desloge, J. G. (2007). Hearing loss and prosthesis simulation in audiology. The Hearing Journal, 60(7), 32–33. https://doi.org/10.1097/01​ .HJ.0000281789.77088.b6

12 Knowledge and Skills for Providing Evidence-Based Services in School-Based Settings Sandra Laing Gillam

Introduction I would like to begin this chapter by telling you a story about my personal journey into the world of speech-language pathology. I began as a student at Auburn University in Auburn, Alabama, with no idea what career I wanted to pursue. During my undergraduate academic program, I was given the opportunity to participate in a full-time internship in a school district in Dothan, Alabama, for an entire semester under the direction of a wonderful speech-language pathologist (SLP), Donna Sue Arieux. Her energy and mentorship fueled my excitement to pursue a graduate degree in speech-language pathology so I could learn more about how to improve the lives of individuals with communication disorders. I also had the opportunity during graduate school to complete my medical internship at the Veterans Administration Hospital in Tuskegee, Alabama, as a trainee for an entire year. Upon graduation, I worked full-time in a school-system in Phenix City, Alabama, and part-time in skilled nursing facilities, home health, rehabilitation centers, hospitals, and private practice. I loved all these work settings, but I quickly learned that my passion was working in the schools. The opportunities for interprofessional practice, collaboration, and engagement with other professionals in all the schools I have worked in over the course of my career have been amazing. Even with mountains of paperwork, high caseloads, and the difficulties inherent in scheduling services around plays, assemblies, recess, and other activities students are forever engaged in, it was one of the most rewarding experiences of my life. The lives of the students I worked with have been shaped in part by my presence and that is something that brings me joy every day. There are always going to be challenges that SLPs and audiologists face regardless of what their work setting is, but there is something about walking through the school hallway each day that makes it a beautiful place to work. There are sounds of excitement, laughter, singing, and the chatter that is associated with making new friends or discussing an interesting new topic. I remember being able to feel the joy students experienced when they learned new things. The schools present unique challenges for all who work there, but they also offer profound opportunities for SLPs and audiologists to contribute to the lives of students who are our future. 237



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SLPs are uniquely trained to provide services to optimize an individual’s ability to communicate and swallow. SLPs engage in preservice education in fluency, speech production, language, cognition, voice, resonance, and feeding and swallowing, although the breadth of professional services is an evolving entity. The services provided by SLPs should be evidence based, which means that the procedures and techniques used are supported by external research (when possible) and clinical expertise and align with parent and student preferences (Gillam & Gillam, 2006). Because the professional roles and responsibilities of qualified SLPs may address several areas of clinical service delivery, the American Speech-LanguageHearing Association (ASHA), the primary professional organization for SLPs and audiologists, drafted a Code of Ethics that makes it clear that professionals should practice only in areas in which they are competent to provide safe and effective services. This determination is based on preservice education and training, continuing education engagement, and practical experience with individuals with communication and swallowing difficulties (ASHA, 2023a). ASHA also requires SLPs to hold the Certificate of Clinical Competence in SpeechLanguage Pathology (CCC-SLP) and to maintain that certification throughout their professional careers. The association currently represents 223,456 members and affiliates including audiologists; SLPs; speech, language, and hearing scientists; audiology and speech-language pathology support personnel; and students who are members of the National Student Speech Language Hearing Association (NSSLHA; ASHA, 2022a). SLPs make up a large percentage of ASHA’s membership (193,799 members) with 50.9% of the total membership (212,534) reporting schools as their primary work setting (ASHA, 2022b). As part of their professional responsibilities, SLPs are expected to engage in advocacy, outreach, supervision, education, research, and administration and leadership activities related to the services they provide (ASHA, 2016). It is important to note that the scope of practice does not change according to where an SLP chooses to practice. Rather, additional knowledge and skills are required in educational settings that may not be as relevant in other settings (e.g., medical, private practice). Audiological services play a crucial role in supporting students identified for special education and those in regular education. There are 13,910 audiologists who are members of ASHA currently, and about 8% of them work in our nation’s schools (ASHA, 2022a). The scope of practice of an audiologist does not change as a result of the setting they work in; however, their activities do have to be logically tied to the provision of services that assist students in meeting educational goals and objectives. Accordingly, audiological services may include the

identification and evaluation of children with hearing loss; determination of the range, nature, and degree of hearing loss (HL) and its impact on learning; the provision of habilitation activities (e.g., language habilitation, auditory training, speech reading); counseling and guidance for students and their families; and activities related to amplification (e.g., selecting and fitting of hearing aids, need for classroom amplification). ASHA and the Educational Audiology Association provide excellent guidance for the role of audiologists in schools (ASHA, 2002). In 2022, audiologists reported spending about 10 hours per week on diagnostic evaluations, 8 hours a week in technological support related to hearing loss (e.g., hearing aids, cochlear implants), and 6 hours weekly in direct intervention in their school-based settings (ASHA, 2022c). The focus of this chapter is on specific knowledge and skills related to the provision of speech-language pathology and audiological services in school-based settings. The first section of this chapter summarizes basic information about the population of students who attend school in the U.S. that SLPs and audiologists may have the opportunity to work with. The next sections outline federal legislation and landmark cases that influence how special education services are provided and to whom, as well as the basic steps involved in the special education process. This is followed by a brief summary of Medicaid as it relates to reimbursement for schoolbased services. Roles and responsibilities specific to school-based SLPs and audiologists (when applicable) are addressed by discussing how goals and objectives must be written to support the attainment of the academic standards students need to be college and/or career ready upon graduation. Service delivery options are slightly different in school settings than in other work environments, and these are described next. In this section, the use of speech-language pathology assistants (SLPAs) and audiology assistants (C-AA) is covered as it relates to the extension of services that may be offered by SLPs and audiologists in schools. The last part of this chapter provides examples of activities related to advocacy, outreach, supervision, education, research, and administration and leadership that SLPs and audiologists may engage in that are distinct to educational settings.

Population in U.S. Schools The number of students enrolled in public schools (prekindergarten through 12th grade) in fall 2021 was 49.5 million (National Center for Education Statistics, 2022a). Demographically, the largest majority of students was described as White (22.4 million), followed



CHAPTER 12   Knowledge and Skills for Providing Evidence-Based Services in School-Based Settings

by Hispanic (14 million), Black (7.5 million), Asian (2.7 million), two or more races (2.3 million), American Indian/Alaska Native (.5 million), or Pacific Islander (.2 million; National Center for Education Statistics, 2022b). Between 2009 and 2021, 15% of students enrolled in schools received special education services (National Center for Education Statistics, 2022c). These statistics are compelling when you consider that overall enrollment during fall of 2020 was 3% lower than in fall of 2019 as a result of the COVID-19 pandemic. Enrollment increased again in 2021, reestablishing an increasing trend for the number of students requiring special education services. The largest percentage of students (33%) who received special education services during 2020–2021 qualified under the category of specific learning disabilities, which is a disorder that manifests in difficulties understanding and/or using spoken or written language. Students with specific learning disabilities may present with difficulties in listening, thinking, speaking, reading, writing, spelling, or mathematical calculation and/or solving mathematical word problems. The next largest population of students who received special education services demonstrated speech or language impairments (19%). Students with speech or language impairments demonstrate difficulties in language form (phonology, syntax, morphology), content (semantics), and/or use (pragmatics including narrative language). Students enrolled in special education services due to other health impairments (e.g., tuberculosis, rheumatic fever, asthma) constituted 15% of the population, with students with autism spectrum disorder (ASD), developmental delays, intellectual disabilities, and emotional disturbances accounting for another 15%. Finally, about 2% of students received special education services who demonstrated multiple disabilities (e.g., hearing impairments, orthopedic impairments, visual impairments, traumatic brain injury, deaf-blindness). It is important to note that even though students with speech or language impairments were reported to constitute 19% of students receiving special education services, all the other categories may also be associated with co-occurring speech, language, hearing, or other communication or swallowing impairments. When primary and secondary disabilities are considered (e.g., a child with an intellectual disability and a speech and/ or language disorder), children with speech or language services make up the largest subgroup of individuals who receive special education and related services in the U.S. schools (Hall-Mills, 2019). Therefore, the SLP and the audiologist play a very large role in the provision of services to students in school-based settings. According to a nationwide school survey conducted by ASHA (2018a), the median caseload, or number of students that an SLP may serve during an average school

year, was 48, although this number varies significantly from one region of the country to the other. Approximately 90% of the SLPs who responded reported they provided services to students with language disorders, speech sound disorders, and ASD in sessions amounting to about 1 hour per week, per student. SLPs and audiologists may also play a role in the delivery of culturally and linguistically appropriate services to students whose primary language is not English. According to recent statistics, there are approximately 5 million English-language learners in public schools today, the majority of whom speak Spanish as their primary language (National Center for Education Statistics, 2022d). A bilingual SLP or audiologist who is fluent in the student’s native language is the most appropriate resource for assessment and treatment of Englishlanguage learners with speech-language and hearing disorders; however, the majority of SLPs and audiologists in the U.S. are not bilingual. If an interpreter is needed, the public school division policy or procedure should be followed to ensure a qualified and competent interpreter is used. The SLP or audiologist must then ensure the interpreter is properly trained to assist in the assessment and treatment of the student. For example, during an assessment, the interpreter must translate exactly what is said by the examiner without using nonverbal cues or rewording the phrasing so standardization guidelines are met. The SLP may work closely with teachers specialized in teaching students whose primary language is not English to support students in becoming proficient in English while addressing accompanying speech and/or language. To the extent possible, speech and language intervention sessions should begin in the student’s native language and move toward the language of educational significance, typically English. Educational performance for the purposes of gauging annual yearly progress (AYP) is assessed in English according to the No Child Left Behind legislation (2001). Accordingly, after a 2-year period during which students are not required to participate in testing, they are expected to have mastered the same academic skills as their monolingual Englishspeaking peers.

Federal Legislation, Landmark Court Cases, and the Provision of Special Education Services in Schools School-based SLPs and audiologists are expected to know and to follow the laws and regulations that govern how and to whom special education services are provided in their educational work settings. The Individuals

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With Disabilities Education Improvement Act (IDEIA, 2004; Table 12–1). IDEIA specifies that children with disabilities have a right to a free and appropriate public education (FAPE) provided in the least restrictive environment (LRE). FAPE requires a school to provide special education designed to meet a student’s unique needs at no charge. FAPE does not require a school to provide the best services possible; rather services must be reasonably calculated to ensure the student makes progress toward their academic goals. The most recent landmark case to reference this rule is Endrew v. Douglas County

School District (2017; Table 12–2, Landmark Cases in Special Education). LRE refers to the concept that students must be educated with their nondisabled peers when it is in the best interest of the student in need of specialized instruction. This often means that students receive specialized support and related services to help them achieve their educational goals. Related services may include occupational therapy to assist students with limited fine motor skills, physical therapy to improve mobility and coordination, psychological services to support students with emo-

Table 12–1.  Federal Legislation: Individuals With Disabilities Act (IDEA) Legislation

Major Highlights

Elementary & Secondary Education Act (1965)

Free and reduced lunch provisions

Initiatives to help low-income families

Additional teachers for low-income schools

Vocational Rehabilitation Act & Section 504 (1973)

Prohibits discrimination against students with disabilities from agencies who receive federal funding

Provides definition for the term appropriate education

Accommodations act

Education for All Handicapped Children Act (1975) PL 94-142

Defines least restrictive environment (LRE)

Individualized education programs

Free and Appropriate Public Education for Students With Disabilities (FAPE)

Education of Handicapped Act Amendments (1986)

FAPE extended to (ages 3–5)

Early intervention programs for B-2

Defines “handicapped infants and toddlers” and early intervention

Americans with Disabilities Act (IDEA; 1990)

Addresses discrimination in the workplace

Equal opportunity to employment, accommodations, services

Special education services required

Individuals with Disabilities Education Act (IDEA; 1990)

Transition from school to workforce

Bilingual education

Due process, confidentiality

Individuals With Disabilities Education Act (IDEA; 1997)

Mediation

IEP team members

State testing, behavior management

No Child Left Behind Act (2001)

Early-intervention reading programs

School choice

Highly qualified teachers, school accountability

IDEA Improvement Act (2004)

Higher standards

Increased funding

Response to intervention

Every Student Succeeds Act (ESSA; 2015)

Standardized testing regulations

Alternative assessments

Bullying prevention



CHAPTER 12   Knowledge and Skills for Providing Evidence-Based Services in School-Based Settings

Table 12–2.  Landmark Cases in Special Education Case

Finding

Impact on Students

PARC v. Pennsylvania (1971)

States may not deny individuals with intellectual deficits FAPE

All students including those with intellectual deficits must be given the same opportunities to succeed in school in preparation for living independently to the extent possible after graduation

Mills v. B.O.E. (Board of Education; 1972)

Schools must provide supplemental services for children to attend school at no cost to the family

Some students require additional supports to make educational progress that others do not. These must be identified by the education team and provided.

Hudson v. Rowley (1982)

Schools must provide sufficient but not the best possible education under FAPE

School was asked to provide the student with an interpreter although she was performing well in school without one; raised the bar for schools

Honig v. Doe (1988)

Schools may not expel students for behavior related to disability

We must work together in teams to ensure students can succeed in spite of their disability

Endrew v. Douglas County School District (2017)

An IEP is adequate as long as it is calculated to confer an educational benefit that is more than de minimis (some progress)

Supreme court ruled the program must be appropriately ambitious and challenging. Raises the bar for school districts to meet for their students. School districts must work more closely with parents to plan education for students.

tional and behavioral needs, and speech and language therapy to improve communication abilities in support of academic performance. For many students the LRE is not the general education classroom, but rather a resource room or a special education classroom. The decision of where and with what support a student receives their education is made by a team of professionals, which often includes an SLP and, by law, must also include the student’s caregiver. IDEA requires schools to create formal educational plans called Individualized Education Programs (IEPs). The IEP is a legal document that must include the child’s present level of performance, a statement of services, and specific and measurable long- and short-term goals. The SLP is an integral part of the IEP development team and will consult with other school personnel to develop and implement goals and objectives to ensure the student has a better chance of meeting the demands of the curriculum and to communicate effectively in the classroom. Dates for the initiation and duration of services must be

stated on the IEP as well as any accommodations and modifications that students need to be successful. The SLP is responsible for identifying accommodations and modifications related to a student’s communication disorder and conveying that information to the IEP team. Accommodations may include changes in the way information is presented to students. For example, rather than reading text, students may be allowed to listen to audio recordings or have materials read aloud. If a student has a language disorder, they may profit from a visual outline or word web rather than a list of written instructions, in which case the SLP would make that recommendation. Response accommodations may be made that alter the way students complete their assignments or take tests. To illustrate rather than write answers, a student may dictate their answers to a scribe, record them on a digital recorder, or use automatic speech-to-text recognition to document their answers. Setting accommodations may include recommendations for students to take tests in a different setting than

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the general education classroom such as a quiet room with fewer distractions, or to sit closer to the teacher so they may have better access to acoustic and visual feedback. Other accommodations may include changes in timing (e.g., extra time to take tests), scheduling (e.g., breaking tasks into manageable, smaller assignments to be completed over time), and organizational skills (e.g., using an alarm or planner for time management, a highlighter to mark text, or instruction in study skills). Students with language impairments often have difficulty with attention, working memory, and organizational skills that require response modifications. The SLP would determine this. Modifications may include a change in content or learning outcomes defined for a student, although the ultimate outcome must be the same as their nondisabled peers. Assignment modifications may include having students complete alternate projects or assignments better aligned with their interests, or different homework problems or test questions from their peers. Curriculum modifications may consist of having students learn different material; for example, a student with a language impairment might continue to work on mastering inflectional morphology (e.g., past tense, third-person singular) under the instruction of the SLP at the same time their peers are learning about relative clauses in the general education classroom. Audiologists may recommend preferential seating, the addition of remote microphone hearing-assistive technologies, and/or supplemental visual technologies or instructions for their students with hearing loss to remove some of the environmental barriers on their ability to communicate and learn. They may also work with the student on self-advocacy strategies to ensure accommodations are provided as needed. These would also be stated on the IEP and tracked over time by the audiologist. The IEP must also include information about plans for the student to transition to a career, a technical school, or college, which must be done by the time they are 16. Issues related to education, training, employment, and independent living must be part of the transition planning process. The transition plan should also include the services and supports the student may need to achieve their postsecondary goals. SLPs and audiologists may be part of the IEP team that develops transition plans for eligible students based on their strengths, needs, preferences, and interests. For example, the SLP may recommend students participate in training to develop communication skills critical for establishing and maintaining positive relationships with colleagues, supervisors, and consumers in the workplace. Communication skills that may need to be addressed prior to graduation or shortly thereafter include turn taking, interview skills, the use of appropriate language,

volume, body language, eye contact, and language used in written expression (e.g., reports, emails). Audiologists may recommend their students with hearing loss participate in these kinds of activities as well as those that help build self-advocacy skills for situations they may encounter in their daily lives including the workplace and the community.

Due Process Federal regulations allow for a due process hearing when families and caregivers allege an issue relating to the identification, evaluation, or education of a child, or the provision of FAPE for the child. Due process encompasses a set of steps that may be taken to formally dispute the information contained in the IEP after which a third party, who may not be an educational professional, determines the outcomes of the litigation. It is possible for the SLP or audiologist to be asked to testify in such a hearing on behalf of the student or the school district as it relates to questions about the goals, accommodations, modifications, and reasonable outcomes for students with speech-language or hearing disorders. The easiest way to avoid complaints that could lead to a due process hearing is to establish professional, positive communicative relationships with the students’ parents and caregivers at the beginning of the special education process. If attempts to resolve parent concerns are unsuccessful, it is critical that the SLP or audiologist follow the school district’s established notification procedures and inform the appropriate school and/or central office staff of the situation. Documentation of the interactions between school-based professionals and the family may be used as evidence in due process proceedings and, as such, should be recorded consistently and professionally. School districts often choose to compromise or enter into a legally binding settlement agreement with parents to avoid litigation. The best protection for the SLP, audiologist, and the school district is to maintain accurate documentation, including parental contacts, dates of service (including why scheduled services were not provided), session activities, and progress toward the attainment of IEP goals. For further discussion of documentation, see Chapter 16.

Identification, Assessment, and Intervention in Schools The process of identification, assessment, and the provision of service delivery in schools follows a specified sequence. First and foremost, schools must identify students who need special education and then determine



CHAPTER 12   Knowledge and Skills for Providing Evidence-Based Services in School-Based Settings

their eligibility for services. This process begins with a referral and, when appropriate, a comprehensive evaluation conducted by trained, licensed school personnel. A part of any comprehensive evaluation should include a hearing screening, and, if necessary, a comprehensive hearing evaluation by an audiologist. The SLP will be involved in conducting comprehensive speech and language evaluations for students independently or in collaboration with other professionals if the student demonstrates other areas of concern (e.g., cognitive, behavioral, academic, motor). Students should be evaluated in a way that allows their unique educational needs to be met through the development of evidence-based intervention plans and the identification of individualized accommodations and modifications. The assessments used to evaluate students must be culturally and linguistically appropriate, be psychometrically sound, consider the use of nonstandard dialects, and be administered in the student’s native language (Laing & Kamhi, 2003). Standardized testing may be used as one tool to identify students with disabilities but should not be the sole determinant of a student’s eligibility for services under IDEA. SLPs have specialized knowledge of descriptive approaches to documenting strengths and weaknesses in language abilities that complement (or are used in lieu of ) information obtained through standardized testing. Language sampling is one descriptive technique SLPs use to assess functional and academic language skills in school-aged students that aligns with recommendations of the National Joint Committee on Learning Disabilities to “document the real-life impact of communication disorders” (Heilmann et al., 2020). This also aligns with the International Classification Functioning, Disability, and Health (ICF; World Health Organization, 2007) to assess an individual’s communicative functioning in authentic contexts, which includes the general education classroom. After a student has been referred for an evaluation, a team is convened to determine if (a) the student falls into one of the 14 identified categories under IDEA and (b) their condition adversely affects their ability to learn. The 14 categories under IDEA include specific learning disability, other health impairment, ASD, emotional disturbance, speech or language impairment, visual impairment, deafness, hearing impairment, deafblindness, orthopedic impairment, intellectual disability, traumatic brain injury, and multiple disabilities (summarized in Table 12–3). After determining that a student falls into one of the 14 IDEA categories, it must be confirmed that the student’s disability adversely impacts their ability to make educational progress. If the assessment team decides that the disability does not require specialized instruction, the student may be given accommodations through a

504 plan. A 504 plan differs from an IEP in that it is a legal, written document that addresses the provision of accommodations rather than specialized instruction related to a disability. Once these steps have been taken and eligibility determined, an IEP is written that school personnel must follow. In the case of dysphagia, the SLP must provide documentation as to how the swallowing and feeding disorder is educationally relevant, which may include something as basic as safety while eating in the school lunchroom. The SLP is responsible for recommendations related to food consistency and procedures for minimizing risk of aspiration and choking during eating, which may include related services such as an extender or aide to monitor the student during lunchtime. The same is true for issues related to hearing loss. The audiologist must make the case that the condition adversely affects the students’ ability to learn in the classroom if it is to be addressed in an IEP. The IEP must not be viewed by anyone outside of the local education agency (LEA), which includes special education administrators, directors, coordinators, or other individuals who work within the district and are responsible for ensuring students receive appropriate services and support. Special education teachers and related service providers, including the SLP and audiologist who are directly involved in the student’s case, would be considered part of the LEA. Members of the LEA are obligated to maintain the privacy of all students and families they serve. Publicly conversing about a student, including use of social media, removing confidential files from the premises, or leaving them unattended or unsecured are examples of situations that compromise the privacy of students and their families. The Family Educational Rights and Privacy Act (FERPA; U.S. Department of Education, 2011a) affords parents and students over 18 years of age certain rights with respect to educational records; however, school-based SLPs and audiologists (and other professionals) who have a legitimate reason to access students’ educational records are permitted (“disclosure without consent”). With this privilege comes a significant responsibility to keep all records secure and all discussions about a student in a private setting and to adhere to any other standards that respect the confidentiality and privacy of students and their families. An outline of the special education process with examples of actions the SLP or audiologist may take is shown in Table 12–4.

Medicaid in Schools Medicaid is a program co-funded by federal and state governments in which each state develops a plan to support the elderly, disabled, and impoverished. Currently,

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Table 12–3.  Disability Categories Defined in the Individuals With Disabilities Education Act (IDEA) Low, Medium or High Incidence in the U.S.

Disability

Definition

 1. Autism

Neurodevelopmental disorder significantly affecting verbal and nonverbal communication and social interaction, engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences

Medium

 2. Deaf-blindness

Concomitant hearing and visual impairments evidence before age 3

Low

 3. Deafness

Severe hearing impairment such that child is impaired in processing linguistic information through hearing without amplification

Low

  4. Hearing impairment

Impairment in hearing (permanent or fluctuating) that impacts learning (not included under deafness)

Low

  5. Emotional disturbance

Behavioral problems, psychological problems that impact learning

Medium

  6. Intellectual disability

Significantly below average general intelligence and adaptive behavior

Medium

  7. Multiple disabilities

Simultaneous impairments occurring at the same time

Low

  8. Orthopedic impairment

Severe impairment of bones or muscles that adversely affects educational performance

Low

  9. Other health impairment

Includes a range of conditions, acute health problems, ADHD

High

10. Specific learning disability

Disorder in basic psychological process leading to difficulty in thinking, speaking, reading, writing and performing math calculations and problem solving

High

11. Speech or language impairment

Communication disorder; stuttering, articulation, language, voice, swallowing

High

12. Traumatic brain injury

Injury to brain resulting in total or partial functional disability; memory issues, cognitive processes impaired

Low

13. Visual impairment (including blindness)

Impairment in vision, even with glasses, that impacts learning

Low

14. Developmental delay

Ages 3–9 with delay in physical, cognitive, social, emotional, or adaptive development

Medium

Note:  Low-incidence disabilities occur in 5% of all children with disabilities; medium-incidence disabilities occur in 28% of all children with disabilities; high-incidence disabilities occur in 67% of all children with disabilities. Retrieved from Congressional Research Service, (2020), https://crsreports.congress.gov

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Table 12–4.  Outline of the Special Education Process Examples Involving SLP or Audiology

IDEA Term

Action Taken

Who Is Involved

Referral

Suspicion of disability, review of concerns

Local education agency (LEA) personnel and parent/caregiver

Student does not perform well on vocabulary assessments, does not answer questions accurately after reading

Review of existing data, including prereferral interventions attempted

Team reviews existing data and determines what, if any, additional data is needed to move forward

Local education agency (LEA) personnel

Recommend moving student near teacher, teacher is asked to ask student to repeat instructions for tasks

Evaluation

Parent consent obtained for evaluation

Local education agency (LEA) personnel

Administer standardized and criterion-referenced measures of language comprehension and production; AUD evaluates hearing

Eligibility determination

Evaluation findings reviewed

Local education agency (LEA) personnel

Determine if student demonstrates a communication disorder and if disorder adversely impacts performance

IEP

Goals and objectives are identified

Local education agency (LEA) personnel and parent/caregiver

Write goals and objectives relevant to communication disorder, specify benchmarks to monitor progress and to identify when goals and objectives have been met, identify relevant accommodations or modifications

Related services

Any necessary related services are identified

Local education agency (LEA) personnel and parent/caregiver

Consult with team about additional services needed; i.e., OT for dysgraphia

Reevaluation and continued eligibility

Review progress, goals, objectives, and classroom performance and conduct additional evaluation information every 3 years; parent consent required

Local education agency (LEA) personnel

Readminister formal testing to determine if student has made adequate progress, to create new goals and objectives, or to dismiss from services

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Medicaid allows for the reimbursement of health claims for services provided to students with disabilities in public schools and who are eligible for Medicaid. Each state creates a plan for the administration of Medicaid in school programs and outlines the requirements for covered services, documentation, and provider requirements. Audiology and speech-language pathology services identified in the student’s IEP are reimbursable if all requirements are met. Medicaid in schools is generally a cost-based reimbursement program that is different from the typical fee-for-service programs in health care. Schools receive reimbursement based on a formula outlined in the state plan. Understanding requirements for medical necessity, prior authorization, and provider requirements is important for SLPs and audiologists who work in schools. Some school districts rely on Medicaid funding to supplement the costs of providing speech-language and hearing services, thereby requiring school-based SLPs and audiologists to follow Medicaid billing procedures. Many ethical issues exist in the cost-recovery process for Medicaid funds. Therefore, it is the professional’s responsibility to study and adhere to the state Medi­ caid laws in documentation, use of graduate students for the delivery of reimbursable services, and signatures of supervising clinicians. Medicaid audits have required payback in these areas, so school districts and individual SLPs and audiologists should carefully adhere to their state Medicaid laws.

Roles and Responsibilities in the Schools The Roles and Responsibilities of Speech-Language Pathologists in Schools (ASHA, 2010) states that “SLPs have integral roles in education and are essential members of school facilities” (p. 1). We have talked about the key role of SLPs in the provision of special education services to students who are eligible for services under IDEA. However, the SLP may take an active role within the general education classroom as well. For example, SLPs may assist in developing and implementing strategies to prevent communication disorders that negatively impact student educational performance or to improve Tier 1 instruction (see below) for all students, including those with communication disorders. Mechanisms used to implement these strategies in the classroom are multitiered systems of support (MTSS) and response to intervention (RTI). Similarly, audiologists may be involved in developing and implementing strategies to support hearing health for all students, which may include recommendations to improve classroom acoustics, reduce auditory distractions, and/or increase the use of visual stimuli.

Response to Instruction/Intervention States that permit the use of RTI set careful guidelines for its implementation. According to the National Center on Response to Intervention (2011), RTI integrates assessment and intervention within a multilevel prevention system to maximize student achievement and to reduce behavior problems. With RTI, schools identify students at risk for poor learning outcomes, monitor student progress, provide evidence-based interventions and adjust the intensity and nature of those interventions depending on a student’s responsiveness, and identify students with learning disabilities or other disabilities. (p. 1)

RTI has four components: It must be implemented schoolwide and involve screening, progress monitoring, and data-based decision making to identify, instruct, and advance students from one tier to another. Eligibility for special education or entitlement under RTI may occur in a variety of different ways. The tiers of RTI represent increasing levels of intensity of interventions. Tier 1 typically involves parent and teacher collaboration. Tier 2 typically begins with classroom-based interventions, perhaps with the involvement of the SLP, audiologist, psychologist, or other identified support personnel. At Tier 3, interventions are increased in frequency and/or intensity. In some states, Tier 3 marks the beginning of the special education process. Each progressive tier is designed to support student success in regular education and prevent the need for movement toward special education services unless the student is unresponsive to intervention. The SLP and audiologist will work with a team of professionals, optimally at all three levels, to plan assessments and interventions to target the student’s areas of need and to make decisions about movement between tiers. School SLPs and audiologists may work alone to design short-term programs called prereferral interventions to address speech-language and hearing difficulties experienced by students in the classroom. Typically, the SLP or audiologist would design interventions that would be carried out by the classroom teacher or trained designee over a specified period. Student performance would be evaluated, changes would be made to the interventions, and a formal referral made if reasonable progress toward educational outcomes is not made. In a recent nationwide survey conducted by ASHA (2018), 68% of SLPs who participated reported they had a role in MTSS/RTI or prereferral in their school-based setting. The most common MTSS/RTI activities they engaged in involved conducting screenings and providing strategies to classroom teachers. The provision of



CHAPTER 12   Knowledge and Skills for Providing Evidence-Based Services in School-Based Settings

strategies to classroom teachers was the role selected by 16% of SLPs working in special day/residential schools, 42% in preschools, 67% in elementary schools, 49% in secondary schools, and 47% when the school types were combined.

Service Delivery Options School SLPs and audiologists provide services using a variety of service delivery models. IDEA intends that whatever the service delivery model, services should be linked to the curriculum. Most states have adopted the Core Content Standards (Common Core State Standards Initiative, 2010) as their curriculum, and states that have not done so have created standards that are very similar in content. This means SLPs and audiologists are expected to consult and collaborate with teachers, who are the curriculum experts for their grade level, to design educationally relevant interventions for students identified with communication disorders. Service delivery for speech-language and hearing disorders in schools may be provided directly or indirectly, both of which may include an array of different options. Direct services may be provided in individual or group sessions and address goals and objectives outlined on the IEP. Indirect services involve activities that are designed to support the student in reaching goals and objectives but that are conducted when the student is not present.

Direct Services The large majority of SLPs and audiologists provide services directly through classroom-based or pull-out services (ASHA, 2020). With the emergence of the COVID-19 pandemic in 2020, there was an unprecedented increase in the use of telepractice services to provide virtual assessment and treatment for school-age students with disabilities. Telepractice approaches may be synchronous (i.e., interactive in real time), asynchronous (i.e., communications recorded for offline use), or hybrid (i.e., combination of interactive and offline methods) and may fall into direct or indirect services depending on which of the approaches is used. The use of mobile learning apps as service delivery tools has also become an emerging practice in educational settings (Flinner & Sullivan, 2021; Hall-Mills et al., 2022). The use of technology in the delivery of speech, language, and hearing services in educational settings is anticipated to become a more conventional model in the future rather than a practice that will be discontinued. This is because many studies have shown it is an effective way to conduct assessments and to deliver services, particularly to underserved populations and in the presence of long-

term shortages of qualified providers (Magimairaj et al., 2022; Zahir et al., 2021). When direct services are provided in pull-out fashion, students miss classroom content, so less restrictive environments such as the general education classroom or other educationally relevant locations are preferred when possible. Classroom-based services are sometimes referred to as integrated, inclusive, embedded, push-in (may have a negative connotation), or collaborative. Students may also be seen in a resource room (e.g., life skills classroom). Some SLPs and audiologists may be asked to work with students at off-campus locations such as community-based vocational settings or even in the home. The goals for this type of service delivery are often captured in the transition component of the IEP. The important thing to consider is that when we can avoid a pull-out model for service delivery, we reduce the time students must spend away from instruction in the curriculum and increase the educational relevance of what we are doing with students during treatment.

Indirect Services Indirect services are provided on behalf of students and are delivered without the student present. These services focus on supporting the student by working with teachers, assistants, parents, other school personnel, or even other students serving as peer models or mentors. This type of service supports the learning environment for a student and may take the form of programming alternative augmented communication (AAC) devices, teaching other students how to appropriately interact with an AAC system user, teaching an assistant a therapy technique, or planning with a teacher to engineer a communication-rich and acoustically sound classroom. These activities represent only a few of the possible indirect services that may be provided in a school setting. Because these types of services are provided indirectly to the student, it is important that parents have a clear understanding of what is going to be done in the IEP. Other terms such as “consultation” and “collaboration” should be used carefully, as each state or school division may define these terms differently, which has educational and reimbursement implications.

3:1 Model The 3:1 model is a combination of both direct and indirect services delivered in the education setting. The 3:1 model combines 3 weeks of direct treatment sessions with 1 week for indirect treatment. This service delivery option provides direct treatment and supports other professionals and family members to improve outcomes for the student. Indirect services include those listed in the indirect services section.

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Scheduling in the Schools It is difficult to characterize a typical daily schedule for school-based SLPs or audiologists. The responsibilities of these professionals are continuously changing because of the ever-expanding scope of practice and the constantly evolving education initiatives at the federal, state, and even local levels. “Scheduling” in the context of schoolbased practitioners typically refers to the provision of direct services, although numerous other responsibilities need to be factored in (e.g., writing goals, preparing materials, programming hearing aids). Designing a schedule to meet students’ needs based on their IEPs requires flexibility and collaboration with staff members. The master, or bell schedule of the school is the best template to use in designing a schedule for speech-language and hearing services. Unfortunately, SLPs and audiologists must plan around many activities during the school day, which requires close collaboration with teachers and administrators to produce a schedule. It is also a given that any schedule needs to be flexible to allow for the inevitable changes that arise during the school year. The schedule should be shared with appropriate school personnel and, naturally, the student.

Audiologists in the schools will rarely find themselves working in one school building. Educational audiologists may find themselves working within a school district or even across different districts in a region. This means educational audiologists may find themselves traveling to different educational facilities frequently. Travel time will be another important factor to consider for any professional working in more than one setting.

Working With Support Personnel ASHA has developed a voluntary credential for SLPAs and audiology assistants who are professionals delegated to extending services of the SLP or the audiologist. The speech-language pathology and audiology assistants’ scopes of practice outline the tasks delegated to the SLPA or audiology assistant, which increase the availability, frequency, and efficiency of services (ASHA, 2022d, 2022e). Minimally, the SLPA must finish an approved course of academic study, complete a supervised clinical experience (minimum of 100 hours under direct supervision of ASHA-certified SLP), and pass the ASHA Assistants Certification Exam to meet the requirements ASHA has

set forth. SLPAs may (a) provide intervention services, (b) assist in the assessment and the delivery of programs designed to be culturally responsive to students with communication and swallowing disorders, and (c) participate in activities designed to protect and/or advocate for students with communication and swallowing disorders. All these activities must be conducted under the direct supervision of a certified SLP. SLPAs are not qualified to interpret test results, diagnose communication and swallowing disorders, develop/write IEP goals, or sign off on any documentation related to the assessment, diagnosis, or treatment of these conditions. Audiology assistants must also complete an approved course of academic study, a supervised clinical experience (minimum of 500 hours), and pass the ASHA certification exam for audiology assistants, among other criteria. Audiology assistants may (a) participate in patient care services, (b) perform hearing device management, and (c) engage in professional activities and advocacy efforts. All of these activities must be conducted under the direct supervision of an ASHA-certified and/or licensed audiologist. Audiology assistants are not qualified to interpret test results, diagnose disorders, develop/write IEP goals, recommend or fit devices, or sign off on any documentation related to the assessment, diagnosis, or treatment of conditions that are the sole responsibility of the audiologist. See Chapter 9 for more information.

Professional Practice in the Schools Advocacy and Education SLPs, audiologists, and support personnel are expected to advocate by educating the public about issues related to evidence-based practices associated with the provision of speech, language, and hearing services to individuals with disabilities. In the schools, this may take the form of teacher/staff development, parent education, or working with administrative staff to ensure the development and maintenance of high-quality programs (ASHA, 2010). For instance, some SLPs have a specialty area, such as developmental language impairment (DLD), and may serve as a resource to an entire school district in meeting the needs of students with this diagnosis. Audiologists may be experts in central auditory processing disorders and may be an important resource in educating schoolbased professionals on proper assessment and management of the disorder. Additional school advocacy topics are specific to the Every Student Succeeds Act (ESSA), IDEA, PACE, and school choice programs.



CHAPTER 12   Knowledge and Skills for Providing Evidence-Based Services in School-Based Settings

Every Student Succeeds Act (ESSA) The Elementary and Secondary Education Act (ESEA) passed in 1965 was designed to ensure equal opportunities for all students and to provide greater flexibility to state and local governments in implementing special education and other related programs for students to be prepared for life beyond high school. In 2015, Congress reauthorized this law as the Every Student Succeeds Act (ESSA). As the U.S. Department of Education continues to develop regulations and guidance to assist states, districts, and schools in implementing ESSA, it is the role of the SLP and audiologist to offer input and feedback to assist in this process as it relates to the students they serve. Specific topics SLPs may engage in include professional development, literacy, and the assessment and treatment of children with disabilities including communication and swallowing disorders. Audiologists may address issues related to over-the-counter hearing aids by consulting with local, state, and federal legislators and individuals about how best to make decisions about their use and for which populations they are appropriate.

Individuals With Disabilities Education Improvement Act (IDEIA) The provision of services to students with language disorders and swallowing issues is an example of an advocacy topic SLPs and audiologists will want to engage in to support best practices in school settings. Recall that to be eligible for school-based special education services, the student must fall into one of 14 IDEIA categories and have a disability that adversely affects their ability to succeed in school such that specialized services are required. Recently, ASHA has asked the U.S. Department of Education to consider inclusion of the term “developmental language disorder” (DLD) as the basis for a disability determination under IDEA regulations. This clarification is important to ensure the designation may be used for evaluation, eligibility, and as part of an IEP to ensure students with the condition receive the support they need to be successful in school (ASHA, 2023b). Similarly, there is a need for education and advocacy regarding the provision of dysphagia services in the schools. Swallowing disorders, or dysphagia, is a condition in which an individual has difficulty swallowing and eating to maintain proper hydration and/or nutrition that falls within the scope of practice of the SLP. The condition may be associated with one or more of the 14 categories of disabilities identified by IDEA. For example, students diagnosed with traumatic brain injury or who have multiple disabilities may also demonstrate dys-

phagia. The 2018 ASHA Schools Survey reported that 10.5% of school-based SLP respondents had an average of 2.6 students with dysphagia on their caseload. Even so, uncertainty persists about the educational relevance of dysphagia management, which is also an important criterion that must be met for a student to be eligible for services in the school setting.

Professional Assessment of Contributions and Effectiveness of Speech-Language Pathologists (PACE) SLPs may be evaluated in school settings by administrative SLPs or by professionals who have no background in the field (e.g., principal, special educator). This can be problematic in some cases because our roles and responsibilities are very different from other professionals working with students in the schools. SLPs may advocate for the use of specialized appraisals such as the one outlined in ASHA’s Professional Assessment of Contributions and Effectiveness of Speech-Language Pathologists (PACE) document (ASHA, 2014). This document serves as a model for the appraisal of the school-based SLP’s performance of workload duties that is better aligned with the specialized knowledge and skills of SLPs.

School Choice The school choice legislation currently under consideration in the U.S. is a complex but important issue that SLPs and audiologists need to be knowledgeable about. The issue is that school choice allows public education funds to follow students to the school that parents select to meet their student’s educational needs. However, the chosen school may not be required to provide special education services, including speech, language, and hearing services that are mandated by federal law. The advocacy point is to ensure school choice programs meet the same requirements as public schools and that parents have the information and resources they need to make an informed decision that is in the best interest of their student (U.S. Department of Education, 2018).

Outreach There are many themes and issues that fall under the umbrella of outreach that the school-based SLP and audiologist may engage in. A popular outreach drive held each May, Better Hearing and Speech Month, is a monthlong campaign to promote awareness of communication and hearing disorders and the role of ASHA members in improving the lives of individuals with speech-language

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and hearing difficulties. ASHA provides advocacy materials and ideas to support these efforts, including press releases, reports, stories, links, facts, and articles specific to school-based services. Another important outreach effort school-based SLPs and audiologists should be involved in is the recruitment of professionals into the field, and specifically into the school setting. There are currently about 56 ASHAcertified SLPs for every 100,000 residents in the U.S. (ASHA, 2022f ) and significantly fewer audiologists per capita. This is not enough to serve the large number of students in the U.S. school population who may require these specialized services. This is even more compelling when we consider the number of students who are bilingual and also require special education services related to communication, hearing, and swallowing disorders. Bilingual SLPs and audiologists represent slightly less than 8% of the current membership of ASHA, with only half reporting they work in an educational setting (ASHA, 2022g). It is ASHA’s vision that pro­ fessionals in the disciplines actively promote the good work that is done to improve the lives of the individuals they serve, and ASHA provides good resources to assist them in carrying out this mission. See Chapter 25 for further discussion.

Supervision Supervision of student SLPs and audiologists (interns), clinical fellows (CFs), SLPAs, and audiology assistants is one of the roles and responsibilities of SLPs and audiologists in the schools. Evidence of current knowledge of supervision practice is a requisite as of 2020 to supervising graduate students and CFs for ASHA certification (ASHA, n.d.). By supervising graduate students and CFs and ensuring positive school-based experiences, we cultivate the next generation of professionals who may consider schools as their future work setting. As supervisors, SLPs and audiologists have the responsibility of ensuring their licensure and certifications are current. Supervision of interns should be a mutually beneficial opportunity. Graduate students bring a wealth of current knowledge on evidence-based practices, while practicing professionals provide their experience and clinical opportunities for students to fine tune their skills.

Research Federal law requires that SLPs and audiologists utilize scientific, research-based procedures and approaches in their practices. When possible, school-based professionals should participate in research that contributes to the

development of these practices. Studying the impact of intervention techniques in authentic clinical practice settings, such as the schools, has been shown to be critical in bridging evidence-to-practice gaps (Nowell, 2018).

Administration and Leadership School-based SLPs and audiologists may take on leadership roles to influence school-based practices in positive ways. The first step in this process is to view oneself as a potential leader. SLPs and audiologists have critical knowledge and skills concerning the foundational speech-language and hearing abilities students need to meet the demands of the curriculum. They may establish themselves as leaders in their schools by engaging in collegial, interprofessional practices and fully connecting their services to goals and objectives outlined in the curricular standards in a seamless manner. Our support of hearing health as well as the speech and language skills that students need to understand, communicate, ask questions, and read and write will go a long way in building relationships with administrators, teachers, and support staff to foster positive changes in the way services are delivered to our students with communication, hearing, and swallowing disorders (Zygouris-Coe & Goodwiler, 2013).

Summary I hope this chapter has provided you with some of the information you need to help you begin to make a decision about whether a school-based work setting is for you. You have learned about some of the specific knowledge and skills related to the provision of speechlanguage pathology and audiological services in schools, including some of the federal legislation and landmark cases that continue to influence how special education services are provided. The basic steps in the eligibility and educational planning process have been summarized, as well as important terminology related to the provision of special education services in schools. The chapter addressed service delivery options that continue to evolve as the use of technology and support personnel take their places in new learning platforms designed to provide better services to students across the U.S. and the world. Professional activities unique to school-based settings have been outlined that include advocacy, outreach, supervision, education, research, and administration and leadership activities. It is through these endeavors that SLPs and audiologists become changemakers whose visions are aligned with ASHA’s to make effective communication accessible and achievable for all.



CHAPTER 12   Knowledge and Skills for Providing Evidence-Based Services in School-Based Settings

References American Speech-Language-Hearing Association. (2002). Guidelines for audiology service provision in and for schools. https://www.asha.org/policy/ gl2002-00005/ American Speech-Language-Hearing Association. (2010). Roles and responsibilities of speech-language pathologists in schools. https://www.asha.org/slp/ schools/prof-consult/guidelines/ American Speech-Language-Hearing Association. (2014). Performance assessment of contributions and effectiveness of speech-language pathologists. https:// www.asha.org/uploadedFiles/SLPs-PerformanceAssessment-ContributionsEffectiveness.pdf American Speech-Language-Hearing Association. (2016). Scope of practice in speech-language pathology. https://www.asha.org/policy/sp201600343/ American Speech-Language Hearing Association. (2018a). 2018 schools survey report: SLP caseload and workload characteristics. https://www.asha.org/ research/memberdata/schoolssurvey American Speech-Language-Hearing Association. (2018b). Highlights and trends: Member and affiliate counts, year-end 2018. https://www.asha.org/ uploadedFiles/2018-Member-Counts.pdf American Speech-Language-Hearing Association. (2020). 2020 schools survey. Survey summary report: Numbers and types of responses, SLPs. https://www​ .asha.org/siteassets/surveys/2020-schools-slpsummary.pdf American Speech-Language-Hearing Association. (2022a). 2021 member and affiliate profile. https:// www.asha.org American Speech-Language-Hearing Association. (2022b). 2021 member and affiliate profile trends, 2001–2021. https://www.asha.org American Speech-Language-Hearing Association. (2022c). Schools survey report: Trends in educational audiology, 2010–2022. https://www.asha.org American Speech-Language-Hearing Association. (2022d). Scope of practice for speech-language pathology assistants. https://www.asha.org/policy/ slpa-scope-of-practice/ American Speech-Language-Hearing Association. (2022e). Scope of practice for audiology assistants. https://www.asha.org/policy/ scope-of-practice-for-audiology-assistants/

American Speech-Language-Hearing Association. (2022f ). Speech-language pathologists’ supply varies by state, region. ASHA Leader Live. https://leader.pubs.asha.org/do/10.1044/leader​ .AAG.27012022.3 American Speech-Language-Hearing Association. (2022g). 2021 demographic profile of ASHA members providing multilingual services. https:// www.asha.org American Speech-Language-Hearing Association. (2023a). Code of ethics. https://www.asha.org/ policy/et2016-00342/ American Speech-Language-Hearing Association. (2023b, February 16). Letter to U.S. department of education leads to meeting on DLD. ASHA Advocate. https://www.asha.org/news/2023/ asha-advocate-02162023/?utm_source=asha&utm_ medium=email&utm_campaign=headlines Americans With Disabilities Act of 1990, 42 U.S.C. § 1201 et seq. (1990). https://www.ada.gov/ law-and-regs/ada/ Common Core State Standards Initiative. (2010). Common core state standards. http://www.core​ standards.org/ Elementary and Secondary Education Act, Pub. L. No. 89-10, 79 Stat. 27, 20 U.S.C. ch. 70 (1965). Endrew F. v. Douglas County School District, Volume 580, U.S. Supreme Court (2017). https://supreme​ .justia.com/cases/federal/us/580/15-827/ Every Student Succeeds Act, 20 U.S.C. § 6301 (2015). https://www.congress.gov/114/plaws/publ95/ PLAW-114publ95.pdf Family Educational Rights and Privacy Act of 1974, 20 U.S.C. § 1232g (1974). https://www2.ed.gov/ policy/gen/guid/fpco/ferpa/index.html Flinner, K., & Sullivan, J. (2021). The speech-language pathologist evaluating appropriateness of learning apps as a service delivery model for children with hearing loss. Perspectives, 6, 1533–1539. https:// doi.org/10.1044/2021_PERSP-21-00057 Flynn, P. (2010). New service delivery models: Connecting SLPs with teachers and curriculum. ASHA Leader, 15(10), 22. Gillam, S. L., & Gillam, R. B. (2006). Making evidence-based decisions about child language intervention in schools. Language, Speech, and Hearing Services in Schools, 37(4), 304–315. https:// doi.org/10.1044/0161-1461(2006/035)

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Goleman, D. (2004, January). What makes a leader. Harvard Business Review. https://hbr.org/2004/01/ what-makes-a-leader Hall-Mills, S. (2019). A comparison of the prevalence rates of language impairment before and after response-to-intervention implementation. Language, Speech, and Hearing Services in Schools, 50(4), 703–709. https://doi.org/10.1044/2019_ LSHSS-18-0144 Hall-Mills, S., Johnson, L., Gross, M., Latham, D., & Everhart, N. (2022). Providing telepractice in schools during a pandemic: The experiences and perspectives of speech-language pathologists. Language, Speech, and Hearing Services in Schools, 53, 290–306. https://doi.org/10.1044/2021_ LSHSS-21-00023 Heilmann, J., Tucci, A., Plante, E., & Miller, J. (2020). Assessing functional language in school-aged children using language sample analysis. Perspectives, 5, 622–636. Individuals With Disabilities Education Improvement Act of 2004, Pub. L. No. 108-446, 20 U.S.C. § 1400 et seq. (2004). https://www.congress.gov/ bill/108th-congress/house-bill/1350 Laing, S., & Kamhi, A. (2003). Assessment of language and literacy in culturally and linguistically diverse populations. Language, Speech, and Hearing Services in Schools, 34, 44–55. Magimairaj, B., Capin, P., Gillam, S., Vaughn, S., Roberts, G., Fall, A., & Gillam, R. (2022). Online administration of the test of narrative language– second edition: Psychometrics and considerations for remote assessment. Language, Speech, and Hearing Services in Schools, 53, 404–416. National Center for Education Statistics. (2022a). Common core of data (CCD), state nonfiscal survey of public elementary/secondary education, 2021–22 preliminary; and Department of Defense Education Activity (DoDEA) data center, enrollment data, 2021. https://www​.dodea.edu/datacenter/enroll​ ment.cfm

National Center for Education Statistics. (2022d). English learners in public schools. Condition of education. U.S. Department of Education, Institute of Education Sciences. https://nces.ed.gov/programs/ coe/indicator/cgf National Center on Response to Intervention. (2011). The essential components of RTI. What is RTI? http:// www.rti4success.org/whatisrti No Child Left Behind Act of 2001, Pub. L. 107-110 (2002). https://www2.ed.gov/nclb/overview/intro/ execsumm.pdf Nowell, S. (2018). Partner up for research-to-practice progress. The ASHA Leader, 23(8). https://doi.org/​ 10.1044/leader.MIW.23082018.34 Rehabilitation Act of 1973, as amended, 29 U.S.C. § 701 (1973). https://www.eeoc.gov/statutes/ rehabilitation-act-1973 Section 504 of the Rehabilitation Act of 1973, Pub. L. No. 93-112, 87 Stat. 394, 29 U.S.C. § 701 (1973). https://www.hhs.gov/sites/default/files/ocr/ civilrights/resources/factsheets/504.pdf U.S. Congress. (2004). Individuals With Disabilities Education Improvement Act (IDEIA) of 2004. http:// idea.ed.gov/explore/view/p/%2Croot%2Cstatute% 2CI%2CA%2C602%2 C3%2C U.S. Department of Education. (1990). Americans With Disabilities Act (ADA). http://www.ed.gov/ about/offices/list/ocr/docs/hq9805.html U.S. Department of Education. (2004). Federal regulations IDEIA 2004. http://idea.ed.gov/explore/ view/p/%2Croot%2Cregs%2C U.S. Department of Education. (2010). Elementary and secondary education, No Child Left Behind legislation and policies. http://www2.ed.gov/policy/ elsec/guid/states/index.html U.S. Department of Education. (2011a). The Family Educational Rights and Privacy Act: Guidance for eligible students. http://ed.gov/policy/gen/guid/ fpco/ferpa/for-eligiblestudents.pdf

National Center for Education Statistics. (2022b). Common core of data (CCD), “state nonfiscal survey of public elementary/secondary education,” 19992000 through 2020-21 and 2021-22 preliminary.

U.S. Department of Education. (2011b). Student placement in elementary and secondary schools and Section 504 of the Rehabilitation Act and Title II of the Americans With Disabilities Act. http://www2​ .ed.gov/about/offices/list/ocr/docs/placpub.html

National Center for Education Statistics. (2022c). Students with disabilities. Condition of education. U.S. Department of Education, Institute of Education Sciences. https://nces.ed.gov/programs/ coe/indicator/cgg

U.S. Department of Education. (2018). 40th annual report to Congress on the implementation of the Individuals With Disabilities Education Act, 2018. https://www2.ed.gov/about/reports/annual/ osep/2018/parts-b-c/40th-arc-for-idea.pdf



CHAPTER 12   Knowledge and Skills for Providing Evidence-Based Services in School-Based Settings

World Health Organization. (2007). International Classification of Functioning, Disability, and Health: Children & youth version: ICF-CY. Zirkel, P. (1998). Counterpoint: National trends in education litigation: Supreme Court decisions concerning students. Journal of Law and Education, 27, 235. Zahir, M., Miles, A., Hand, L., & Ward, E. (2021). Information and communication technology

in schools: Its contribution to equitable speechlanguage therapy services in an underserved small island developing state. Language, Speech, and Hearing Services in Schools, 52, 644–660. Zygouris-Coe, V., & Goodwiler, C. (2013). Language and literacy demands of content area courses in the era of the common core state standards: Teachers’ perspectives and the role of the SLP. Perspectives on School-Based Issues, 61–67. https://doi.org/10.1044/ sbi14.3.61

253

13 Service Delivery in Early Intervention Corey Herd Cassidy

Introduction Early intervention (EI) services are evidence-based, specialized services designed to meet the needs of infants and toddlers (and their families) from birth to age 3 years who have or may be at risk for developmental delays or disabilities. The primary goal of EI services is to address the identified needs of young children to lessen the effects of their disabilities or delays. These services are designed to provide resources and supports for the child and family to ensure the child has every opportunity to develop and learn. The Individuals With Disabilities Education Act (IDEA) is a federally mandated system originally introduced in 1975 as Public Law 94-142 called the Education for All Handicapped Children Act. It was enacted to ensure equitable educational opportunities for children aged 5 to 21 years. Over time, the system has been restructured and renamed several times. As of 1997, the act was revised to include the Program for Infants and Toddlers With Disabilities, also called Part C, to serve children between the ages of birth to 3 years and their families. The most current system, the Individuals With Disabilities Education Improvement Act (IDEIA), was authorized in 2004 with additional IDEIA Part C Final Regulations confirmed in 2011 (IDEIA, 2011). These documents reflect empirically based practices in the arena of EI. This chapter presents the evidence that supports intervention in the birth to 3-year-old population as well as the most current IDEIA regulatory requirements regarding EI policies, procedures, and practices that impact infants and toddlers with disabilities and their families. In 2008, the American Speech-Language-Hearing Association (ASHA) presented five guiding principles that reflect evidence-based best practices for speech-language pathologists (SLPs) and audiologists who provide Part C EI services to young children and their families. Updates addressing the five principles, as well as implementation for best practice, are also available through the ASHA Early Intervention Practice Portal (ASHA, 2023b). This chapter presents each of these principles and discusses how each may be effectively implemented by SLPs and audiologists. The chapter discusses how SLPs and audiologists need to collaborate with other service providers and family members within the EI system to provide effective and meaningful service delivery. Family-centered practices and the need to consider and incorporate natural environments into the provision of EI services are presented

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and discussed. The concept of cultural competence in the EI arena, including the definitions and the circumstances that influence the provision of effective and appropriate family-centered services, is defined. This chapter discusses each step of the EI process, including considerations regarding eligibility, the creation of the Individualized Family Service Plan (IFSP), and transitioning from Part C to Part B (Special Education) or other services. In addition, the chapter presents the scopes of practice for SLPs and audiologists who work in the EI arena and introduces the provider to information about different team formats in EI programs. Research supporting the fact that the period from birth to age 3 is a critical time in a child’s development is shared and the most current evidence regarding the foundation of and best practices in EI is discussed. The chapter presents general advice for providing best practices within natural environments as well as suggestions for establishing a positive and safe work environment. Finally, current trends and best practices in the use of remote service delivery, or telehealth, in the EI arena are shared.

What Is Early Intervention? Before 1975, approximately 1 million children with disabilities were denied pertinent services and were provided only minimal education in separate facilities and institutions. Public Law (PL) 94-142, also known as the Education for All Handicapped Children Act, was passed in 1975 and is considered by many to be the most significant act in the history of education in regard to children with disabilities. This act mandated free appropriate public education (FAPE) for all children with disabilities from 5 to 21 years of age. Through a series of reauthorizations, FAPE was extended to include children with disabilities from 3 to 21 years of age. PL 94-142 is the predecessor to both IDEA and IDEIA. FAPE is often used interchangeably with IDEA and IDEIA, as it also refers to all amendments affecting the 1975 act. In 1986, IDEA was passed. This amendment to the original PL 94-142 provided the federal mandate for special education services in each state for children with disabilities from birth to 21 years of age. It outlined the system of funding employed for special education and related services. Provisions were put in place through Part H of IDEA to provide incentives to states to provide services to children from birth to 3 years of age. Congress established the Part H (Early Intervention) program of IDEA in recognition of “an urgent and substantial need” to: n

enhance the development of infants and toddlers with disabilities,

n

reduce educational costs by minimizing the need for special education through EI,

n

minimize the likelihood of institutionalization and maximize independent living, and

n

enhance the capacity of families to meet their child’s needs.

IDEA Part C In 1997, IDEA (PL 105-17) was restructured and Part H became Part C — the Program for Infants and Toddlers With Disabilities. IDEA was modified once again in 2004 as IDEIA. Federal Part C regulations now require that a statewide policy and system of EI services be in effect to ensure appropriate EI services are available to all infants and toddlers with disabilities and/or significant developmental delays as well as to their families. For a state to participate in the program, it must ensure EI will be available to all eligible children and their families. Each state’s governor must designate a lead agency to receive the funding and to administer the program. The governor must also appoint an Interagency Coordinating Council (ICC), including parents of young children with disabilities, to advise and assist the lead agency. Currently, all states and eligible territories are participating in the Part C program. Annual funding to each state is based upon census figures of the number of children birth to 3 years of age in the state’s general population. Part C services may be extended to include children up through 6 years of age; however, few states have adopted this practice. In 2011, the IDEIA Part C Final Regulations (IDEIA, 2011) were presented. The final regulations reflected changes made to the IDEA, as amended by the IDEIA of 2004, and made other necessary changes needed to implement the EI Program for Infants and Toddlers With Disabilities. One of the most significant changes in these regulations provided states the discretion to extend eligibility for Part C services through age 5 years to children with disabilities who are eligible for services under Part B, Section 619 (Preschool Grants) and who previously received services under Part C. Each state’s Part C system is distinct in its funding structure. Part C programs coordinate EI funding from federal, state, local, and private sources. Annual federal funding to each state Part C EI program varies based on the census figures for the number of children in the general population between the ages of birth through 2 years in each state. Most Part C funding tends to come from the state (Hebbeler et al., 2011). Part C federal funds cover EI administrative costs, while services are provided through state funding, third-party payers, and families who pay fees for services (Searcy, 2018; Vail



CHAPTER 13   Service Delivery in Early Intervention

et al., 2018). Evaluations, assessments, development of the IFSP, and service coordination must be provided at no cost to families (IDEA, 2004). Some programs also offer additional EI services free of charge or on a sliding scale, although specific policies vary from state to state. Some private insurance and Medicaid plans cover EI services. When a child is not eligible for EI services or transitions out of a Part C program, families may choose to self-pay or use their medical insurance to seek private services beyond what a school district offers (Vail et al., 2018).

Evidence Supporting Early Intervention Children grow and develop differently and at their own pace. Decades of research support the fact that the period from birth to age 3 is a critical time in a child’s development and an important time for parents to have access to accurate information and consistent support (Center on the Developing Child at Harvard University [CDCHU], 2008, 2010). Research has shown that a child’s earliest experiences play a critical role in brain development; therefore, it is crucial that services are provided during these early years (CDCHU, 2008). According to the CDCHU (2008, 2010), neural circuits, including those that create the foundation for learning, behavior, and health, are the most flexible during the first 3 years of life. The findings also indicate that early social/emotional development and physical health provide the foundation upon which both cognitive and language skills develop. Positive early experiences that involve stable relationships with responsive adults within safe and supportive environments and appropriate nutritional opportunities are all key elements of healthy brain development (CDCHU, 2010). According to Guralnick (2011), the earlier intervention supports and services are provided, the more likely children who have disabilities or developmental delays are to achieve successful learning outcomes related to the development of effective communication, language, and swallowing skills. Services have been shown to positively influence outcomes across developmental domains, including health, language and communication, cognition, and social/ emotional well-being of infants and toddlers who have disabilities or are at risk for developmental delays (Branson & Demchak, 2009; CDCHU, 2010; Guralnick, 2011; Hebbeler et al., 2011; Joint Committee on Infant Hearing, 2007; Landa et al., 2010). Benefits of Part C services to society also include reducing economic burden through later academic success and a decreased need for special education in the school years (Hebbeler, 2011). Therefore, intervention is likely to be more effective and less costly when it is

provided earlier rather than later in life. These research findings underscore the importance of intervention in the earliest years and support the impact of IDEIA Part C services on children, families, and society as a whole.

Range of Early Intervention Services Broadly speaking, EI services are specialized health, educational, and therapeutic services designed to meet the needs of infants and toddlers from birth to age 3 years who have or may be at risk for developmental delays or disabilities, and their families. The primary goal of EI is to decrease the effects of a disability or delay by identifying and addressing the needs of young children across five developmental areas including cognitive development, communication development, physical development (including vision and hearing), social or emotional development, and adaptive development (IDEIA, 2004). EI services bring families and service providers from many aspects of the community together, including public and private agencies, childcare centers, local school districts, and private providers. Supports and services are intended to work together to meet children’s unique needs and those of their family in their natural environments. Services may be simple or complex depending on each child’s needs. They can range from relatively uncomplicated, such as prescribing glasses for a 2-year-old, to significantly more complex, such as needing to develop a multifaceted comprehensive approach with a variety of services and team members. Depending on the child’s needs, services may include family training, counseling, and home visits; special instruction; speech-language pathology services; audiology services; occupational therapy; physical therapy; psychological services; medical services (for diagnostic or evaluation purposes); health services needed to enable the child to benefit from the other services; social work services; assistive technology devices and services; transportation; nutrition services; and service coordination services. Table 13–1 illustrates a sample of the coordination services that may be provided under the scope of IDEIA Part C Final Regulations.

Roles and Responsibilities of Speech-Language Pathologists and Audiologists in Early Intervention In the EI arena, SLPs are qualified to provide services to families and young children who demonstrate or are at risk of developing disabilities or delays in the areas of

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Table 13–1. Early Intervention Services Provided Under IDEIA Part C Final Regulations n

Assistive technology devices and services

n

Counseling and home visits

n

Early identification, screening, and assessment services

n

Family training

n

Health services necessary to enable the infant or toddler to benefit from the other early intervention services

n

Medical services only for diagnostic or evaluation purposes

n

Occupational therapy

n

Physical therapy

n

Psychological services

n

Service coordination services

n

Sign language and cued language services

n

Social work services

n

Special instruction

n

Speech-language pathology and audiology services

n

Transportation and related costs that are necessary to enable an infant or toddler and the infant’s or toddler’s family to receive another service

n

Vision services

Source:  Adapted from Individuals With Disabilities Education Improvement Act. (2011). Part C Final Regulations. https://www.gpo.gov/fdsys/ pkg/FR-2011-09-28/pdf/2011-22783.pdf

communication, speech, language, cognition, emergent literacy, and/or feeding and swallowing difficulties (ASHA, 2016). Table 13–2 presents the roles and responsibilities of SLPs in EI. The knowledge, skills, and experience of audiologists who are specifically educated to provide services to young children are also needed in the EI arena. Audiology services in EI include the establishment of an accurate diagnosis of auditory and vestibular function, effective family counseling provided in conjunction with the diagnostic process, and timely service coordination for those children who require audiological services (ASHA, 2013; JCIH, 2007). Table 13–3 presents the roles and responsibilities of audiologists in EI. SLPs and audiologists must also consider the ASHA Code of Ethics (ASHA, 2023a), which states both professions must only participate in roles that are within the professional scopes of practice. EI SLPs and audiologists must demonstrate documented high levels of competence evidenced by level of education, discipline-specific

training, and experience. Additionally, the SLP and audiologist roles and responsibilities in EI are guided by both state licensure regulations and service delivery models as implemented by local agencies.

Guiding Principles of Early Intervention Five guiding principles reflect current best practices when providing EI for young children and their families (ASHA, 2023b). These principles specifically note that supports and services must be (a) family centered; (b) culturally and linguistically responsive; (c) developmentally supportive and promotive of children’s participation in their natural environments; (d) comprehensive, coordinated, and team based; and (e) based on the highest quality internal and external evidence available. Each one of these principles is discussed in greater detail throughout the chapter.



CHAPTER 13   Service Delivery in Early Intervention

Table 13–2.  Roles and Responsibilities of Speech-Language Pathologists in Early Intervention n

Demonstrate knowledge of typical norms from birth to age 5 years across developmental domains

n

Engage in prevention and early identification activities to promote healthy development and reduce risk factors that can impact a child’s development

n

Understand federal, state, agency, and professional policies and procedures related to screening, evaluating, and assessing infants and toddlers with, or at risk for, disabilities

n

Conduct screening, evaluation, and assessment to identify young children with, or at risk for, a delay or disorder

n

Establish eligibility for services and guide the development of an intervention program in collaboration with the family

n

Make referrals to other professionals and, with the family’s consent, inform the referral source of the outcome of the eligibility process

n

Develop a plan for implementing services and supports that includes evidence-based speech-language pathology intervention approaches, methods, and settings

n

Gather and report treatment outcomes and document progress

n

Revise intervention plans and determine appropriate discharge criteria

n

Collaborate with families, caregivers, agencies, and other professionals involved on the IFSP team to support implementation of intervention strategies in everyday routines

n

Support family interactions that reflect cultural beliefs, values, and priorities

n

Coordinate services (including evaluation and assessment, development of an IFSP, and access to resources) and ensure services are implemented, as agreed upon by the team

n

Participate in transition planning to ensure seamless transition and timely access to services for families moving from one program to another

n

Advocate at the local, state, and national levels regarding public policy, funding, and infrastructure for early intervention services

n

Raise awareness about the importance of early intervention by working with families and other professionals; develop and disseminate resources

n

Remain informed of current evidence-based practice in early intervention

n

Support the advancement of the knowledge base related to the nature and treatment of speech, language, cognitive-communication, and swallowing development and disorders in infants and young children

Source:  Adapted from American Speech-Language and Hearing Association. (2023). ASHA early intervention practice portal. https://www.asha.org/practice-portal/professional-issues/early-intervention/

Family-Centered Services The first guiding principle that reflects current best practices by SLPs and audiologists when providing services in EI focuses on the inclusion of families in a functional and meaningful way (ASHA, 2023b). When engaged in family-centered practices, the SLP or audiologist engages with each family based on their own unique circumstances to strengthen their capacity to support and enhance their child’s development and learning (IDEA, 2011; Division for Early Childhood [DEC], 2014). Based on this principle, families who are engaged

in EI services receive complete and unbiased information from their service providers, they are involved in all aspects of their child’s services to the extent to which they choose and they receive services that build upon their strengths as a whole (Crawford & Weber, 2014; DEC, 2014; Dunst et al., 2014; Dunst, 2017; McWilliam, 2010b; Ross, 2018; Trivette & Dunst, 2007). Effective family-centered practices involve working collaboratively with families in all aspects of service delivery. This involves relating to family members as people rather than as patients. A family-centered approach recognizes the importance of all family members, including

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Table 13–3.  Roles and Responsibilities of Audiologists in Early Intervention n

Oversee early identification (via newborn and early childhood screening) programs and ensure appropriate procedures are followed (Joint Committee on Infant Hearing [JCIH], 2007)

n

Report results of newborn hearing screenings to state newborn hearing screening and follow-up programs (based on state-by-state regulations)

n

Establish an accurate diagnosis of hearing status

n

Provide information about the child’s hearing status and eligibility for Part C services to the referral source (only with the family’s consent)

n

Coordinate timely audiologic services

n

Evaluate infants and young children with hearing and vestibular deficits for amplification and other sensory devices, assistive technology, and vestibular rehabilitation

n

Fit and maintain amplification, other sensory devices, and assistive technology; frequently validate that the devices are providing the intended benefit

n

Provide effective family support and counseling regarding the nature of auditory and vestibular conditions and implications for language development, modes/methods of communication, communication access strategies/accommodations, and acoustic modifications

n

Advocate for a continuous process of family-focused service delivery

n

Refer families to parent-to-parent support and other consumer-based organizations

n

Educate other professionals about the needs of infants and young children with hearing and vestibular/ balance deficits and the role of audiologists in diagnosing and managing them

n

Coordinate services (including evaluation and assessment, development of an IFSP, and access to resources) and ensure services are implemented, as agreed upon by the team

n

Advocate for the rights to and funding of services for infants and young children with reduced hearing, auditory disorders, and/or vestibular disorders

n

Remain informed of research in early intervention to support advancement of the knowledge base related to the nature, identification, and treatment of hearing and vestibular deficits in infants and young children.

Source:  Adapted from American Speech-Language and Hearing Association. (2008). Core knowledge and skills in early intervention speech-language pathology practice. http://www.asha.org/policy; American Speech-Language and Hearing Association. (2013). Supplement to the JCIH 2007 position statement: Principles and guidelines for early intervention following confirmation that a child is deaf or hard of hearing [Position statement]. http://www.asha.org/policy

siblings, grandparents, and extended family members. The collaboration between families and service providers creates an environment in which both the child’s and family’s needs are supported and their capacity to learn and develop is promoted. This active family involvement plays a key role in promoting the learning outcomes of young children by enhancing their academic achievement; cultivating their reading, mathematics, social, and emotional skills; and reducing the frequency of problem behaviors (Galindo & Sheldon, 2012; Ma et al., 2016; Powell et al., 2010; Van Voorhis et al., 2013). The principle of family-centered services is based on a family-systems model for implementing EI and family support assessment and intervention practices. According to Dunst and Trivette (2009), the family-systems model focuses on four evidence-based operational components.

The model is implemented by first identifying the family’s concerns and priorities. At this level, family aspirations and priorities are determined using needs-based assessment procedures and strategies to determine what the family considers important. The second step toward implementation of the family-systems model is identification of the supports and resources that can be used by the family to address their concerns and priorities. The family’s personal social network and potential sources of information and assistance are identified, in addition to emphasizing the particular strengths of the family that increase their likelihood to utilize those resources when needed. The third step in the model involves identifying family members’ existing abilities and interests to obtain needed supports and resources. The family’s strengths and capabilities are explored and considered as a basis



CHAPTER 13   Service Delivery in Early Intervention

for promoting their abilities to obtain and mobilize their resources. The fourth and final step in implementation of the family-systems model involves coaching the family to use help-giving practices to build their capacity; these practices are intended to be used by the family to carry out actions to obtain supports and resources to meet their identified priorities and concerns. This final step is intended to enhance a family’s ability to become more self-sustaining with respect to acquiring, recognizing, and utilizing their own competencies and skills to effectively meet their needs and achieve their goals (Dunst, 2017; Dunst & Trivette, 2009). IDEIA Part C requires that families are provided the opportunity to participate in all aspects of their child’s services. To ensure that the family, and not just the child, receives EI services that build upon their strengths, collaboration between families and providers is the foundation of family-centered services (Crawford & Weber, 2014; DEC, 2014; Dunst, 2017; McWilliam, 2010b; Ross, 2018; Trivette & Dunst, 2007). The DEC presents recommended practices (2014) that outline familycentered, collaborative, and capacity-building practices. These recommendations, presented in Table 13–4, are based on both the best empirical available evidence and

experience in the field and provide guidance to service providers and families regarding the most effective ways to improve learning outcomes and promote the development of young children who have or are at risk for developmental delays or disabilities. Families collaborate with providers to design and implement services that align specifically with their own preferences, resources, concerns, and priorities (IDEIA, 2011). This collaboration leads to a partnership that creates a learning environment supportive of both the child’s and family’s needs while achieving mutually agreed-upon outcomes and promoting family capacities (DEC, 2014; Roberts et al., 2016). This partnership begins by determining the definitions and roles of both the family and the SLP or audiologist. The term family can have many different meanings. Families define themselves by who lives together, who makes decisions, what roles family members play, and how members support each other. Each family operates as a system, and for each child, the family system represents the group of individuals who have the most influence on that child’s growth and development. Building rapport, collaborating with one another, and facilitating an individualized, supportive EI process are all critical components to

Table 13–4.  Division for Early Childhood (DEC) Recommended Family Practices in Early Intervention n

Providers build trusting and respectful partnerships with the family through interactions that are sensitive and responsive to cultural, linguistic, and socioeconomic diversity

n

Providers provide the family with up-to-date, comprehensive, and unbiased information in a way that the family can understand and use to make informed choices and decisions

n

Providers are responsive to the family’s concerns, priorities, and changing life circumstances

n

Providers and the family work together to create outcomes or goals, develop individualized plans, and implement practices that address the family’s priorities and concerns and the child’s strengths and needs

n

Providers support family functioning, promote family confidence and competence, and strengthen familychild relationships by acting in ways that recognize and build on family strengths and capacities

n

Providers engage the family in opportunities that support and strengthen parenting knowledge and skills and parenting competence and confidence in ways that are flexible, individualized, and tailored to the family’s preferences

n

Providers work with the family to identify, access, and use formal and informal resources and supports to achieve family-identified outcomes or goals

n

Providers provide the family of a young child who has or is at risk for developmental delay/disability, and who is a dual language learner, with information about the benefits of learning in multiple languages for the child’s growth and development

n

Providers help families know and understand their rights

n

Providers inform families about leadership and advocacy skill-building opportunities and encourage those who are interested to participate

Source:  Adapted from Division for Early Childhood. (2014). DEC recommended practices in early intervention/early childhood special education 2014. http://www.dec-sped.org/recommendedpractices

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working effectively with each family. By asking questions about routines, joining their activities, and communicating effectively, EI providers learn how each family works. Services can then be implemented that include opportunities for families and caregivers to directly participate in intervention (DEC, 2014). These steps offer families an opportunity to recognize that the dynamics of the family are vitally important for individualized and meaningful services for their unique child and family (SpecialQuest Multimedia Training Library, 2007). SLPs and audiologists must learn to adapt their knowledge and expertise to fit the needs of each child and family, ensuring the family’s needs are being addressed and learning is supported. The unique needs of each child and family determine which skills the clinician uses, how knowledge is shared, and which strategies are developed. The SLP and/or audiologist should combine their professional expertise and knowledge of activities with the child- and family-specific expertise the parent brings to the table. Together, they can create interventions focused on how the family will encourage the growth, development, and participation of their child when the clinician is not present (McWilliam, 2004). Raver and Childress (2015) report families need to be involved and responsive to their child’s needs and development to ensure intervention is effective. Engagement and involvement by families is essential to strengthen their existing knowledge and skills to promote the child’s development of new skills and to enhance both child and family outcomes (DEC, 2014). SLPs and audiologists who use a family-centered approach effectively collaborate with families to share information, strengthen family functioning, and empower decision making. Establishing a positive relationship with a family is key to facilitating their participation throughout the EI process. Building rapport and trust that lead to a true partnership begins with the first contact and continues through transition (Jung & Grisham-Brown, 2006). Meeting families where they are; practicing active listening; and helping them identify priorities, resources, strengths, and needs related to their child’s development and their family lay the foundation for a supportive EI system. SLPs and audiologists join the parents through their relationship and via common concerns about the infant or toddler. They both observe the child’s growth and development and offer developmentally appropriate anticipatory guidance. The SLPs’ and audiologists’ roles therefore include the need to adapt and apply their knowledge with each family in each intervention visit, to identify the strengths each parent brings to the relationship with their child, to support the parent’s engagement with their child, and to encourage the parents to take the lead in the EI experience. A young child’s devel-

opment occurs within the context of their family and community (Dunst et al., 2001). It is because of the profound influences of family and community that SLPs and audiologists working in EI focus on how to support the development of infants and toddlers within these contexts. The guiding principles of Part C recognize that infant and toddler development unfolds during family routines and activities. Supports and services that focus on these routines and activities provide family members with useful, meaningful strategies that can be used daily within the context of those activities unique to each individual family (Crawford & Weber, 2014; DEC, 2014; Dunst et al., 2014; Dunst, 2017; McWilliam, 2010b; Ross, 2018; Trivette & Dunst, 2007; Woods et al., 2004). Establishing and Maintaining Rapport. Building rapport with a family begins with the first contact and affects the relationship throughout the process of intervention. Strong rapport takes time to establish and effort to maintain, but it can be a means of encouraging open communication and learning for everyone involved. Working from a family-centered perspective, SLPs and audiologists are able to build strong relationships with the families they serve by recognizing the family’s strengths and perspectives in the first stages of the EI process, then considering the demands of intervention in relation to the benefits at each subsequent stage. Keeping an open dialogue with family members and consistently discussing these demands and benefits are key to maintaining rapport among the team members. Table 13–5 provides suggestions for building positive relationships with families.

Culturally and Linguistically Responsive Services The second guiding principle that reflects current best practices for SLPs and audiologists engaged in the EI arena states that families of infants and toddlers with a disability or developmental delay must have access to culturally and linguistically responsive and competent services (ASHA, 2023b; IDEIA, 2011). Culturally and linguistically responsive practices refer to the ability of providers to effectively interact with and support people of different cultures. Children and families receiving EI supports and services are increasingly diverse and present with different cultures, ethnicities, traditions, values, and belief systems. Cultural and linguistic responsiveness involves understanding, including, and responding to these variables; valuing the diversity of the families; and seeking further knowledge regarding culture and language (Hopf et al., 2021). To provide this level of service, SLPs and audiologists must engage in cultural



CHAPTER 13   Service Delivery in Early Intervention

Table 13–5.  Suggestions for Building Positive Relationships With Families n

Show genuine interest in the family’s life, routines, activities, and interests and in the child’s needs and achievements

n

Be sensitive to each family’s readiness to share information and to receive feedback

n

Facilitate a family member’s participation at a level that is comfortable for them

n

Encourage family members to be active participants in all aspects of the early intervention process, including referral, assessment and evaluation, development of the IFSP, and intervention planning

n

Respect the family’s time by being punctual for visits and offering flexible scheduling

n

Acknowledge the complexities of raising a child with developmental delays or disabilities and helping as needed

n

Provide complete, unbiased information and allow family members time to make informed decisions, even when the family’s decisions differ from choices you would have made

n

Respect family’s rights throughout the early intervention process

Source:  Adapted from Early Childhood Learning & Knowledge Center. (2023). Creating bright futures: Building relationships with families [Facilitator’s guide]. https://eclkc.ohs.acf.hhs.gov/children-disabilities/inclusionchildren-disabilities-training-guide/creating-bright-futures-building-relationships-families; Individuals With Disabilities Education Improvement Act. (2011). Part C Final Regulations. https://www.gpo.gov/fdsys/pkg/ FR-2011-09-28/pdf/2011-22783.pdf

competence, a complex process in which an individual engages in ongoing self-assessment and continual cultural education over time, is willing to share their own values and beliefs, and is open to the values and beliefs of others (Hopf et al., 2021). It is important that providers are aware of the different cultural dimensions and the unique influences of each family’s cultural and linguistic background to ensure they are utilizing effective clinical approaches within their services, engaging the family, and building trust in the family’s decisions regarding EI services and supports. Cultural responsiveness involves the ability to interact effectively with all people regardless of their culture and to recognize how their cultural dimensions may impact a family’s approach to services for their child (ASHA, 2021). By becoming more culturally competent and responsive, the SLP and audiologist reduce their own cultural biases and recognize the cultural issues important to each family. Table 13–6 illustrates variables that should be considered with regard to differences among cultures. This topic is covered extensively in Chapter 21. Cultural perspectives that relate directly to services within EI include views of (a) children and child rearing, (b) disability and causation, (c) intervention, (d) medical treatment and healing, (e) family and family roles, and (f ) language and communication styles (Hanson & Lynch, 1990; Peredo, 2016). Additionally, according to Hanson and Lynch (1990), several factors regarding the nature of EI should be considered to provide effective

EI services to families from culturally and linguistically diverse backgrounds. These factors include (a) attitudes regarding intervention, (b) methods used and location of services, (c) qualifications of the service providers, and (d) styles of interaction and communication in the provision of services. When providing culturally responsive services to families, SLPs and audiologists should consider factors that affect families’ perspectives as well as issues that may relate directly to services. Bradshaw (2013) provided a framework for EI service providers to meet the needs of culturally diverse children and families. The framework was created to organize existing research and literature on cultural responsiveness in a way that fits the unique context of EI and synthesizes both knowledge and best practices into four guiding principles. The first principle involves Examining One’s Own Culture and encourages EI providers to take an in-depth look at their own cultural values and beliefs. The second principle, Acquiring Knowledge of Family Cultures, highlights the importance of finding out about the cultures of the families they serve. These first two principles are foundations for the third, which focuses on Building Culturally Responsive Practices. This principle actively engages the provider in developing and implementing culturally responsive practices that respond to the unique strengths, needs, and desires of families. The fourth principle, Reflecting and Evaluating Practices, encourages EI service providers to reflect often on their practices to identify their most

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Table 13–6. Variables Regarding Cultural Differences Personal space

In some cultures, it is common for people to stand approximately three feet apart when having a personal conversation. In other cultures, it is typical to stand much closer. Each distance may feel awkward to someone who is unfamiliar with the other style; the conversational partner may try to move closer or farther away, depending upon their own comfort.

Eye contact and feedback behaviors

In some cultures, individuals are encouraged to look each other directly in the eye and to participate actively in providing feedback behaviors (e.g., leaning forward, smiling, nodding). In contrast, people from other cultures may show respect or deference by not engaging in eye contact or by participating more passively in their body language and conversation.

Interruption and turn-taking behaviors

Some cultures have come to expect a conversation to progress linearly (i.e., one speaker at a time), while it may be more natural for several people to be talking at once in another culture. Listening skills that address different cultural rules regarding turn taking in conversation must be developed when considering and accommodating multiple styles.

Gesturing

Hand and arm gesturing can vary quite a bit in different cultural backgrounds. In general, extreme gesturing should not necessarily be interpreted as excitement as it may just be an ordinary manner of communication, depending on the speaker.

Facial expressions

Variance in this form of communication is also common; it is important to not assume someone is cold or distressed based solely on one’s own cultural experience.

Silence

Americans often find it more difficult to tolerate periods of prolonged silence than do others from different cultures; follow the cues and try to avoid filling the silence with noise if it seems like an acceptable period of time.

Dominance behaviors

In some cultures, prolonged eye contact, an erect posture, looking down at someone’s hands or hips, looking at someone with lowered lids, and holding the head high are all examples of behavior that may be interpreted as assertive or even aggressive. The interpretation of these behaviors may vary from one culture to another.

Volume

Irritation often results when culturally different speakers consider differing levels of acceptable volume. It is important to remember that each individual may be reacting based on the rules learned in their own background and what may be considered normal by their peers.

Touching

Some cultures may perceive someone as cold and aloof if there is not much touching and/or proximity to one another. In other cultures, touching may be perceived as intrusive or rude.

Source:  Adapted from Peredo, T. N. (2016). Supporting culturally and linguistically diverse families in early intervention. Perspectives of the ASHA Special Interest Groups, 1(1), 154–167. https://doi.org/10.1044/persp1.SIG1.154; Saldaña, D. (2011). Cultural competency: A practical guide for mental health services providers.

and least effective practices with families of cultures different from their own (Bradshaw, 2013). By following the framework, the provider engages in active listening and learning about the family’s own system. During the initial assessment for the program planning process, the SLP and audiologist ask questions and listen to the family members discuss their needs and

concerns. Based on their feedback and by collaborating with family members, outcomes are then aligned with family culture, values, needs, and priorities. Since intervention activities are built directly into family routines that already exist, the routines-based approach builds upon the strengths inherent to individual family systems while eliminating cultural mismatches (Raver &



CHAPTER 13   Service Delivery in Early Intervention

Childress, 2014). By determining optimal routines and empowering parents to incorporate opportunities into their own everyday activities, the SLP and audiologist can provide effective services while respecting and considering every family’s culture and value system (Peña & Fiestas, 2009; Bradshaw, 2013). In providing linguistically responsive services, the EI service provider must consider both the home language(s) as well as acquisition of the language needed for the child’s academic success. This consideration will look different depending on the services and supports being provided. IDEIA regulations define native language as the language typically used by an individual. In the case of a child receiving services, native language is the language typically used by the parents or caregivers (IDEIA, 2011). Unless it is not feasible to do so, prior written notice regarding EI services must be provided to families in their native language, as well as EI supports and services in the language(s) most likely to result in an accurate representation of the child’s skills (DEC, 2014; IDEIA, 2011). The SLP and audiologist will want to teach families and caregivers how to implement strategies in their home language to maximize comprehension and carryover of both knowledge and skills (Peredo, 2016). Service providers often work with families and interpreters to support both the home language(s) and acquisition of the language needed by the child for academic success. Ultimately, the clinician can build strong relationships with families and address their individualized needs by recognizing that each family is a whole unit with its own unique set of values. By respecting the choices that families make in child rearing, serving the family’s functional needs, and viewing the culture and the home language of the family as a strength, clinicians can implement the principles of family-centered practice to effectively respond to and support culturally and linguistically diverse families in EI (Peredo, 2016).

Developmentally Supportive Services in the Natural Environment Effective EI services meet the family where they are, at the level of their needs, and in the environments in which they find themselves (DEC, 2014). The primary purpose of EI is to support family efforts and to build their confidence and competence in meeting the needs of their children. With that purpose in mind, intervention visits that occur within each family’s support system and natural environment may be best suited to positive developmental outcomes for children and families. Furthermore, services that address family routines, concerns, and priorities through authentic experiences, active exploration, and interactions with both people and the environment and that are consistent with

the child’s age, cognitive skills, communication skills, strengths, and interests are considered developmentally supportive (DEC, 2014). IDEIA Part C (2004) requires that EI services be provided, to the maximum extent appropriate, in natural environments. This is the third of the five guiding principles. According to IDEIA (2011), natural environments are defined as “settings that are natural or typical for a same-aged infant or toddler without a disability, [and] may include the home or community settings.” Natural environments include the home and other settings in which children without delays and disabilities participate in their communities. Natural environments are not places where children go because of their disabilities, the convenience of the SLP or audiologist, or access to a special place or equipment. Instead, they are settings and activities in which each individual child’s family participates or would like to participate (Raver & Childress, 2015; Ross, 2018; Rush & Shelden, 2011; Woods, 2008; Woods et al., 2011). Table 13–7 presents the variables an SLP and audiologist should consider when determining a child’s natural environment.

Table 13–7. Variables Related to Natural Environments n

Settings include the child’s home and yard, as well as other locations where the child and family live, learn, and play. These may include a childcare site, relative’s home, family member’s place of work, park, grocery store, or library.

n

Materials include anything found in the child’s physical environment, including but not limited to toys, rocks, books, swings, grass, spoons, a high chair, or a favorite comfort item.

n

People include parents, siblings, relatives, friends, neighbors, teachers, or anyone else with whom the child might interact on a consistent or regular basis.

n

Activities include any that incorporate the interests and routines of the child and family. These might involve daily activities and routines, such as eating, bathing, and dressing; recreation, such as playing, reading, walking, camping, swimming, and going to the playground; and community participation, such as faith traditions, holiday celebrations, cultural practices, shopping, and different forms of transportation.

Source:  Adapted from Pacer Group. (2020). Natural environments support early intervention services. https://www.pacer.org/ parent/php/PHP-c178.pdf

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When considering the provision of EI services in natural environments, SLPs and audiologists must determine not only where the supports are provided but also how to provide them. Children learn best when they learn in context and have multiple opportunities to practice the skills and abilities throughout the day. It is much easier for infants and toddlers to generalize their newly learned skills when they have learned them during meaningful, functional activities as they happen naturally, rather than learning them in contrived situations in a clinical setting. It is the clinician’s job to provide parents with this perspective. SLPs and audiologists must learn to think beyond the traditional home visit and consider the multitude of activities that occur outside of their scheduled block of time (Hanft et al., 2004). Thinking beyond the typical home visit requires a shift in how EI has been provided in many localities. Therefore, to help the teams move forward, the SLP and audiologist need to understand the similarities and differences between traditional home visits and intervention that is provided when incorporating each family’s priorities, routines, and activities. Services provided through traditional home visits tend to be limited to what can be accomplished during the span of time the SLP and family have allotted for the visit. Specific skills may be addressed in isolation, and activities may be discussed but not practiced because they do not coincide with the scheduled time. In contrast, supports and services that consider the concept of natural environments use that allotted home visit time to explore a variety of family routines and activities to find out how they can be enhanced to address IFSP outcomes both during and between EI visits. Since SLPs and audiologists may join the family in those activities, the intervention visit should be scheduled in response to the activities being explored and is therefore flexible with regard to day and time. Intervention provided in the home or other natural settings and environments gives SLPs and audiologists the opportunity to see what daily life is like for the family. Everyday experiences, events, and places familiar to the family should be incorporated as opportunities to promote incidental teaching and natural learning throughout each day (McWilliam, 2010b; Raver & Childress, 2015; Ross, 2018; Rush & Sheldon, 2011). These interactions may include learning what goes well for each family in each scenario and determining how and what assistance the family may need. By becoming familiar with the specifics of each family’s routine and activities, SLPs and audiologists can help parents develop individualized outcomes and intervention strategies based on activities that are meaningful and useful to the family during their daily life.

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Comprehensive, Coordinated, and Team-Based Services The fourth of the five guiding principles of EI (ASHA, 2023b) states that supports and services should be “comprehensive, coordinated, and team-based.” Regardless of state or local programming methods, all young children and their families follow the same basic steps as they enter and move through the EI system. The process, often called the supports and services pathway, begins with referral for assessment and follows the child and family while they continue to receive services through the Part C program. The supports and services pathway helps identify eligible families, with its purpose being to maximize family and child outcomes through the delivery of EI services. It consists of seven distinct components of service delivery, including referral, intake, eligibility determination, assessment for service planning, IFSP development, implementation and reviews of the IFSP, and transition activities. Embedded in each of these processes is the legal acknowledgment of the family’s and child’s procedural rights and safeguards. Figure 13–1 provides the typical sequence a family follows while involved in Part C services.

Referral A primary referral source, such as a parent, pediatrician, or health department representative, identifies a child who may have a developmental delay or may need further assessment. Referral sources often have concerns based on results of developmental screenings, observations, or a diagnosis indicating a potential developmental delay. Anyone in the community can refer a child who might be eligible for Part C services as long as parent/guardian permission is secured. The referral is made to the Part C local Central Point of Entry at the lead agency. The Central Point of Entry collects the referral information and assigns a service coordinator to meet with the family. During the referral process, information regarding the local or statewide EI process is shared with the family and initial information regarding the child and family is gathered. Each local lead agency develops policies and procedures in the community to ensure fast response from the Central Point of Entry and to move quickly toward the next step in the EI process. The IDEIA (2011) requires that providers make referrals within 7 days after the infant or toddler is identified as having a possible disability or delay. Following receipt of a referral, the lead agency has 45 days to complete the intake or screening, initial evaluation, initial assessments, and initial team meeting

i

TEXAS TECH UNIVERSITY



CHAPTER 13   Service Delivery in Early Intervention

Referral

Intake

Eligibility Determinaon

Assessment for Service Planning

Development of the Individualized Family Service Plan

Implementaon and Review of the Individualized Family Service Plan

Transion Figure 13–1.  Sequence of early intervention.

to develop the initial IFSP for the child and the family (IDEIA, 2011).

Intake Intake involves face-to-face and/or phone meetings with the family to continue gathering information to determine eligibility. Such information includes developmental history, medical history and medical home information, family routines, schedules, and activities of interest as well as the completion of a developmental screening if needed. In-depth information is shared with the family regarding the Part C system, including eligibility criteria, IFSP development if the child is eligible, family cost-share participation, and child and family procedural rights and safeguards. At this point, the Central Point of Entry, or a service coordinator assigned to the family, begins the process of eligibility determination.

Eligibility Determination Eligibility determination is the process of determining whether a child meets the system’s eligibility criteria to receive EI services. This process includes the evaluation of the child’s skills and needs through a review of information, including medical/developmental reports, assessment reports, observations, and parent reports. According to IDEIA § 303.321(a)(2)(i), evaluation is defined as “the procedures used by qualified personnel to determine a child’s initial and continuing eligibility” (IDEIA, 2011). Eligibility determination is based on the child’s needs within the child’s natural environment, which may include the home or any community setting in which children without disabilities participate (e.g., childcare centers, public playgrounds). All areas of a child’s development are considered to determine whether the child has a delay and/or differences in development

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that qualify them for Part C services. As such, “no single procedure may be used as the sole criterion for determining a child’s eligibility” (IDEIA, 2011, § 303.321[b]); these procedures must include administration of an evaluation instrument, an interview with the parent to gather the child’s history, identification of the child’s level of functioning in each of the developmental areas, gathering of information from a variety of sources to understand the full scope of the child’s individual strengths and needs, and a review of the child’s medical, educational, and/or other records (IDEIA, 2011). This information is reviewed by a multidisciplinary team that determines whether a child meets one or more of the criteria for eligibility. Part C of IDEIA 2004 states that systems must provide services to any child “under 3 years of age who needs early intervention services” (IDEIA, 2004, § 632[5][A]) because the child (i) is experiencing developmental delays, as measured by appropriate diagnostic instruments and procedures in one or more of the areas of cognitive development, physical development, communication development, social or emotional development, and adaptive development; or (ii) has a diagnosed physical or mental condition which has a high probability of resulting in developmental delay. (IDEIA, 2004, § 632[5][A])

A state may also provide services, at its discretion, to at-risk infants and toddlers. States have some discretion in setting the criteria for each of these variables. As a result, definitions of eligibility differ significantly from state to state. Evaluation procedures used to determine developmental delay involve determining the status of the child in each of the developmental areas. Part C of IDEIA (2011) requires a multidisciplinary composition of the team, including the parent and two or more individuals from separate disciplines or professions, with one of the individuals serving as the service coordinator. The multidisciplinary evaluation team typically includes at least two early childhood professionals who are appropriately qualified in their areas of expertise (e.g., SLP, occupational therapist, developmental specialist), at least one of whom is qualified in the primary areas of concern. The service coordinator works with the multidisciplinary evaluation team to facilitate the evaluations, ensuring all the appropriate procedures are completed and properly documented. At a minimum, a multidisciplinary evaluation team gathers information from a review of pertinent records related to a child’s current health status and medical history, family report, and the results of appropriate diagnostic methods. These methods may include additional reports from other sources, criterion-referenced instruments such as

developmental checklists, a developmental history, language samples, criterion-referenced or norm-referenced instruments, observation of the child, play-based evaluations, and routine-based interviews. When the clinician is working with families for whom English is not the native language or when there is a language barrier, an interpreter must be involved. The evaluation must be completed in the native language of the family or in the language(s) most likely to result in an accurate representation of the child’s skills (DEC, 2014; IDEIA, 2011). Developmental Delay.  Each state determines criteria for developmental delays in its own way. Many states determine criteria quantitatively, including (a) the difference between chronological age and actual performance level expressed as a percentage of chronological age, (b) delay expressed as performance at a certain number of months below chronological age, or (c) delay as indicated by standard deviation below the mean on a normreferenced instrument. There is wide variability in the type of quantitative criteria states use to describe developmental delays and a wide range in the level of delay states require for eligibility. Common measurements of level of delay are 25% delay or two standard deviations (SD) below the mean in one or more developmental areas, or 20% delay or 1.5 SD in two or more areas. Traditional assessment instruments, yielding scores in standard deviations or developmental age in months, may not adequately address some developmental domains or may not be comparable across developmental domains or across age levels (Benn, 1994; Brown & Brown, 1993). For this reason, some states have included qualitative criteria for determining developmental delays, such as delays indicated by atypical development or observed atypical behaviors. Atypical Development.  Children are considered to have atypical development if they demonstrate abnormal or questionable sensory–motor responses (such as abnormal muscle tone, poor quality of movement patterns, or oral–motor skills dysfunction such as feeding difficulties) or have an identified affective disorder (such as a delay in achieving expected emotional milestones, a persistent failure to initiate or respond to most social interactions, or distress that does not respond to comforting by caregivers). Diagnosed Physical or Mental Condition.  A diagnosed physical or mental condition applies to children who have a high probability of exhibiting a developmental delay if EI services are not provided. This includes conditions such as chromosomal abnormalities, genetic or congenital disorders, severe sensory impairments, inborn errors of metabolism, disorders reflecting distur-



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bance of the development of the nervous system, congenital infections, disorders secondary to exposure to toxic substances including fetal alcohol syndrome, and severe attachment disorders. At Risk.  An at-risk infant or toddler is defined under Part C as “an individual under 3 years of age who would be at risk of experiencing a substantial developmental delay if EI services were not provided to the individual” (IDEIA, 2004, § 632[1]). Although many states are interested in serving children at risk, they also fear increasing the numbers of eligible children because of escalating costs. Two categories of risk that are frequently described by states that do serve these children include conditions of biological/medical risk (e.g., repeated infections or prenatal drug exposure) and environmental risk (e.g., history of abuse or neglect). When diagnostic assessment tools do not establish eligibility, the state lead agency must ensure that informed clinical opinion is independently considered to establish eligibility of services for children who are considered at risk (IDEIA, 2011). States that do not serve children at risk under their guidelines for eligibility typically indicate that they will monitor the development of these children and refer them for EI services if and when delays are manifested. Under Part C (IDEIA, 2004), young children who are English-language learners with typical development do not qualify for EI services. Dual-language learners who present with difficulties in developing their native language and a second language, however, may be eligible for services.

Assessment for Service Planning Assessment, as defined by Part C of IDEIA, includes “the ongoing procedures used by qualified personnel to identify the child’s unique strengths and needs and the early intervention services appropriate to meet those needs throughout the period of the child’s eligibility” (IDEIA, 2011, § 303.321[a][2]). This is a multistep process that includes identification of the family’s resources, priorities, and concerns through family-centered assessment, multidisciplinary team observations, and assessment of eligible children. In addition to assessing the family, assessment is also an opportunity to determine the child’s strengths and needs in all areas of development. The assessment process provides the IFSP team with an opportunity to identify EI supports and services that may be necessary to address the child’s unique needs. Although assessment tools may vary, ASHA (2023) recommends combining formal and informal assessment tools that include both standardized and nonstandardized measures to provide the most comprehensive picture of the child. This combination of assessment

tools provides information regarding the communication skills of the child in comparison to same-age peers. Conducting an assessment with a comprehensive battery is more conducive to encouraging family and team member participation and collaboration and to guiding the IFSP development. Some local and statewide systems have implemented specific requirements regarding the choice and use of assessment tools for the purposes of both eligibility determination and assessment for service planning.

Development of the Individualized Family Service Plan Based on the assessment for service planning, the IFSP is developed. The IFSP is a written plan for providing EI services to eligible children and their families. The plan is developed jointly by the family, the service coordinator, and others, such as the SLP, audiologist, physical therapist, nurse, and social worker, who may be providing EI services to the child and family. The IFSP is based on the multidisciplinary evaluation and assessment of the child and the assessment of the resources, priorities, and concerns of the child’s family. The plan includes outcomes, strategies, and services necessary to enhance the development of the child and the capacity of the family to meet the special needs of the child (IDEIA, 2004, § 303.340[2]). Part C of IDEIA mandates that the IFSP meeting must be conducted in settings and at times that are convenient to the family. The meeting and the documents must also be in the native language of the family, and an interpreter must be involved if the native language of the family is not English. The SLP or audiologist must work collaboratively with the interpreter to ensure families fully understand their rights and role in the EI system. There are eight required components of the IFSP (PL 108-446, Sec. 636[d]): 1. A statement of the infant’s or toddler’s present levels of physical development (including fine motor, gross motor, vision, hearing, and health status), cognitive development, communication development, social or emotional development, and adaptive (self-help) development based on objective criteria. This can be listed as an age level or a range. 2. A statement (with the family’s permission) of the family’s resources, priorities, and concerns related to enhancing the development of the family’s infant or toddler with a disability. Priorities may include the hopes and dreams of the family for their child. This statement may also include information

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about how the family would like its child to more fully participate in family and community activities. Resources include people in the family’s life whom they rely on and interact with. 3. A statement of the measurable results or outcomes expected to be achieved for the infant or toddler and the family. The statement should include emergent literacy and language skills that are developmentally appropriate for the child. The statement should also include the criteria, procedures, and timelines used to determine the degree to which progress toward achieving the results or outcomes is being made. Any modifications or revisions of the results/outcomes/services that may be necessary should be included. Outcomes are statements about what the family wants its child to learn or do. For example, an IFSP outcome may focus on the child learning to sit at the table with the family at dinner and eat with a spoon, walk around the block to the playground with the family in the evening, or say new words to tell the family what toys the child wants. Outcomes should be individualized for each child and family. As such, they should be contextualized, functional, and discipline free. Outcomes should be relevant to the family and focused on the whole child and his or her participation in activity settings that are important to the family. 4. A statement of specific EI services based on peer-reviewed research, to the extent possible, necessary to meet the unique needs of the infant or toddler and the family. The statement should include the frequency, intensity, and method of delivering services. Supports and services should be individualized. If a group of IFSPs is reviewed within a local system, the reviewer should see this individualization with varying services and supports being provided among IFSPs. EI services include, but are not limited to, service coordination, speech-language therapy, physical therapy, occupational therapy, special instruction, and assistive technology. All children must receive service coordination. Additional services are dependent upon many variables and often change over the course of the child’s involvement in EI. 5. A statement of the natural environments in which EI services will appropriately be provided. If the services will not be provided in a natural environment, a justification must be presented. Natural environments include locations where children live, learn, and play, and how they learn in those natural places.

6. The projected dates of initiation of services and the anticipated length, duration, and frequency of the services. Projected start dates must include the month, date, and year. 7. The identification of the service coordinator from the profession most immediately relevant to the child’s or family’s needs (or who is otherwise qualified to carry out all applicable responsibilities under this part). All families in EI have a service coordinator who is responsible for overseeing the IFSP, ensuring that all the IFSP services are provided and that changes in the IFSP are made when necessary. 8. The steps to be taken to support the transition of the toddler with a disability to preschool or other appropriate services. This transition plan must be individualized for each child. According to IDEIA § 303.344(d)(4), when addressing the needs of children who are at least 3 years of age and receiving services through the provisions in the 2011 IDEIA Part C Final Regulations, the IFSP must also include “an educational component that promotes school readiness and incorporates preliteracy, language, and numeracy skills” (IDEIA, 2011).

IFSP Implementation and Review Implementation and review of the IFSP involves the coordination and monitoring of the delivery of IFSP supports and services. EI services must begin within 30 days of the IFSP being written and agreed upon by the multidisciplinary team. Periodic reviews are held to facilitate IFSP changes as necessary. These changes may reflect the child’s development and any changes, including those that may be medical in nature, that occur in regard to a family’s priorities and concerns. IFSP reviews must take place at least once every 6 months or each time a child has either achieved a documented outcome or presents with a new area of need (IDEIA, 2004). Annual reviews must be completed within 365 days of the initial or previous annual IFSP meeting.

Transition Transition is the entry and exit of children and families to and from EI services. This is an ongoing process that begins with the child and family as they enter the system and ends when they transition from the EI program under Part C to the next program or other appropriate services identified for the child who is no longer eligible to receive Part C or Part B services. The service coordinator tends to be the provider who is primarily responsible



CHAPTER 13   Service Delivery in Early Intervention

for assisting families through the transition process. All service providers, however, including the SLP and audiologist, should be knowledgeable about the transition process. Transition should be discussed at every IFSP meeting. As the child approaches 30 months of age, the service coordinator should increase the level of detail of these discussions in preparation for the child aging out of the EI system at the age of 3 years. Under the Final Regulations (IDEIA, 2011), notice of transition must occur no fewer than 90 days before the toddler’s third birthday. Children transitioning from EI include those who no longer qualify for Part C supports and services prior to the age of 3 years, children who are turning 3 years old and whose parents do not want to pursue Part B services (essentially preschool services), and/or children who are between 2 and 3 years of age and are preparing to transition to Part B services. Under the Final Regulations (IDEIA, 2011), each state can choose to extend Part C services to children eligible for preschool services beyond the age of 3 until they enter or are eligible under state law to enter kindergarten. The state may choose to implement this option for children beyond 3 years of age until the beginning of the school year following their third, fourth, or fifth birthday. Currently, very few states are choosing this option. Regardless of their choice, each state must include a description of the policies and procedures in place to ensure an effective and seamless transition for young children from receiving EI services under Part C of IDEIA to preschool or other appropriate services or for those who are exiting the Part C program altogether. Transition plans look different for each child and are dependent on the child’s and family’s needs. Regardless of where the child transitions, there may be an adjustment for the child and family when leaving the Part C system. The SLP and audiologist may be able to help the family with this adjustment by discussing the process and being prepared to answer any questions about the transition from Part C services to preschool services (IDEIA Part B).

Service Coordination Under IDEIA Part C (2004), service coordination is defined as an active, ongoing process that assists and enables families to access services and ensures their rights and procedural safeguards. Part C mandates that every family in the EI system receives service coordination at no cost. In some states, the SLP or audiologist, as a member of the IFSP team, may assume the functions of the service coordinator. When they are not responsible for the service coordination role, it is still imperative that they understand this role within the system to effectively collaborate with the service coordinator.

The service coordinator’s primary function is to serve as the single point of contact for all team members, including the family, throughout the EI process (IDEIA, 2004). The service coordinator brings expertise to the EI team in navigation of the EI system, use of family-centered practices, connections between families and community resources, the fostering of strong family-professional partnerships, and facilitation and documentation of the EI process (Workgroup on Recommended Knowledge and Skills for Service Coordinators [RKSSC], 2020). Ultimately, service coordinators help the family identify and obtain needed services and assistance. Often, the service coordinator is the initial point of contact and may play the important role of assisting the family as they begin to understand and process the nature of their child’s disability and needs. The family’s first interactions with the service coordinator may have a significant influence on their level of trust and expectations of the EI system as a whole (Dunst et al., 2014; RKSSC, 2020). Once a referral has been made for EI services, a service coordinator is assigned to the family as quickly as possible and becomes actively involved in the IFSP process. Table 13–8 illustrates the tasks that a service coordinator must accomplish efficiently and effectively. The service coordinator supports the family members as they develop, implement, and monitor their intervention plan based on the IFSP. Service coordinators help families develop the knowledge and skills necessary to advocate for their children in the future. Service coordinators also access and coordinate resources and services for families. Ultimately, the service coordinator must ensure the EI services are family centered and collaborative among the multidisciplinary team members. When service coordination is not effective, families may not have a clear understanding of their child’s strengths or needs. They may be left to coordinate information and services from multiple sources on their own. In this case, intervention and transition are likely to be fragmented and the family may be unaware of all available resources. All service providers must communicate regularly with assigned service coordinators to ensure cohesion between their services and the needs of the children and families (ASHA, 2023b; RKSSC, 2020).

The Team Approach The EI system relies heavily on a team approach to service delivery. In addition to working closely with family members, SLPs and audiologists need to collaborate with service coordinators, specialists within other domains, physicians, and educators. Regardless of the severity of a child’s or family’s needs, services in EI include all types of resources or supports that the child needs and is eligible

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Table 13–8.  Service Coordination Tasks n

Informing the family of their rights and procedural safeguards as well as the various timelines specified by Part C of IDEA 2004 and the final regulations implemented in 2011

n

Establishing a collaborative relationship with the family

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Collecting information about family priorities, resources, and concerns, as well as daily routines and activities

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Supporting the family’s problem-solving skills as a course of action begins to develop

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Planning the developmental evaluation/assessment, formulating questions that reflect the family’s concerns, and addressing state eligibility standards with the family and the team members

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Compiling and integrating information from various sources to develop a comprehensive developmental profile of the child

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Facilitating communication among the various team members and the family to develop functional, meaningful outcomes based on the family’s and child’s daily routines and activities

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Ensuring intervention services are provided in a timely manner and are directly related to functional outcomes, and maintain communication and collaboration among team members to ensure outcomes are being addressed

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Coordinating early intervention and other services for the family (including educational, social, and medical supports and services that are not provided for diagnostic and evaluation purposes)

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Conducting referral and other activities to assist the family in identifying available providers

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Overseeing the evaluation and review of the IFSP and subsequently monitoring the services specified in the IFSP

n

Conducting follow-up activities with the family and the team members

n

Coordinating and frequently reviewing the child’s plan for transitioning from the early intervention system with the family

Source:  Adapted from American Speech-Language and Hearing Association. (2023). ASHA early intervention practice portal. https://www.asha.org/PRPSpecificTopic.aspx?-folderid=8589943999§ion=Key_Issues; Individuals With Disabilities Education Improvement Act. (2011). Part C Final Regulations. https://www.gpo.gov/fdsys/pkg/FR-2011-09-28/pdf/2011-22783.pdf; Workgroup on Recommended Knowledge and Skills for Service Coordinators. (2020). Knowledge and skills for service coordinators. https://tinyurl.com/KSSC-8-12-20Final

to receive (ASHA, 2023b). When team members communicate well with one another, all participants reap the benefits from the comprehensive services. Access to all necessary supports and services, the provision of skills and resources from multiple agencies, and the sharing of information and opinions across areas of expertise are just a few of the benefits of teams collaborating within the system. The integration of services, including the coordination of the team members, is critical to the effective nature of EI and is an essential element of familycentered and best practices to support young children and their families (Early Childhood Personnel Center, 2017). Collaboration among team members provides opportunity for the development and coordination of interventions that complement one another. Team

members who communicate well and collaborate across areas of expertise, including family members, benefit from joint professional development and consultation that results in enhanced knowledge and skills (Boyer & Thompson, 2014; Coufal & Woods, 2018). As discussed earlier, the roles and responsibilities of the service coordinator are central to successful communication among the team members. Part C of IDEIA 2004 requires members of the IFSP team to coordinate their approaches, consult with one another, and recognize that the child and family outcomes are a responsibility to be shared by the entire team. Collaboration is dependent upon the type of team model that is used, the lead agency’s program guidelines, and the knowledge and skills of the individual team members (ASHA, 2023b). Although collaboration among team members



CHAPTER 13   Service Delivery in Early Intervention

may vary, professional communication with the family is essential. Part C of IDEIA 2004 uses the term “multidisciplinary” to describe the EI team approach, though other team models may be applied depending on the needs of the child and family. Three team models are commonly used within EI. In addition to multidisciplinary teams, interdisciplinary and transdisciplinary team models may be options within the local and/or state service delivery systems. Each one of these types of teams is different in the amount of communication and coordination required among team members (Paul-Brown & Caperton, 2001). Regardless of the model chosen, SLPs and audiologists are often integral members of these teams. Multidisciplinary Teams.  In a multidisciplinary approach, service providers from different disciplines (e.g., physical therapy, occupational therapy, and audiology) assess and/or provide intervention to the family and child separately. Each provider completes an evaluation and/or assessment and makes recommendations independently of the other disciplines. Although several providers may be involved with the family, each professional works distinctly and separately in providing services. Team members focus on their own disciplines and subsequent perspectives and do not tend to engage in collaborative planning or service provision. The service coordinator is typically a designated position within this type of team. Unfortunately, because collaboration among team members is often limited, cohesion of services may be affected (Paul & Roth, 2010). As stated earlier, Part C of IDEIA (2011) requires a multidisciplinary composition of the IFSP team, including the parent and two or more individuals from separate disciplines or professions, with one of the individuals being the service coordinator. Interdisciplinary Teams.  Interdisciplinary teams have a greater focus on collaboration and communication. Typically, providers from various disciplines conduct the evaluation and/or assessment with the child and family individually; occasionally, an “arena” method of evaluation, in which multiple team members are present during the evaluation and/or assessment, may also be conducted. The team members then communicate with one another and integrate the findings to determine the needs, recommendations, and services for the child and their family (Paul & Roth, 2010). Transdisciplinary Teams.  The transdisciplinary team model involves a greater degree of collaboration among team members than the other service models. This approach is often more difficult to implement because of the need for increased collaboration and communi-

cation. However, it is the model that IDEIA (2011) expects to be utilized to support the design and delivery of services for children with disabilities and delays and their families (Paul et al., 2006). The transdisciplinary approach requires the team members to share roles and systematically cross discipline boundaries. The purpose of the approach is to pool and integrate the expertise of team members so that more efficient and comprehensive assessment and intervention services are provided. Communication among team members involves continuous give and take from all members on a consistent basis. Evaluation and assessment, as well as intervention services, are typically conducted jointly by designated members of the team assigned to the child/family; one team member will then serve as the primary service provider and will provide direct services that relate to all of the developmental disciplines for the child and family (Paul et al., 2006; Paul & Roth, 2010). The most current and collaborative approach in early intervention, and a combination of the layers of teamwork as presented above, is interprofessional education (IPE) and interprofessional collaborative practice (IPP). Consistent with the World Health Organization (WHO) definitions, ASHA defines IPE as an activity that occurs when two or more professions learn about, from, and with each other to enable effective collaboration and improve outcomes for individuals and families. ASHA defines IPP as a service that occurs when multiple service providers from different professional backgrounds provide comprehensive health care or educational services by working with individuals and their families, caregivers, and communities to deliver the highest quality of care across settings (ASHA, 2021). Early intervention is an interdisciplinary field with a history of collaborative teamwork that consistently contributes to and benefits from IPP. SLPs need to engage with other service providers and family members within the early intervention system through interprofessional collaboration to ensure effective and meaningful service delivery. As members of interprofessional teams, your contributions may vary depending on the knowledge and skills you possess as well as those represented by other service providers and professionals on the team. The Interprofessional Education Collaborative (IPEC, 2016) presents guiding principles and core competencies that intersect with the collaborative team approach required within early intervention services to provide the highest quality of services. The IPEC core competencies define the goals and outcomes for both preprofessional preparation and professional practice across disciplines. To provide effective services in early intervention, SLPs must embrace and demonstrate services that are defined and delivered by the framework of these competencies.

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Services Based on the Highest Quality of Evidence Part C services under IDEIA were created to enhance the development of infants and toddlers with disabilities, to minimize potential developmental delay, and to reduce educational costs to society by minimizing the need for continuing special education services as children with disabilities reach school age (IDEIA 2004, § 1400[20]). EI practices are based on the integration of the highest quality and most recent research, informed professional judgment and expertise, and family preferences and values (DEC, 2014). This is the fifth guiding principal, using the highest quality of evidence available to support the provision of the most effective EI services. The foundation of support for practice includes both internal and external evidence. Internal evidence is based on policy, informed clinical opinion, values and perspectives of professionals and consumers, and professional consensus; external evidence is drawn from empirical research published in peer-reviewed journals. All of these considerations are evaluated in the delivery of EI services to realize positive outcomes for infants, toddlers, and their families (DEC, 2014).

Evidence Supporting Routines-Based Intervention As stated earlier, the first guiding principle that reflects current best practices of SLPs and audiologists in EI addresses the delivery of family-centered services (ASHA, 2023b). This practice involves working collaboratively with families in all aspects of EI. A family-centered approach recognizes the importance of all family members and involves the awareness and inclusion of the beliefs, values, principles, and practices that strengthen the family’s capacity to enhance their child’s development and learning (IDEIA, 2004). Effective family-centered practices are responsive to the unique circumstances of each family and provide families with unbiased and comprehensive information to make informed decisions (DEC, 2014). Routines-based intervention (RBI) is an approach that builds the capacity of the family to address the child’s strengths and needs by embedding instruction within the context of a family’s everyday activities and routines (Florida State University, 2011; McWilliam, 2010a; Salisbury et al., 2018). SLPs and audiologists who practice RBI collaborate with other providers, family members, caregivers, and teachers to develop childspecific strategies that are practiced within the family’s natural environment (McWilliam, 2010a, 2010b, 2016; Raver & Childress, 2015; Salisbury et al., 2018). Rather than bringing toys, books, and other materials into the natural environment, RBI emphasizes family-focused

and family-implemented intervention using toys and objects from the family’s own home or other natural environments. Implementation of this strategy encourages practice and facilitates generalization of the strategies used within treatment sessions between sessions (Crawford & Weber, 2014; Friedman et al., 2012; Woods et al., 2004). Audiologists and SLPs who incorporate RBI in their EI practice establish techniques, such as naturalistic language facilitation and/or swallowing strategies, that families can use to maximize the child’s development and learning within their everyday routines and activities (Dunst et al., 2012). These techniques are based on collaboration with the parents, family, caregivers, and other providers to identify typical learning opportunities in the child’s home and community; determine the child’s interests, strengths, and motivation within their daily routines; and create communication and participation goals during learning opportunities (Dunst et al., 2012).

Evidence Supporting the Coaching Model EI SLPs and audiologists may often find it easier to simply do it themselves. Working intentionally with parents, family members, and caregivers to strengthen their knowledge and skills to effectively engage with their child, however, has a significant impact on their development of the child(ren) in their care (CDCHU, 2016). Effective EI providers empower families when they coach caregivers to support their child in their natural environments (Hanft et al., 2004; Rush & Sheldon, 2011). With the shift to family-centered services under IDEIA Part C in 2004, there was a subsequent change from direct one-on-one intervention with the child and to implementation of an early childhood coaching model. The evidence gathered over the past decade continues to support this model in practice today (CDCHU, 2016; DEC, 2014; Hanft et al., 2004; Rush & Sheldon, 2011). Coaching models focus on family-implemented interventions and collaborative consultation between the service providers and the family members. Coaching in EI is an adult learning strategy intended to build the family’s capacity to enhance their child’s development using everyday interactions and activities. EI providers support families during visits by joining the family in their routines and activities and coaching caregivers as they practice using intervention strategies with their children (Rush & Sheldon, 2011). During the initiation of the coaching process, the door is opened to engage in a conversation regarding this approach. The SLP or audiologist and the parent develop a plan together that includes the purpose and specific outcomes of the coaching. As noted previously, the purpose within EI is typically to support the child’s participation and development in



CHAPTER 13   Service Delivery in Early Intervention

ordinary family and community life. Following the initial discussion, the SLP or audiologist may choose to observe the parents as they use an existing strategy, try out a new skill, or demonstrate a skill that has been used between visits. The SLP or audiologist may also observe the parent engaging in an activity with the child. When the SLP or audiologist has an opportunity to see the parent and child interact, it allows them to (a) see what the parent or family member is doing well and (b) offer additional suggestions and/or modifications. Such active guidance provides an opportunity to build partnerships with families. These partnerships enhance the family members’ effectiveness as they engage in everyday learning opportunities with their children (Rush & Shelden, 2011; Shelden & Rush, 2001). Table 13–9 illustrates five research-based practice characteristics and strategies for implementation by a provider that lead to the intended outcomes of coaching in EI.

Other Considerations for Early Intervention Services in Natural Environments When intervening with families, SLPs and audiologists must be able to establish and maintain rapport as well as professional boundaries, gather information, and handle difficult situations, including reporting suspected child

abuse and neglect. These topics will be discussed next. SLPs and audiologists must also be flexible in their approaches to these activities, as each family requires a unique approach to benefit from EI.

General Safety and Health Considerations Providing best practices and quality services are priorities for SLPs or audiologists in EI. Since these best practices mean providing services primarily in settings that are natural to the family, it is important that the provider consider their own personal safety and other issues unique to providing services outside of clinic- or centerbased settings. Visiting families in natural environments means clinicians are often on their own in unfamiliar locations. It is important that the SLP or audiologist share their schedule with others, including the dates and times during which they will be at specific locations. It is also a good idea for the provider to keep a cell phone with them for safety purposes when engaged in visits; they should keep the ringer turned off in respect for the family they are visiting. Visiting families with another staff person is also considered appropriate, particularly when a provider feels uncomfortable in an environment on their own. Maintaining their own safety ensures the SLP or audiologist will have the opportunity to effectively share their knowledge and skills with families.

Table 13–9.  Characteristics and Roles of Providers When Coaching in Early Intervention Joint planning

At the beginning of the visit, discuss the plan and goals from the last visit with the family members. Encourage the family to share what they have tried with their child as well as what did and did not work.

Observation

Watch the family members as they play, interact, and engage in their everyday routines and/ or activities with the child. You might show them a strategy to use and encourage them to try the strategy with the child while you observe.

Action

Help the family practice new ways to help their child meet their goals within the context of their everyday routines and activities. Encourage the family to consider ways to implement the strategies together.

Reflection

Ask questions about what the family members have already tried with their child and what is typical for their family. Listen to the family and discuss what has already worked, what has not worked, and why their efforts have or have not been successful.

Feedback

In response to the family’s reflections, share information, including thoughts, ideas, and feedback that might facilitate the determination of additional strategies to best support the family as they work with their child to meet their goals.

Joint planning

At the end of the visit, work with the family to come up with a specific plan to address the child’s goals between now and the next visit. Schedule your next visit.

Source:  Adapted from Rush, D. D., & Sheldon, M. L. (2011). The early childhood coaching handbook.

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Table 13–10 provides additional safety tips for EI visits in natural environments. Additional information regarding safety in the workplace is available in Chapter 18. The SLP or audiologist should also take precautions to consider the health and wellness of all participants when engaging in EI visits. There are a number of ways in which a provider can protect themselves, the child, and the family members. These include washing hands before and after the EI session, wearing a mask during the visit, particularly if anyone is not feeling well or has recently recovered from COVID-19, and practicing social distancing between the provider and family members. When possible, the EI visit might be held outside to limit close contact between individuals in an indoor environment; effective outdoor natural environments in which to connect with children and families may include a backyard, playground, or open space in the neighborhood.

Maintaining Professional Boundaries Establishing and maintaining a relationship with families while upholding professional boundaries can be tricky for the SLP and audiologist. To build rapport, sharing some personal information can be helpful when

getting to know the family. Knowing what is appropriate to share and how much, and how to handle situations when families want more information about the clinician are important considerations when working closely with families. Another aspect of maintaining professional boundaries involves knowing how deeply to become involved in a family member’s personal life. Parents often share a great deal about their lives with the SLP or audiologist, particularly when presented with challenging circumstances. It is ultimately the provider’s responsibility to know when they are becoming too involved. When professional boundaries are crossed, it becomes difficult to serve the family objectively and in a manner that makes them feel empowered to help themselves.

Reporting Child Abuse and Neglect EI personnel, including SLPs and audiologists, are mandated reporters of suspected child abuse or neglect in all states. As a mandated reporter, service providers are required to report suspected child abuse or neglect. Although it is an aspect of the job that, hopefully, SLPs and audiologists do not have to think about often, reporting suspected child abuse or neglect is always diffi-

Table 13–10.  Safety Strategies for Visits in Natural Environments n

Always keep a cell phone with you on visits in natural environments.

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Keep your car keys in your pocket or on your body; do not leave them on a table or place them on the floor.

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Be aware of your clothing; dress in comfortable clothing and limit jewelry.

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Do not take a purse into a family’s home. Put your purse or any personal belongings in the trunk of the car prior to arriving at your destination.

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Clearly document your visits, particularly if anything or anyone makes you uncomfortable or causes you concern. Discuss these concerns with your supervisor immediately.

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Visit families who live in areas where safety is a concern with another provider.

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Avoid making visits on Friday afternoons or on the first or last day of the month to areas where safety is a concern (as the arrival of paychecks or federal aid checks may cause an increase in the number of people in the area). Consider morning visits to these areas whenever possible.

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Survey the area thoroughly before leaving the car or the home; look all around for any signs of danger.

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When possible, park on the street rather than in the driveway (to ensure your car will not be blocked in by other vehicles).

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When walking to your car, have your keys available.

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Make eye contact and be friendly with people as you walk to/from a family’s home; become a familiar face in the neighborhoods in which you provide services.

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Be aware of your limits and ask for help when needed. Trust your instincts; if you feel uncomfortable in a home or in a situation, excuse yourself and leave.

Source:  Adapted from Partnership for People With Disabilities. (2010). Kaleidoscope: New perspectives in service coordination.



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cult. Therefore, it is important that the clinician become familiar with how to make a report in their area, what information Child Protective Services (CPS) needs, and any documentation required when making a report. They should also be aware of internal policies within their agency for making CPS reports. Refer to Chapter 20 for additional considerations regarding child mistreatment.

Managing an Unclean Environment Each environment in which the SLP or audiologist provides services may present a different level of cleanliness. The challenge that faces providers is to maintain the balance between respect for the family and comfort for themselves while providing services in these environments. Table 13–11 provides some considerations to increase comfort while providing family-centered services.

Challenges and Evidence-Based Practices for Remote Service Delivery Multiple terms are used to describe the methodology in which services are provided to young children and families through video or audio technology to connect service providers and educators with parents and/or other caregivers in ways that support their child’s development throughout their everyday activities and routines. These terms include “remote service delivery,” “remote learning,” “distance learning,” “telehealth,” “teletherapy,”

“telepractice,” “virtual home visits,” and “virtual learning” (Poole et al., 2020). Telehealth is the most common term used when addressing reimbursement of live video conferencing under Medicaid and private health insurance plans. Therefore, the term remote service delivery will be used to discuss the range of services provided via technology, and the term telehealth will be used to discuss the use of video conferencing to provide services in EI (Poole et al., 2022). In early 2020, assessment and service delivery in EI via remote service delivery and/or telehealth was possible with advanced tools; several remote training programs for families, caregivers, and service providers; protocols for direct clinical services; and evidence to support these practices in place (Buzhardt & Meadan, 2022). At that point in time, these protocols and processes were viewed as an option to expand access to evidencebased practices to more people regardless of location; in some cases, telehealth was seen as a way in which services could be expanded at a lower cost. These practices were typically used in special circumstances and with specific populations, including families who lived in remote areas or those who were restricted in participating in home visits. In the spring of 2020, however, the landscape changed when the COVID-19 pandemic forced EI programs to stop or severely limit face-to-face interactions between children, families, caregivers, and providers. Suddenly, there was an immediate need for remote and telehealth services, including screening and diagnostics, direct intervention services, clinical consultation, professional development and training, assessment administration, and support for services in natural

Table 13–11.  Considerations to Increase Comfort in an Unclean Environment n

Wear clothing that can be easily laundered.

n

Keep a change of clothing in the car.

n

Keep hand sanitizer in the car and approved disinfecting wipes in the trunk to clean any toys or materials after the visit.

n

Bring a large book or small blanket to spread out on the floor on which everyone can sit and play.

n

Remember that you are in someone’s home and, although it may not be as clean as your standards, it may suit the family’s standards.

n

Recognize that, if the unclean environment is truly a health hazard to the child (e.g., roaches in the child’s bedroom, spoiled formula in the infant’s bottle, an unsafe heating element), you will need to communicate with the family about the issue and offer to assist in finding a solution. If the family is unable or unwilling to act to correct the health hazard, you may need to file a report with Child Protective Services.

Source:  Adapted from Partnership for People With Disabilities. (2010). Kaleidoscope: New perspectives in service coordination.

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environments (Buzhardt & Meadan, 2022). Over the past 3 years, the demand for remote services and telehealth in EI has resulted in swift, widespread changes in how infants, toddlers, and their families receive services. These changes have included the ways in which technology is used to provide access across diverse populations, practical considerations that providers need to consider, and the evidence that has emerged to support the ways in which SLPs and audiologists should provide remote services in EI. When technology is used to provide any remote services in EI, it is imperative that it is used in an effective way for all participants. Although the most commonly used service to support remote EI services has been telehealth, or live video conferencing, this service requires broadband internet access by all participants. Because not all families, caregivers, or service providers have adequate resources to support remote engagement, other approaches should be considered (Poole et al., 2022). These remote approaches may include web-based training modules, email and/or text communications between telehealth sessions, telephone consultations, and the creation of videos by parents and caregivers for review and later coaching and/or feedback. Many families may also find these remote alternatives to telehealth to be as or more effective as either an alternative or supplement to video conferencing. Both the Division for Early Childhood (2020) and the Early Childhood Technical Assistance Center (2020) have published recommendations related to features of video conferencing platforms to consider for use in EI (Edelman, 2020). In addition to using those approaches that are accessible and effective for all participants, there are several practical considerations that must be considered when providing remote services in EI. These include updates to the sources of funding that support services. The DEC (2020) and the Early Childhood Technical Assistance Center (2020) have compiled resources to support the navigation of billing for telehealth services through Medicaid and private insurance. The Centers for Medicare and Medicaid Services (2020) have also expanded the types of telehealth services that are now reimbursable, including EI services. An additional practical consideration involves the secure delivery of remote services. While it is important to protect the personal information of all participants when engaging in telehealth, families may have limited home resources that do not adhere to strict HIPAA security requirements. Within the past 2 years, in response to the overwhelming need for telehealth services during the pandemic, the Department of Health and Human Services stated that providers “may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom,

or Skype, to provide telehealth without risk [of ] penalty for noncompliance with the HIPAA Rules Delivering services securely” (Health and Human Services, 2020). Regarding best practices employed by SLPs and audiologists when engaging in remote service delivery, recent literature presents evidence that telehealth can be an effective alternative and/or supplement to face-to-face methods to provide diagnostic and assessment services (Ferguson et al., 2019; Greenwood et al., 2022; Wallisch et al., 2019). According to the literature, SLPs and audiologists primarily use the coaching approach when providing remote services to provide parents, caregivers, and even siblings with strategies that can be embedded into their everyday routines and activities to promote the child’s engagement, development, and learning; current research also supports parent coaching and/or direct intervention services in the EI arena (Akemoglu et al., 2022; McCarthy et al., 2019; Poole et al., 2022)

Summary EI is a federally mandated system that operates under IDEIA. The system, which has been restructured multiple times since its inception in 1997, authorizes services to meet the needs of infants and toddlers, and their families, from birth to age 3 years who have been or may be at risk for developmental delays or disabilities. In 2008, ASHA presented five guiding principles that continue to reflect best practices for SLPs and audiologists who are providing EI services to young children and their families. This chapter discussed how each of those five guiding principles may be effectively implemented by SLPs and audiologists within the EI system. Cultural competence, including the definitions and the considerations that influence the provision of effective and appropriate services, was addressed. This chapter defined family-centered practices based on the family systems model and presented the rationale for incorporating natural environments and embedding routines and everyday activities into the provision of EI services. Each step of the EI process, including final regulations and considerations regarding eligibility and the creation of the IFSP, was presented and discussed. The chapter outlined the team approach to EI, different team formats, and the basic considerations for each type of team. Evidence to support the basis of EI and the inclusion of both routines-based intervention and coaching in service delivery were also presented. This chapter offered general advice for providing best practices within natural environments and suggestions for establishing a positive and safe work environment. Finally, current challenges and evidence-based practices related to remote service delivery were presented and discussed.



CHAPTER 13   Service Delivery in Early Intervention

References Agner, J. (2020). Moving from cultural competence to cultural humility in occupational therapy: A paradigm shift. The American Journal of Occupational Therapy, 74(4), 7404347010p1–7404347010p7. https://doi.org/10.5014/ajot​.2020​.038067 Akemoglu, Y., Hinton, V., Laroue, D., & Jefferson, V. (2022). A parent-implemented shared reading intervention via telepractice. Journal of Early Intervention, 44(2), 190–210. Alfuraydan, M., Croxall, J., Hurt, L., Kerr, M., & Brophy, S. (2020). Use of telehealth for facilitating the diagnostic assessment of autism spectrum disorder (ASD): A scoping review. PLoS ONE, 15(7), Article e0236415. American Speech-Language-Hearing Association (ASHA). (2006). Roles, knowledge, and skills: Audiologists providing clinical services to infants and young children birth to 5 years of age. https://www​ .asha.org/policy/ks2006-00259/ American Speech-Language-Hearing Association (ASHA). (2013). Supplement to the JCIH 2007 position statement: Principles and guidelines for early intervention following confirmation that a child is deaf or hard of hearing. https://www.asha.org/policy/ ps2013-00339/ American Speech-Language-Hearing Association (ASHA). (2016). Scope of practice in speechlanguage pathology. https://www.asha.org/policy/ sp2016-00343/ American Speech-Language-Hearing Association. (2021). 2021 Demographic Profile of ASHA Members Providing Multilingual Services. https:// www.asha.org/siteassets/surveys/demographicprofile-bilingual-spanish-service-members.pdf American Speech-Language-Hearing Association (ASHA). (2023a). Code of ethics. https://www.asha​ .org/policy/et2016-00342/ American Speech-Language-Hearing Association (ASHA). (2023b). Early intervention practice portal. https://www.asha.org/PRPSpecificTopic. aspx?-folderid=8589943999§ion=Key_Issues Balthrop, C., & Coleman, W. (2003, March). Why is Suzy so weird? Understanding cultural differences in the classroom [Conference session]. Virginia Association for Early Childhood. Benn, R. (1994). Conceptualizing eligibility for early intervention services. In D. M. Bryant & M. A.

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COVID-19 version. https://www.medicaid.gov/ medicaid/benefits/downloads/medicaid-chiptelehealth-toolkit.pdf Coufal, K. L., & Woods, J. J. (2018). Interprofessional collaborative practice in early intervention. Pediatric Clinics, 65, 143–155. https://doi.org/10.1016/j.pcl​ .2017.08.027 Crawford, M. J., & Weber, B. (2014). Early intervention every day! Embedding activities in daily routines for young children and their families. Brookes. Division for Early Childhood (DEC). (2014). DEC recommended practices in early intervention/early childhood special education 2014. http://www.decsped.org/recommendedpractices Division for Early Childhood (DEC). (2020). Resources to support early intervention and early childhood special education during the COVID-19 outbreak. https://www.dec-sped.org/covid-19 Dunst, C. J. (2017). Family systems early childhood intervention. In H. Sukkar, J. Kirby, & C. J. Dunst (Eds.), Early childhood intervention: Working with families of young children with special needs (pp. 36– 58). Routledge. Dunst, C. J., Bruder, M. B., & Espe-Sherwindt, M. (2014). Family capacity-building in early childhood intervention: Do context and setting matter? School Community Journal, 24(1), 37–48. https://files.eric​ .ed.gov/fulltext/EJ1032240.pdf Dunst, C. J., Bruder, M. B., Trivette, C. M., Hamby, D., Raab, M., & McLean, M. (2001). Characteristics and consequences of everyday natural learning opportunities. Topics in Early Childhood Special Education, 21(2), 68–91. https://doi.org/10.1177/​ 027112140102100202 Dunst, C. J., Raab, M., & Trivette, C. M. (2012). Characteristics of naturalistic language intervention strategies. Journal of Speech-Language Pathology & Applied Behavior Analysis, 5, 8–16. https://www .thefreelibrary.com/Characteristics+of+naturalistic+ language+intervention+strategies.-a0299887454 Dunst, C. J., & Trivette, C. M. (2009). Capacity building family-systems intervention practices. Journal of Family Social Work, 12, 119–143. https:// doi.org/10.1080/10522150802713322 Early Childhood Learning & Knowledge Center. (2023). Creating bright futures: Building relationships with families [Facilitator’s guide]. https:// eclkc.ohs.acf.hhs.gov/children-disabilities/ inclusion-children-disabilities-training-guide/

creating-bright-futures-building-relationshipsfamilies Early Childhood Personnel Center. (2017). Crossdisciplinary competencies. https://ecpcta.org/ cross-disciplinary-competencies/ Early Childhood Technical Assistance Center. (2020). Remote service delivery and distance learning. https:// ectacenter.org/topics/disaster/tele-intervention.asp Edelman L. (2020). Planning for the use of video conferencing for early intervention home visits during the COVID-19 pandemic. https://ectacenter.org/ ~pdfs/topics/disaster/Planning_for_the_Use_of_ Video_Conferencing_in_EI_during_COVID-19​_ Pandemic.pdf Ferguson, J., Craig, E. A., & Dounavi, K. (2019). Telehealth as a model for providing behaviour analytic interventions to individuals with autism spectrum disorder: A systematic review. Journal of Autism and Developmental Disorders, 49(2), 582–616. Friedman, M., Woods, J., & Salisbury, C. (2012). Caregiver coaching strategies for early intervention providers: Moving toward operational definitions. Infants & Young Children, 25(1), 62–82. https:// doi.org/10.1097/IYC.0b013e31823d8f12 Galindo, C., & Sheldon, S. B. (2012). School and home connections and children’s kindergarten achievement gains: The mediating role of family involvement. Early Childhood Research Quarterly, 27(1), 90–103. https://doi.org/10.1016/j.ecresq​ .2011.05.004 Greenwood, C., Higgins, S., McKenna, M., Buzhardt, J., Walker, D., Ai, J., . . . Grasley-Boy, N. (2022). Remote use of individual growth and development indicators (IGDIs) for infants and toddlers. Journal of Early Intervention, 44(2), 168–189. Guralnick, M. J. (2011). Why early intervention works: A systems perspective. Infants & Young Children, 24, 6–28. https://doi.org/10.1097/IYC​ .0b013e3182002cfe Hanft, B. E., Rush, D. D., & Shelden, M. L. (2004). Coaching families and colleagues in early childhood. Brookes. Hanson, M. J., & Lynch, E. W. (1990). Honoring the cultural diversity of families when gathering data. Topics in Early Childhood Special Education, 10(1), 112–132. https://doi.org/10.1177/02711214900​ 1000109 Health and Human Services. (2020). Notification of enforcement discretion for telehealth remote communi-



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cations during the COVID-19 nationwide public health emergency. https://www.hhs.gov/hipaa/ for-professionals/special-topics/emergencypreparedness/notification-enforcement-discretiontelehealth/index.html Hebbeler, K., Greer, M., & Hutton, B. (2011). From then to now: The evolution of Part C. Zero to Three Journal, 31, 4–10. Hebbeler, K., Spiker, D., Bailey, D., Scarborough, A., Mallik, S., Simeonsoon, R., . . . Nelson, L. (2007). Early intervention for infants & toddlers with disabilities and their families: Participants, services, and outcomes. National Early Intervention Longitudinal Study (NEILS). https://www.sri​ .com/wp-content/uploads/2021/12/neils_final​ report_200702.pdf Hopf, S. C., Crowe, K., Verdon, S., Blake, H. L., & McLeod, S. (2021). Advancing workplace diversity through the culturally responsive teamwork framework. American Journal of Speech-Language Pathology, 30(5), 1949–1961. https://doi.org/​ 10.1044/2021_AJSLP-20-00380 Individuals With Disabilities Education Improvement Act (IDEIA), Pub. L. No. 108-446, § 632, 118 Stat. 2744 (2004). http://idea.ed.gov/ Individuals With Disabilities Education Improvement Act (IDEIA). (2011). Part C final regulations. 34 C.F.R. §§ 303. https://www.gpo.gov/fdsys/pkg/ FR-2011-09-28/pdf/2011-22783.pdf Interprofessional Education Collaborative. (2016). Core competencies for interprofessional collaborative practice: 2016 update. Interprofessional Education Collaborative. https://ipec.memberclicks.net/ assets/2016-Update.pdf Joint Committee on Infant Hearing (JCIH). (2007). Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics, 120(4), 898–921. https:// pediatrics.aappublications.org/content/120/4/898 Jung, L. A., & Grisham-Brown, J. (2006). Moving from assessment information to IFSPs: Guidelines for a family-centered process. Young Exceptional Children, 9(2), 2–11. https://doi.org/10.1177/1096​ 25060600900201 Kashinath, S., Woods, J., & Goldstein, H. (2006). Enhancing generalized teaching strategy use in daily routines by parents of children with autism. Journal of Speech, Language, and Hearing Research, 49, 466–485. https://doi.org/10.1044/1092-4388​ (2006/036)

Landa, R., Holman, K., O’Neill, A., & Stuart, E. (2010). Intervention targeting development of socially synchronous engagement in toddlers with autism spectrum disorder: A randomized controlled trial. Journal of Child Psychology and Psychiatry, 52(1), 13–21. https://doi:10.1111/j.1469-7610​ .2010.02288.x Ma, X., Shen, J., Krenn, H. Y., Hu, S., & Yuan, J. (2016). A meta-analysis of the relationship between learning outcomes and parental involvement during early childhood education and early elementary education. Educational Psychology Review, 28(4), 771–801. https://doi.org/10.1007/ s10648-015-9351-1 McCarthy, M., Leigh, G., & Arthur-Kelly, M. (2019). Telepractice delivery of family-centered early intervention for children who are deaf or hard of hearing: A scoping review. Journal of Telemedicine and Telecare, 25(4), 249–260. McManus, B. M., Richardson, Z., Schenkman, M., Murphy, N. J., Everhart, R. M., Hambidge, S., & Morrato, E. (2020). Child characteristics and early intervention referral and receipt of services: A retrospective cohort study. BMC Pediatrics, 20(1), 1–10. http://dx.doi.org/10.1186/s12887-020-1965-x McWilliam, R. A. (2004). Early intervention where it counts: Natural environments. All Together Now!, 10(3), 3–6. McWilliam, R. A. (2010a). Routines-based early intervention: Supporting young children and their families. Brookes. McWilliam, R. A. (2010b). Assessing families’ needs with the routines-based interview. In R. A. McWilliam (Ed.), Working with families of young children with special needs (pp. 27–60). Guilford Press. Pacer Center. (2020). Natural environments support early intervention services. https://www.pacer.org/ parent/php/PHP-c178.pdf Partnership for People With Disabilities. (2010). Kaleidoscope: New perspectives in service coordination [Trainer’s notebook]. Virginia Commonwealth University. Paul-Brown, D., & Caperton, C. J. (2001). Inclusive practices for preschool-aged children with specific language impairment. In M. J. Guralnick (Ed.), Early childhood inclusion: Focus on change (pp. 433– 463). Brookes. Paul, D., Blosser, J., & Jakubowitz, M. (2006). Principles and challenges for forming successful

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literacy partnerships. Topics in Language Disorders, 26(1), 5–23. Paul, D., & Roth, F. (2010). Guiding principles and clinical applications for speech-language pathology practice in early intervention [Electronic version]. Language, Speech, and Hearing Services in Schools. https://doi.org/10.1044/0161-1461(2010/09-0079) Peña, E., & Fiestas, C. (2009). Talking across cultures in early intervention: Finding common ground to meet children’s communication needs. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, 16, 79–85. https://doi.org/10.1044/cds16.3.79 Peredo, T. N. (2016). Supporting culturally and linguistically diverse families in early intervention. Perspectives of the ASHA Special Interest Groups, 1(1), 154–167. https://doi.org/10.1044/persp1​ .SIG1.154 Poole, M. E., Fettig, A., McKee, R. A., & Gauvreau, A. N. (2022). Inside the virtual visit: Using tele-intervention to support families in early intervention. Young Exceptional Children, 25(1), 3-14. https://doi.org/10.1177/1096250620948061 Powell, D. R., Son, S. H., File, N., & San Juan, R. R. (2010). Parent–school relationships and children’s academic and social outcomes in public school prekindergarten. Journal of School Psychology, 48(4), 269–292. https://doi.org/10.1016/j.jsp.2010.03​ .002 Puig, V. I. (2012). Cultural and linguistic alchemy: Mining the resources of Spanish-speaking children and families receiving early intervention services. Journal of Research in Childhood Education, 26(3), 325–345. https://doi.org/10.1080/02568543.2012​ .684421 Raspa, M., Bailey, D. B., Olmsted, M. G., Nelson, R., Robinson, N., Simpson, M. E., & Houts, R. (2010). Measuring family outcomes in early intervention: Findings from a large-scale assessment. Exceptional Children, 76(4), 496–510. https://doi​ .org/10.1177/001440291007600407 Raver, S. A., & Childress, D. C. (2015). Familycentered early intervention: Supporting infants and toddlers in natural environments. Brookes. Roberts, M. Y., Hensle, T., & Brooks, M. K. (2016). More than “Try this at home”— including parents in early intervention. Perspectives of the ASHA Special Interest Groups, 1(1), 130–143. https://doi​ .org/10.1044/persp1.SIG1.130

Ross, K. D. (2018). Speech-language pathologists in early childhood intervention: Working with infants, toddlers, families, and other care providers. Plural Publishing. Rush, D. D., & Shelden, M. L. (2011). The early childhood coaching handbook. Brookes. Saldaña, D. (2001). Cultural competency: A practical guide for mental health service providers. Hogg Foundation for Mental Health. Salisbury, C., Woods, J., Snyder, P., Moddelmog, K., Mawdsley, H., Romano, M., & Windsor, K. (2018). Caregiver and provider experiences with coaching and embedded intervention. Topics in Early Childhood Special Education, 38(1), 13–29. Searcy, K. L. (2018). Funding and documentation for early intervention (0 to 3 years). In N. Swigert (Ed.), Documentation and reimbursement for speechlanguage pathologists: Principles and practice (pp. 251– 291). Slack Incorporated. Segal, R., & Beyer, C. (2006). Integration and application of a home treatment program: A study of parents and occupational therapists. American Journal of Occupational Therapy, 60, 500–510. https://doi.org/10.5014/ajot.60.5.500 Shelden, M. L., & Rush, D. D. (2001). The ten myths about providing early intervention services in natural environments. Infants and Young Children, 14(1), 1–13. Shelden, M. L., & Rush, D. D. (2010). A primarycoach approach to teaming and supporting families in early childhood intervention. In R. McWilliam (Ed.), Working with families of young children with special needs (pp. 175–202). Guilford Press. Shelden, M. L., & Rush, D. D. (2013). The early intervention teaming handbook: The primary service provider approach. Brookes. Trivette, C. M., & Dunst, C. J. (2007). Capacity building family-centered help-giving practices. Winterberry Research Reports, 1, 1–10. https:// www.wbpress.com/shop/capacity-building-familycentered-helpgiving-practices/ Turnbull, A. P., Summers, J. A., Turnbull, R., Brotherson, M. J., Winton, P., Roberts, R., & Stroup-Rentier, V. (2009). Family supports and services in early intervention: A bold vision. Journal of Early Intervention, 29(3), 187–206. https://doi​ .org/10.1177/105381510702900301 Vail, C. O., Lieberman-Betz, R. G., & McCorkle, L. S. (2018). The impact of funding on Part C



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systems: Is the tail wagging the dog? Journal of Early Intervention, 40, 229–245. Van Voorhis, F. L., Maier, M. F., Epstein, J. L., Lloyd, C. M., & Leung, T. (2013). The impact of family involvement on the education of children ages 3 to 8: A focus on literacy and math achievement outcomes and social-emotional skills. MDRC. Wallisch, A., Little, L., Pope, E., & Dunn, W. (2019). Parent perspectives of an occupational therapy telehealth intervention. International Journal of Telerehabilitation, 11(1), 15–22. Wayman, K., & Lynch, E. W. (1991). Home-based early childhood services: Cultural sensitivity in a family systems approach. Topics in Early Childhood Special Education, 10(4), 56–76. https://doi.org/​ 10.1177/027112149101000406 Woods, J., Kashinath, S., & Goldstein, H. (2004). Effects of embedding caregiver-implemented

teaching strategies in daily routines on children’s communication outcomes. Journal of Early Intervention, 26(3), 175–193. https://doi.org/10.1177/​ 105381510402600302 Woods, J. (2008). Providing early intervention services in natural environments. The ASHA Leader, 13(4). https://doi.org/10.1044/leader.FTR2.13042008.14 Woods, J., Wilcox, M. J., Friedman, M., & Murch, T. (2011). Collaborative consultation in natural environments: Strategies to enhance family-centered supports and services. Language, Speech, and Hearing Services in Schools, 42(3), 379–392. https://doi.org/​ 10.1044/0161-1461(2011/10-0016) Workgroup on Recommended Knowledge and Skills for Service Coordinators (RKSSC), National Service Coordination Leadership Institute Group. (2020). Knowledge and skills for service coordinators. https://tinyurl.com/KSSC-8-12-20Final

283

14 Service Delivery Issues in Private Practice Robin L. Edge

Introduction Of the 9,564 respondents included in the American Speech-Language-Hearing Association’s (ASHA) SLP Healthcare 2021 Survey, 17.1% reported they would like to change work settings, citing not feeling valued, unsatisfactory salary or benefits, and high productivity demands as the top reasons why (ASHA, 2021). Starting a private practice is one way for therapists to control these issues. A private practice is a business setting in which the clinician/owner independently operates the business. In 2021, 22.4% of speech-language pathology ASHA members and 31.2% of audiology ASHA members were employed in a private practice (ASHA, 2022a). Of the 22.4% of speech-language pathology private practitioners, 10.4% reported working full-time in the practice and 12% reported working part-time; of the 31.2% of private practice audiologists (AuDs), 24.9% were employed full-time and 6.4% were employed part-time (ASHA, 2022b). Of the 377 ASHA-certified assistants (23 audiology assistants and 354 speech-language pathology assistants [SLPAs]), 22.3% reported working full-time in a private practice setting, with 12.2% reporting part-time work in the setting (ASHA, 2022a). A private practice setting appeals to individuals who are typically well versed in business management and practices and who enjoy the autonomy of working without the larger structure of a health care or school setting. This chapter discusses the basic tenets of starting a private practice including business structures, roles, and work frequency; a business plan and location; credentials and qualifications needed to start a private practice; and service rates, billing, and networking resources. The information here provides an introductory overview of starting a private practice with resources cited to provide more in-depth information on each topic. It is important to note that this chapter should not be considered a substitute for consulting business advice from financial and legal professionals before starting a private practice.

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Advantages and Disadvantages of a Private Practice The advantages of owning a private practice include the autonomy of creating policies and procedures for the business, being responsible for the decisions and demands of the business, and having flexible scheduling and caseload management. However, a significant disadvantage is that the entire business burden falls to the owner. The flexibility of one’s schedule and caseload management are desirable features, but the downside is that revenue for a private practitioner can be inconsistent as it is dependent on factors often outside of the owner’s control. Business revenue can be affected by the cancellation rate of patients, the availability of the therapists, and the timeliness of reimbursement by payers. To account for this inconsistency in revenue, a private practitioner must manage finances to cover bills, taxes, and salary if revenue is slower than expected. Additionally, the business owner receives no paid time off for sickness, vacation, or to complete continuing education; income is decreased each day patients are not seen. Successful private practitioners must plan ahead and save for times when patients cannot be treated. Additionally, solo private practice owners do not have coverage for days off and can spend much time alone. This can be isolating and difficult for some and should be considered before starting a private practice. Another challenge faced by private practitioners is that no benefits are provided when owning a business. When you start a full-time private practice, you will need to provide your own benefits including purchasing health insurance individually and contributing to an individual retirement account. Purchasing independent health insurance can be costly when the business owner is not covered under another family member’s plan. In addition to health insurance, established health care facilities, school systems, and other employee settings typically provide retirement benefits to their employees, with some employers matching employees’ retirement contributions. This income should be considered when deciding to start a full-time private practice. To be competitive with other companies, as a practice owner, you would need to consider providing each of these benefits for yourself and employees you hire or supplementing salaries so you and your employees can independently provide these benefits. Many of the chapters included in this text cover issues that are particularly relevant to starting a private practice, including working in health care (11), education (12), and early intervention (13), as well as professional issues (1–6), career issues (7–10), and working productively (16–25). These chapters should be consulted as needed as you contemplate your transition

from employee at a larger agency to joining the ranks of speech-language pathology and audiology private practitioners.

Private Practice Options Private Practice Goals As one contemplates starting a private practice, many important decisions must be made. First, it is important to set business goals. Why does starting a private practice appeal to you? What are you looking to accomplish? What does success in a private practice mean to you? Providing detailed answers to these questions will become the road map for your practice planning stages. After you articulate your motivations and desired outcomes for the practice, it is important to decide how much you want to work for the business. Do you want to build a practice for full- or part-time employment for yourself or do you prefer to provide therapy services on an as-needed basis? Clinicians who work full-time for their private practice do not provide therapy services outside of their practice, whereas part-time or on-call (i.e., PRN) private practitioners often keep their positions at their primary place of employment and build their practice outside of their regular working hours on a part-time or as-needed basis. This allows therapists to build their private practice caseload over time without the financial burden of losing their salary in the process. Before embarking on this, check your contract with your current employer to ensure a noncompete clause is not included. A noncompete clause states that you agree not to work with a rival company or start a similar business in the same area for a specified period (Doyle, 2020). If you signed a contract with a noncompete clause, you will be unable to work in the designated geographical area until the stated time limit expires. This type of clause is one of the reasons it is always recommended to have a second party review any contract before signing. As the practice grows, the speech-language pathologist (SLP) or audiologist can transition from full-time employment at a company to full-time self-employment as it becomes financially feasible to do so. Some private practitioners provide services on a contract basis to facilities that need speech-language pathology or audiology coverage for their patients or students. This is a straightforward way to ease into a private practice without the need to take on patient billing. The financial ramifications of starting a private practice should not be ignored, as business trends report that it can take up to 5 years before a business begins to be profitable (Davidson, 2019). Although these financial projections are generalities from business research, the



CHAPTER 14   Service Delivery Issues in Private Practice

speed of profitability of a business is largely dependent on start-up money and overhead expenses. Obviously, the financial burden of starting a practice is lessened if the business owner can rely on income from outside sources, including family members. Having a carefully planned budget allows a practice owner to foresee the financial resources needed for a successful business while also strategically planning for long-term operating costs and potential expansion (McQuerrey, 2019). The U.S. Small Business Administration (n.d.-b) provides resources for business budget planning, and a small business–certified public accountant can assist with the budgeting planning and projections.

Role at the Practice The next important question to be considered when starting a private practice is what type of practice you want. Do you want to provide direct therapy services to patients, or do you envision hiring therapists to treat patients while you manage the practice? Some private practices are staffing companies that contract their hired SLPs and audiologists to other health care and educational agencies in need of services rather than directly treating patients or supervising therapists. The owner of a staffing private practice focuses their time on recruiting therapists to work for the company as well as identifying medical and/or school settings in need of therapy services. Private practitioners can also become consultants. Rather than providing direct treatment or staffing services, consulting SLPs and audiologists are paid by other agencies to provide case review and information regarding specific patients, disorders, or treatment techniques. For example, a consulting SLP or audiologist may be called as an expert witness in a trial to review the viability of treatments rendered to a patient if a family is litigating against a hospital, clinic, or school system. Additionally, a clinician may consult by offering continuing education courses on an area of expertise or by offering individual counsel to therapists who may not be experienced in treating a particular disorder. The most common type of private practices in speech-language pathology and audiology are ones in which direct services are provided to patients, with consulting only contributing a portion of most private practitioners’ income (ASHA, 2022a).

Business Structures Once you decide to start a private practice, the next decision to be made is the business structure of the practice. The type of business organization you open depends on two main factors: the owner’s desire to independently own or co-own the business and the liability the owner is willing to assume for the business. Legal liability is

when you are “legally responsible for a financial loss of another” (Landes, 2022). In other words, if you are liable for a business, you are obligated to pay the business debts with your personal finances. Based on the ownership structure you desire and the acceptable liability risk you are willing to assume, there are four legal organizational structures of a private practice: sole proprietorship, partnership, limited liability company, or corporation (ASHA, 2023l; U.S. Small Business Administration, n.d.-a). A brief overview of each of these business structures will be discussed below. Consulting your local U.S. Small Business Administration and/or legal counsel for more in-depth information regarding business structures before starting a practice is prudent. Sole Proprietorship.  A sole proprietorship provides the private practice owner/operator full control over the business, as the practice does not exist without the owner. Because no other individuals are involved with the practice, business decisions can be made easily when compared with business structures involving partners. Sole proprietorship is the simplest and most common business structure as there are minimal legal restrictions and no cost to start this type of business (U.S. Small Business Administration, n.d.-a). One difference between this structure and others is that a sole proprietorship owner reports business income and loss on his or her personal income taxes. This means the business owner is personally financially responsible for any debt the business incurs and all the owner’s personal assets can be used to pay off business debt. This is the highest level of liability one can assume. Because only one person is responsible for the business, it can be difficult to raise capital for a sole proprietorship as the growth of the business is limited due to the finite amount of work one person can execute or manage. Partnership. A partnership is the easiest business structure for two or more people desiring to own a business together (U.S. Small Business Administration, n.d.-a). There are two types of partnership business structures: a limited partnership and a limited liability partnership. In a limited partnership, one partner assumes full liability for the business and pays the selfemployment taxes while other partners have both limited liability and limited control of the business (U.S. Small Business Administration, n.d.-a). In this business structure, the partner who pays the employment taxes assumes most of the responsibility for the business and makes most of the decisions for the business. In business terminology, this person has unlimited liability. The remaining partners have limited liability, meaning their financial responsibility for the business is limited to a fixed sum. This is contrary to the unlimited liability

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partner, who carries unlimited responsibility for the business finances. A limited liability partnership (LLP) is similar to the limited partnership described above with the exception that in an LLP, all owners have fixed-sum limited financial liability for the business. This business structure protects all the business partners from the debts accrued by the business, as no partner is solely personally responsible for the financial decisions made by the other business owners (U.S. Small Business Administration, n.d.-a). The taxation of an LLP differs from that of a limited liability company (LLC), discussed below, in that the LLP is always taxed as a partnership and an LLC has several taxation options (Murray, 2020). Limited Liability Company.  An LLC is a business structure that protects the owners’ personal assets if the business faces bankruptcy or lawsuits (U.S. Small Business Administration, n.d.-a). An individual or a group of people can own an LLC. In most cases, LLC business partners’ personal assets are protected should the business fall on financial trouble. Although an LLC and an LLP are similar, the main difference is that an LLC can be owned by a corporation, whereas an LLP cannot. In the partnership structure, at least one managing partner assumes liability for the business. In an LLC, all partners can have limited liability, allowing benefit from the protection of the corporation structure while assuming a partnership business model (Feigenbaum, 2019). Business profits and losses go through the owner’s personal income without paying corporate taxes, but selfemployment taxes for Medicare and Social Security must be paid (U.S. Small Business Administration, n.d.-a). LLCs have lower tax rates than corporations but protect the personal assets of business owners like an LLP. This personal asset protection is the biggest benefit of this business structure. Unlike partnerships, LLCs must register with the secretary of state where the business is located (Feigenbaum, 2019). Corporation.  The final business structure is a corporation. Corporations differ from the previous business models as they are considered a legal entity separate from the owners and the business is held legally responsible for any business matters (U.S. Small Business Administration, n.d.-a). This means the business owners in a corporation have no personal liability for the business decisions and their personal assets cannot be used to pay the corporation’s debts. Unlike the other models, corporations pay taxes on profits and are taxed again when the profits are distributed to company shareholders. Although this structure has the highest level of protection for company owners, corporation owners typically pay more taxes than LLPs, LLCs, or sole proprietorships. Unlike other business structures, corporations can raise

funds for the business through the sale of company stocks. See the U.S. Small Business Administration website (http://www.sba.gov) for more information regarding types of corporations as well as the other business structures discussed above. As seen in Table 14–1, each type of business structure has advantages and disadvantages. The type of business structure you choose will depend on multiple variables, including your desire to have a partner, the start-up money you need, the personal liability risk you are willing to assume, the tax structure you desire, and state regulations and restrictions. If you want to own the business alone, a partnership is the only business structure that will not work. If you want to own the business with others, a sole proprietorship is not appropriate. LLCs and corporations can be owned by either an individual or a group. Liability for the business owner differs among business structures, with the sole proprietorship structure having the most personal liability for the owner and the corporation structure carrying the least personal financial liability. Regardless of the business structure chosen, you should open separate business accounts to keep business financials separate from your personal financial information. Seeking advice from a business consultant, attorney, and/or accountant is recommended to help in this decision-making process. ASHA, the American Academy of Private Practice in Speech-Language Pathology and Audiology, and the American Academy of Audiology (AAA) all have resources to assist with this decision.

Taxes The business structure you choose will determine the tax liability of your business. If you choose any business structure besides a sole proprietorship, your private practice will need to apply for an employer identification number (EIN). An EIN is the business’s federal tax identification number or the business equivalent of an individual’s Social Security number. The EIN will be used to pay taxes on income the practice makes and in all correspondence with the Internal Revenue Service (IRS). Taxes for the sole proprietorship business structure can be filed with an EIN or under the owner’s personal social security number, although many business advisors recommend always filing business taxes using an EIN (Maina, 2023). Unlike personal income tax filings, taxes for a business are typically filed quarterly on or around April 15, June 17, September 16, and January 15 (IRS, n.d.). A certified tax accountant can work with you to estimate the amount you need to withhold for taxes based on your specific circumstances, but the standard estimate is 30% (Smith, 2022). In other words, no more than 70% of your revenue can be considered expendable money for business expenses and salaries because



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Table 14–1.  Advantages and Disadvantages of Business Structures Business Structures

Advantages

Sole Proprietorship

Partnership

Limited Liability Company

Simple, most common

Capital easier to acquire

Minimum legal restrictions

Support system of other owners

Owner has full control

In LLP all owners have fixed liability

No cost to start

Disadvantages

Unlimited liability for owner Difficult to raise capital Business growth can be limited

Hybrid between partnership and corporation Most flexibility for customization Limited owner liability Can be owned by individual or multiple people

In general partnership, one owner has unlimited liability Divided authority among partners Decisions can be difficult if partners’ opinions differ

More complicated structure warrants more detailed and structured agreement Can be expensive to set up

Corporation Limited liability to owners Personal assets may not be seized Easy to transfer ownership Easy to expand Funds can be raised by selling stocks Most expensive to set up Double taxation Government regulations apply Can only operate in state where it was chartered without permission

Source:  Adapted from American Speech-Language-Hearing Association. (2023). Frequently asked questions about business practices. https://www.asha.org/practice/faq_business_practices_both/

30% should be saved for taxation purposes. Consulting a small business–certified public accountant can not only provide strategies for saving to pay taxes but can also assist with qualifying tax exemptions. Financial Recordkeeping. A very important, but sometimes overlooked, part of taxes for a small business is the recordkeeping required to claim business-related expenses on business taxes. Although the intricacies of the specific tax laws are fluid and ever-changing (and beyond the scope of this chapter), detailed records should be kept for your business for each expense claimed on the tax return. Additionally, all business transactions (both monies made and monies spent) should be logged in a systematic and organized manner to ease the burden of filing taxes. The IRS provides resources that discuss taxation for small businesses in detail (https://www.irs​ .gov/businesses) and it is highly recommended that a certified public accountant be consulted to assist with filing business taxes. Organized and consistent accounting records are imperative for any small business, especially in the event

the business is chosen for audit by the IRS (McQuarrie, 2022). An audit is a formal examination of “an organization’s or individual’s financial records to determine if they are accurate and in accordance with any applicable rules (including accepted accounting standards), regulations, and laws” (AccountingEDU.org, 2023). During an audit, all recordkeeping will be reviewed for accuracy, which may affect the money taxed over the audit period. If the business has worked with a certified public accountant, they will be able to assist with the IRS audit and, in some circumstances, the services of a tax lawyer may prove beneficial as well. Financial business records should be kept a minimum of 5 years after filing the tax return as audits can be conducted years after taxes are filed.

Business Plan A business plan is a vital tool when starting a private practice as it guides you through each stage of business development and management, including your products or services, marketing strategies, and finances. An essential

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first step in ensuring business success is the completion of a competitive analysis to determine market competition for the services or products you will provide (U.S. Small Business Administration, n.d.-c). This competitive analysis, a preliminary step to the actual business plan, will help determine the need for the business’ services and/or products based on the current market in the geographical area or in the virtual space where the business will operate. This analysis will also identify potential barriers and any indirect or secondary competitors in the area that may impact the success of the business. The U.S. Small Business Administration website (n.d.-c) and the ASHA website have valuable resources for completing a competitive market analysis (2023f ). Once the competitive market analysis is complete, the next step is to complete a business plan. The business

plan is a road map for the proposed business that guides the owner through each stage of business development (U.S. Small Business Administration, n.d.-d). A detailed business plan is always necessary, but it is required if outside funding is sought to start the business. A traditional business plan format is very detailed and typically includes an executive summary, company description, market analysis, organization and management, services provided, marketing and patient recruiting, funding requests, financial projections, and an appendix of supporting documents including licensing, permits, and certifications needed (U.S. Small Business Administration, n.d.-d). See Table 14–2 for a summary of these business plan sections. Consulting various business professionals will be helpful when writing the business plan to ensure no

Table 14–2. Traditional Business Plan Format Executive Summary

n

What is your company and why will it be successful? Mission statement n Services n Basic information about the company’s leadership, employees, and location n Financial information and growth plans if asking for financing n

Company Description

n n

Market Analysis

n n

Specific details about services provided including consumers Provide details as to what will make the business a success Competitive research of the state of the market in your area What are other businesses doing and what strengths does your business bring to the market?

Organization and Management

n n

Describe your business structure Include who will run the business and key information about each person

Service or Product Line

n

Describe your services and how they will benefit your customers

Marketing and Sales

n

Describe how you will attract and retain customers Describe your complete marketing and sales strategies

n

Funding Request

n

Financial Projections

n

Appendix

n

Outline your funding requirements, clearly explaining how much funding you will need and what you will use it for

Provide a prospective financial outlook for the business including income statements, balance sheets, cash flow statements, and capital expenditure budgets n Provide monthly projections for the first year Provide supporting documents or materials that were requested. Common items include credit histories, resumes, product pictures, letters of reference, licenses, permits, or patents, legal documents, permits, and other contracts.

Source:  Adapted from U.S. Small Business Administration. (n.d.-d). Write your business plan. https://www.sba.gov/business-guide/ plan-your-business/write-your-business-plan



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necessary details are omitted. A certified public accountant can assist with the business financials, including tax and withholding needs, and can establish billing and revenue tracking procedures. An attorney who specializes in business and contract law can assist throughout the business planning process and should be consulted to review all contracts and business structure decisions. The U.S. Small Business Administration website provides a business plan toolkit (U.S. Small Business Administration, 2023) to assist in this process, and numerous online business resources are available for more direction in developing your detailed business plan (Lavinsky, 2014; Rittenberg & Main, 2022; Wetherill, 2018). A helpful part of the business plan is calculating a revenue-to-cost ratio, which is a measure that compares the cost of running the business to the operating income of the business. To calculate a revenue-to-cost ratio, divide the businesses operating expenses by the operating income for the same period of time (Thompson, 2018). Operating expenses are all the costs incurred in running the business and include fixed expenses such as rent, insurance, utilities, and taxes as well as fluid or variable expenses such as salaries, marketing costs, licensure fees, certification fees, continuing education costs, equipment, technology, and testing and therapy materials. Business income or revenue includes all income produced by the business as well as interest earned on loans or savings. A revenue-to-cost ratio is a measure of how efficiently the business is running. A low revenueto-cost ratio indicates the business is running efficiently and is not overspending to generate revenue (Thompson, 2018). A high revenue-to-cost ratio indicates a small profit margin because it takes most of the revenue made by the business to run the company. Typically, the revenue-to-cost ratio is higher upon starting the business due to the initial financial resources needed to start the business but should decrease each year as the business operates. Because of this, many businesses do not start maximum revenue generation until up to 5 years after opening (Thompson, 2018; Ward, 2019). Once initial nonrepeatable business startup costs are incurred, the revenue-to-cost ratio should decrease, indicating more business profits. If it does not, the business plan should be reevaluated to determine how the business can be restructured to run in a more cost-effective and financially sustainable manner.

Marketing Strategy Another integral part of the business plan is the marketing and operational strategies for outreach and advertis-

ing to attract business (ASHA, 2023d; McCoy, 2019; McCoy & Roehl, 2019; Weimann, 2003). Your marketing strategies address how you will disseminate information about your business and the services you provide. For speech-language pathology and audiology, common ways to market your services are through the ASHA, AAA, and related professional organization websites; by having a strong business presence on social media, webpages, and blogs; and by networking with local doctors, hospitals, rehabilitation centers, teachers, school speechlanguage pathology/special education directors, support groups, personal contacts, and other private therapists for referrals. Obtaining an advanced degree or specialization certification can help assert your expertise and set yourself apart from other professionals, which can be a powerful marketing strategy (American Board of Audiology [ABA], n.d.; ASHA, 2023g).

Location of Private Practice Once the business structure has been determined and the business plan developed, it is time to determine the location of the private practice. Do you want to open a clinic and have patients come to you for services or do you want to travel to them to provide services in their natural environment? Providing services in patients’ homes requires less start-up overhead as you do not need to provide the clinic space, but traveling to see patients is time consuming and lowers the number of patients you can see daily. Typically, insurance does not reimburse travel expenses or travel time, so this loss should be considered when deciding where to provide therapy services. Treating patients in a clinic space allows for more people to be seen per day, as no travel is involved, but has the added expense of overhead for clinic space. Another option for treatment location is telepractice. Telepractice is using telecommunications technology to provide speech-language pathology and audiology services at a distance and is now a common treatment modality throughout health care (ASHA, 2023q). This option gives you the ability to treat more patients as you are not traveling and does not require the overhead costs of clinic space. If you plan to provide therapy via telepractice, there are important roles and responsibilities to follow (ASHA, 2023q). Consideration should also be given to the added costs of the specific technical requirements needed for telepractice and for obtaining state licensure in each state where your patients live. The cost-effectiveness of providing services in a home health versus clinical versus teletherapy setting should be evaluated before deciding which environments you will work in.

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Private Practice Credentials and Qualifications Certification The clinical credentials needed to start a private practice are the same as any SLP and audiologist providing services. To work in any environment, you should give serious consideration to having your Certificate of Clinical Competence (CCC) in speech-language pathology or audiology and/or ABA certification. The CCC-SLP and CCC-A are voluntary, entry-level credentials recognizing SLPs and audiologists who have met established criteria and standards of practice to deliver high-quality clinical service (ASHA, 2023m). You may also want to obtain specialty certifications, which can be helpful in demonstrating your expertise to attract patients to your practice (ABA, n.d.; ASHA, 2023g). The costs for completing continuing education courses and paying association dues should be factored into the business’s annual budget and cost projections, including the revenue lost by not treating patients while participating in continuing education courses. ASHA certification requires practicing SLPs and audiologists to acquire 30 hours of continuing education every 3 years to remain certified. See more about specialty certifications and ASHA certification requirements in Chapter 3.

State Licensure No matter the work setting or state of practice location, state licensure in the states in which SLPs and audiologists practice must be obtained. If practicing in multiple states, multiple state licenses are needed and should be factored into the business’ budget. ASHA provides state licensure requirements and contact information on its website (ASHA, 2023e).

Liability Insurance Medical liability insurance is a type of professional liability insurance that protects a health care provider from liability associated with wrongful practices that result in a client’s injury, medical expenses, and property damage, including the cost of litigation related to medical claims (National Association of Insurance Commissioners Center for Insurance Policy and Research, 2022). Comprehensive medical liability insurance should be purchased by each clinician working in the practice for protection if a malpractice claim is filed by a client. There are numerous companies that provide medical liability insurance for SLPs and audiologists, with two of the most common being the Healthcare Providers Service Organiza-

tion (HPSO) and Proliability. ASHA and AAA members may receive a discount on professional liability insurance. Contact information is provided for each company in the Resources section of this chapter.

Business Licenses Unlike clinicians in other work settings, private practice SLPs and audiologists may be required to obtain various business licenses. State and local business licensing requirements vary among states and local jurisdictions within the same state. These licenses and permits include a state business license, tax registration, unemployment insurance, business name registration, local business license, and various local permits to operate the business. A state business license is used for the state to track and monitor businesses operating in the state. Tax registration is required in states with sales tax so customers can be charged sales tax if needed. Unemployment insurance is required in some states for businesses with employees. Most states require the business name to be registered and may require local business licenses in addition to state licenses, as well as zoning, health, building, and environmental permits (FindLaw, 2022). Consult local government policies and regulations and a business organization attorney to determine what type of licenses and permits are needed as well as local zoning laws. Local zoning laws are important, especially for a home-based private practice, as some locations do not allow businesses to operate out of a residential area. It is important to note that a business license does not replace a license to practice, and both are required.

Ethics As multiple chapters in this text have highlighted, the importance of all SLPs or audiologists to conduct themselves in an ethical manner cannot be overstated (see Chapter 4 and Edge & Sirmon-Taylor, 2019). According to ASHA, the Code of Ethics “reflects professional values and expectations for scientific and clinical practice. It is based on principles of duty, accountability, fairness, and responsibility and is intended to ensure the welfare of the consumer and to protect the reputation and integrity of the professions” (ASHA, 2023h, p. 2). The code is the framework of guiding principles for SLPs and audiologists to best serve patients, research participants, and the public, and should always be adhered to (Edge et al., 2016). Private practitioners should be especially careful of ethics violations, as this therapy setting tends to require fewer checks and balances than medical facilities and schools. As such, accountability procedures



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are imperative for a private practice (Trulove & Fitch, 1998). Resources highlighting potential ethical concerns commonly associated with private practices should be consulted (Denton, 2009) and business policies and procedures should be developed and strictly followed to prevent unethical practice. Chapter 4 discussed the ASHA and AAA unethical practice complaint processes and risk management strategies to decrease the possibility of committing an ethical violation. If a CCC-SLP or CCC-AuD is found to have violated the ASHA Code of Ethics, the member’s full name, city, state, and violated principles and rules as well as the board’s decision of sanctions may be published in The ASHA Leader, depending on the nature and severity of the violation. This information is then made available to the public via the ASHA Certification and Ethics Verification online tool. Any public ethics violation is associated with the member for the remainder of their career, and this negative publicity may decrease referrals to the practice and deter clients. ASHA ethics violations can also be reported to state licensure boards and may result in the loss of state licensure and limit a professional’s ability to practice (ASHA, 2023n).

Cultural Competence Cultural competence is the “ability of individuals and systems to work or respond effectively across cultures in a way that acknowledges and respects the culture of the person or organization being served” (Williams, 2001, p. 1). The ASHA Code of Ethics mandates an understanding and appreciation of cultural diversity (see Chapter 21) by prohibiting discrimination in the delivery of services “on the basis of age; citizenship; disability; ethnicity; gender; gender expression; gender identity; genetic information; national origin, including culture, language, dialect, and accent; race; religion; sex; sexual orientation; or veteran status” (ASHA, 2023, p. 3). Being sensitive to the needs of culturally diverse patients and their families is not only mandated by the ASHA Code of Ethics, but also benefits any speech-language pathology/audiology practice greatly (or can harm a practice quickly if a clinician is not culturally sensitive and aware of patients’ diverse needs). It is important to be sensitive to patients’ cultural diversity, as the U.S. is becoming increasingly more culturally diverse. Cultural sensitivity is also important to eliminate the disparities in the health status of minorities, to provide quality services and health outcomes to patients, and to follow legislative, regulatory, and accreditation mandates (ASHA, 2023i). ASHA’s Multicultural Issues Board has developed cultural competence resources to assist its members

with increasing their proficiency when working with culturally diverse patients, including a Cultural Competence Checklist: Personal Reflection (ASHA, 2010a) and Cultural Competency Checklist: Service Delivery (ASHA, 2010b). Practicing as a culturally competent clinician is compulsory in a speech-language pathology/audiology practice and doing so decreases the chance of liability or malpractice claims against the clinician or practice (ASHA, 2023i). Although it is important for all practicing health care providers to be culturally competent, private practitioners need to keep in mind that the success of the practice depends on a reputation of quality service provision that is culturally sensitive to its clientele. Word of negative experiences with any professional can quickly negatively impact business demand and can have dire financial consequences for the practice.

Resources Needed for Private Practice Start-Up Funds The availability of financial resources is typically the most pressing requirement to start a private practice. In the business planning stage, a detailed budget projecting the financial resources needed to start the business is essential, as well as how you plan to fund the business (U.S. Small Business Administration, n.d.-b). It is important that the budget be realistic rather than a conservative estimate of costs in the event of unforeseen expenses. Is the funding for the business coming from savings, a bank loan, or from a business partner? A detailed and well-developed budget is necessary for any private practice to succeed and must include obvious expenses such as space and staff, but also less obvious expenses such as marketing, business licenses, insurance. A financial business analyst can provide direction in creating a budget and potential start-up funding source. As discussed above, depending on the type of private practice, space may or may not be needed. Regardless of space, supplies will be needed for the business such as computers, computer software, tablets, mobile apps, billing and scheduling software, and an electronic medical record system. Relatedly, storage space will be needed, physical and/or electronic, for records, in a manner compliant with the Health Insurance Portability and Accountability Act (HIPAA; Lusis, 2008).

Staff Although it is possible for the private practice owner to be the scheduler, biller, office manager, and therapist, as

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the practice grows and the needs and the demands on the owner’s time become more complex, staff will most likely be needed. When staff are added, you must decide which staff will most benefit the business and how they will be paid. Common private practice staff members include an office manager, a billing clerk, and other therapists. An office manager often handles the day-today management of the business, including scheduling appointments and checking people in upon arrival to the clinic. The office manager also typically inventories and orders supplies to keep the office running smoothly. The medical billing and coding specialist is responsible for submitting invoices for services provided and organizing the financials of the business. Commonly, private practices hire other therapists, including SLPs, audiologists, or related therapists, to provide services. One important decision that must be made is how the hired therapists and staff will be paid ​ — ​either by the hour or as salaried employees. Direct employees and contracted employees typically have two major differences: rate of pay and the provision of benefits. Contracted staff are typically paid more per hour than directly employed staff, as they often do not receive benefits such as retirement and health insurance, and they are typically only paid for the hours they provide services to patients. Direct employees, on the other hand, usually receive a lower rate of pay per hour, but are typically paid regardless of services provided and are often given benefits. If direct employees are salaried, often the business provides workers compensation, unemployment, health insurance, and retirement opportunities to them. Some states require certain services be provided to employees by employers. This information should be researched during the business planning phase and added to the budget projections. Seeking counsel from a business consultant will be beneficial in determining these state-mandated requirements in addition to which payment model for your staff is best.

Electronic Medical Records and Practice Management Software Electronic medical records (EMRs) and practice management software assist clinicians with clinical documentation and scheduling, registration/insurance authorization, and billing (Krebs, 2008). ASHA provides a list of commercially available EMR and practice management software systems commonly used by SLPs and audiologists on its website but does not endorse the use of any specific software system (ASHA, 2023i, 2023k). ASHA recommends clinicians evaluate EMR and practice management software for applicability to their practice based on the software’s target use and accessibility.

Payment for Services Private Fee for Service One of the most important decisions to be made for a private practitioner is how the business will be reimbursed for services, as there are two primary methods by which the practice can be paid for services provided. The first is only providing services to patients who pay for services themselves, known as private pay or fee-forservice patients. The major benefit of a private fee-forservice billing structure is that billing is quite simple as insurance is not filed. The drawback of the fee-for-service payment model is that only accepting private payment may limit the practice’s patients as some potential patients may be unable to afford services or may prefer to utilize their insurance coverage. The ability to build a full private practice caseload from patients that privately pay without insurance may be dependent on the socioeconomic environment in your area (WBCSD Social Capital, 2013), as well as your specialization and experience levels. If a full caseload cannot be achieved with only fee-for-service patients, you will need to consider accepting insurance payments to increase your caseload. Foehl (2009) provides strategies for analyzing the payer source for a private practice to maximize payer and patient mix and increase revenue in a private practice.

Insurance The other reimbursement method for therapy services is billing patient insurance. Although the details of insurance billing are vast and ever-changing, a basic discussion of insurance billing will be presented here. There are two types of insurance coverage: government funded and privatized. There are two major types of government funded insurance (Medicaid and Medicare) and three main types of private insurance coverages (health maintenance organizations, preferred provider organizations, and exclusive provider organizations). Medicaid.  Medicaid is a U.S. government health care program that provides insurance coverage for low-income adults, children, pregnant women, some elderly adults, and people with disabilities (Medicaid.gov, 2022). According to Medicaid.gov, 84.4 million people in the U.S. received Medicaid health benefits in October 2022 (2023). Medicaid is jointly funded by states and the federal government according to federal regulations. As such, states have autonomy as to how the program is administered, including what services are covered and reimbursement rates. Although states are given great flexibility in how they structure Medicaid services for their residents, they have to follow the broad federal



CHAPTER 14   Service Delivery Issues in Private Practice

guidelines. Most states provide Medicaid coverage for speech-language pathology and audiology services, but they are not required to do so by the federal government, except for children birth to 21 years of age (ASHA, 2023o). Federal Medicaid policies mandate that a physician refer patients to SLPs and audiologists before services can be provided. The process of acquiring these referrals from physicians can be time and labor intensive for therapists, billing specialists, and office managers. Typically, health care professionals must apply to become Medicaid providers in each state in which services will be provided. The policies and procedures to become a Medicaid provider can vary greatly from state to state, with some states using managed care organizations (MCOs) to provide services to patients. MCOs contract with the state to accept a certain number of patients per month for a standard monthly payment for services, with the intent of lowering health care costs for states (Medicaid.gov, n.d.). Service providers participating in an MCO typically have little difficulty filling their caseload, but often receive lower reimbursement rates than therapists not participating in an MCO (Medicaid. gov, n.d.). This trade-off should be considered before deciding whether or not to join an MCO when starting a private practice. Each state may have multiple MCOs providing therapy services to Medicaid patients, and therapists typically have to apply separately to become a provider for each MCO. This application process is often laborious and time consuming, which should be considered when deciding whether or not to become a Medicaid provider. Additionally, each therapist in the practice must apply for provider status individually before becoming an in-network Medicaid provider. ASHA provides resources to assist with Medicaid policies and procedures (ASHA, 2023o), and Chapter 10 of this text provides more information regarding Medicaid coverage, including International Classification of Diseases, 11th revision (ICD-11) codes (World Health Organization, 2023). Medicaid.gov provides links to each state’s Medicaid profile, with service rates typically published in each state’s Medicaid provider manual (2022). Medicare.  Medicare is the federal insurance program for people aged 65 and older, some people under 65 with certain disabilities, and people with end-stage renal disease (Medicare.gov, n.d.-b). In 2022, 58.6 million people in the U.S. received Medicare health care benefits (Freed et al., 2022), 86.2% of whom were 65 or older, with the remainder under 65 with disability coverage (Tarazi et al., 2022). Different parts of Medicare provide coverage for various services. Medicare Part A provides hospital coverage for patients under the plan. Medicare Part B covers certain doctors’ services, outpatient care, medical supplies, and preventative services. Part D pro-

vides prescription drug coverage for patients, and Part C, also known as Medicare Advantage, is a bundled version of health services including Part A, Part B, and usually Part D. At the time of this writing, Medicare Part B pays for medically necessary outpatient speech-language pathology services at 80% of the Medicare-approved amount after the Part B deductible is met (Medicare.gov, n.d.-c). Medicare covers hearing and balance audiology diagnostic testing as determined by the reasons the tests were performed but does not cover therapeutic services (Medicare.gov, n.d.-a). Chapter 10 of this text, ASHA, and the federal government provide resources with indepth information about Medicare coverage and billing. Private Insurance. Privatized insurance is another potential source of revenue for a private practice. Private health insurance is provided by companies that are not part of the government, but rather are funded by the insured participants and/or the insured participants’ employers. During the first 6 months of 2022, 68.1% of Americans under 65 were covered by private health insurance, with 8.3% uninsured during that same time (Cohen & Cha, 2022). The remaining Americans were insured by Medicaid or Medicare. Private plans vary not only among states, but also among employers in the same state. Employers can purchase the insurance benefits they would like, so it is common for two policies from the same insurance company to have vastly different coverages and payments per service even if both businesses are located in the same city. There are multiple types of private insurance MCOs in the U.S., including health maintenance organizations (HMOs), preferred provider organizations (PPOs), and exclusive provider organizations (EPOs). Each of these types will be discussed below, and Chapter 10 of this text provides additional information regarding private health plans. ASHA also provides resources for therapists working with private insurance companies (ASHA, 2023k, 2023p). Health Maintenance Organizations.  An HMO is a health insurance plan that provides health services for patients for a fixed annual fee by acting as a liaison between health care providers and facilities and patients (Healthcare.gov, 2022). Medical professionals are paid the same fee regardless of the number of patients they treat. Typically, HMO plans require patients to select a primary care physician who must be seen for a referral prior to seeing other health care providers. This can slow the process of receiving the care patients need, as wait time for appointments can be long. This can also affect the time it takes patients to be referred for speechlanguage pathology/audiology services by their doctor. HMOs often provide preventative care, such as yearly

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well-check physicals or mammograms for patients, for a reduced or free copay in an effort to keep members from contracting an illness that could be prevented. Coverage may be limited or reduced and require more out-of-pocket spending when patients see a non-HMO network provider. Preferred Provider Organizations.  A PPO is an MCO of doctors, hospitals, and other health care providers that have agreements with insurance companies to provide services to insured patients for a reduced rate (Healthcare.gov, 2022). PPOs negotiate with providers to set fee schedules with the maximum amount they will reimburse for a particular service. These plans typically cost patients more in monthly premiums than HMOs but offer more flexibility for patients and reduced wait time as they do not need to see their primary care provider for referrals to many specialists. Generally, PPOs cover speech-language pathology/audiology services for outof-network providers more often than HMOs. Exclusive Provider Organizations. An EPO is a health insurance plan developed as a hybrid between HMO and PPO plans. While receiving health care benefits from an EPO, patients do not have to receive a referral from a primary care physician but do have to see health care providers contracted with the EPO to be an in-network provider. Unlike the previous plans discussed, absolutely no out-of-network providers may be used. Unlike HMOs, providers in an EPO are paid for each service rendered to a patient rather than the monthly fee regardless of the number of patients treated. Health care providers typically offer reduced rates to EPOs in exchange for being a part of the network. Although the money made per therapy session is often less with an EPO versus being an out-of-network provider in a PPO, the ease of patient access by being listed as an EPO-qualifying provider is often worth the decreased rate per session (ASHA, 2023k). The intricacies and details of becoming an insurance provider and billing insurance claims are beyond the scope of this chapter. The main question regarding insurance is, should your practice join an insurance network? The advantage of being an in-network provider is that the insurance company will refer patients to your practice. The disadvantage is that you cannot bill the patient for the difference in what you actually charge for a service and what the insurance company pays you for the service (remember, they negotiate lower rates for in-network providers). With HMO and PPO private insurers, you can accept patients even if you are not a network provider. Typically, the insurance coverage for out-of-network providers is poor, but you can bill the patient for the difference between what you charged for

the service and what you were reimbursed for the service. If you are starting a private practice and need to recruit patients, being an in-network provider is a way to quickly fill your caseload. If you already have a full caseload, you may prefer not to join a network so you can receive higher reimbursement rates. An important caveat here is that a provider cannot charge Medicare and some private insurance companies a different rate than their normal fee for service; therefore, if you plan to accept insurance and private pay clients, the minimum amount private pay clients must be billed is the same as the standard Medicare and insurance rates (ASHA, 2023p).

Rates for Services How much should a private practitioner charge for speech, language, and or audiology services? How do beginning private practice owners know how much to charge for services? One might assume you just call other speech-language pathology and audiology clinics in the area to verify rates and set your rates similarly. Setting rates solely based on competitors’ rates alone can be considered collusion by price fixing, which may be considered unethical and/or illegal. Collusion occurs when competing companies work together to influence service pricing to create an unfair market advantage (U.S. Department of Justice, 2021). Competing businesses setting similar prices can eliminate or reduce the competition for services provided in a market. This can have a negative impact on consumers in the area and fellow business owners providing competing services. If other health care providers in the area are not consulted on service rates, how does a new private practitioner know what fees to charge per service? Fees need to be individualized to each practice based on the priorities and needs of the business considering clinician experience, advanced training or specializations, and the cost of living in the area. Cost of living information can be found online from the U.S. Department of Labor, Bureau of Labor Statistics Occupational Employment Statistics (United States Department of Labor, Bureau of Labor Statistics, 2022). Because billing fees vary by region, accessing cost of living for your area is imperative before starting a practice to help determine a range of fees that would be appropriate for the area. After considering cost of living and clinician expertise and experience, the most important resource for setting private practice rates is the business plan. Using the business plan, factor in the costs of running the private practice including overhead and travel time. Once the rate is tentatively set, complete a cost analysis to determine how many patients you would have to see in a week to cover business expenses including salary. If the



CHAPTER 14   Service Delivery Issues in Private Practice

business rates are set too low, covering the overhead of the practice may be difficult and the business will fail to realize its revenue potential. If business rates are set too high, obtaining clients for the practice will be difficult and the business will not make enough money to cover expenses (Castro-Casbon, 2019). If the practice has contracts with insurance companies, these contracts should be consulted before setting private practice rates as some insurance contracts have clauses that state providers cannot bill insurance at a higher rate than uninsured patients are billed. Some insurance contracts do not allow patients to pay for services out of pocket and mandate that insurance must be billed for the service. If the practice plans to accept fee-for-service payments and insurance payments, reviewing the insurance contracts with an attorney will be invaluable to ensure you do not violate your insurance contracts or state and local policies regarding self-payments for patients. Regardless of your fee structure for services, many private insurers, as well as Medicare and Medicaid, pay providers’ fees set by Current Procedural Terminology (CPT) codes. CPT codes are a set of medical codes created by the American Medical Association (2022) used to classify any medical procedure performed on a patient. Medicaid reimbursement rates by provider type and CPT code as well as information on how to become a Medicaid provider in the state can be found on each state’s Department of Health website (Medi­caid​ .gov, 2021). ASHA publishes a Medicare Fee Schedule for Speech-Language Pathologists (ASHA, 2023b) and Audiologists (ASHA, 2023a) each year. Consulting these resources will provide information on the reimbursement rates, policies, and procedures to expect when working with patients covered by Medicaid and Medicare health insurances. Finding this information for private insurance may be more difficult, as each policy is different. Patients’ insurance cards will have contact information for the company to find coverage, rate, and benefit limit information.

Billing Billing practices for health care providers accepting third-party insurance can be overwhelming and time consuming for many clinicians. Traditionally, SLPs and audiologists are not highly trained in medical coding and billing, and private practice clinicians may find billing difficult. Once claims are submitted, they need to be tracked, with possibly more information submitted if the initial claim is denied. Many times, services must be preauthorized with the insurance company before clients are seen. The time these billing tasks take can detract from the time the business owner has to treat

clients and create revenue for the business. To assist its members with learning medical coding and billing, ASHA provides six coding and reimbursement modules covering CPT codes, ICD codes, documentation (one for SLPs and one for audiologists), and application for SLPs and audiologists (ASHA, 2023c). Even with helpful resources such as these, billing third-party payers can require a steep and time-consuming learning curve for many clinicians. For some, it is more cost-effective to hire a medical billing and coding specialist to submit client claims. Medical billing specialists are trained in medical coding and billing practices and often have quicker payment times than clinicians, especially clinicians unfamiliar with ICD-11 (World Health Organization, 2023) and Diagnostic and Statistical Manual (DSM-5; American Psychiatric Association, 2013) coding systems. Most billing specialists are trained to work with government and private insurance systems and can assist with in-network provider applications as well as claims and claim management. The billing specialist may be a fulltime employee in the practice or an independent contractor who charges a fee per claim submitted. Insurance claims for services provided should be filed in a timely manner. “Timely” may vary for each insurance provider and should be researched so you do not lose payment for claims. The difficulty navigating private insurance should not be underestimated when a clinician is considering whether the practice will bill third-party insurance for services provided or if the services of a billing specialist will be utilized.

Outcomes Data for Private Practices As discussed in Chapter 16 of this text, documentation of services is imperative for SLPs and audiologists regardless of employment setting (Moore, 2023). For any therapist in any setting, progress notes and clinical records should be kept in a timely and organized manner as mandated by the ASHA Code of Ethics (ASHA, 2023). The specific documentation requirements and formatting for private practitioners will often be determined by the payer of the services, as insurance companies often ask for specific types of outcomes data to ensure highquality care for patients. With health care costs in the U.S. increasing, justifying the need for health care services using evidence-based treatments via sound documentation is imperative to ensure insurance companies pay for the services patients need (ASHA, 2004; Edge & Sirmon-Taylor, 2019; Straus et al., 2018). Chapter 6 discusses evidence-based practice and its importance for SLPs and audiologists. Many EMRs have documentation programs for various insurers built into their

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software and formatted for specific insurance companies’ requirements. For SLPs and audiologists to justify the value of the services provided, they must use reliable data collection methods. Formatting requirements may change based on insurance policies and procedures, but the underlying tenet of assessing patient gains due to your services remains constant.

Networking When starting a private practice, building a network of collaborators will be extremely beneficial (Schwab, 2016). Examples of helpful collaborators are SLPs and audiologists who specialize in areas you do not, or medical doctors, psychologists, and physical and occupational therapists to whom you can make (and hopefully receive) referrals. This networking can happen through professional networking events in your community. You can also use these events as a marketing strategy for your business. Joining local civic or community services organizations in your area is another way to create a network for your business. One of the easiest referral sources is by word of mouth, so getting the word out about your business is key. Joining online business meetup groups, having a strong web presence, and attending continuing education events or health care symposiums in the local area are all other ways to broaden your network. Chapter 8 of this text provides more information on professional networking to successfully advance your career.

Summary This chapter presented issues related to individuals wishing to pursue a speech-language pathology or audiology private practice. Although one can work as a private practitioner on a part-time or as-needed basis, this chapter was written from the perspective of a clinician going into private practice as a full-time practitioner/ owner. The benefits of owning a private practice were discussed, including the flexibility of scheduling and the autonomy of creating the policies and procedures for the practice. The biggest drawback of a private practice is that it is extraordinarily hard work, as the entire business burden falls to you, and you MUST manage finances well to cover all the direct and indirect costs of running a practice. Income as a private practice owner may be inconsistent as it depends on client availability, payment methods, and timing of payments from payers. The expense of paying for one’s own benefits and taking time off for illness and vacation should not be underestimated. It is common for new businesses to make minimal profit for the first few years, information that

should be carefully considered before deciding to pursue a practice full-time. The learning curve for a new private practitioner is steep, as 66.65% of owners surveyed reported it took between 1 and 3 years to adjust to working in a private practice, with 42.85% reporting it took 2 or 3 years to adjust to the business (Fortson, 2014). As seen in Table 14–3, clinicians reported a variety of issues as the most challenging aspects of owning a private practice. Private practice options were also discussed, including working full- or part-time in the business, the role of the owner in the business, business structures, and the importance of a business plan. The location of the practice, credentials, qualifications, resources needed to start a practice, importance of ethics and cultural competence, and billing issues were also discussed.

Table 14–3. Private Practitioners Report of the Hardest Part of a Private Practice

Challenge Insurance billing

Percentage of Practitioners Reporting 25

Regulations

16.67

Recruiting clients

12.5

Personal record keeping for tax purposes

8.3

Scheduling

8.3

Cancellations

4.1

Running a small business with no business background

4.1

Dealing with parents who are not responsible

4.1

Staff management

4.1

Different insurance policies for each client

4.1

Responsibility

4.1

Hiring staff for rural areas

4.1

Source:  Adapted from Fortson, M. K. (2014). Private practice in speech-language pathology and audiology: Experience, preparation, and confidence levels of practicing professionals. Rehabilitation, Human Resources and Communication Disorders Undergraduate Theses, 28. https://scholarworks.uark.edu/cgi/ viewcontent.cgi?article=1027&context=rhrcuht



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Owning and operating a private practice can be very invigorating and rewarding, but the glamorous thought of owning a practice should not downplay the difficult work involved in developing and maintaining a successful private practice. SLPs and audiologists need experience in the field before deciding to start a practice, as this work experience is invaluable in learning to provide quality patient care. It is difficult to increase your entrylevel clinical skills quickly without the support system of fellow service providers and colleagues often received when working at a larger company. Having this experience will be of great benefit as you start an independent practice. When private practitioners were asked what best prepared them to run a practice, 95.8% said experience in other therapy settings (Fortson, 2014), highlighting the value of gaining experience before trying to build a practice. Working at a private practice can feel isolating and lonely, so it is extremely important for clinicians to reach out to other private practitioners for support. Members of the American Academy of Private Practice in Speech Pathology and Audiology may be a beneficial support group, as well as the resources provided by ASHA (2023l; Dougherty, 2014) and AAA (2021).

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American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

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American Speech-Language-Hearing Association. (2023f ). Business plan market analysis: Describe the industry and your competition. https://www.asha​ .org/practice/marketanalysis/

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American Speech-Language-Hearing Association. (2023g). Clinical specialty certification. https://www​ .asha.org/certification/specialty/

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American Speech-Language-Hearing Association. (2023h). Code of ethics. https://www.asha.org/ policy/et2016-00342/ American Speech-Language-Hearing Association. (2023i). Cultural competence check-ins. https://www​ .asha.org/practice/multicultural/self/ American Speech-Language-Hearing Association. (2023j). Electronic medical records (EMRs) and practice management software for audiologists. https://www.asha.org/practice/emrs-and-practicemanagement-software-for-audiologists/ American Speech-Language-Hearing Association. (2023k). Electronic medical records (EMR) and practice management software for speech-language pathologists. https://www.asha.org/practice/ emr-and-practice-management-software-for-slps/ American Speech-Language-Hearing Association. (2023l). Frequently asked questions about business practices. https://www.asha.org/practice/faq_​ business_practices_both/ American Speech-Language-Hearing Association. (2023m). General information about ASHA certification. https://www.asha.org/certification/ aboutcertificationgeninfo/ American Speech-Language-Hearing Association. (2023n). How ASHA’s Board of Ethics sanctions individuals found in violation of the Code of Ethics. https://www.asha.org/practice/ethics/sanctions/ American Speech-Language-Hearing Association. (2023o). Introduction to Medicaid. https://www​ .asha.org/practice/reimbursement/medicaid/ medicaid_intro/ American Speech-Language-Hearing Association. (2023p). Private health plans frequently asked questions: Speech-language pathology. https://www​ .asha.org/practice/reimbursement/private-plans/ php_faqs_slp/ American Speech-Language-Hearing Association. (2023q). Telepractice. https://www.asha.org/ practice-portal/professional-issues/telepractice/ Castro-Casbon, J. H. (2019, May 15). Why the “going rate” for private speech therapy services doesn’t matter. The Independent Clinician. https:// independentclinician.com/the-going-rate-forprivate-speech-therapy-doesnt-matter-and-hereswhy/ Cohen, R., & Cha, A. (2022). Health insurance coverage: Early release of estimates from the National

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https://www.kff.org/medicare/issue-brief/ medicare-​advantage-in-2022-enrollment-updateand-key-trends/#:~:text=In%202022%2C%20 nearly%20half%20of,enrolled%20in%20Medicare​ %20Advantage%20plans Healthcare.gov. (2022). How to pick a health insurance plan. https://www.healthcare.gov/choose-a-plan/ plan-types/ Internal Revenue Service. (n.d.). Employment tax due dates. https://www.irs.gov/businesses/smallbusinesses-self-employed/employment-tax-duedates#:~:text=Forms%20Filed%20Quarterly%20 with%20Due,of%20the%20previous%20 calendar%20year Krebs, J. M. (2008). Paper, paper everywhere? How to go paperless in your private practice. The ASHA Leader, 13, 20–22. Lavinsky, D. (2014, January 30). How to write a business plan. Forbes. https://www.forbes.com/sites/ davelavinsky/2014/01/30/how-to-write-a-businessplan/?sh=24069d687d04 Landes, A. (2022, August 9). Legal liability: What is means & how it works. https://www.landesblosch​. com/blog/legal-liability-what-it-means-and-how-​ it-works/ Lusis, I. (2008). Private practice and HIPAA. The ASHA Leader, 13. https://leader.pubs.asha.org/ doi/10.1044/leader.BML.13122008.3 Maina, D. (2023, January 19). Benefits of EIN for sole proprietor: 8 reasons why an EIN is crucial for your business. Bonsai. https://www.hellobonsai.com/ blog/benefits-of-ein-for-sole-proprietor McCoy, Y. (2019). Finding the right market for your private practice, Part 1. The ASHA Leader Live. https://leader.pubs.asha.org/do/10.1044/finding-theright-market-for-your-private-practice-part-1/full/ McCoy, Y., & Roehl, T. (2019). Ways to grow your private practice client base. The ASHA Leader Live. https://leader.pubs.asha.org/do/10.1044/ ways-to-grow-your-private-practice-client-base/full/ McQuarrie, K. (2022, November 29). Small-business bookkeeping basics. Business.org. https://www .business.org/finance/accounting/small-businessbookkeeping-basics/ McQuerrey, L. (2019, March 12). Why is it important for a business to budget? Chron. https://small business.chron.com/important-business-budget385.html

Medicaid.gov. (n.d.). Managed care. https://www​ .medicaid.gov/medicaid/managed-care/index.html Medicaid.gov. (2021). State overviews. https://www​ .medicaid.gov/state-overviews/index.html Medicaid.gov. (2022). Medicaid. https://www.medicaid​ .gov/medicaid/index.html Medicaid.gov. (2023). February 2023 Medicaid & CHIP enrollment data highlights. https://www​ .medicaid.gov/medicaid/program-information/ medicaid-and-chip-enrollment-data/reporthighlights/index.html Medicare.gov. (n.d.-a). Hearing & balance exams. https://www.medicare.gov/coverage/hearingbalance-exams Medicare.gov. (n.d.-b). The official U.S. government site for Medicare. https://www.medicare.gov/ Medicare.gov. (n.d.-c). Speech-language pathology services. https://www.medicare.gov/coverage/ speech-language-pathology-services Moore, B. (2023). Documentation issues. In M. W. Hudson & M. DeRuiter (Eds.), Professional issues in speech-language pathology and audiology (5th ed.). Delmar Cengage Learning. Murray, J. (2020, August 12). What is a limited liability partnership? The Balance. https://www .thebalancemoney.com/how-to-form-a-limitedliability-partnership-398325#toc-limited-liabilitypartnership-vs-llcs National Association of Insurance Commissioners Center for Insurance Policy and Research. (2022, June 23). Medical malpractice insurance. https:// content.naic.org/cipr-topics/medical-malpracticeinsurance Rittenberg, J., & Main, K. (2022, August 20). How to write a business plan (2023 guide). Forbes. https:// www.forbes.com/advisor/business/how-to-write-abusiness-plan/ Straus, S. E., Glasziou, P., Richardson, W. S., & Haynes, R. B. (2018). Evidence-based medicine: How to practice and teach EBM (5th ed.). Elsevier. Schwab, E. F. (2016). Surviving and thriving your first year in private practice. Seminars in Hearing, 37(4), 293–300. Smith, R. (2022, November 11). How much to set aside for small business taxes. Bench. https://bench​ .co/blog/tax-tips/how-to-set-aside-business-taxes/​ #mvbv3

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Tarazi, W., Welch, P., Nguyen, N., Bosworth, A., Sheingold, S., De Lew, N., & Sommers, B. (2022). Medicare beneficiary enrollment trends and demographic characteristics. U.S. Department of Health and Human Services Issue Brief No. HP-2022-08. https://aspe.hhs.gov/sites/default/files/documents/ f81aafbba0b331c71c6e8bc66512e25d/medicarebeneficiary-enrollment-ib.pdf Thompson, J. (2018, November 21). How to calculate a cost-to-income ratio. Bizfluent. https://bizfluent​ .com/how-6398870-calculate-cost-to-income-ratio​ .html Trulove, B. B., & Fitch, J. L. (1998). Accountability measures employed by speech-language pathologists in private practice. American Journal of SpeechLanguage Pathology, 7, 75–80. United States Department of Justice. (2021). Price fixing, bid rigging, and market allocation schemes: What they are and what to look for. https://www .justice.gov/atr/file/810261/download#:~:text​ =Price%20fixing%2C%20bid%20rigging%2C%​ 20and%20other%20forms%20of%20collusion​ %20are,United%20States%20Department%20 of%20Justice. United States Department of Labor, Bureau of Labor Statistics. (2022, July 19). Occupational employment statistics. https://www.bls.gov/oes/tables.htm U.S. Small Business Administration. (2023). Business smart toolkit. https://www.sba.gov/partners/ counselors/instructional-materials-trainers/ business-smart-toolkit U.S. Small Business Administration. (n.d.-a). Choose a business structure. https://www.sba.gov/businessguide/launch-your-business/choose-businessstructure U.S. Small Business Administration. (n.d.-b). Fund your business. https://www.sba.gov/business-guide/ plan-your-business/fund-your-business U.S. Small Business Administration. (n.d.-c). Market research and competitive analysis. https://www​ .sba.gov/business-guide/plan-your-business/ market-research-competitive-analysis U.S. Small Business Administration. (n.d.-d). Write your business plan. https://www.sba.gov/businessguide/plan-your-business/write-your-business-plan Ward, S. (2019, September 27). How to get your new small business to make money. The Balance. https://www.thebalancemoney.com/the-two-mainproblems-of-starting-a-small-business-2948554

WBCSD Social Capital. (2013). Measuring socioeconomic impact: A guide for business. https://www​ .enterprise-development.org/wp-content/uploads/ WBCSDGuidetoMeasuringImpact.pdf Weimann, G. (2003). Where to start marketing? Develop a plan! The ASHA Leader, 8(2), 10–11. Wetherill, A. (2018). Steps to a successful business plan. The ASHA Leader, 23(7), 40–41. Williams, B. (2001). Accomplishing cross cultural competence in youth development programs. Journal of Extension, 39, 1–6. World Health Organization. (2023). ICD-11 2023 release is here. https://www.who.int/news/item/1402-2023-icd-11-2023-release-is-here

Resources ASHA’s Coding, Reimbursement, and Advocacy Modules:  https://www.asha.org/practice/ reimbursement/coding/ ASHA’s Cultural Responsiveness Resources: https://www.asha.org/practice-portal/ professional-issues/cultural-responsiveness/ ASHA’s Ethics Resources: https://www.asha.org/practice/ethics/ ASHA’s Marketing Information: https://www.asha.org/practice/marketing/ ASHA’s Overview of Medicaid Coverage: https://www.asha.org/practice/reimbursement/ medicaid/ ASHA’s Overview of Medicare Coverage: https://www.asha.org/practice/reimbursement/ medicare/ ASHA’s Multicultural Affairs and Resources: https://www.asha.org/practice/multicultural/ ASHA’s Resource Guide for a Private Audiology Practice:  https://www.asha.org/articles/privateaudiology-practice/ ASHA’s Resource Guide for Speech-Language Pathologists in Private Practice:  https://www.asha.org/ slp/Private-Practice-in-Speech-Language-Pathology/ ASHA’s State Licensure Information: https://www.asha.org/advocacy/state/ American Academy of Audiology 11480 Commerce Park Drive, Suite 220 Reston, VA 20191



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Telephone: 703-790-8466 Website: https://www.audiology.org

Phone: 1-800-982-9491 Website: https://www.hpso.com

American Academy of Private Practice in Speech Pathology and Audiology PO Box 252 Granville, NY 12832 Email: [email protected] Website: https://www.aappspa.org

Internal Revenue Service See local white pages or website for address and telephone number of local office. Website: https://www.irs.gov/

American Speech-Language-Hearing Association 2200 Research Blvd. Rockville, MD 20850-3289 Telephone: 301-296-5700 Website: https://www.asha.org HPSO 1100 Virginia Drive, Suite 250 Fort Washington, PA 19034

Proliability 12421 Meredith Dr. Urbandale, IA 50398 Phone: 1-866-795-9340 Website: https://www.proliability.com U.S. Small Business Administration 409 3rd St. SW Washington, DC 20416 Website: https://www.sba.gov/

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15 Strategically Promoting Access to Speech-Language Pathology and Audiology Services Brooke Hallowell

Introduction Access to quality services for people with hearing, balance, speech, language, swallowing, and related concerns is limited in myriad ways, even though the number of people of all ages needing such services is steadily increasing. To counteract strategically the forces that threaten access to services, we must have a clear understanding of the barriers to access and a sound rationale for the need for our services. In this chapter, we discuss the factors that impede access despite a dire and growing need for services. We then consider strategic means of enhancing access by addressing disparities that limit access for people from underserved and minoritized populations, optimizing reimbursement for clinical services, finding alternative ways to fund clinical services, pursuing legislative channels to enhance access, engaging in advocacy, using care extenders, taking advantage of technology, educating the public, and modifying our service-providing environments.1

Identifying Barriers to Access A first step in considering how we may strategically promote access to services of audiologists and speech-language pathologists (SLPs) is to examine why many of the people who need these services cannot or do not obtain them. Identifying challenges to access helps us then consider opportunities for enhancing access by strategically addressing those challenges. Here, we will consider barriers to access that relate to infrastructure, funding, sociocultural influences on access to care, and navigation through health care systems. A host of additional critical barriers not addressed in detail in this chapter 1

 iven the context of this book, the content in this chapter is primarily relevant to readers in the United States and other G English-speaking and minority-world contexts. The global need for SLP and audiology services certainly demands global efforts to promote access to our services.

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relate to systems of privilege and oppression, such as racism, sexism, xenophobia, ableism, heterosexism, ageism, and deep-seeded cultural complexities (Hallowell, Hyter, et al., 2021).

Addressing Challenges With Infrastructure Despite wonderful progress in expanding our professions throughout the world over recent decades, many countries still lack formal programs to educate SLPs and audiologists. Many also lack the recognition of our professions by governments and health care systems. In some regions of the world, our professions are in their infancy. Even where the professions exist, there are insufficient numbers of clinicians to meet local and national needs (Ali & Syed, 2021; ASHA, 2022; Pillay et al., 2020; Royal College of Speech and Language Therapists, n.d.). Additionally, people living in rural areas throughout the world tend to have poorer access to services than those living in more urban areas (Eubank et al., 2022; Jones et al., 2017; Lowe & Nobriga, 2021; Morton et al., 2022). Thus, simply in geographic limitations, much of the world’s population does not have access to our services. Needs for transportation, facilities, and workforce are best addressed through collaborative efforts of government agencies, colleges and universities, professional organizations, nonprofit entities, and passionate professionals.

Examining Funding Challenges In much of the world, reimbursement and funding problems constitute the greatest barriers for access to audiology and speech-language pathology services. In higher-resourced countries where the professions of speech-language pathology and audiology are well established, an emphasis on cost containment in all areas of health care delivery is at the root of many barriers to access. Children and adults with disabilities face unique difficulties as they attempt to obtain services through progressively more unwieldy health care systems. Overall, access to our services is being reduced by the coverage and reimbursement limitations imposed by third-party payers and ever-changing means of determining how our services are to be reimbursed. In the United States, physician referrals are decreasing, authorizations for evaluations and treatment are processed slowly, insurance claims are often denied, and the appeals process can be cumbersome and lengthy. Additionally, public and private health insurance carriers’ reimbursement rates are at times well below the actual cost of providing services (Lim et al., 2010; McManus et al., 2010). As a result, some health care employers

are eliminating positions or are placing clinicians on asneeded schedules, actions that further jeopardize access to services. Primary care physicians are more aggressively guarding scarcer financial resources to ensure the availability of basic health care for their patients. Many physicians see audiology and speech-language pathology services as a low priority (Zazove et al., 2020) or as services that should be paid for by other entities such as school districts, public service organizations, or clients themselves. Insurance companies are following suit.

Identifying Sociocultural Barriers to Access Given increased diversity through worldwide migration and immigration and increasing work to empower marginalized groups and advocate for greater inclusion, clinicians everywhere are more and more likely to work with people who are diverse in multiple respects. To ensure access, service-providing agencies must demonstrate understanding of concerns and needs of people who are diverse, such as in race, ethnicity, religion, education, sex, sexual orientation, gender identity, age, income, education level, socioeconomic level, and languages spoken — plus the complex intersectionality of these constructs. If they do not, and if they do not engage actively in inclusive action of marginalized people, large populations of people will not gain access in the first place or will be alienated from services they need. Our cultural responsiveness as clinicians is vital to engaging diverse people to benefit from our services and helping them to retain access to us. When expanding services for specific populations, it is important to consider cultural beliefs such as those regarding health care and the nature of disabilities. Hospitalbased services may not attract people who would more likely gravitate to community-based and nonmedicalized models of care. Not having proficient speakers of a person’s primary language available to provide services severely limits what we can offer. Disregard for cultural and religious beliefs leads to stunted opportunities for access to care. For example, consider the consequences of the following on a person’s willingness to engage in our services: n

The assumption that a person is comfortable with the diagnostic process of labeling a disability despite a strong sense of stigma associated with disability, or a desire to protect a loved one from being labeled as having a problem

n

A lack of recognition that a person may see their engagement in rehabilitation as a refusal to accept a disability that was bestowed on them by a higher power



CHAPTER 15   Strategically Promoting Access to Speech-Language Pathology and Audiology Services

n

Prioritization of foci on impairments and deficits rather than on life participation

n

A focus of interventions on individuals rather than on their families and support systems

Recognizing the Burdens of Navigating Health Care Systems Understanding today’s medical literature and health insurance materials can be daunting for even the most sophisticated person. For those with literacy problems, difficulties are substantial and, as a result, differentially impact access and related needs for patient support and advocacy.

Ensuring Others Understand the Need for Our Services Why is it critical that an individual obtain services for communication disorders? What are the consequences for a child or adult with communication challenges when services are inaccessible or nonexistent? Members of our professions must address the answers to these questions and elaborate upon them if we are to substantiate the need for our services to consumers, third-party payers, legislators, and other professionals in health care and education. Likewise, the effectiveness of our interventions must be demonstrated and promoted continuously. The projected needs for audiologists and SLPs in the next decade exceed those of most health care professions. The need for services provided by audiologists is expected to increase by 13% from 2019 to 2029; the need for SLPs is expected to increase by 27% during the same period (U.S. Department of Labor, 2022). There are several reasons for this growing need: n

The aging population is expanding, with corresponding increases in hearing loss, balance challenges, and neurologically based challenges to speech, language, cognition, and swallowing (U.S. Department of Labor, 2022; World Health Organization, 2022).

n

Advances in medical technology are saving lives and increasing the life span.

n

Bilingual/multilingual and multiethnic populations, which have proportionately greater needs for speech and language diagnostic and intervention services, are expanding (Centeno et al., 2020).

n

There is a greater emphasis on early identification and diagnosis, as well as increased referrals

of students to professionals (U.S. Department of Labor, 2022). n

There is a greater emphasis on health promotion and disease prevention.

n

While enrollments in elementary and secondary schools have fluctuated in recent years, enrollments in special education for specific learning disabilities, which ideally benefit from speechlanguage pathology and audiology services, continue to increase (Mason et al., 2020; National Center for Education Statistics, 2022).

Another factor affecting the need for services for people with communication disorders is the accelerating worldwide dependence on information technology, requiring people to have ever more effective communication abilities. On a daily basis, we are required to manage greater amounts of complex language-based information. Those who have untreated communication challenges risk becoming marginal participants in our society, observers on the sidelines. In the United States, literacy data are not promising, especially in lower-income areas. Only about one-third of elementary students in the United States were proficient in reading and math prior to the COVID-19 pandemic (National Center for Education Statistics, 2022), a figure that has continued to decline since the onset of the pandemic. Many of the parents and guardians of children with low literacy levels, especially those with low incomes, are unable to provide basic reading support due to their own low education levels. Children who are poor readers, particularly those raised in poverty, have a greater likelihood than good readers to experience academic failure and to enter adulthood in poverty, with a greater likelihood of criminal behavior (Maughan et al., 2009; McNeilly, 2016; Snow & Powell, 2008). The prevalence of language-learning disabilities and illiteracy in state prisons provides dramatic evidence of the cost of not providing speech-language pathology and audiology services. Up to 75% of adults remanded to prisons have significant communication disorders, which are vitally linked to literacy (Parsons & Sherwood, 2016; Shippen et al., 2010; Sondenaa et al., 2016). Likewise, teenage parents raised in poverty have a high prevalence of speech-language and literacy problems; this may affect not only their own economic and social futures but also those of their children. Additionally, in high-technology industries, employers report difficulty recruiting candidates with even minimal literacy and mathematical abilities (Rainee & Anderson, 2017). For many individuals, access to our services is crucial for establishing the communication skills necessary for success in education, employment, and social interaction.

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The social consequences of communication disorders remain fundamentally challenging, too. Despite worldwide efforts to improve the ways people with disabilities are treated and regarded, many individuals with communication disorders face stigmatization, low self-esteem, and social exclusion.

Optimizing Reimbursement for Clinical Services Unless the financial viability of service providers and their institutions is ensured, there will be limited or no access to speech-language pathology and audiology services. The primary means by which financial viability can be maintained is through the enhancement of clinical revenues; that is, earned income. In today’s health care environment, multiple sources of reimbursement for evaluations, treatment, and consultation must be identified and developed. Contractual agreements with third-party payers (insurance companies) can be carefully negotiated to ensure clinical revenues and minimize financial risk. One must know in detail the policies and procedures of multiple payers and stay abreast of changes in policies and procedures of each payer. This requires dedication to ongoing communication with payers and follow-up to those communications by the provider.

Proactively Avoiding Reimbursement Denial One especially effective approach to optimizing an organization’s payer reimbursements is to identify the most common reasons for authorization and/or treatment denials an organization experiences and then develop action plans that address each reason. Generally, the most common reasons for denials in the United States are: n

There is insufficient documentation.

n

An appropriate physician referral was not obtained.

n

The service provided was not covered by the client’s health insurance plan.

n

The service was deemed not medically necessary.

n

The authorization period had lapsed.

n

The patient was no longer improving.

Given that these causes typically make up 80% to 90% of the reasons for denial by public and private insurance companies, clinical professionals and administrators may best use their time and resources by proac-

tively addressing the causes of each of these problems. By implementing careful documentation strategies, along with ongoing verification procedures to ensure attention to each of these potential pitfalls, service providers may greatly reduce the percentage of reimbursement claims that are denied. Many service-providing organizations have automated denial management processes for a systematic approach for analyzing claim problems, tracking denials and appeals, and preventing future denials. Also essential to predictable clinical revenue flow is a sound understanding of the diagnosis and treatment classification coding systems that are the basis for reimbursement in the United States — that is, the International Classification of Diseases (ICD) and Common Procedural Terminology (CPT) codes, as they relate to speech-language pathology and audiology services. Failure to keep abreast of variations in coding and billing procedures from one insurance carrier to another and to use current ICD and CPT coding can be costly. The American Speech-Language-Hearing Association (ASHA) provides substantial resources to members seeking guidance in billing, coding, and reimbursement best practices. Fortunately, compliance with the Health Insurance Portability and Accountability Act (HIPAA) helps reduce inconsistency in billing codes accepted by various payers through required uniform coding processes. Medicare administrative contractors, such as national government services, are required to meet regularly with providers to identify coding, billing, and documentation problems that bring about denials. Working with providers, such entities strive to eliminate these problems, thus saving resources for providers and payers. Educating administrators, payers, and physicians about possible health care cost savings associated with speech, language, swallowing, and hearing services is an additional means of enhancing access to these services. Another approach to enhancing clinical revenues is offering services for which clients or their employers pay directly. Direct payment is the usual form of reimbursement for some services, such as accent modification and individualized coaching for professional speakers. Patients and clients may also pay out of pocket for most clinical services. Emphasizing the possibility of direct payment to those who can afford it is an alternative route to accessing care that is not dependent on insurance coverage and helps to enhance providers’ clinical revenues. Some SLPs have enhanced communication access greatly by developing centers where intervention, activity, and support groups are emphasized over one-on-one sessions and where insurance coverage may not even be relevant. Given the numbers of people helping to cover costs of group meetings, costs are lower than for individual sessions. In addition, by working outside the confines of insurance regulations, clinicians may be more creative in



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expanding programming options. Centers that are not medically focused expand opportunities for people with communication challenges to enhance life participation through meaningful communication, well beyond the typical brief periods for which they are eligible for services through their insurance carriers. Wonderful examples of such centers focused on aphasia and related disorders are touted by Aphasia Access (https://www .aphasiaaccess.org).

Rebutting Denials Based on Medical Necessity As health care organizations attempt to rein in health care costs, the loosely defined and yet broadly and inconsistently applied concept of medical necessity is frequently used to deny authorizations or reauthorizations for care. Strictly defined, medical necessity relates to treating conditions that result from illness, injury, or disease. First-level claims reviewers, whose purpose is to protect health insurance company funds, typically apply this restricted definition, leading to denied claims for audiology and speech-language pathology services. In most instances, claims reviewers have minimal to no understanding of speech-language pathology or audiology and thus are poorly prepared to render informed decisions concerning the medical necessity of our services. Because of their inexperience with our professions, third-party payers are often more easily convinced of the necessity for the treatment of physical disabilities than they are of the need to treat problems associated with cognitive and communication disorders. Further, reviewers in commercial insurance companies tend to implement medical necessity requirements based on cost, predictable outcomes, and the medical nature of conditions being treated, not on knowledge specific to audiology and speech-language pathology. Clinicians must be able to provide substantive arguments demonstrating how most of our services do, in fact, meet definitions and criteria of medical necessity. The term “medical necessity” does not have one standardized definition that is agreed upon across health plans and government entities. Thus, each third-party payer has considerable discretion for determining the type, scope, and duration of covered benefits as they relate to the construct in contract language. Overall, the criterion of medical necessity requires that the service we are providing is: n

appropriate given the person’s age, health status, and diagnosis;

n

based on published evidence that the service will elucidate, prevent, or improve the person’s condition; and

n

likely to lead to greater quality of life and better functioning in whatever ability has been impaired.

When documenting medical necessity, clinicians typically include details about aspects of medical history that have influenced the individual’s status, a diagnosis related to the clinician’s scope of practice (e.g., aphasia, sensorineural hearing loss), date of onset, an evidencebased treatment plan, and progress notes that refer to the medical necessity.

Emphasizing Evidence-Based Practice Evidence-based practice (EBP) is a concept applied increasingly by many payers to further restrict access and reduce care and, thus, their payments. This topic is discussed in depth in Chapter 6. Simply stated, health insurance companies tend to permit authorizations and reimbursements only for those interventions for which efficacy and effectiveness are supported by published research. While laudable in principle, implementation of strict EBP rules reduces access to all health care disciplines for minoritized and underrepresented groups, who generally are disproportionately excluded from clinical effectiveness studies (Bierer et al., 2022; Epstein, 2008; Kneipp et al., 2009; Nolan & Bradley, 2008). As a result, these groups suffer disproportionately when an insurance company’s coverage is dependent on published evidence of a treatment’s effectiveness. Another drawback of such emphases on EBP is third-party payers’ lack of validation of clinicians’ essential attention to practicebased evidence in balance with EBP (Hallowell, 2023). Despite concerted efforts to address treatment efficacy and outcomes research in communication sciences and disorders, work to develop a solid foundation in EBP through our own disciplines lags behind the implementation of EBP requirements imposed by the insurance industry and by government policymakers. A rich resource of EBP guidance across the speech-language pathology scope of practice is SpeechBite (speechbite .com), an online searchable database that provides intervention studies and ratings of the research quality of each. ASHA and members of several of its affiliated special interest divisions, as well as the Academy of Neurologic Communication Disorders and Sciences (ANCDS; ancds.org), have prepared extensive systematic reviews and bibliographies summarizing treatment efficacy in a wide range of clinical areas such as stuttering, cognitive and communicative problems associated with traumatic brain injury, feeding and swallowing disorders, hearing loss, hearing aids, audiological rehabilitation, aphasia, child language disorders, autistic spectrum disorder, phonological disorders, and dysphagia. ASHA offers a

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free, searchable collection of evidence maps on its website (http://www.asha.org). This information helps to support claims of effectiveness and to reverse denials based on the concepts of medical necessity and evidence-based medical necessity. It may also be used advantageously when negotiating contracts with insurance companies.

n

Ensuring Alternative Funding Approaches In the face of dramatic cuts in reimbursement rates, organizations typically must enhance access to services by systematically developing funding alternatives that supplement clinical revenues. These alternatives have long been central to the operation of most nonprofit organizations, which are commonly required to provide services to clients regardless of their ability to pay. Amid grave reductions in clinical revenues in the current service delivery arena, alternative funding sources are now more critical than ever. Even for-profit agencies are developing their own nonprofit foundations or are partnering with extant foundations that will help support the provision of services to clients whose access might otherwise be curtailed. Service-providing agencies can best support their nonclinical revenue base by strategically developing a funding plan consisting of several possible revenue sources. Essential components include the following: n

Ensuring a fundraising-oriented board of directors and chief executive officer or executive director, an experienced development professional, staff, volunteers, and any additional “friends” of the organization

n

Developing a case statement that describes the agency’s mission and vision and details of why donors should invest their resources in its programs and services

n

Establishing a resource development or fundraising team, including members of the organization’s donor base of individuals

n

Patients/clients, foundations, and corporations that support programs and services for people with communication disorders. The donor base may include, but should not rely solely on, federated donor bases, such as (in the United States) United Way, United Black Fund, or Easter Seals Society.

n

Engaging in specific fundraising activities. These may include the following: n An annual fund campaign — This is typically conducted during the last quarter of a

n

n

n

n

calendar year to take advantage of contributions that individuals and corporations make to reduce their income tax liability. Special events — Examples are benefit concerts, special recognition dinners, golf outings, fashion shows, marathons, and evenings at the theater. In addition to raising operating revenue for the organization, these events generate publicity, media attention, and community goodwill. They also introduce potential donors to the organization and its mission. Online fundraising — Most organizations’ websites have links on their home pages to guide potential donors on how to support the organization. Planned and deferred giving programs —  These long-range funding programs typically yield benefits in an average of 5 to 7 years. They include bequests, gift annuities, charitable remainder annuity trusts, charitable remainder unitrusts, pooled income funds, charitable life insurance, and gifts of real estate and goods (e.g., works of art). Guidance from professionals with expertise in planned giving, estate planning, law, and accounting is essential to successful planned and deferred giving programs. Corporate partnerships — Partnerships between corporations and nonprofit organizations serving people with communication disorders may help to augment client access through agencies’ improved fiscal stability. Corporations are most likely to adopt a charity or one of its programs in communities where corporations have a significant presence (e.g., in areas where their corporate headquarters are located). Fraternal organizations and sororities — In the United States, community fraternal organizations such as the Eagles, Elks, Junior League, Kiwanis, Lions, and Rotary are all sources of client- or program-specific funding. SERTOMA and Scottish Rite, though present in only certain regions of the United States, are also fraternal organizations with long-standing histories of support for audiology and speech-language pathology services. Delta Zeta sorority has historically supported programs that serve people who are deaf or hard of hearing. Most of these entities entertain proposals to fund services, equipment, or materials needed by individuals unable to afford these.



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n

Research funding to support clinical services — Clinical research funding from local, regional, state, and federal agencies may strengthen a service-providing agency’s fiscal stability. Often, research instrumentation and materials purchased through grant funds (e.g., diagnostic equipment, published tests, treatment materials, computers, and software) enrich not only the research environment but the organization’s clinical environment as well. Also, indirect cost or overhead monies provided by funding agencies can be used to support an organization’s general operational costs, thus enhancing clinical access.

Agencies that do not have in-house development expertise can contract with fundraising consultants for specific resource development projects and/or longrange planning. In many instances, these arrangements are more cost-effective and further allow the organization’s staff to concentrate on more profitable activities, such as acquiring major gifts.

Advancing Legislation to Improve Access In the United States, several pieces of federal and state legislation have been passed to ensure children and adults with special conditions have access to adequate and appropriate levels of service. Knowledge of federal laws, their state equivalents, and the rules and regulations that guarantee access to special services, including speech-language pathology and audiology, is essential. The Social Security Act, for example, contains several titles — that is, chapters or subsections — that ensure reimbursement for speech-language pathology and audiology services, including: n

Title 5, which supports the Maternal Child Health Bureau’s programming for children with special needs and includes newborn hearing screenings

n

Title 18, Medicare, which provides for speechlanguage pathology and audiology coverage (Medicare coverage is also available for those under the age of 65 who have disabilities lasting longer than 2 years, such as chronic neurological conditions)

n

Title 19, Medicaid, which addresses health care and long-term care of people who meet low income and asset guidelines

n

Title 20, the social services subsidy, which in some instances supports social work services and,

in turn, can help families access speech-language pathology and audiology services n

Title 21, Children’s Health Insurance Program (CHIP), a funding source for speech-language pathology and audiology services, usually administered by a state’s Department of Human Services, Medicaid Division

n

Individuals With Disabilities Education Improvement Act (IDEIA), the primary funding vehicle for states’ preschool early intervention, elementary, and secondary special education programs

n

Rehabilitation Act, which funds rehabilitation services, including audiology and speechlanguage pathology, for individuals ranging in age from 16 and up.

Many of these reimbursement mechanisms have mixed histories in their effectiveness in supporting services for populations with special chronic or degenerative conditions. Several other pieces of federal legislation indirectly support our services in the United States. The Americans With Disabilities Act (ADA), for example, does not ensure funding per se, yet it does require employers to make certain resources available in cases in which communication disorders have a demonstrated impact on an individual’s ability to perform job duties. Likewise, the Rehabilitation Act is a national law that prohibits discrimination against qualified people with disabilities for employment in the federal sector. Additionally, the Every Student Succeeds Act (ESSA) is intended to support education of all children, including those with disabilities, in the public schools through high standards, an emphasis on school and teacher accountability, and selective funding programs.

Advocating for Our Professions The goals of improved access and quality of care of most current health insurance companies are often in direct conflict with the insurance companies’ goals of cost containment. Improving access for speech-language pathology and audiology services requires that action plans for advocacy be thoughtfully developed and executed at various levels of governmental bureaucracies in the public and private reimbursement arenas (Hallowell, 2023; Henri & Hallowell, 1999; Henri et al., 1997; Miller & Roup, 2022). People coping with communication disorders are often at a disadvantage when the need arises for personal advocacy concerning access or reimbursement. Many individuals with communication disorders have

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difficulty advocating vigorously for their own needs. This problem may be further compounded by difficulties related to communication infrastructure, travel, distance from legislators in rural areas, and literacy. Furthermore, individuals who would benefit from our services often do not have the knowledge necessary to confront a complex bureaucratic system to obtain coverage for needed services. Audiologists and SLPs thus have numerous opportunities to initiate or support consumers’ advocacy efforts. These opportunities require that we professionals be knowledgeable about the content and the process required for an effective advocacy effort (Hallowell, 2023). Historically, most audiologists and SLPs have had little experience, and often little inclination, to participate in public policy development, political advocacy, and lobbying. Given the ongoing dramatic challenges to consumer access and the consequent fiscal instability of service-providing agencies, though, it is no longer possible for clinicians, administrators, educators, and consumers to remain passive, adopting a “let someone else do it” attitude. Together, professionals and consumers must participate in coordinated efforts aimed at educating and influencing decision makers about the value of audiology and speech-language pathology services and especially about the societal consequences of not providing these services. Information related to access issues must be disseminated and used as a basis for action. Specific actions for advocacy are described below. Given the regional and national variations in how such actions may be carried out, many of the actions described here are couched in terms that are primarily appreciable in the United States; all are modifiable for actions in other regions and countries.

Actions for Advocacy and Professional Assertiveness Advocacy Among Clinicians and Clinical Administrators Specific action steps in which clinicians and clinical administrators may make solid contributions to advocacy efforts to improve consumer access are summarized here. Pursue Continuing Education.  Clinicians who consistently and attentively read current publications and participate in seminars and workshops to improve their knowledge concerning managed care and its impact upon our services will be most effective as advocates. National and state professional organizations offer resources to assist members in their efforts to stay attuned to health care policy changes and maintain current understanding

of coding and billing procedures. The reader is encouraged to visit their websites regularly and stay current with professional publications for audiologists and SLPs. Educate and Empower Consumers.  Clinicians must take advantage of the direct access they have to consumers to provide counseling and education that will motivate consumers and their families to appreciate: n

the complex relationships between an individual’s communication abilities and the success one experiences in other life arenas, such as progress in school or independent living;

n

any restrictions consumers’ insurance companies place on the treatment of communication and/ or swallowing disorders; and

n

specific means by which consumers may become more involved in advocacy.

Address Literacy and Nondominant Language Challenges.  Given the dire lack of professional interpreters in most health care environments (Espinoza & Derrington, 2021), case managers, volunteers (e.g., retired insurance specialists, law students), and community members with shared cultural and linguistic backgrounds may be enlisted to help those with literacy problems to navigate and understand health care and health insurance information. All written materials should be written in what the Institute of Medicine calls plain language. This includes organizing the most important action-focused information first, breaking information into understandable units, avoiding jargon, and making the pages easy to read. Also, ensuring materials are translated and published in multiple languages is important for those who are less proficient in English than another language. Educate and Market to Third-Party Payers. Providers must convince insurance representatives of the need to include speech-language pathology and audiology services in health care plans. We must also convince physicians of the necessity of our services. Educate and Market to Referral Sources. Many of the decision makers who have the greatest potential to make an impact on patient access are often unaware of the issues faced by people with communication and swallowing problems and of the vital role that SLPs and audiologists play. It is important that decision makers such as physicians, discharge planners, and directors of student services and special education programs be educated about the link between communication abilities and one’s success in life.



CHAPTER 15   Strategically Promoting Access to Speech-Language Pathology and Audiology Services

Appeal Denials of Treatment Authorization and Reimbursement.  Providers must work with their clients to appeal vigorously all decisions denying coverage of services. A concerted appeals process in a service providing agency helps improve access to services in that agency, as success rates for concerted appeals are high. To support these efforts, our national professional associations provide guidance on appealing denials on their websites, including model letters that can be sent to health insurance companies to reverse authorization and reimbursement denials as well as treatment efficacy statements that can be appended to an appeal letter as a supporting document. Promote Access to People With Geographic and Transportation Challenges.  It is important that service providers develop and promote telepractice services, including the requisite internet and telephone infrastructure, to enhance access for those who have limited access to on-site services. Clinical agencies should also provide their clientele with information on how to access public transportation, and the option of home health care if possible. Contribute Financial Support. Contributions to political action committees help to advance concerted professional advocacy efforts at state and federal levels. ASHA and AAA each support a political action committee and host online content to assist members in advocating for services. Write to Legislators.  As they want to remain in office and be reelected, legislators have a vested interest in knowing their constituents’ concerns. Without the strong voice of professionals who understand the impact of policy decisions on consumers, legislators are unlikely to be sensitive to and knowledgeable about critical issues important to informed decision making. Professionals do not need to be sophisticated about legislative processes to join in legislative campaigns to address the numerous challenges to patient access. National, state, and local organizations offer ample guidance. Taking advantage of the grassroots advocacy resources of our professional organizations, free of charge, allows professionals to read concise descriptions of issues that need to be addressed and specific actions professionals may take. These actions almost always involve calling, writing, or emailing legislators. At annual professional conventions, congressional affairs staff members may offer hands-on help with letter writing and related advocacy projects. Further assistance is available through our professional associations’ websites. Invite Legislators to Work Settings.  Hosting a member of Congress in the clinical environment allows clini-

cians to directly discuss and demonstrate problems of access, the need for access, and the ways in which speechlanguage pathology and audiology services improve the quality of life of legislators’ constituents. Visit Legislators.  Because legislators have temporary terms, it is a good idea to visit and write to elected officials on a yearly basis, in their local or national offices, to keep them informed about critical access and service delivery issues confronting children and adults. Seek support in these efforts through professional associations. For example, the government relations staff of ASHA arranges appointments for professionals visiting Washington, D.C., and provides in-person briefings and other materials. See Chapter 25 for further discussion of legislative advocacy. Participate in Clinical Research.  Given the dire need for empirical research to support EBP, clinicians’ roles in research are more important than ever. For those not having skills, time, training, or resources to initiate or oversee research programs, there are ample possibilities for collaboration with university-based researchers. Check out funding sources to support such collaboration. Engage in Quality Improvement.  By maintaining ongoing quality improvement programs, providers continue to demonstrate cost-effective, functional treatment outcomes, which are essential to local, state, and national advocacy efforts. ASHA and AAA have developed resources to assist their membership in developing and maintaining quality improvement programs.

Advocacy Among Consumers and Their Significant Others Consumers and their significant others are among the most powerful and credible advocates in improving access to audiology and speech-language pathology services. As there are often limitations due to consumers’ communication disorders, support from family and clinicians in encouraging consumer advocacy is essential. Specific ways in which consumers and their significant others may make solid contributions to advocacy efforts to improve access to services include active writing to legislators and visiting legislators, as described previously. Backing by the SLP or audiologist in each of these efforts may be helpful, as may be the support of the consumer’s primary care physician. Actively Pursue Coverage for Speech-Language Pathology and Audiology Services.  It is important that consumers pursue adequate coverage by health

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insurance companies. Consumers often are unaware of the coverage provided by their health care policies and restrictions that many place on speech-language pathology and audiology services. Careful study of a health plan’s coverage and policies is a first step toward proactively seeking greater access to services. For those covered by employer-sponsored plans, staff members of the employer’s human resource department may offer assistance in checking on specific coverage issues. Referring an insurance case (or utilization) reviewer to a particular policy document may easily resolve some coverage issues. In cases in which needed services are not covered, consumer appeals to third-party payers regarding the need for services to enhance independence, educational status, medical management, and/or overall quality of life may help to shape future policy modifications. Report Health Care Policy Coverage Inconsistencies.  When there are discrepancies between what an insurance company purports to cover, through its promotional materials and policy documentation, and its actual practice in authorizing and/or reimbursing for services, appeals brought by consumers are critical. Discrepancies can be reported at a variety of levels. Working through a hierarchy of contacts is recommended, beginning with insurance case reviewers, thereon to consumer liaisons and up to CEOs. If necessary, state insurance commissioners may be contacted. If reporting at each of these levels fails, contacting your United States congressperson or senator often helps. Other avenues for advocacy in the face of restricted services include letters to the editor in newspapers and professional journals and carefully constructed press releases that may lead to newspaper, radio, and/or television coverage of access problems. If aired constructively, such media coverage may help to foster public education about access issues while exerting due pressure on insurance companies. Educate Employers.  Organizations that pay for insurance coverage for their employees should be urged to reconsider contracts with companies that have a pattern of limiting or violating their coverage policies or of not covering critically needed services. Consumer feedback to employers’ human resources departments helps raise awareness of a plan’s effectiveness and worth and has been found to be especially effective.

Advocacy Among Educators and Students Before they enter the clinical workforce, it is important that students gain awareness and knowledge of professional practice issues and how they may foster positive

changes within their profession. Such preparation is especially essential in medical, rehabilitation, and skilled nursing contexts, where supervisors and other experienced practitioners are increasingly called to engage in billable clinical service as opposed to training and supervisory activity related to issues of insurance coverage (i.e., coding, authorizations, documentation, billing, appeals, and marketing). Graduates who are savvy about these issues and about productive actions for advocacy will have a distinct advantage over others in the job market and in their initial stages of clinical practice. An additional advantage to having students get involved in professional practice issues is that students can achieve significant advocacy work while they are still in school. Specific actions in which faculty members and students may engage to advance advocacy for clinical access are addressed here. Learn About Modes of Service Delivery, Health Policy, and Their Effects on People With Communication and Swallowing Disorders.  It is essential that all faculty members in clinical education programs obtain an understanding of health care reimbursement principles and their ramifications for practice in speechlanguage pathology and audiology. Such an understanding, in turn, helps foster students’ potential for strategic advocacy as well as effective future professional practice. Continuing education is available through current publications, internet resources, conferences, seminars, and workshops. Three methods of advocacy by educators and students are curricular revision, education of medical students, and engagement in concerted legislative advocacy. Ensure Service Delivery and Advocacy Are Included in Curricula.  Coursework emphasizing the interconnections among functional outcomes, cost-effectiveness of intervention, reimbursement, and consumer access will help to foster professional advocacy for years to come. Infusing such concepts throughout the curriculum will help students to see the importance of such concepts in their current and future professional roles. Ensure Interprofessional Education. Opportunities to engage students from varied health-related professions in preceptorships related to our field, and clinical observation of audiology and speech-language services, enhance appreciation of our services among future clinicians across disciplines. Likewise, presenting lectures or workshops to students and professors in other fields helps elevate the community’s understanding of the impact of communication disorders upon a person’s life trajectory and how these conditions may be beneficially addressed.



CHAPTER 15   Strategically Promoting Access to Speech-Language Pathology and Audiology Services

Engage in Concerted Legislative Advocacy. Students and faculty have clout as political constituents whose voice may have an impact on legislators. It is important that faculty and students be encouraged to participate in advocacy efforts sponsored by national, state, and local professional organizations and student and consumer groups. Academic classes or student groups may organize letter-writing campaigns involving significant numbers of participants.

Care Extenders One way to cope with limitations in access to professional specialized care that people with communication and swallowing disorders are facing is to expand the reservoir of individuals who may provide needed care. Care extenders consist of individuals who are not certified or licensed SLPs or audiologists, but who nevertheless engage in furthering the development or rehabilitation of communication and swallowing skills. Ideally, they are trained and monitored by a fully certified clinician. They may be support personnel (e.g., aides, technicians, or assistants), clinicians in training, family members, or community volunteers.

Support Personnel Many SLPs and audiologists find the use of professional aides, technicians, and assistants essential for ensuring clients’ access to care. Support personnel may help in the handling of large caseloads so that more clients are treated and/or more treatment time per client is offered than would otherwise be possible. They may also allow fully credentialed clinicians more time to treat individuals with severe and complex communication disorders, thus improving overall quality of care. An additional advantage is that the level of care needed by an individual may be more closely matched with the level of training and experience of an aide or assistant. Services once thought to be within the sole domain of SLPs or audiologists, but that do not require the skills and expertise of professionals with all the training and experience required for clinical certification, may be offered by people whose services are far less costly. Support personnel vary widely in their level of academic and on-the-job training. Speech-language pathology aides, for example, generally have training in specific areas of practice and have more limited responsibilities than assistants. The increase of support personnel in speechlanguage pathology and audiology has led to further proliferation of regulations and standards. Within the United States, states vary in the use of terms used to refer

to the various levels of training and/or licensure required of support personnel. State laws also vary in the tasks in which support personnel are permitted to engage. Examples of tasks that speech-language pathology assistants may perform under the supervision of an SLP, according to ASHA’s Scope of Practice for SpeechLanguage Pathology Assistants (ASHA, 2022), include conducting speech-language screenings and participating in treatment plans or protocols established by a certified SLP. Examples of tasks audiology assistants may perform under the supervision of an audiologist include conducting hearing screenings, applying electrodes for electronystagmography testing, and checking calibration for audiological equipment. Support personnel may perform clerical duties, document test results and patient/client progress, prepare diagnostic and treatment materials, schedule diagnostic and treatment activities, and participate in research projects, in-service training, and public relations programs. Examples of tasks that support personnel are generally not permitted to perform include diagnostic testing or interpretation of test results, hearing aid fitting, patient/client or family counseling, development or modification of a patient’s/ client’s individualized treatment plan, and discharging a patient/client from services. Regardless of specific duties performed, an ongoing supervisor relationship by a fully licensed and certified SLP or audiologist is critical. Despite the advantages mentioned, the use of support personnel has not been fully embraced in our field. Those opposing support personnel maintain that the quality of care rendered to patients is diminished, that time savings through services provided do not merit the increased time demands for supervision, and that the job security of licensed professionals is threatened. There is also concern that cost-minded health care and educational administrators at times abuse the use of support personnel by compelling them to provide services outside their scope of practice and by implementing cost-saving hiring practices in which ideal supervisorto-support staff ratios are exceeded. An additional drawback is that many health insurance companies still do not recognize support personnel as qualified service providers and therefore do not pay for treatment delivered by these people. See Chapter 9 for more discussion of this topic.

Graduate Students The provision of supervised evaluation and treatment services by graduate students in speech-language pathology and audiology has long been a source for extending care to clients/patients. In many university clinics, ample free and low-cost services are made available to

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surrounding communities while providing diverse clinical learning opportunities to student clinicians. Additionally, networks of student volunteers may be helpful in extending services beyond clinical and diagnostic treatment sessions. Examples are students serving as communication partners, in-home respite providers, support group assistants, and volunteers in a wide array of clinical educational contexts.

Trained Volunteers Trained volunteers can be effective care extenders. As no compensation is involved, and as these individuals are clearly identified to clients/patients as volunteers, there are fewer legal and licensure-related problems than in the use of multiskilled professionals. Volunteers provide additional opportunities to practice and maintain developing communication skills. Before their direct involvement with patients or clients, volunteers may be required to observe treatment sessions and then may be guided by the clinician in the provision of treatment-reinforcing activities such as repetitive drills. Volunteers may also be trained to handle other tasks, such as clerical work, scheduling, and equipment maintenance, allowing skilled clinicians more time to spend with clients/patients.

Family Members and Other Caregivers Engaging family members and other people who play important roles in the lives of people with communication challenges has always been essential to the effectiveness of our work. Given the current health care service delivery climate, such people are often required to assume greater responsibilities in caring for their significant others. As with trained volunteers, coaching and training by the skilled clinician are essential. Treatment-complementing activities provided by a properly guided caregiver can be highly effective; in fact, they are essential for enhancing the life participation goals of the people we serve.

Expanding Access Through Technology Advances in technology improve and augment the clinical services of SLPs and audiologists. For many individuals, these advances improve access to services, particularly for those with limited physical accessibility to evaluations or intervention. Technology also may be a cost-effective support for clinicians wishing to access current information to improve their clinical skills. See Chapter 23 for continued discussion of technology as a professional issue.

Telepractice Telepractice is the use of electronic information and communications technologies to provide and support clinical services when there is a distance between participants. Audio, visual, and text media are generally combined in telepractice applications. The terms “telehealth,” “telemedicine,” and “telerehabilitation” are also sometimes used, although many authors and practitioners prefer the term telepractice, as it is more inclusive of services offered outside of primary health care and medical practices. From its inception, one of the most promising aspects of telepractice has been the improvement of access to care in remote areas where skilled service providers are scarce or absent (Swanepoel et al., 2010). In addition to the lack of geographic access to service providers, other barriers to care might be alleviated by telepractice. These barriers include: n

distance from services;

n

transportation challenges;

n

limited financial resources, including insurance coverage and subsidized services;

n

family, educational, and cultural factors;

n

restrictive infection control precautions;

n

anxiety associated with in-person visits, especially in medical contexts; and

n

health care delivery characteristics, including poor care coordination, long waiting times for appointments, shortages of specialists, and bureaucratic obstacles to services (Raatz et al., 2021; Weidner & Lowman, 2020).

In addition to expanding access for disadvantaged populations and patients in rural areas, opportunities have expanded for home health services through technology. As home health care remains an important form of service delivery, it is essential that clinicians stay abreast of telepractice mechanisms that may allow replacing some home visits with video visits, checking up on carryover of treatment activities, and furthering patient and family education in naturalistic environments rather than in unfamiliar clinic spaces. An additional advantage of providing care through distance technology is that it may expand clinicians’ availability to people who live in areas that are considered unsafe, such as some urban neighborhoods, prisons, and even within active international war zones (Bowman, 2022; Hart, 2010). In conjunction with the expansion of digital technology, enabling image capturing, compression, trans-



CHAPTER 15   Strategically Promoting Access to Speech-Language Pathology and Audiology Services

mission, and interpretation, interest in telepractice is expanding rapidly across a vast array of health care professions. Restrictions to in-person access due to the COVID-19 pandemic have led to substantially more initiatives in virtual engagement and increasing openness to virtual engagement from the perspective of the people we serve (Hallowell, Enderby, et al., 2021; Hao et al., 2021). High-speed, high-bandwidth telecommunication systems are expanding globally. In addition to improved access, advantages reported by evaluators of some rural telepractice programs include reduction of duplicative diagnostic services, improved consumer confidence in local medical personnel and facilities, reduced need for referral to service providers outside the local area, improved recruitment and retention of health care personnel, improved productivity and workload management, and improved continuing education for service providers (Boisvert & Hall, 2019). Clinical applications in telepractice are found in virtually every health specialty. As discussed in Chapter 23, a growing number of published empirical studies directly address the effectiveness of telepractice delivery in audiology and speech-language pathology. New developments in technological access to care will be shaped by ongoing developments in health policy as it affects telepractice. The following factors are influential in continuing efforts to expand service delivery options for professionals in our disciplines: n

licensure issues, especially for services provided among states;

n

training in the use of telepractice technology;

n

establishment of standards;

n

reimbursement issues;

n

patient confidentiality and data security issues;

n

attitudes of providers and patients;

n

means of ensuring quality of clinician–patient relationships;

n

potential cost savings;

n

demonstration of clinical outcomes; and

n

telecommunications infrastructure and costs.

Information Technology Given that access to care involves more than direct contact with a skilled clinician, the notion of technological access also includes the use of telecommunications and information technology to improve access to information that may allow consumers and potential consumers

to learn about communication problems, diagnostic and treatment options, and prevention strategies. For those who remain without phones and/or computers and internet connection, access to information resources is tenuous. Funding for technology through regional clinics and public facilities, such as libraries, is highly variable across the country and is often subject to changes in tax or grant allocations and annual budgets. Deficits in language and literacy skills impose further obstacles to care for disadvantaged populations. Gaps in access widen when information services are improved only for those with the means, education, and skills to pursue those services. See Chapter 23 for more information on telepractice and technology in the professions.

Educating the Public Most individuals take communication for granted and are frequently unaware of the link between one’s communication abilities and one’s success in life. To improve access to speech-language pathology, audiology, and swallowing services, it is increasingly more critical to improve the general public’s and consumers’ awareness and knowledge about speech-language pathology and audiology services. Examples of awareness campaign content and methods and tips for expanding awareness through social media and professional networking sites may be found through national websites of our professional associations and those of many regional and specialty-focused organizations. Ideas for celebrating Better Hearing and Speech Month (celebrated in many countries in May of each year) are readily shared through professional association websites and social media platforms, with ample information about how to reach out to media, consumers, and educational and health care providers, plus ideas for getting involved.

Adjusting Service-Providing Environments Certain environmental and operational adjustments must be made to improve access to speech-language pathology and audiology services. Flex time, compressed workweeks, and remote and hybrid options are becoming the norm. Recognizing the value of schedules that are more convenient for consumers, organizations are expanding their daily work hours and days of operation and, as a result, improving their revenues. Speech-language pathology and audiology providers are following suit. In environments where traditional appointment schedule models create significant hardships for the people we serve, creative, nontraditional scheduling

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approaches have been found helpful. Another tactic being used to improve access and attendance is the development of interagency collaborations in which several agencies contribute to fund a minibus to bring clients to their locations. To improve geographic access, satellite offices (leased, shared, or donated space) may be considered.

Summary In this chapter, we identified significant barriers that influence access to audiology and speech-language pathology services and stressed the broad and serious consequences of current service delivery trends on our field. We also emphasized the growing need for our services across the age continuum. Access to audiology and speech-language pathology services can be significantly enhanced through comprehensive, focused strategies that remove or minimize barriers and maximize the use and impact of health care and educational resources, both financial and human. With this in mind, we described effective strategies to improve revenues, decrease costs, and increase clinical outcomes. To subsidize diminishing reimbursements, strategies to create alternative funding sources were presented. More than ever, it is the responsibility of all audiologists and SLPs to ensure barriers are eliminated and resources are maximized. To accomplish these goals, our roles in educating the public and in advocacy were described. Acknowledgments.  Recognition is extended to Dr. Bernard P. Henri for his strong contributions to earlier versions of this chapter.

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audiologist- and speech-language pathologist-topopulation ratios. https://www.asha.org/siteassets/ surveys/audiologist-and-slp-to-population-ratiosreport.pdf Bierer, B. E., Meloney, L. G., Ahmed, H. R., & White, S. A. (2022). Advancing the inclusion of underrepresented women in clinical research. Cell Reports Medicine, 3(4), 100553. https://doi.org/10.1016/​ j.xcrm.2022.100553 Boisvert, M. K., & Hall, N. (2019). Telepractice for school-based speech and language services: A workload management strategy. Perspectives of the ASHA Special Interest Groups, 4(1), 211–216. https://doi.org/10.1044/2018_PERS-SIG18-20180004 Bowman, A. (2022). Hope in the midst of war: Meet the Ukrainian speech therapist inspiring her students. Inspire More. https://www.inspiremore.com/ hope-in-the-midst-of-war-meet-the-ukrainianspeech-therapist-inspiring-her-students/ Centeno, J. G., Kiran, S., & Armstrong, E. (2020). Aphasia management in growing multiethnic populations. Aphasiology, 34(11), 1314–1318. https:// doi.org/10.1080/02687038.2020.1781420 Epstein, S. (2008). The rise of “recruitmentology”: Clinical research, racial knowledge, and the politics of inclusion and difference. Social Studies of Science, 38(5), 801–832. https://doi.org/10.1177/0306312​ 708091930 Espinoza, J., & Derrington, S. (2021). How should clinicians respond to language barriers that exacerbate health inequity? AMA Journal of Ethics, 23(2), E109–116. https://doi.org/10.1001/amaj​ ethics.2021.109 Eubank, T. N., Beukes, E. W., Swanepoel, D. W., Kemp, K., & Manchaiah, V. (2022). Community‐based assessment and rehabilitation of hearing loss: A scoping review. Health & Social Care in the Community, 30(5). https://doi.org/10.1111/ hsc.13846 Hallowell, B. (2023). Aphasia and other acquired neurogenic language disorders: A guide for clinical excellence (2nd ed.). Plural Publishing. Hallowell, B., Enderby, P., Mills, J. A., DeGroote, W., Skelton, P., Diaz, J., & Relan, P. (2021). Rehabilitation for patients with communication impairment after COVID-19 illness. OpenWHO. World Health Organization. http://dx.doi.org/10.13140/RG.2.2​ .2​3594.75209



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Hallowell, B., Hyter, Y. D., Watson, J. B., Combiths, P., Lansing, C. R., Ramkissoon, I., & Flynn, T. (2021). Final report by the ad hoc committee to develop guidance for members and students engaging globally in clinical, scholarly, and other professional activities. American Speech-Language-Hearing Association. https://www.asha.org/siteassets/ reports/ Hao, Y., Zhang, S., Conner, A., & Lee, N. Y. (2021). The evolution of telepractice use during the COVID-19 pandemic: Perspectives of pediatric speech-language pathologists. International Journal of Environmental Research and Public Health, 18(22), 12197. https://doi.org/10.3390/ijerph182212197 Hart, J. (2010). Medical connectivity: Expanding access to telespeech in clinical settings: Inroads & challenges. Telemedicine Journal and E-Health, 16(9), 922–924. http://dx.doi.org/10.1089/ tmj.2010.9945 Henri, B. P., & Hallowell, B. (1999). Relating managed care to managing care. In B. S. Cornett (Ed.), Clinical practice management for speechlanguage pathologists: Principles and practicalities. Aspen Publishers. Henri, B. P., Hallowell, B., & Johnson, C. (1997). Advocacy and marketing to support clinical services. In R. Kreb (Ed.), A practical guide to treatment outcomes and cost effectiveness (pp. 39–48). American Speech-Language-Hearing Association. Jones, D. M., McAllister, L., & Lyle, D. M. (2017). Rural and remote speech-language pathology inequities: An Australian human rights dilemma. International Journal of Speech-Language Pathology, 20(1), 98–101. https://doi.org/10.1080/17549507 .2018.1400103 Kneipp, S. M., Lutz, B. J., & Means, S. (2009). Reasons for enrollment, the informed consent process, and trust among low-income women participating in a community-based participatory research study. Public Health Nursing, 26(4), 362–369. https://doi.org/10.1111/j.1525-1446​ .2009.00791.x Lim, S., McManus, M., Fox H., White, K., & Forsman, I. (2010). Ensuring financial access to hearing aids for infants and young children. Pediatrics, 126(1), S43–S51. https://doi.org/10.1542/ peds.2010-0354i Lowe, S. M., & Nobriga, C. V. (2021). Head and neck cancer in a rural U.S. population: Quality of life, coping, health care literacy, and access

to services. American Journal of Speech-Language Pathology, 30(3), 1116–1133. https://doi.org/​ 10.1044/2021_ajslp-20-00223 Mason-Williams, L., Bettini, E., Peyton, D., Harvey, A., Rosenberg, M., & Sindelar, P. T. (2020). Rethinking shortages in special education: Making good on the promise of an equal opportunity for students with disabilities. Teacher Education and Special Education, 43(1), 45–62. https://doi​ .org/10.1177/0888406419880352 Maughan, B., Messer, J., Collishaw, S., Pickles, A., Snowling, M., Yule, W., & Rutter, M. (2009). Persistence of literacy problems: Spelling in adolescence and at mid-life. Journal of Child Psychology and Psychiatry, 50(8), 893–901. https:// doi.org/10.1111/j.1469-7610.2009.02079.x McManus, M. A., Levtov, R., White, K. R., Forsman, I., Foust, T., & Thompson, M. (2010). Medicaid reimbursement of hearing services for infants and young children. Pediatrics, 126, S34–S42. https:// doi.org/10.1542/peds.2010-0354h McNeilly, L. (2016). Rise in speech-language disorders in SSI-supported children reflects national trends. ASHA Leader, 21(3). https://doi.org/10.1044/ leader.PA2.21032016.np Miller, E. L., & Roup, C. M. (2022). The importance of professional advocacy at the state level: A coalition model. Seminars in Hearing, 43(01), 35–44. https://doi.org/10.1055/s-0042-1743543 Morton, M. E., Gibson-Young, L., & Sandage, M. J. (2022). Framing disparities in access to medical speech-language pathology care in rural Alabama. American Journal of Speech-Language Pathology, 31(6), 2847–2860. https://doi.org/10.1044/2022_ ajslp-22-00025 National Center for Education Statistics. (2022). National assessment of educational progress. https:// nces.ed.gov/nationsreportcard/ Nolan, P., & Bradley, E. (2008). Evidence-based practice: Implications and concerns. Journal of Nursing Management, 16(4), 388–393. https://doi​ .org/10.1111/j.1365-2834.2008.00857.x Parsons, S., & Sherwood, G. (2016). Vulnerability in custody: Perceptions and practices of police officers and criminal justice professionals in meeting the communication needs of offenders with learning disabilities and learning difficulties. Disability & Society, 31(4), 553–572. https://doi.org/10.1080/​ 09687599.2016.1181538

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Pillay, M., Tiwari, R., Kathard, H., & Chikte, U. (2020). Sustainable workforce: South African audiologists and speech therapists. Human Resources for Health, 18(1). https://doi.org/10.1186/s12960020-00488-6 Rainee, L., & Anderson, J. (2017). The future of jobs and job training. Pew Research Center. https:// www.pewresearch.org/internet/2017/05/03/ the-future-of-jobs-and-jobs-training/ Raatz, M., Ward, E. C., Marshall, J., Burns, C. L., Afoakwah, C, Byrnes, J. (2021). A time and cost analysis of speech pathology paediatric feeding services delivered in-person versus via telepractice. Journal of Telemedicine and Telecare. Advance online publication. https://doi.org/10.1177/1357633X2​ 11012883 Royal College of Speech and Language Therapists. (n.d.). Speech and language therapy. https://www​.rcslt.org Shippen, M. E., Houchins, D. E., Crites, S. A., Derzis, M. C., & Dashaunda, P. (2010). An examination of the basic reading skills of incarcerated males. Adult Learning, 21(3/4), 4–12. https://doi.org/​ 10.1177/104515951002100301 Snow, P. C., & Powell, M. B. (2008). Oral language competence, social skills and high-risk boys: What are juvenile offenders trying to tell us? Children & Society, 22(1), 16–28. https://doi.org/10.1111/j.10​ 99-0860.2006.00076.x Sondenaa, E., Wansholm, M., & Roos. E. (2016). Case characteristics of prisoners with communication problems. Open Journal of Social Sciences,

4(4), 31–37. https://www.scirp.org/html/5-1760​ 857_65496.htm Swanepoel, D., Clark, J., Koekemoer, D., Hall, J. W., III, Krumm, M., Ferrari, D. V., . . . Barajas, J. J. (2010). Telehealth in audiology: The need and potential to reach underserved communities. International Journal of Audiology, 49(3), 195–202. https://doi.org/10.3109/14992020903470783 U.S. Department of Labor. (2022). Occupational outlook handbook: Health care occupations. https:// www.bls.gov/ooh/healthcare Wales, D., Skinner, L., & Hayman, M. (2017). The efficacy of telehealth-delivered speech and language intervention for primary school-age children: A systematic review. International Journal of Telerehabilitation, 9(1), 55–70. https://doi.org/10.5195​ %2Fijt.2017.6219 Weidner, K., & Lowman, J. (2020). Telepractice for adult speech-language pathology services: A systematic review. Perspectives of the ASHA Special Interest Groups, 5(1), 326–338. https://doi.org/10.1044/​ 2019_persp-19-00146 World Health Organization. (2022). Ageing and health. https://www.who.int/news-room/fact-sheets/detail/ ageing-and-health Zazove, P., Plegue, M. A., McKee, M. M., DeJonckheere, M., Kileny, P. R., Schleicher, L. S., . . . Mulhem, E. (2020). Effective hearing loss screening in primary care: The early auditory referral-primary care study. Annals of Family Medicine, 18(6), 520– 527. https://doi.org/10.1370/afm.2590

16 Documentation Nicole E. Corbin and Erin E. G. Lundblom

Introduction Audiologists and speech-language pathologists (SLPs) provide services within diverse, ever-changing professions that encompass a vast array of disorders and individuals across the life span. One consistency across professions is clinical documentation, which is one of our most important professional responsibilities. Clinical documentation is our communicative tool that creates the evidence or record of clinical services provided to an individual. Effective clinical documentation is essential to the skilled reporting of clinical encounters. Through clinical documentation, audiologists and SLPs paint a picture of a clinical case to make it “alive” so others can experience the clinical case, including the clinical problem solving employed by the practitioner. Professional relationships with patients, families, and other professionals are maintained and enhanced through clinical documentation. Clinical documentation also establishes a legal record of care and is required for reimbursement of services from third-party payers, including Medicaid and Medicare. Third-party payers set eligibility requirements for services. The laws for education and the requirements for insurance, including Medicaid and Medicare, establish the foundation on which documentation requirements are built. The professional community further establishes the expectations within the discipline that form the content of what is documented. Clear documentation is critical regardless of the work setting, as it establishes justification and rationale for treatment, reveals the progress that did or did not happen, and creates a legal record of services provided. This chapter outlines the purpose of clinical documentation, general principles of clinical documentation, various types of documentation, and how legislation and regulations may influence clinical documentation. Portions of this chapter are based on information from the previous edition of this textbook.

Purposes of Clinical Documentation for Consumers Clinical documentation is a vital tool in transmitting the story of what we do when we provide clinical services. Clinical documentation is how an audiologist or SLP can share a description of an individual and communicate the practitioner’s clinical actions and thoughts about clinical problem solving to 323



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others. Clinical documentation becomes a legal record of what occurred during service provision. When considering the aims of clinical documentation, the primary purpose should be to support the care of those we serve to improve outcomes through enhanced communication (Kuhn et al., 2015). At a minimum, clinical documentation should provide sufficient and accurate information about a person, reflect the person’s story in as much detail as needed, explain the clinical services provided, capture the clinical reasoning of the practitioner (e.g., support a diagnosis, justify treatment), and provide enough information to ensure services were delivered safely and effectively. Clinical documentation may travel across many different consumers, so accurate, thorough clinical documentation can help to promote continuity of care among clinical providers. There are various types of clinical documentation, as overviewed in a later section. As such, the communicative purpose of clinical documentation naturally diverges into additional aims, which may be influenced by other stakeholders. For example, third-party payers can influence clinical documentation to justify the need for services to support reimbursement. Whereas legislation, such as the Individuals With Disabilities Education Improvement Act (IDEIA, 2004) requires an evaluation report to document an adverse educational impact for disability eligibility. A variety of examples of secondary purposes of clinical documentation are indicated below (Hapner, 2008; Paul & Hasselkus, 2004). This list is not exhaustive or prescriptive, but rather an overview of the varied needs that clinical documentation may meet for the variety of stakeholders of clinical services. n

Support a diagnosis by sharing clinical impressions

n

Support a treatment recommendation by sharing clinical impressions

n

Justify the initiation of treatment

n

Provide a foundation or entry point preceding clinical management

n

Justify the continuation of treatment

n

Support the medical necessity of a clinical service

n

Explain the need for skilled services

n

Describe progress in treatment

n

Describe responsiveness to intervention

n

Justify discharge from care

n

Support reimbursement for clinical services

n

Answer specific questions from a referral source/ professional

n

Support continuity of clinical care through sharing information from evaluation to intervention

n

Communicate with or transfer information to other practitioners (e.g., audiologists, SLPs) and professionals (e.g., physicians)

n

Act as a guide to referral for additional services

n

Facilitate quality improvement of clinical processes

n

Document communication among involved parties (practitioners, client, caregivers, or legally responsible parties)

n

Protect legal interests of involved parties (the person, service provider, facility)

n

Serve as evidence in a court of law

n

Provide data for continuing education

n

Provide data for research

General Principles of Clinical Documentation for Practitioners Documentation is an expectation of all clinical work environments for audiologists and SLPs. As practitioners, we must record every clinical service provided through written documentation — evaluation reports, treatment plans, progress monitoring notes, and so on. Types of clinical documentation may vary substantially across different clinical settings. One similarity that presents between different types and formats of clinical documentation across clinical practice settings is the need to write in a professional, technical style. Learning to write clinical documents correctly and adequately is a skill that is essential to a career as an audiologist or SLP. Clinical writing is a formidable skill to develop, so it must be practiced repeatedly — just like any other skill.

Planning Clinical Documentation: Purpose and Audience To begin writing a clinical document, the audiologist or SLP must first identify and understand the purpose of the document. Most clinical documents traditionally have two basic purposes — to inform and to persuade. The first purpose may seem obvious. Clinical documentation must convey information about a clinical encounter with a reader. This can be achieved easily when presenting objective information (e.g., the sequence of events that unfolded during a clinical encounter, test

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scores). The second purpose — to persuade — may seem less apparent. Persuasion occurs when the audiologist or SLP explains how the objective information or evidence was used to support their clinical decisions (e.g., modifying a test procedure, making a diagnosis or treatment recommendation). Thus, audiologists and SLPs must develop clinical writing skills that enable them to unambiguously convey information and capture their clinical reasoning and decision making. Another consideration in the process for clinical documentation is to identify the audience of the clinical document. A practitioner may begin by asking, “Who is the audience?” The natural answer to this question may be the consumer — the patient and/or family receiving clinical services — which is accurate. Clinical documentation, however, may also be intended for and/ or accessed by a wide range of other professionals who also play a significant role in service provision for the patient. These individuals may differ based on settings, ranging from physicians, nurses, allied health professionals, and social workers in medically oriented environments to educational psychologists, teachers, special education teachers, and administrators in educational environments. Clinical documentation must also communicate on behalf of the patient with persons representing external agencies and organizations such as an insurance reviewer. The list of possible audience members for clinical documentation may continue to expand depending on the complexity of the clinical case. The potential audience for any clinical document may also range greatly from those with no clinical background on a disorder or clinical process to experts with extensive clinical knowledge. Because clinical documentation is a legal document, it becomes part of a person’s medical or educational records. The audience for the clinical document may then continue to grow over time as more and more people access the clinical document. Therefore, when reconsidering the question, “Who is the audience?” the vastness of possible answers reinforces the need for clinical documentation to be accurate, accessible, and understandable to all. Audiologists and SLPs communicate with a wide range of people through clinical documentation, so clinical documentation must be crafted to meet the diverse needs of the audience. A final consideration is to think about the possible attitudes, values, and beliefs the audience may hold toward the purpose and information contained in the clinical document. This may be important when considering how to share information, including the practitioner’s clinical thought processes. For example, a person may indicate to a practitioner that they do not believe in the impact of a diagnosis or proposed treatment. One such situation may be a person who presents with a hearing loss that could benefit from a hearing aid, but the

person has indicated they do not think a hearing aid will help them because it did not help another family member. The practitioner may need to craft the clinical documentation to provide clear support of the diagnosis, impact on activity and participation for the person, and the benefits of the proposed treatment approach. Did you know? In 2021, legislation was passed that required most medical notes to be open access to patients in electronic health records (Jin, 2021). This means that in medical environments, patients are an audience member for your documentation. This is an important aspect as you consider the language and jargon you might use.

Product: Written Clinical Documentation In every clinical work setting, clinical documentation is a tangible product. Clinical documentation is the product that employs professional writing with a technical style to capture a clinical encounter and the practitioner’s clinical process. Professional writing contrasts with creative writing, which is commonly taught in K–12 school systems and required in general education electives in higher education. The purpose of creative writing is to entertain, provoke, or inform across many genres and subgenres. In contrast, professional writing is purposeful, intended to convey relevant information in a clear, concise, and effective manner with the main objectives to inform and to persuade. In our fields, professional writing employs a technical writing style, which provides a set of standards, writing rules, and recommendations for tone, grammar, and structure. Clinical Documentation Writing Guidelines. Employing a technical writing style in professional writing helps to ensure effective communication that can guide the reader through a complex topic to better support understanding. Some general suggestions can help both novice and expert writers craft clinical documentation that is accessible to a wide audience for varied purposes (Burns & Willis, 2017; Goldfarb & Serpanos, 2020; Pearsall & Cook, 2010). n

Organize the content for your purpose and audience.  Given the variety of clinical practice settings, the format, style, length, and degree of detail will naturally vary. A practitioner must choose the level and amount of detail needed to



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fulfill the purpose of the clinical document and the reader’s needs — but no more than that (Pearsall & Cook, 2010). At minimum, the clinical document should be a written representation of the clinical case, including the practitioner’s clinical reasoning. As many others have explained, if you do not write it in the clinical document, then it did not happen (Hapner, 2008; Moore, 2010). While a practitioner does not want to go into the weeds with too many details, the practitioner should include specific observations made during the clinical encounter and critical evidence that supports clinical decision making. When organizing written content, the practitioner should firmly keep the reader in mind to identify what content they need and how best to represent the content for them. n

n

Write clearly for the reader.  Clinical documentation should be accurate, concise, and informative. The language and grammar should be adapted so the content of the clinical document is accessible, useful, and relevant to a wide audience including laypersons and experts. Word selection and sentence construction should be readable and understandable. Some general suggestions include: n

Avoid jargon (e.g., “parent-directed language,” “binaural”), technical words (e.g., “morphology,” “syntax,” “immittance,” “wide dynamic range compression”), and descriptors that imply judgment (e.g., “good,” “poor,” “very”). If professional vocabulary is included, explain the terminology.

n

Use active rather than passive voice to clearly state who or what the actor is and what they are doing. When possible, use action verbs. Examples of a sentence written in both passive and active voice are provided below.



n



n

 Passive:  “The client was able to read the paragraph without error.”  Active:  “The client read the paragraph without error.”

n

Create simple sentences using a subject and verb framework. This provides a structure to which the writer can add grammatical segments to expand or clarify the information. Avoid lengthy or run-on sentences.

n

Use abbreviations and acronyms sparingly. Use acronyms only after spelling out the full title, such as for names of tests.

Format your clinical documentation to increase accessibility.  Organize the content of

your clinical documentation using headings and visual displays of data so readers can access the information that is most important to them. Use tables, lists, and graphics to represent data and written text to explain or interpret the data. n

Proofread to verify the meaning is clear and to check for errors.  Clinical documentation should provide a clear rationale for clinical reasoning. Review word choice and sentence structure to ensure conciseness, coherence, and precision. Carefully check spelling (e.g., proper nouns, medications) and grammar (e.g., verb tense, punctuation).

Clinical documentation varies due to differences in type, format, and purpose across clinical settings, but not in the professional and technical writing skills required to adequately complete the task. In settings that utilize brief forms or templates for clinical documentation, the audiologist or SLP still needs to determine what details and evidence should be included to support clinical reasoning. The practitioner who is adept at implementing professional and technical writing in clinical documentation will know how to approach both brief and extensive clinical documents, whereas a clinician who has only learned how to use a form or template for clinical documentation will have trouble writing a well-reasoned, organized clinical document. Repeated exposure to different types, formats, and styles of clinical writing used by audiologists and SLPs is a powerful learning tool to develop professional and technical writing skills.

Types of Clinical Documentation SLPs and audiologists provide services in a variety of settings such as schools, hospitals, clinics, universities, private practice offices, and telepractice. Clinical documentation is the primary tool used in each of these settings to detail the clinical service provided, share clinical judgments, and facilitate planning and continuity of care. The following section provides an overview of common types of clinical documentation used in these settings. Later in this chapter, nuances of different types of clinical documentation are explored based on regulatory influences.

Evaluation Reports The evaluation report is a tool that captures the practitioner’s evaluative process of gathering information about the strengths and needs of a person for diagnosis (or eligibility in some settings) and to identify goals

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and strategies suggested for intervention. To develop a written evaluation report, the practitioner must integrate information from multiple sources. Part of the evaluation report shares the person’s case history or background information to document the reason for referral, concerns, and available information from other professionals. The practitioner may obtain information about the referral reason, concerns, family perspective of problem, possible solutions, and priorities through an informal interview with the patient. Clinical observations made by the practitioner are also included as part of the evaluation report. Results of assessment measures are often shared in a visual format such as in a table that details test scores. Written text provides information that includes the description of the measure or method implemented with an explanation and interpretation of test scores or results. A key component of the report is the interpretation of information presented to capture a diagnosis, including skills and needs. The summary of the report should then proceed to recommended services and prognosis. Evaluation reports generally conform to some variation of the following format (Moore, 2010, 2018): n

Identifying information such as name, age, date of birth, sex assigned at birth, and pronouns

n

Date of encounter

n

Referral source

n

List of persons and/or personnel present during the encounter n

n

Statement of credentials for provider and any technicians or assistants present

Reason for assessment/chief complaint n Symptoms

n

n

Changes in speech, language, swallowing, vestibular, or hearing status

n

Risk assessment for changes in speech, language, swallowing, vestibular, or hearing status associated with another diagnosis

Background information including case history, results from prior evaluations, information gleaned from other professional reports, and notes from an interview with the consumer

n

Notes from an interview with the consumer

n

Record of all assessments performed, including the methods used (e.g., conventional, modified, behavioral, conditioned play)

n

Reliability rating

n

Behaviors observed during clinical encounter

n

Results obtained from assessments performed

n

Information on progress in academic or curricular areas

n

Information on classroom assessments and statewide assessments

n

Information from other professionals involved in the consumer’s care

n

Input from the consumer on their disabling condition, thoughts, desires, and wishes

n

Clinical interpretations and judgments

n

Counseling performed

n Summary/conclusions n Recommendations

The format of and information included in the evaluation report may also vary between medical and educational settings. Both settings may also employ a report template — more on this later. Audiological templates might also report the results of a consumer’s response to a trial fitting of hearing aids and/or other hearingassistive technology.

Treatment Documentation Treatment plans establish a rationale for intervention by explaining the needs and the goals or objectives of intervention. Goals may include specific target behaviors or outcomes, which are described in an observable and measurable way. Treatment plans become the blueprint for clinical management services focused on intervention. Typical components of a treatment plan include: n

Identifying information such as name, age, date of birth, assigned sex at birth, and pronouns

n

Case history

n

Results from prior evaluations

n

Date of clinical encounter

n

Results from subjective outcome measures or self-assessment questionnaires

n

List of persons and/or personnel present during the encounter

n

Information gleaned from other professional reports

n

Statement of credentials for provider and any technicians or assistants present



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n

Rationale for treatment, which may come from the following: n

Case history

n

Results from prior evaluations

n

Results from subjective outcome measures or self-assessment questionnaires

n

Information gleaned from other professional reports

n

Notes from an interview with the consumer

n

Description of current status of the consumer, including skills and needs

n

Treatment recommendations

n

Description of counseling with consumer regarding treatment plan

n

Prognosis with treatment

n

Goals, including rationales

n

Amount of treatment (e.g., number, length, and frequency of sessions)

In health care and other settings, treatment plans are commonly referred to as plans of care, which outline the skilled services to be provided by a qualified health care professional. Like treatment plans, plans of care include measurable goals, recommendations, and prognostic statements. Treatment plans are less commonly used in audiology. Rather, audiologists often implement evaluation reports that contain components of the treatment plan (e.g., hearing aid evaluation, cochlear implant evaluation). Progress monitoring is an important work expectation required in all clinical settings, and progress during treatment sessions should be charted for each session. SLPs and audiologists are trained in these methods and may serve as a resource to other professional personnel. A SOAP note format, further described in Table 16–1, is useful for therapy note documentation across practice settings. Writing the note at the end of the session or right after the session is completed ensures both accuracy and completion of the requirement. Many school (and medical/clinic) sites now have clinicians document in real time, during the session as it occurs, to reduce inefficiencies and increase productive face-to-face billable time. Be mindful if you are completing documentation in the room. Staring at a screen and quietly documenting may be uncomfortable for your patient. If you are working with adult clientele, you might consider active ways for them to be involved in

your documentation process. They can be asked to confirm your thoughts, assumptions, and data as you enter them into an electronic system. When working with children, consider what activities might engage a child as you document your session. Progress reports summarize and document progress toward achieving treatment goals. These documents are often required by third-party payers and government funding sources (e.g., insurance companies, Medicaid, Medicare). The format may vary depending on the clinical setting. For instance, some settings may use a service log of goals addressed, while others may implement a more thorough written document that includes background on treatment, interpretation of data, clinical observations about progress, prognosis for change, and recommendations. Regardless of setting, typical components of a progress summary report include: n

Identifying information such as name, age, date of birth, sex assigned at birth, and pronouns

n

Date of clinical encounter

n

List of persons and/or personnel present during the encounter

n

Statement of credentials for provider and any technicians or assistants present

n

Summary of diagnostic information, including case history and chief complaints

n

Status at the beginning of treatment period

n

Number and length of treatment sessions

n

Summary of treatment

n

Record of counseling provided

n

Interpretation of progress

n Recommendations n

Indications and contraindications to treatment

A discharge summary is a written report of progress in treatment prior to discharge. This is often required when a person moves across levels of care — hospital to rehabilitation to home. A discharge summary is similar in format to a progress summary but may differ in scope as it covers the clinical service period from the last progress note or clinical service in totality with the inclusion of postintervention needs. A discharge from clinical services is based on many factors including progress or lack thereof toward goals, successful fitting of hearing aids, and so on.

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Table 16–1.  SOAP Notes Subjective:  Write your opinion or impressions regarding relevant student or client behavior status in a brief statement. Include your impressions about the client’s level of awareness, motivation, mood, willingness to participate, attitude or impressions toward the communicative disorder, and so on. You may also list anything the client and/or family/ caregiver may report to you before, during, or after a session.

n

J. was quiet today. Mother reports that J. did not sleep well last night. Mother reports a big increase in J’s use of her communication board.

Objective:  Record measurable information or progress-monitoring data collected during the therapy session.

n

J.’s use of /s/ in initial and final position in words in spontaneous speech: n Initial:  16/20 opportunities (70%) n Final:  10/20 opportunities (50%)

Assessment:  Describe your analysis and/or interpret data for the current session and compare to previous level of performance.

n

Previous goals addressed the use of /s/ in the initial position of words. Today’s reassessment indicated that J. is now using /s/ in word-final position in spontaneous speech, though not at mastery level. Some generalization to the use of /s/ in word-initial position in spontaneous speech were also noted, both of which are an improvement. J.’s progress on his /s/ goal suggests he is beginning to master this skill. The addition of a visual cue to the lips has improved J.’s ability to produce the /b/ sound as indicated by his performance (e.g., baseline 0%, last week 25%, this week 50%).

n

Continue plan of treatment. Monitor /s/. Target /b/ in the initial position at the word level.

Note if: 1. The person made progress on the goal(s). 2. Performance was similar in previous session(s). a. If performance has been unchanged over multiple sessions, you may need to discuss and indicate if a change in the treatment program is warranted. Then, note the specific change in (P) section. 3. The performance on goal(s) decreased. a. If performance decreased, note a likely reason (e.g., from (S), child was tired) and/ or if treatment program change is warranted. (Again, note specific change in (P) section.) Plan:  Identify proposed therapy targets for the next session. Note any changes to the client’s goals (longor short-term), new goals ((long- or short-term), modifications to activities or materials, changes to reinforcement schedules, and so on.

In an educational/school setting, discharge summary reports may be required when a student is being dismissed from a particular service such as speech-language services based on meeting their speech-language goals but may continue to receive academic special education learning support, for instance due to a specific learning disability. Or, a discharge summary report would be required when a student is being discharged from all special education

and related services describing the reason why (e.g., mastery of goals, exit from school-based services due to age requirements, transition to a new level of care), the prognosis for continued success within the general curriculum or new programming, and any additional information that would serve the best interest of the student such as any needed accommodations, modifications, and/or adaptations to optimize educational success.



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Other Professional Communication Correspondence with patients, families, and other professionals is another important professional activity. Audiologists and SLPs engage in many kinds of professional correspondence — referral letters, letters of medical necessity, thank-you letters, and emails/patient portal communications. The ability to communicate effectively through this type of clinical documentation demonstrates professionalism and clinical competence.

Electronic Health Records The advent of electronic health records (EHRs) both streamlined and complicated clinical documentation. Electronic records use free text, structured text, checkboxes, fillable blanks, and interactive text that includes clinical decision-making support functions. Some EHR systems allow the practitioner to automatically apply blocks of text to an electronic record by simply typing an abbreviation or word. Despite this automation, practitioners still need to know exactly what information is relevant and accurate for documentation of a given clinical encounter. It is important to learn how to succinctly represent clinical thinking to share information, explain and support what was done, and share clinical conclusions. Skilled professional writers can shift between different styles of clinical documentation, such as abbreviated EHR templates to full evaluation reports, because these professionals have learned to employ clinical writing frameworks to capture clinical processes and clinical thinking in writing. Words of caution:  Electronic systems make cutting and pasting quick and easy. However, each time you cut and paste information, you run the risk of acting too quickly and introducing errors into your documentation if the information you are using is incorrect or incomplete. As the clinical service provider, it is your ethical responsibility to verify all communications you are generating. A few extra minutes proofreading your documentation can prevent you from looking careless or sloppy.

Audiologists work with many different devices in their daily clinical practice. Getting this equipment to “talk” to an EHR system may be more easily said than done. Audiologists who are making decisions about compatibility will need to thoughtfully work with health records vendors to determine options for optimum transfer of data.

Influences on Clinical Documentation To ensure clinical documentation is completed correctly, it is helpful to understand the reasons for documentation requirements. In medical, educational, and other settings, the “how to” of documentation may change periodically based on regulatory influences. Typically, forms and required paperwork will be designed to comply with applicable legal requirements. The laws for education set the clinical documentation required in those settings, whereas the requirements for insurance, including Medicaid and Medicare, establish the foundation on which documentation requirements are built in health care settings. Third-party payers also set forth eligibility requirements for services in other settings, such as private practice.

Ethics Most professional services are funded through thirdparty payers, generally either government funding or insurance. As a result, there are requirements for documentation to demonstrate that requirements are met. The ASHA Code of Ethics (American Speech-LanguageHearing Association [ASHA], 2023), Principle I, Rule O requires that “Individuals shall protect the confidentiality and security of records of professional services provided, research and scholarly activities conducted, and products dispensed. Access to these records shall be allowed only when doing so is legally authorized or required by law.” Additional Code of Ethics also apply such as Principle I, Rule P and Q (Table 16–2). Similarly, the American Academy of Audiology Code of Ethics (5e) states, “Individuals shall maintain accurate documentation of services rendered according to accepted medical, legal and professional standards and requirements” (American Academy of Audiology, 2019). These requirements, then, apply to all work settings.

Confidentiality Clinical practitioners must consider how to safeguard information in clinical documentation for consumers. Health information is regulated by different federal and state laws, depending on the source of the information and the entity entrusted with the information. The Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) are two federal laws that regulate privacy and the exchange of specific types of information. Clinical service providers who work in health care or education will interact with FERPA and HIPAA. Confidentiality is not only the law but also a form of

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Table 16–2.  Code of Ethics Applicable to Clinical Documentation Principle of Ethics I Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or who are participants in research and scholarly activities. Rule O

Individuals shall protect the confidentiality and security of records of professional services provided, research and scholarly activities conducted, and products dispensed. Access to these records shall be allowed only when doing so is legally authorized or required by law.

Rule P

Individuals shall protect the confidentiality of information about persons served professionally or participants involved in research and scholarly activities. Disclosure of confidential information shall be allowed only when doing so is legally authorized or required by law.

Rule Q

Individuals shall maintain timely records; shall accurately record and bill for services provided and products dispensed; and shall not misrepresent services provided, products dispensed, or research and scholarly activities conducted.

Source:  American Speech-Language-Hearing Association. (2023). Code of ethics. https://www.asha.org/ policy/et2016-00342/

respect to those we serve, as outlined above in our ethical considerations. HIPAA.  HIPAA, originally enacted in 1996, is a federal law that pertains to protected health information (PHI) with amendments in 2003 that address electronic transmission of records and increased restrictions on accessibility to health records. HIPAA created a national standard to protect a person’s health information from being disclosed without a person’s consent or knowledge. The U.S. Department of Health and Human Services issued the HIPAA Privacy Rule to implement the requirements of HIPAA. The privacy rule mandates that a covered entity may not use or disclose PHI except as permitted by the rule. PHI is any identifiable information about a person’s health status that is created, collected, or transmitted. PHI cannot be shared without consent of the person. The Privacy Rule safeguards PHI while the HIPAA Security Rule protects electronic protected health information or e-PHI. All professionals working in health fields must follow the HIPAA privacy and security rules (HIPAA, 1996). Refer to Table 16–3 for more information. FERPA.  Laws in education are centrally concerned with protecting student confidentiality, specifically related to students with disabilities. These students are considered a protected class of individuals. FERPA, enacted in 1974, is the federal law that addresses student records, including who can access student education records

and the need for consent from a student or parent (if the student is a minor) for the disclosure of personally identifiable information in educational records. FERPA applies to any public or private elementary, secondary, or postsecondary school. It also applies to state and local education agencies that receive funding from the U.S. Department of Education. FERPA affords parents the right to have access to their children’s education records, the right to request to have the records amended, and the right to have some control over the disclosure of personally identifiable information from the education records. When a student turns 18 years old, or enters a postsecondary institution at any age, the rights under FERPA transfer from the parents to the student (“eligible student”). Refer to Table 16–3 for more information. In addition, Chapter 12, “Knowledge and Skills for Providing Evidence-Based Services in School-Based Settings,” within this textbook further discusses this information.

Educational Settings: IDEA IDEA (2004) is the law that makes a free, appropriate public education available to eligible children with disabilities and ensures special education and related services to those children. IDEA directs how states and public agencies provide early intervention, special education, and related services to eligible infants, toddlers, children, and youth with disabilities. Infants and toddlers, birth through age 2 years, with disabilities and their families receive early intervention

Table 16–3.  Summary of FERPA and HIPAA FERPA

HIPAA

The Family Educational Rights and Privacy Act (FERPA) is a federal law enacted in 1974 that protects the privacy of student education records.

The Health Insurance Portability and Accountability Act (HIPAA) is a national standard that protects sensitive patient health information from being disclosed without the patient’s consent or knowledge. Via the Privacy Rule, the main goal is to ensure individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high-quality health care and to protect the public’s health and well-being.

The act serves two primary purposes: 1.  Gives parents or eligible students more control of their educational records 2. Prohibits educational institutions from disclosing “personally identifiable information in education records” without written consent Who must comply?

n

n

Any public or private school: n Elementary n Secondary n Postsecondary Any state or local education agency

Any of the above must receive funds under an applicable program of the U.S. Department of Education.

n

Every health care provider who electronically transmits health information in connection with certain transactions

n

Health plans

n

Health care clearinghouses

n

Business associates that act on behalf of a covered entity, including claims processing, data analysis, utilization review, and billing

Protected information

Student Education Record: Records that contain information related to a student and that are maintained by an educational agency or institution or by a party acting for the agency or institution

Protected Health Information: Individually identifiable health information that is transmitted or maintained in any form or medium (e.g., electronic, oral, or paper) by a covered entity or its business associates, excluding certain educational and employment records

Permitted disclosures

n

School officials

n

To the individual

n

Schools to which a student is transferring

n

n

Specified officials for audit or evaluation purposes

Treatment, payment, and health care operations

n

n

Appropriate parties in connection with financial aid to a student

Uses and disclosures with opportunity to agree or object by asking the individual or giving opportunity to agree or object

n

Organizations conducting certain studies for or on behalf of the school

n

Incident to an otherwise permitted use and disclosure

n

Accrediting organizations

n

n

Appropriate officials in cases of health and safety emergencies

n

State and local authorities, within a juvenile justice system, pursuant to specific state law

Public interest and benefit activities (e.g., public health activities, victims of abuse or neglect, decedents, research, law enforcement purposes, serious threat to health and safety)

n

To comply with a judicial order or lawfully issued subpoena

n

Limited data set for the purposes of research, public health, or health care operations

Permitted disclosure means the information can be, but is not required to be, shared without individual authorization. Protected health information or individually identifiable health information includes demographic information collected from an individual and (a) is created or received by a health care provider, health plan, employer, or health care clearinghouse and (b) relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and (i) that identifies the individual or (ii) with respect to which there is a reasonable basis to believe the information can be used to identify the individual.

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(EI) services under IDEA Part C. The main document under IDEA Part C is the Individual Family Service Plan (IFSP). IFSPs are developed with a different focus from the Individual Education Plan (IEP). Services to infants and toddlers are addressed through a focus on the family system in combination with direct services to the child. Providing services in a natural environment and combining resources of educational and other state and local agencies is a common way of supporting the needs of these children and families. IFSPs are outcome driven, and the documentation of an IFSP is designed accordingly. IFSPs are developed by a team, which includes the parents and all providers who work with the child and the family. The IFSP describes the child’s present level of development, the family’s strengths and needs, the specific services to be provided to the child and the family, and a plan to transition to public school settings like preschool classroms. Programming for infants and toddlers is different from state to state with documentation requirements influenced by state and local regulations. Refer to Table 16–4 for the required components of an IFSP as defined in IDEA. Additionally, see Chapter 13, “Service Delivery in Early Intervention,” for further discussion. Children and youth ages 3 through 21 years receive special education and related services under IDEA Part B. The main document under IDEA Part B is the IEP. The IEP process is a federally mandated requirement, which results in a document that is legally binding and portable, meaning the family can take it to different school districts in the United States to receive services identified in the IEP. Most IEPs are now electronic or web based, with the forms reflecting all the federal requirements. Refer to Table 16–5 for the required components of an IEP as defined in IDEA.

Medicare are extremely complex. An important part of documentation in health care settings is the billing codes. The system of codes is regulated by the Centers for Medicare and Medicaid Services (CMS), which has established recognized codes under HIPAA (ASHA, n.d.-b). Medicare requires that services provided need to be “reasonable and necessary.” There are three types of codes: CPT (Current Procedural Terminology) codes, HCPCS (Healthcare Common Procedure Coding System) codes, and ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) codes (Table 16–6). Additionally, see Chapter 11, “Service Delivery in Health Care Settings,” for further discussion. Clinical notes are required under Medicare for purposes of billing and documenting services. The documents include evaluation notes, treatment encounter notes, progress notes, and discharge notes. Medicare requires that services provided need to be “reasonable and necessary.” ASHA’s Speech-Language Pathology Medical Review Guidelines (ASHA, 2015) identifies the documentation required to establish the basic elements of coverage: n

The services must be consistent with the standards found in the Medicare manuals, local coverage determinations, and guidelines and literature from the professions.

n

The services can only be safely and effectively performed by a skilled SLP due to the level of intricacy of the service or the clinical complexity of the patient.

n

The patient’s diagnosis may not be the only factor in determining reasonable or necessary. The patient’s need for skilled services must be evident in the documentation.

n

The amount, frequency, and duration of therapy must be accepted standards of care as documented by professional guidelines and literature. (p. 8)

Health Care Settings Health care settings include hospitals, rehabilitation centers, home health care, skilled nursing facilities, or other long-term care settings. Services in health care settings are authorized under insurance requirements, which are primarily based on Medicare requirements. Medicare provides health insurance for individuals who are over 65 years of age and for individuals with certain disabling conditions. Medicare is divided into two programs: Medicare Part A and Medicare Part B. Part A is hospital insurance and covers services provided in hospitals, skilled nursing facilities, home health care services, and hospice. Part B services cover physician services, audiology testing services, outpatient services, and rehabilitation services (ASHA, n.d.-d). Documentation requirements are the same for both parts of Medicare, although billing and documentation under

Creation of a clinical record provides “an overall indicator of clinical service and quality and serves as a basis for planning care and for service continuity” (Sutherland Cornett, 2006, p. 3). Each of the different types of notes has specific requirements, depending on the purpose of the note, as captured in Table 16–7. Documentation must comply with all legal/regulatory requirements applicable to Medicare claims, which is outlined in the Medicare Benefit Policy Manual published by CMS. Clinical documentation templates are also available through CMS.

Table 16–4.  IDEA Requirements for Individual Family Service Plans (IFSPs) IDEA Required IFSP Components

Explanation

Sec. 303.344 Content of an IFSP

The Individualized Family Service Plan (IFSP) provides the mechanism for planning and documenting the early intervention services required for an infant or toddler (birth to 3 years of age) with a disability and her/his family.

(a) Information about the child’s status. The IFSP must include a statement of the infant or toddler with a disability’s present levels of physical development (including vision, hearing, and health status), cognitive development, communication development, social or emotional development, and adaptive development based on the information from that child’s evaluation and assessments conducted under §303.321. (b) Family information. With the concurrence of the family, the IFSP must include a statement of the family’s resources, priorities, and concerns related to enhancing the development of the child as identified through the assessment of the family under §303.321(c)(2). (c) Results or outcomes. The IFSP must include a statement of the measurable results or measurable outcomes expected to be achieved for the child (including pre-literacy and language skills, as developmentally appropriate for the child) and family, and the criteria, procedures, and timelines used to determine — (1) The degree to which progress toward achieving the results or outcomes identified in the IFSP is being made; and (2) Whether modifications or revisions of the expected results or outcomes, or early intervention services identified in the IFSP are necessary. (d) Early intervention services. (1) The IFSP must include a statement of the specific early intervention services, based on peer-reviewed research (to the extent practicable), that are necessary to meet the unique needs of the child and the family to achieve the results or outcomes identified in paragraph (c) of this section, including — (i) The length, duration, frequency, intensity, and method of delivering the early intervention services; (ii) (A) A statement that each early intervention service is provided in the natural environment for that child or service to the maximum extent appropriate, consistent with §§303.13(a)(8), 303.26 and 303.126, or, subject to paragraph (d) (1) (ii)(B) of this section, a justification as to why an early intervention service will not be provided in the natural environment. (B) The determination of the appropriate setting for providing early intervention services to an infant or toddler with a disability, including any justification for not providing a particular early intervention service in the natural environment for that infant or toddler with a disability and service, must be —

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Functional ability:  A statement of the child’s functional ability across five developmental areas: physical (including vision and hearing), cognitive, communication, social/emotional, and adaptive Family information:  A statement of the family’s resources, priorities, and concerns about the infant or toddler with a disability. Measurable results or outcomes:   A statement of the measurable results or outcomes expected to be achieved for the infant or toddler and the family, as well as preliteracy and language skills as developmentally appropriate Criteria, procedures, and timelines:  A statement of the criteria, procedures, and timelines used to determine the degree to which progress toward achieving the results or outcomes is being made Modifications or revisions:   A statement of the modifications or revisions if necessary to the results, outcomes, or services Specific early intervention services:  A statement of the specific early intervention services needed to meet the unique needs of the infant or toddler and the family Natural environment:  Services must be delivered in the child’s natural environment to the maximum extent appropriate, and only elsewhere when early intervention cannot be achieved for the child in the natural environment. Justification of the extent, if any, to which services will not be provided in natural settings is required. Service Delivery:  The IFSP must include the dates for initiation of services including the frequency, intensity, and method of delivering services as well as the anticipated duration of services.

Table 16–4.  continued IDEA Required IFSP Components

Explanation

(1) Made by the IFSP Team (which includes the parent and other team members); (2) Consistent with the provisions in §§303.13(a)(8), 303.26, and 303.126; and (3) Based on the child’s outcomes that are identified by the IFSP Team in paragraph (c) of this section; (iii) The location of the early intervention services; and (iv) The payment arrangements, if any. (2) As used in paragraph (d)(1)(i) of this section— (i) Frequency and intensity mean the number of days or sessions that a service will be provided, and whether the service is provided on an individual or group basis; (ii) Method means how a service is provided; (iii) Length means the length of time the service is provided during each session of that service (such as an hour or other specified time period); and (iv) Duration means projecting when a given service will no longer be provided (such as when the child is expected to achieve the results or outcomes in his or her IFSP). (3) As used in paragraph (d)(1)(iii) of this section, location means the actual place or places where a service will be provided. (4) For children who are at least three years of age, the IFSP must include an educational component that promotes school readiness and incorporates pre-literacy, language, and numeracy skills. (e) Other services. To the extent appropriate, the IFSP also must— (1) Identify medical and other services that the child or family needs or is receiving through other sources, but that are neither required nor funded under this part; and (2) If those services are not currently being provided, include a description of the steps the service coordinator or family may take to assist the child and family in securing those other services. (f ) Dates and duration of services. The IFSP must include— (1) The projected date for the initiation of each early intervention service in paragraph (d)(1) of this section, which date must be as soon as possible after the parent consents to the service, as required in §§303.342(e) and 303.420(a)(3); and (2) The anticipated duration of each service.

Service Coordinator:  The IFSP must specify the name of the service coordinator from the profession most relevant to the infant’s or toddler’s or family’s needs who will be responsible for the implementation of the plan and for coordination with other agencies and persons, including transition services. Transition:  The IFSP must include steps to be taken to support the transition of the toddler with a disability to preschool or other appropriate services. The transition plan also requires supports for the family in the transition process.

continues

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Table 16–4.  continued IDEA Required IFSP Components

Explanation

(g) Service coordinator. (1) The IFSP must include the name of the service coordinator from the profession most relevant to the child’s or family’s needs (or who is otherwise qualified to carry out all applicable responsibilities under this part), who will be responsible for implementing the early intervention services identified in a child’s IFSP, including transition services, and coordination with other agencies and persons. (2) In meeting the requirements in paragraph (g)(1) of this section, the term “profession” includes “service coordination.” (h) Transition from Part C services. (1) The IFSP must include the steps and services to be taken to support the smooth transition of the child, in accordance with §§303.209 and 303.211(b)(6), from part C services to — (i) Preschool services under part B of the Act, to the extent that those services are appropriate; (ii) Part C services under §303.211; or (iii) Other appropriate services. (2) The steps required in paragraph (h)(1) of this section must include — (i) Discussions with, and training of, parents, as appropriate, regarding future placements and other matters related to the child’s transition; (ii) Procedures to prepare the child for changes in service delivery, including steps to help the child adjust to, and function in, a new setting; (iii) Confirmation that child find information about the child has been transmitted to the LEA or other relevant agency, in accordance with §303.209(b) (and any policy adopted by the State under §303.401(e)) and, with parental consent if required under §303.414, transmission of additional information needed by the LEA to ensure continuity of services from the part C program to the part B program, including a copy of the most recent evaluation and assessments of the child and the family and most recent IFSP developed in accordance with §§303.340 through 303.345; and (iv) Identification of transition services and other activities that the IFSP Team determines are necessary to support the transition of the child. Sources: American Speech-Language-Hearing Association. (n.d.-b). Individualized education programs (IEPs), individualized family service plans (IFSPs), and section 504 plans. https://www.asha.org/SLP/schools/IEPs/ Individuals With Disabilities Education Act of 2004 (IDEA), 20 U.S.C. §§ 614[d][A][i][I].

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Table 16–5.  IDEA Requirements for Individualized Education Plans (IEPs) IDEA Required IEP Components

Explanation

The required components of an IEP, as defined in IDEA §300.347(a) “Content of IEP” are —

An IEP is a written statement for a child with a disability that is developed with certain requirements of law and regulations. The IEP has two general purposes: (a) to establish measurable annual goals; and (b) to state the special education and related services and supplementary aids and services that the public agency will provide to, or on behalf of, the child.

(1) A statement of the child’s present levels of educational performance, (2) A statement of measurable annual goals, including benchmarks or short-term objectives, (3) A statement of special education and related services and supplementary aids and services to be provided to the child, or on behalf of the child, and a statement of the program modifications or supports for school personnel that will be provided for the child, (4) An explanation of the extent, if any, to which the child will NOT participate with nondisabled children in the regular class and in the activities described, (5) A statement of any individual modifications in the administration of state or districtwide assessments of student achievement that are needed in order for the child to participate in the assessment, (6) The projected date for the beginning of the services and modifications, and the anticipated frequency, location, and duration of those services and modifications, and (7) A statement of how the child’s progress toward the annual goals will be measured and how the child’s parents will be regularly informed of the child’s progress. (b) Transition planning — beginning at age 14.

Present Levels:  A statement of the child’s present levels of academic achievement and functional performance, including how the child’s disability affects their involvement and progress in the general education curriculum Annual Goals:  A statement of annual goals including academic and functional goals Measuring Progress:  A description of how the child’s progress toward meeting the annual goals will be measured and when progress reports will be provided Special Education and Related Services:  A statement of the services to be provided to the child or on behalf of the child Supplemental Aids and Services:  A statement of the services to be provided to the child or on behalf of the child Extent of Nonparticipation:  An explanation of the extent if any to which the child will not participate with nondisabled children in the regular class and in extracurricular and nonacademic activities Accommodations in Assessment:  A statement of individual accommodations that are necessary to measure the academic achievement and functional performance of the child on state and districtwide assessments Service Delivery:  The projected date for the beginning of the services and modification and the anticipated frequency, location, and duration of those services and modifications Transition:  For students approaching the end of secondary school education, the IEP must also include statements about transition services to help youth with disabilities prepare for life after high school. Those components include measurable postsecondary goals based upon transition assessment related to training, education, employment, and independent living skills and transition services needed to assist the youth in reaching those goals.

Sources: American Speech-Language-Hearing Association. (n.d.-b). Individualized education programs (IEPs), individualized family service plans (IFSPs), and section 504 plans. https://www.asha.org/SLP/schools/IEPs/ Individuals With Disabilities Education Improvement Act of 2004 (IDEA), 20 U.S.C. §§ 614[d][A][i][I]. Center for Parent Information & Resources. (2022, April). Contents of the IEP. https://www.parentcenterhub.org/iepcontents/

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Table 16–6.  Billing Code Systems Code System

Abbreviation

Services Covered

Administrator

Current Procedural Terminology

CPT

Procedures or services

American Medical Association (AMA)

Healthcare Common Procedures Coding System

HCPCS

Devices, supplies, equipment

Centers for Medicare and Medicaid Services (CMS)

International Classification System of Diseases–10th Revision–Clinical Modification

ICD-10-CM

Diagnoses and disorders

National Center for Health Statistics

Source:  Adapted from ASHA. (n.d.-c). Introduction to billing code systems. https://www.asha.org/practice/reimbursement/coding/ code_intro/

Table 16–7.  Medicare Documentation Requirements Evaluation note

Plan of care notes

n

Date of service

n

Description of problem

n

Date of onset

n

Description of objective methods to document current functional status

n

The use of the following documentation tools is allowed to support claims: n ASHA National Outcome Measurement System (NOMS) n Functional Communication Measures (FCM) for reporting on the Physician Quality Reporting Initiative (PQRI) n Continuity Assessment Record and Evaluation (CARE) as of October 2019

n

When not used, Medicare recommends one of the following: n Individual item and summary scores of functional assessments (and comparisons to prior assessment scores) from commercially available treatment outcomes instruments other than those listed above; or n Functional assessment scores (and comparisons to prior assessment scores) from tests and measurements validated in the professional literature that are appropriate for the condition/function being measured

n

Statement of prognosis

n

Time frame for therapy

n

List of positive prognostic indicators and barriers that will be used to determine progress

n Diagnoses n

Long-term treatment goals

n

Rehabilitation therapy service types: PT, OT, or SLP, when appropriate

n

Describe type as a specific treatment or intervention type

n

Therapy amount: Number of treatment sessions per day

n

Therapy frequency: Number of treatment sessions per week

n

Therapy duration: Total number of weeks or treatment sessions

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Table 16–7.  continued Treatment encounter note

n

Documentation is required for every treatment day and every therapy service

n

Date of treatment

n

Identification of specific service provided, correlated to billing and coding

n

A description of skilled intervention procedures and outcomes

n

Total treatment time

n Recommendations

Progress note

Discharge note

Audiological diagnostic testing

n

Signature and professional identification of qualified professional

n

Provides justification for the medical necessity of treatment

n

An assessment of improvement, extent of progress (or lack thereof ) toward each goal

n

Plans for continuing treatment

n

Reference to additional evaluation results (see Evaluation section above)

n

Treatment plan revisions

n

Changes to long- or short-term goals

n

Objective evidence or a clinically supportable statement of expectation that the patient’s condition has the potential to improve or is improving in response to therapy; maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.

n

The discharge note shall include all treatment provided since the last progress report.

n

A summary of all treatment provided

n

A statement regarding progress or lack thereof and the reason for discharge

n

A statement that the provider agrees with discharge

n

Date of service

n

The name and professional identity of the person who ordered the evaluation

n

The services and procedures performed including the reason for the test and their outcomes

n

Clinical assessment of the findings

n Recommendations n

The follow-up provided to the referral source

n

The name and professional identity of the person who performed the service

Under Medicare, hearing and balance testing is covered under “other diagnostic tests,” but Medicare has no provision to pay for routine hearing testing or audiological therapeutic services (CMS, n.d.-b). At the time of writing, most audiology services require a physician’s referral to be reimbursed under Medicare. Some private insurance providers require prior authorization, especially for certain procedures. According to ASHA (n.d.-e), requirements include documenting the details of a physician’s referral, services performed, and the follow-up provided to the physician. Requirements for documenting audiological testing are

included in Chapter 15, section 80.3 of the Medicare Benefit Policy Manual (CMS, n.d.-a), which includes the following: Documenting for Audiological Tests. The reason for the test should be documented either on the order, and/or the audiological evaluation report, and/or in the patient’s medical record. Examples of appropriate reasons include, but are not limited to: n

Evaluation of suspected change in hearing, tinnitus, or balance



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n

Evaluation of the cause of disorders of hearing, tinnitus, or balance

n

Determination of the effect of medication, surgery, or other treatments

Information on CPT codes and other requirements for audiology under Medicare can be found on the ASHA websites provided or from CMS. All the information provided previously regarding Medicare documentation applies when appropriate to audiology services, but the specifics of documentation are too complex and lengthy for this chapter. Audiologists who work in private practice or other clinical settings are often dispensing audiologists. Fitting and selling hearing aids involves documentation related to these activities. ASHA scope of practice documents, guidelines, and state licensure laws have information pertinent to any requirements and necessary documentation. As explained throughout this chapter, a primary purpose of clinical documentation focuses on capturing clinical procedures, the patient’s performance, and the practitioner’s clinical reasoning in a written format. Documentation in health care settings is also focused on reimbursement and may require a shift in thinking for SLPs and audiologists. Increased scrutiny on the need for skilled services increases the attention that SLPs and audiologists need to pay to documentation (Hapner, 2008). Additionally, individuals who are reviewing claims are typically not SLPs or audiologists. Consequently, clinicians in these settings need to be sure they not only know the requirements but also document so someone outside of the profession can understand the notes (Hapner, 2008; Sutherland Cornett, 2006; Swigert, 2003). Reviewers need to be able to determine easily if the services are medically necessary and if criteria are met. Although information provided here deals primarily with Medicare requirements, private health plans also cover speech-language and audiology services. As stated, many plans match or model Medicare requirements, but individual plans vary in the amount, type, and conditions covered. Most services provided in hospitals are generally covered, but there are variations among plans (e.g., health maintenance organizations, preferred provider organizations, and individual, indemnity, or fee for service).

documentation extend first and foremost to providing appropriate clinical care to the individual, then to the employer and payer for compliance, and finally to the provider to ensure development of a legal record and to meet mandates for reimbursement. Lack of adequate documentation can lead to numerous types of problems, with time and energy then needed to contest, follow up, and challenge issues related to the lack of documentation. While each setting has its own requirements and standards, there is no doubt that conducting high-level professional services includes both the delivery of competent services as well as the documentation of these services because “if it’s not documented, it didn’t happen.”

References American Academy of Audiology. (2019). Code of Ethics of the American Academy of Audiology. https://www.audiology.org/wp-content/uploads/​ 2021/05/201910-CodeOfEthicsOf-AAA.pdf American Speech-Language-Hearing Association. (n.d.-a). Documentation in schools. https://www​ .asha.org/practice-portal/professional-issues/ documentation-in-schools/ American Speech-Language-Hearing Association. (n.d.-b). Individualized education programs (IEPs), individualized family service plans (IFSPs), and section 504 plans. https://www.asha.org/SLP/ schools/IEPs/ American Speech-Language-Hearing Association. (n.d.-c). Introduction to billing code systems. https:// www.asha.org/practice/reimbursement/coding/ code_intro/ American Speech-Language-Hearing Association. (n.d.-d). Medicare. http://www.asha.org/public/ coverage/medicare.htm American Speech-Language-Hearing Association. (n.d.-e). Medicare frequently asked questions: American Speech-Language-Hearing Association. (n.d.-f ). Private health plans: An overview. http://www.asha.org/practice/reimbursement/ private-plans/overview/

Summary

American Speech-Language-Hearing Association. (n.d.-g). Speech-language pathology and the Physician Quality Reporting System. http://www.asha.org/ Members/research/NOMS/PQRI/

Learning to keep clear, concise, and complete documentation is one of the most important habits a clinical practitioner can develop. The benefits of appropriate

American Speech-Language-Hearing Association. (n.d.-h). Telepractice. https://www.asha.org/ practice-portal/professional-issues/telepractice/



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American Speech-Language-Hearing Association. (2015). Speech-language pathology medical review guidelines. http://www.asha.org/uploadedFiles/SLPMedical-Review-Guidelines.pdf

Jin, J. (2021). What to consider when reading your medical notes. Journal of the American Medical Association, 326(17), 1756. https://doi.org/10.1001/ jama.2021.16493

American Speech-Language-Hearing Association. (2023). Code of ethics. https://www.asha.org/policy/ et2016-00342/

Moore, B. J. (2010). If it’s not documented, it didn’t happen. Perspectives on Administration and Supervision, 20, 106–110..

Audiology. http://www.asha.org/Practice/reimburse​ ment/medicare/audiology-medicare-FAQs/

Moore, B. (2018). Documentation and reimbursement in pediatrics: School settings. In N. Swiggert (Ed.), Documentation and reimbursement for speech-language pathologists: Principles and practice. SLACK, Inc.

Burns, A. E., & Willis, L. B. (2017). Professional communication in speech-language pathology: How to write, talk and act like a clinician. Plural Publishing. Centers for Disease Control. (2022, June 27). Health information & privacy: FERPA and HIPAA. https:// www.cdc.gov/phlp/publications/topic/healthinfor​ mationprivacy.html Center for Parent Information & Resources. (2022, April). Contents of the IEP. https://www.parent​ centerhub.org/iepcontents/ Centers for Medicare & Medicaid Services. (n.d.-a). Medicare billing for speech-language pathologists in private practice. https://www.cms.gov/Regulationsand-Guidance/Guidance/Transmittals/downloads/ R106BP.pdf__ Centers for Medicare & Medicaid Services. (n.d.-b). Audiology services. https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/PhysicianFee​ Sched/Audiology.html Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. §§ 1232g (1974). https://www2.ed.gov/ ferpa Goldfarb, R., & Serpanos, Y. C. (2020). Professional writing in speech-language pathology and audiology (3rd ed.). Plural Publishing. Hapner, E. R. (2008). Documentation that works [Abstract]. Perspectives on Voice and Voice Disorders, 33–42. https://pubs.asha.org/doi/10.1044/vvd​ 18.1.33 Health Insurance Portability and Accountability Act (HIPAA), 45 CFR Parts 160, 162, and 164 (2002). https://www.govinfo.gov/content/pkg/PLAW104publ191/pdf/PLAW-104publ191.pdf Individuals With Disabilities Education Improvement Act of 2004 (IDEA), 20 U.S.C. §§ 614[d] [A][i][I] (2004). https://www.congress.gov/bill/​ 108th-congress/house-bill/1350

Moore, B. J., & Montgomery, J. K. (2018). Speech language pathologists in public schools: Making a difference for America’s children (3rd ed.). Pro-Ed. Paul, D., & Hasselkus, A. (2004). Clinical recordkeeping in speech-language pathology for health care and third-party payers. ASHA. Paul, R., & Schoen Simmons, E. (2021). Introduction to clinical methods in communication disorders (4th ed.). Brookes Publishing. Pearsall, T. E., & Cook, K. C. (2010). The elements of technical writing. Pearson. Shipley, K., & McAfee, J. (2021). Assessment in speechlanguage pathology (6th ed.). Plural Publishing. Sutherland Cornett, B. (2006). Clinical documentation in speech-language pathology: Essential information for successful practice. ASHA Leader, 11(12), 8–25. Swigert, N. (2003). Dollars and documentation. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 12(2), 32. Swigert, N. (Ed.). (2018). Introduction. In Documentation and reimbursement for speech-language pathologists: Principles and practice. SLACK Inc. Thomson Kuhn, M. A., Basch, P., Barr, M., & Yackel, T. (2015). Clinical documentation in the 21st century: Executive summary of a policy position paper from the American College of Physicians. Annals of Internal Medicine, 162, 301–303. https:// doi.org/10.7326/M14-2128 U.S. Department of Education. (2011, February). The Family Educational Rights and Privacy Act: Guidance for eligible students. https://studentprivacy​ .ed.gov/sites/default/files/resource_document/file/ for-eligible-students.pdf

17 Developing Leadership Skills Gail J. Richard

Introduction We all function as leaders in our everyday lives, whether we realize it or not. As speech-language pathologists (SLPs) and audiologists, we assume responsibility for the well-being of our clients. They depend on us to evaluate and diagnose the communication disorder that is negatively impacting their lives. They trust us to determine an appropriate treatment plan to address the presenting deficits. The very nature of our professions requires that we responsibly communicate impressions and suggested interventions with confidence and authority to the clients we serve. In our clinical practice, research lab, or academic classroom, we function as leaders — influencing others to bring about change. Wikipedia (n.d.) defines leadership as a practical skill regarding the ability to guide other individuals, teams, or organizations. Yukl (1981) described leadership as the process of influencing or directing others to follow. Leadership is an interactive process to bring about change in working toward a common goal (Ebener, 2012). The arena of leadership can be as small as our individual work setting or as large as a national or international platform. Leadership can be part of our work responsibilities, such as supervision of an assistant, student intern, or colleague. We might function as a department or division chair in a hospital or university. Other leadership experiences might be with volunteer service activities in the community or with a professional association at a regional, state, or national level. There are many steps and stages to developing expertise in leadership during our lifetime. There are different types of leadership opportunities, each requiring a certain skill set to be effective. We rely on individuals in leadership positions to make positive changes in our lives. We admire and respect their ability and commitment to make a difference. Most of us aspire to be effective when we are in a responsible leadership position. This chapter is intended to provide you with some inspirational and aspirational information to consider as you reflect on progressing down a pathway to leadership.

Roles of a Leader “Leadership is a role or a function, not a person or a position” (Ebener, 2012). The goal of a leader is to facilitate a group effort to achieve certain objectives. Leadership style depends on the goal, the 343



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makeup of individuals in the group, and the personality traits of the individual in charge. However, there are certain roles a leader must assume when taking charge in a situation. How the roles are fulfilled can vary based on the individual, but effective leaders must be aware of the important roles they play at various times. Five of those roles are discussed in the following section, specifically that of a motivator, organizer, influencer, mediator, and spokesperson. Aspects are also addressed in the discussion of leadership characteristics.

Motivator Most individuals agree to serve in a leadership capacity because they have a vested interest in or passion for the outcome. Even reluctant leaders accept the role of leadership because they believe an initiative is important and will make a positive difference. One of the challenges is to share that vision with clients, employees, colleagues, or members of an organization to inspire their cooperation in achieving the desired outcome. The leader must actively work to prevent discouragement or frustration when efforts stall or are not successful. An effective leader stays positive and maintains focus on the group’s progress rather than ruminating on problems. While evaluating what isn’t working is important, it should be utilized as a learning tool to move forward. Acknowledge setbacks, but invest the majority of energy in generating enthusiasm for an optimistic approach to the desired goal. Motivating others to become involved, coordinating efforts, and working cooperatively are important roles for the person in charge.

Organizer It is a leader’s responsibility to ensure people’s valuable time is utilized effectively. Establish an agenda for meetings and maintain the time frame. Gather relevant information and keep discussion focused by reiterating facts to minimize emotional statements. Don’t allow tangents or personal topics to derail the meeting. Frame discussion by introducing background information, the issue at hand, and the desired outcome. Once discussion is over, clearly state the resulting action to bring closure to the topic. The following is an example for framing discussion : “At the previous meeting, there were some unresolved questions regarding possible placement options that could provide the necessary accommodations for this student to be successful. The case manager has completed additional research and visited some potential programs. We’ll let her share impressions and options. Please ask questions so we can reach a recommended decision before we end our meeting today.” This introduction summarizes previous discussion, states

what has occurred to move the agenda forward that will be shared in the current meeting, and clearly outlines the objective to be accomplished before adjourning.

Influencer Strategic thinking must always be aligned with the organization’s priorities (Axelrod, 2016). An effective leader anticipates potential problems and is prepared to address difficult issues. Present information in an objective, factual manner, and always consider all aspects of an issue to avoid bias. Individuals are more likely to resist suggestions if they feel material is skewed or being presented from only one perspective. Constructive debate is important to explore divergent views, but the leader must guide the group back to a collective agreement on decisions. Listing advantages and disadvantages is one method to consider all perspectives while weighting the advantages toward the desired outcome. A skilled leader can subtly move opinions toward the objective without dictating the desired direction.

Mediator Leadership is not without risk (Heifetz & Linsky, 2002). People will resist change, and emotions can be intense when controversial decisions are introduced. Don’t allow tensions to escalate or remain unresolved. The sooner a problem is addressed, the less likely it is to grow out of proportion. Listen to where people are and help the group see the benefit of considering other options or compromising on a position. Manage a dominant personality by acknowledging their concern and then reiterate the follow-up options to bring closure to their turn at speaking. It is important to deal with conflict in a factual way and not take dissension personally. An effective leader will carefully avoid becoming defensive, will listen calmly and attentively, and will try to resolve problematic issues in a reasonable and equitable manner.

Spokesperson As a leader, you are often the spokesperson for the group you represent. Poise in front of a group is an important aspect of effective communication. It can be annoying to listen to a leader who uses lots of verbal fillers such as “you know,” “um,” and “like.” Ineffective speaking can compromise the message. There is a great deal of research in communication studies and political science regarding the listener’s focus on how the message is presented rather than the actual content. When speaking in front of a group, be articulate, clear, and focused. Prepare notes for reference to stay on topic and avoid rambling or going off on personal tangents. The message becomes



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diluted and an audience stops paying attention when tangential information begins to dominate the verbal presentation. It is not about you; the communication’s focus needs to be on the information you are sharing.

Effective Leadership Skills There are a variety of characteristics that epitomize an effective leader. In fact, the list could be quite extensive. To organize and highlight some of the primary traits, the following list uses the acronym of leadership to discuss some of the important skills exemplified by effective leaders. L

Listen

E

Efficient

A

Access

D

Dependable

E

Expectations

R

Responsive

S

Share

H

Hierarchy

I

Innovative

P

Prioritize

L:  Engage in Active Listening William Shakespeare said, “Give every man thine ear but few thy voice” (Sisson, 1960). Good advice for an effective leader! When facilitating a group, it is important to ask questions and listen carefully to the opinions being expressed. Committee members will not appreciate being told what to think or do. A leader who imposes his own agenda will usually fail to engage members in thoughtful discussion and participation in the project. An effective leader allows members to express their viewpoints and uses that information to subtly guide the group in the desired direction. Active listening is a technique that focuses the group on the speaker (Kummer, 2011). As a leader, you set an example for courteous and respectful attention when others are expressing their thoughts. Principles of active listening suggest that you not interrupt and try to avoid imposing your own perspective on the speaker’s comments. It is not necessary to endorse or comment on each point being made by the speaker. Acknowledge the speaker by showing interest nonverbally, such as nodding or maintaining an attentive body posture. Questions

should be framed for clarification or additional information rather than challenging the speaker’s viewpoint. Careful listening allows the leader to gauge the position of a group and determine the necessary next steps to productively move an agenda item forward. Additional information might need to be generated or provided, or further clarification could be necessary if there is confusion. If the group seems comfortable and there is a general sense of consensus, the leader should close discussion and move to resolution or the desired action.

E:  Be Efficient An effective leader needs to be efficient and organized. The leader’s role is to facilitate the work of the group. Volunteers or employees who are dedicating their time to an initiative will not appreciate sitting in a meeting if they feel their time is being wasted. Productive facilitation of a meeting requires extensive preparation and anticipation of all contingencies. An agenda and materials should be provided so members arrive confident and prepared for the work to be addressed. A leader who is disorganized and floundering in a meeting generates frustration and confusion, leading to other members trying to take control. As a result, little will be accomplished and people will lose confidence in the leader’s ability to direct the actions of the group. An aspect of efficiency in conducting a meeting is knowing when to continue discussion on an item and when to move on. It is not unusual for debate to become redundant, with multiple speakers reiterating the same point. It is also possible for one individual who disagrees with the group to continue emphasizing their point after other speakers express an opinion. The leader conducting the meeting can request that only new ideas be expressed and that individuals who have already spoken refrain from speaking again. This provides all participants with an opportunity to express their perspectives without belaboring the same points.

A:  Access Resources An aspect of being organized is the ability to access appropriate resources to ensure members have adequate information to make informed decisions. Good leadership doesn’t function in a vacuum; it relies on data and knowledge from a variety of sources. Don’t be afraid to say, “I don’t know the answer to that, but I will find out and get back to you.” It is not unusual for individuals to introduce statements to support their position that are not always grounded in fact. Rumor and innuendo can quickly derail a project and cause group members to question or lose confidence in an agreed-upon plan. It is imperative that a leader gather information that is

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objective and factual so the group can make knowledgebased decisions. An effective leader also consciously works on developing networks of support resources that can be accessed when questions arise. It is not necessary to reinvent the wheel if someone else has experience with a certain situation and can offer advice. The use of consultants or specialists can be extremely beneficial when a group is exploring new options and requires additional information. Engaging in multiple types of experiences over time will lead to building a network of colleagues that can be accessed for advice, questions, and guidance.

D:  Be Dependable Mark Twain said, “Always do what is right. This will gratify some people and astonish the rest.” (https://www. goodread.com). A leader must be dependable and responsible. It is difficult to follow the direction of a leader who isn’t consistent and supportive of coworkers. Simple actions, such as being on time or following through to complete expected tasks, can help to instill confidence in leadership. Everyone needs to consistently follow the expectations established by the leader. “Do as I say, not as I do” creates dissension and mistrust in a leader. The leader’s action should match their verbal expectations. Being dependable also implies that a leader’s actions are conducted with integrity. Colleagues need to be able to trust the individual in charge and rely on the fact that the leader will work cooperatively with everyone in the group to accomplish joint initiatives. Avoid any suggestion or suspicion of preferential treatment behind the scenes or outside discussions that favor one individual or group over others. The leader should be a role model who instills trust and accepts responsibility for the actions taken by the group. Open communication, honesty, and transparency in decisions contribute to a sense of dependability and trust in leadership.

E:  Establish Expectations A leader must establish clear expectations. Colleagues working together need to understand their responsibilities and know what is expected of them. Timelines should be established and reviewed on a regular basis to determine progress toward goals. Sequenced objectives or steps should be spelled out for general agreement and consensus. If an individual is not meeting responsibilities, the leader should have a private conversation with that person to clarify specific actions that need to be completed. One suggestion is to prepare a graph listing each action item, the date for completion, and names of individuals responsible for addressing the item. The graph can be reviewed and modified as necessary, but

it provides a concrete iteration to avoid any confusion regarding expectations for the group. It also keeps the group informed and knowledgeable regarding tasks other members are involved in completing. A simple internet search can help you find a variety of project management tools for use with your team.

R:  Respond in a Timely Manner Procrastination and avoidance are banes to effective leadership. People in charge must be responsive to individuals with whom they are working. Questions and requests for information should be addressed as quickly as possible. If there are complications or issues that necessitate additional work, inform colleagues of the problem and reassure them that you will be back in touch as soon as possible. When colleagues complete assigned tasks, praise their efforts and acknowledge the work done. It is important that people feel rewarded and appreciated for their efforts.

S:  Share Ideas Consistent communication is essential in moving actions forward in an organization. Sharing ideas in a transparent way keeps everyone informed on progress and decisions. No one likes to feel like they aren’t informed or included in information sharing. Surprises regarding group initiatives are not necessarily a good thing in an organization. Effective leaders communicate with other people, not to them. They bring a collaborative spirit to the group that encourages engagement of all members. There will be individual differences in the way that members participate, ranging from the very vocal to the quiet assimilators. An effective leader conducts discussion in a way that invites everyone to share ideas and viewpoints. The exchange of ideas, both positive and negative, leads to healthy and robust debate that fosters more positive consensus when moving actions forward.

H:  Develop a Hierarchy of Leadership Skills Leadership is a skill that can be learned but requires patience and a variety of different experiences. As you have read through some of the characteristics discussed in this section, it should become apparent that not every leader will be well versed in all these skills, and certainly not during initial leadership activities. Individuals will have different strengths and weaknesses in their leadership attributes. An effective leader is aware of their strong points and knows how to compensate or work on improving areas in which they are not as proficient.



There are many types of opportunities to develop leadership skills. When I served as President of the American Speech-Language-Hearing Association (ASHA) in 2017, I overheard a student commenting that she aspired to be president of ASHA. That is a laudable goal, but not one that I ever anticipated for myself. Many volunteer opportunities preceded my achieving that prestigious position. I participated in numerous and varied volunteer service and employment positions before I felt ready to pursue that office. In each activity, I had the opportunity to develop and improve the many leadership skills involved in effectively leading a national association. Some activities allowed me to focus on verbal presentation skills, some provided opportunities to learn how to deal with conflict and controversy, and others taught me how to effectively organize and run meetings. There are numerous aspects to effective leadership. Small, focused steps to develop leadership skills require a conscious effort to realistically evaluate our talents and specifically target areas to improve. Soliciting feedback from trusted colleagues who will provide constructive criticism is invaluable in promoting the continued evolution of leadership skills. The section on Pathways to Leadership further expands on this topic.

I:  Be Innovative “We can’t solve problems by using the same kind of thinking we used when we created them.” This quote attributed to Albert Einstein (https://www.goodread .com) provides some insight regarding the importance of thinking creatively. One characteristic of an effective leader is the ability to be flexible in approaching issues. While there is merit to sharing a historical perspective on how things were addressed in the past, it is also important to explore different options. Problems can be approached as opportunities to try something new. Every obstacle has a solution if we have the patience and courage to take some risks with creative thinking. Visionary thinking is a beneficial attribute in a leader. However, it is important to bring the group along for the journey. Sometimes the leader is far advanced from where other members are and needs to slow down and explain how she arrived at a new idea. A leader must also be open and flexible to alternative suggestions, giving them appropriate attention and discussion rather than just dismissing them. There can also be what are referred to as CAVE dwellers in the group — individuals who are Consistently Against Virtually Everything. An effective leader knows how to share innovative ideas in a positive, nonthreatening way so other members can embrace the possibilities and give them due consideration. You might also experience an individual who undermines the leader’s ideas

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behind the scenes, planting doubt and dissension in the group. Meet individually with that person and explain that they are welcome to express their concerns with you or in front of the whole group. Negative comments or concerns shared outside the meeting can’t be addressed or resolved by the leader if the leader isn’t aware of them. Some strategies for addressing conflict are provided later in this chapter.

P:  Prioritize In any given day, there are many issues to be addressed. An effective leader will highlight the primary goals so appropriate energy is directed toward achieving them. Leadership requires the ability to determine which items are most critical, will be most impactful, and will be a good investment of time and resources. Prioritizing within a leadership role is constant — agenda items, actions to be taken, discussion issues to introduce, delegation of assignments, and so on. Efficiency is enhanced with effective prioritization in consideration of the available units of time. Multiple ideas and initiatives can be part of any group’s agenda. An effective leader knows how to prioritize and focus the members. The threat of not seeing the forest among the trees is a saying that resonates with leadership skills. Tangential discussion needs to be controlled and minimized. Off-target discussion tends to dilute energy and waste time, leading to frustration. The leader of a group maintains focus on the big picture, or main objective, so that members experience a sense of accomplishment for their efforts.

Reflection on Leadership Characteristics The list of characteristics provided is intended to illustrate some of the primary skills effective leaders demonstrate. It is certainly not exhaustive. It might be beneficial to take a moment and reflect on individuals who you believe demonstrate exceptional leadership. What are the characteristics you admire in their repertoire of abilities? Use that reflection to compile your own list of leadership traits that you aspire to develop and master. Individualize the list based on your personal strengths as well as areas that might need more attention. Resources in the area of leadership are plentiful. Take time to access some of the many books and modules on leadership styles. Part of effective leadership is recognizing your own manner of interacting with people and utilizing a style that is comfortable and compatible with your personality. Don’t try to become something that conflicts with your inherent nature. Adopting a certain leadership style because it sounds good doesn’t mean it

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will work effectively for you. Strong leaders embrace their best attributes and acknowledge aspects that are challenging for them. For example, I am a doer and am very aware of the need to be patient and allow time for group members to assimilate information before pushing forward. Going a bit slower helps to prevent conflict, defensiveness, and having to go back and re-explain things. Making sure questions have been answered and everyone has the knowledge to move forward results in improved consensus and overall efficiency.

Fiduciary Responsibilities As a member of a committee or board, you will be expected to meet fiduciary responsibilities. Fiduciary duty is defined as someone who holds something in trust for another. Other individuals expect the people with authority to act in the best interests of the organization. Decisions should be made on an informed basis, in good faith, and with the intention that the action is in the best interests of the individuals it affects (Gattuso, 2018). Fiduciary responsibilities are generally delineated in three areas: n

duty of care,

n

duty of loyalty, and

n

duty of fidelity to purpose.

These three guiding principles are inherent in good leadership. They ensure that good judgment is exercised in all decisions, conflicts of interest are avoided, assets are used responsibly, and actions are taken using adequate oversight, reflection, and integrity. They are each discussed in more detail in the following section.

Duty of Care Duty of care addresses the way in which persons should perform their responsibilities as leaders. The individual should be knowledgeable regarding discussion, actions, or decisions that will be made. This ensures the leader is acting in an informed manner, having read and reviewed provided data, materials, or other information. They have listened carefully to information presented to further inform the group that has the authority to make decisions. In addition to being informed, duty of care implies that the individual acts in good faith. Directors must act in what they believe are the best interests of the group they represent. Given similar circumstances, what decision would other individuals who have entrusted their

well-being to this leader determine as the best option? Leaders are protected from personal liability under duty of care if they have acted with the best knowledge available at the time and in good faith that they were protecting the interests of their respective group (Gattuso, 2018). Regular attendance at meetings is one obvious way to meet duty of care, but being present is not enough to fulfill this responsibility. As previously mentioned, preparation prior to attendance at the meeting is critical to ensure you are an active, engaged participant. Be prepared to ask clarification questions or clearly express an opinion with objective rationale to support your position. Don’t be afraid to entertain opposing viewpoints that allow the group to feel that all aspects of an issue have been discussed and carefully considered. Utilize the expertise of others. Sometimes it is prudent to form a committee charged with developing an action plan or recommendation that can be brought back to a governing board or group. Maintaining an official record of meetings is another aspect of duty of care. One error that occurs frequently is allowing minutes to become a transcript of the meeting. Minutes should reflect the major agenda items addressed and include specific decisions that were acted upon with appropriate justification or rationale, as well as subsequent steps for implementation. Detailed discussion attributed to specific individuals is not necessary. The minutes should reflect the consensus actions that occurred to inform members of the group that is represented by leaders at the meeting.

Duty of Loyalty Duty of loyalty means that the individuals serving as leaders are obligated to be faithful to the organization’s interests. The motivation to serve must be guided by the desire to function in the best interests of the constituency represented. An individual cannot advance personal interests above the interests of the organization. The focus of actions taken must be for the good of the whole and not benefit any one constituency or individual at the expense of others. An aspect of duty of loyalty often requires that individuals serving in a leadership capacity are asked to complete and sign a disclosure statement to identify any potential personal or financial conflicts of interest that could occur. An example of a financial disclosure is when a speaker is presenting on a topic for which they have published materials that result in royalties or financial benefit. It is prudent to inform the audience of that financial relationship. An example of a personal conflict of interest would be if a leader advocates for doing business with a specific company owned by a family mem-



ber. While that business arrangement might be in the best interests of the organization, it is imperative that the leader disclose the relationship and abstain from voting or influencing the decision in which they have a personal interest. Many employment settings, particularly state affiliated institutions and agencies, require employees to sign disclosure statements to raise awareness regarding the importance of avoiding any potential conflicts of interest. Enhancing one’s personal reputation or prestige by taking advantage of affiliation with an organization is also a violation of duty of loyalty. Individuals cannot advocate for themselves by using their leadership position in an organization to gain personal privileges or advantages. An example might be someone trying to secure personal favors by suggesting that they could influence a board’s decision due to their position. Confidentiality of nonpublic information is also inherent in duty of loyalty. There is a saying that “loose lips sink ships,” meaning that unguarded talk can have a detrimental impact on an outcome. Individual points of view discussed in a meeting should not be shared outside the setting unless they are part of the public record. While open, honest discussion is crucial to achieve effective results, the leader needs to emphasize the critical importance of maintaining confidential information. It is typical that the head of a group is designated as the public spokesperson; other members should defer to that individual in any public forum. The integrity of an organization can quickly be undermined if individual members violate confidentiality.

Duty of Fidelity to Purpose Fidelity to purpose requires that all group members act in accordance with the organization’s governing documents, such as bylaws, mission and vision statements, and any applicable rules and legal regulations (Gattuso, 2018). All actions considered by the group should be guided by adherence to the designated purpose of the organization. This implies that members of the organization have access to and are familiar with the governing documents. Good governance standards recommend that bylaws be reviewed regularly and updated as necessary to ensure compliance with the direction of the association. Fidelity to purpose also implies that assets or resources are used responsibly to accomplish the agreed-upon mission, vision, and goals of the established organization. Each decision should be weighed carefully against the purpose of the organization. Will it benefit the greater good? Is it consistent with the best interests of members of the organization? While an action or direction

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might be laudable, leaders must always evaluate if an action is consistent with advancing the objectives of the organization.

Strategies for Conflict in Leadership Interaction with professional colleagues is usually incredibly stimulating and fulfilling. The personal rewards from volunteering in various organizations are invaluable, as is the network of friends and resources that evolves from those experiences. However, it also not unusual to experience conflicting opinions while engaged in a group effort. There can be strong personalities and philosophies that must be addressed in a tactful respectful manner to move a group’s initiatives forward. As a leader, you want to be able to approach difficult situations with confidence in your skills to manage the emotions and focus on the eventual outcome or resolution. Leadership requires the ability to resolve conflict in the least disruptive way that allows the best interests of the group to prevail. A first step when confronted with a conflict is to take some time for self-reflection by asking questions to explore the situation. Understanding the perspective or position of other individuals will help you evaluate the situation and determine a course of action to productively lead the group effort (Abrams, 2009).

n

Can you clearly articulate the problem? Work carefully to remove layers of vested interest, emotion, and personal investment to identify the main issue.

n

Do you have accurate information regarding the issue? An effective leader will approach a problem as objectively as possible with emphasis on facts rather than anecdotal reports or personal narratives.

n

Have we considered all the options? The ethics and consequences of any action must always be taken into account. List advantages and disadvantages of the proposed ideas. Generate best- and worst-case scenarios for the options.

n

Is what we are proposing feasible and realistic? There are always constraints to consider when determining a course of action, such as finances, time commitment, and positive and negative impacts.

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Once a conflict has been recognized and acknowledged, it is imperative to manage emotions in a constructive way that prevents negative interactions within the group. The reflection questions are a technique to keep the discussion focused on clearly defining the problem and possible outcomes rather than bogged down in voicing opinions. Once the issue has been clarified, you are ready to implement strategies toward resolution. A template of strategies (Abrams, 2009; Richard, 2019) for dealing with conflict in a positive way to move the group forward is summarized in Figure 17–1.

Making a Plan The initial step in dealing with conflict is to clearly frame the issue. Paraphrase the problem in a clear, concise statement and articulate the tentative outcome of the group’s plan. The goal is what the group would like to see happen to address the issue under discussion. This is often a stage where people can get stuck in argumentative options. A good leader can avoid that by maintaining focus on what the group wants to achieve. Emphasize the desired outcome or solution to keep the group moving forward. A next step in realizing the plan is to ask the group what it will look like or what will happen if the plan is successful. At this point, the

leader might want to list specific, measurable outcomes that will result if the plan is successful in addressing the problem or issue. A final step would be to delineate what strategies, resources, or support will be required to accomplish the objective. This is an opportunity for the leader to designate who is involved in which aspects and what their responsibilities will be. It can be a good idea to make a graph that illustrates each step, people responsible, timeline, resources required, and so on. In this way, there is a concrete objective document that summarizes the initiative. Everyone in the group can follow the plan’s progress as it moves forward by updating phases on the graph.

Problem-Solving Model A large part of leadership involves being an effective problem solver. Being visionary and forward thinking is important in the big picture of effectively leading a group of individuals, but it is also imperative to deal with personal conflicts within a group. Organizations can waste a great deal of time and energy when conflicts arise and individuals are taking sides and exerting energy to defend their positions rather than being part of the solution. Leadership is about moving beyond the conflict to determine a solution.

Figure 17–1.  Strategy template for resolving conflict.



Once again, the first step in problem solving is to clearly and objectively define the problem or primary issue of concern. After carefully analyzing the problem, gather all the pertinent information that helps to substantiate the issue and present it to the group. Don’t rely on innuendo; get the facts. Then you can begin as a group to generate multiple alternatives to address the issue. Multiple options provide a vehicle for discussion and an equitable way to resolve the conflict. Instead of saying, “This is what we are going to do,” present several alternatives that can be talked through. Each option can be weighed for advantages and disadvantages so a final determination can be reached that everyone is comfortable with implementing. It also eliminates the stigma of someone winning or pushing their opinion as the only option. An effective leader can subtly guide the discussion toward consensus as discussion of disadvantages eliminates options that were originally under consideration.

Scripting Comments Dealing with conflict as a leader necessitates preparation before convening a meeting with the entire group. Although it might seem as if the person in charge is acting spontaneously, exemplary leaders have done their homework prior to stepping into the room. They have thought carefully through the issue and determined how to address the conflict so that emotions don’t escalate, time isn’t wasted, and the purpose of the meeting isn’t negated. It is always a good idea to begin a meeting that could become contentious with a positive statement that transitions into the concern or primary purpose of the meeting. The leader of the group needs to set the tone and the direction that discussion will take. Present the problem in professional language that avoids judgmental or personal challenges that could put anyone in a defensive position. It’s not necessary to be ambiguous; state the issue but do so with examples that clarify any concerns and maintain focus on the issue. Always emphasize that the goal is a resolution. Provide opportunity for discussion but make sure everyone knows there will need to be some changes and compromises so the initiative can move forward toward resolution. Invite different perspectives and acknowledge conflicting variables but advocate for a cooperative, collaborative discussion that moves respectfully toward a solution or plan.

General Reminders Address the elephant in the room! An effective leader doesn’t avoid conflict and hope it resolves on its own. That approach usually results in an issue escalating out of proportion and undermines the ability to foster a col-

CHAPTER 17   Developing Leadership Skills

legial atmosphere within the group. Maintain a factual, objective style of interaction to diffuse emotionality. A bit of levity or humor can often ease a tense situation. Take time to differentiate perceptions from facts; perceptions often become distorted and misrepresented. Clear, consistent communication can move discussion away from tangential defensive arguments into productive strategizing and brainstorming. Approaching an issue from a different perspective will sometimes reframe the issue and allow people to consider a new option. Don’t court conflict, but don’t avoid it either. A good leader learns to manage, balance, and channel the emotion, passion, energy, and commitment that individuals bring to a group setting. While those characteristics can sometimes trigger conflict, they can also be a huge advantage and asset in achieving the work of an organization.

Pathways to Leadership Developing leadership skills is a lifelong activity. Leadership develops over time as an individual participates in a variety of different types of experiences. There is a saying that most great leaders start out as great followers. The skills involved are developed and enhanced through modeling and mentoring. I received an email from a student several years ago that helps to illustrate one of the most important first steps along the pathway to leadership — observing effective leaders. I’ve taken the liberty of modifying some wording to clarify, but the message is intact from this remarkable young woman. She was a college student– athlete who served on one of my university committees. She was then selected to be the student representative on a search committee I chaired to hire a new director of athletics. She never spoke to me about her experience serving on the committee, but I have kept and treasured her email for years. Dr. Richard, I wanted to tell you, whether you know it or not, about the impact you had on me while enrolled at the university. As a member of the Intercollegiate Athletic Board, I observed you leading meetings and organizing all of the work we accomplished. I also served on the Director of Athletics search committee. This is where I learned the most from you. I volunteered to be the student representative on the search committee to gain interview experience for my future. I asked my coach for advice and he told me to “watch Dr. Richard question the candidates and you will learn a lot.” Not sure

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what to expect and a little intimidated, I went to the first on-campus interview looking forward to the experience. Watching you interview the candidates, observing their behavior and responses, and then listening to your evaluation of each candidate in postinterview discussion was invaluable and a priceless learning experience. With this experience I was able to apply those skills to be selected for a paid internship at Boeing. Out of over 1,000 applicants, Boeing interviewed the top 20. Going into my first-ever interview, I felt surprisingly calm and prepared. Unbeknownst to you, “Coach Richard,” I relate my success directly to you. I want you to know that you handed me an opportunity to learn and observe, and I am truly grateful for the experience.

My Pathway to Leadership Strong leaders are not one-dimensional; they participate in a variety of different types of activities that broaden their perspective. Diverse interests provide opportunities to interact with people from all walks of life. Liberal arts colleges often focus their recruitment messages on the importance of developing the mind, body, and spirit of students. An individual who has only one all-consuming interest can limit their opportunities to explore and appreciate a larger perspective, which is critical in effective leadership. My pathway to leadership, summarized in Figure 17–2, was an exercise I completed for the ASHA Committee on Leadership Cultivation. My background included activities in theatre, athletics, and speech-language pathology. Theatre developed my skills in public speaking and poise in front of an audience. Athletics taught me the importance of collaboration and teamwork toward a common goal, as well as time management. Speech-language pathology required incredible organization and focus, while clinical skills required innovation, insight, communication, and strategic planning. My first professional presentations were sharing results from my master’s thesis. The topic was one that was familiar and comfortable for me to discuss with other professionals. My first employment position was in the public schools, where I provided in-service presentations for teachers. After transitioning to a university position, I became involved in committees on campus that provided insight to other disciplines and governing approaches. I then volunteered to serve in my state speech-language pathology association that led to chairing committees, serving on the executive board, and eventually election to president of the state association.

I wanted to learn more about our profession at a national level and was elected to represent my state on the ASHA Legislative Council, which led to leadership positions in that group. Committee membership and serving as a committee chair led to my position on the board of directors and, finally, as president of ASHA. While pursuing professional volunteer service opportunities, I was also involved in committees at the university, serving and then chairing committees such as faculty senate and the University Personnel Committee that made tenure, retention, and promotion decisions. My involvement in athletics led to being appointed as the National Collegiate Athletics Association (NCAA) Faculty Athletics Representative for the university and serving on the NCAA Management Council for our athletic conference. All of those experiences contributed toward building my hierarchy of leadership skills that kept me moving down a leadership pathway. I actively sought out some of those experiences due to my interest or passion for the topic, while other opportunities resulted from someone asking if I would serve in a leadership capacity. Not all were positive experiences, but I learned invaluable lessons in every activity. Be receptive and willing to participate in opportunities that cross your path.

Your Pathway to Leadership Leadership allows you to have an impact and provides an opportunity to choose where to commit your time, energy, and talent. Carefully choose the steps to take as you begin the journey on your leadership pathway and engage in positive, rewarding experiences that foster your desire to continue on the pathway. Initial leadership experiences should focus on activities that you are comfortable and familiar with or that you have a special passion or interest for. Volunteer service often grows out of frustration with an issue that needs to be addressed. An interest or passion for the topic provides the motivation to stay engaged with the responsibilities that will accompany the commitment. Rather than complain about the way something is being managed, jump in and make it better! There are many opportunities for committee work as part of your undergraduate and graduate programs. The chance to work with colleagues might arise from fundraising activities, National Student Speech-Language-Hearing Association (NSSLHA) chapter events, or universitysponsored events with the community. These are excellent ways to observe campus leaders or serve as a leader with a support system in place and structure already provided. Once you graduate, your employment setting will provide opportunities to serve on a committee in the school, hospital, or agency where you work. Offering to

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Figure 17–2.  Pathway to leadership example.



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provide an in-service training for professional colleagues is a chance to develop early presentation skills to build your repertoire of leadership skills. Share information you acquired by attending a conference in a department meeting. Submit a poster session to the state association convention, where you can interact with colleagues oneon-one. Explore opportunities in your local community or place of worship to broaden the scope and type of volunteer service you participate in, such as Big Brothers Big Sisters, helping with a fundraising marathon, or United Way or Habitat for Humanity projects. Community boards and councils are usually very grateful for volunteer participation. As you become more skilled, transition to state-level activities. Join the state professional association and volunteer to help with their annual meeting. Assist with advocacy and legislative efforts that impact professional services to clients. Committee or board membership often transitions to leadership positions over time. Active engagement in state association activities provides opportunities to observe seasoned leaders and begin developing and demonstrating your own leadership style. Engagement with ASHA can be extremely stimulating and rewarding. Consider joining a Special Interest Group (SIG) on a professional topic of interest to you. Each SIG has a coordinating committee, community discussion site, access to the Perspectives journal, and sponsors continuing education sessions at the ASHA convention. Go to the ASHA website and sign up to receive Headlines and Advocacy updates to stay apprised of current events and requests to provide input to legislators. Respond to calls for feedback on issues, attend membership forums at sponsored ASHA meetings, and complete the volunteer form to express interest in appointment to ASHA committees, boards, and councils. Explore similar activities with other related professional associations that are pertinent to your work setting or area of professional focus. Take advantage of the many leadership development opportunities sponsored by ASHA. The 2018 Association Media and Publishing Excel Awards recognized ASHA with a bronze award for the Leadership Academy, citing the innovative commitment to providing leadership development activities for its members. The ASHA Leadership Academy website (https://community.asha .org/leadershipacademy) has training modules for beginning, intermediate, and advanced leadership skills. ASHA offers several leadership and mentoring programs designed for more individualized participation. The website includes assessment tools for an individual to examine leadership strengths and areas for improvement, as well as an evaluation of leadership styles and behaviors that are most natural for an individual and that can be incorporated into a personal plan for developing leadership skills. A community discussion site allows elec-

tronic interaction for questions, ideas, and insights to be shared. There are also videos that highlight young members talking about their journey toward leadership (ASHA, leadership-pathways). Additional resources and a toolkit are also provided. These resources are available to all members. Use the example in Figure 17–2 to chart your own leadership pathway. The trail could be very winding with many twists and turns. Embrace the presented opportunities from a variety of sources. There is no right or wrong path and you won’t get lost. Each activity will help you better understand and strengthen the traits in your leadership style. It is not unusual for some of our best learning experiences to result from failure or an incident that did not go as smoothly as expected. Observing poor leadership might help us recognize what we don’t want to do in a specific situation. Embrace every opportunity as an exercise to build additional leadership skills.

Summary Effective leadership requires excellent communication skills, strong interpersonal skills for interaction, active listening to hear all viewpoints, and the ability to set a vision and approach it in an organized way. It is also important to be practical and grounded in the reality of available resources in regard to finances and manpower. Leadership is about investing your time and talent in an activity to make a difference. Mahatma Gandhi said, “The best way to find yourself is to lose yourself in the service of others.” Leadership is not about power or being in control; it is about adding value and making a contribution. One of my favorite stories to share when I am encouraging people to become involved in volunteer service and leadership activities is the story of the starfish. One day a man was walking along the beach when he noticed a boy picking something up and gently tossing it into the ocean. Approaching the boy, he asked, “What are you doing?” The youth replied, “Throwing starfish into the ocean. The surf is up and the tide is going out. If I don’t throw them back, they’ll die.” “Son,” the man said, “Don’t you realize there are miles and miles of beach and hundreds of starfish? You can’t make a difference!” After listening politely, the boy bent down, picked up another starfish, and threw it back into the surf. Then, smiling at the man, he said, “I made a difference for that one.” — Adapted from Loren Eiseley, 1979



The desire to make a difference is a noble motivation. The decision to dedicate time and energy to a specific purpose is a significant investment for an individual. Leadership can be a conscious decision, but it can also be thrust upon you due to extenuating circumstances. There have been many reluctant leaders who found themselves faced with a situation they could not, in good conscience, walk away from. They accepted the responsibility and executed the task to the best of their ability. Others embrace the challenge and seek opportunities to develop their leadership skills. Their mantra echoes the sentiment of Ralph Waldo Emerson: “Do not go where the path may lead. Go instead where there is no path and leave a trail” (www.goodread.com).

References Abrams, J. (2009). Having hard conversations. Corwin — A SAGE Company. Axelrod, N. (2016, Oct 24). Exceptional boards: Strengthening the governance team [Conference session]. Meeting hosted by the American Society of Association Executives, Charleston, SC. Ebener, D. (2012). Blessings for leaders. Liturgical Press.

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Eisley, L (1979). The star thrower. Harper-Collins. Gattuso, C. (2018). Legal responsibilities of members of the board of directors [Presentation to board of directors]. American Speech-Language-Hearing Association, Rockville, MD. Heifetz, R., & Linsky, M. (2002). Leadership on the line. Harvard Business Review Press. Kummer, A. (2011). Successful leadership: Influencing others to follow your lead. In R. Lubinski & M. Huson (Eds.), Professional issues in speech-language pathology and audiology (4th ed., pp. 444–458). Plural Publishing. Leadership. (2022, January 12). In Wikipedia. https:// en.wikipedia.org/wiki/leadership Richard, G. (2019). Strategies for engaging in difficult conversations in the school setting [Webinar]. American Speech-Language-Hearing Association. Sisson, C. J. (1960). William Shakespeare: The complete works. Harper & Row. Yukl, G. (1981). Leadership in organizations. Prentice Hall.

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18 Safety in the Workplace Cynthia McCormick Richburg and Donna Fisher Smiley

Introduction Safety in the workplace is a topic on many professionals’ minds, specifically considering recent events occurring in offices, chain stores, factories, malls, hospitals, and schools all over the world. Unfortunately, the issues surrounding workplace safety are often overlooked or set aside by employers and employees. However, workplace safety is something about which we should all think, learn, and routinely update our knowledge. Safety in the workplace involves multiple disciplines and can be described as the policies and procedures put in place to ensure the safety, health, and well-being of all employees and constituents associated with an employment setting. Workplace safety involves the identification of threats and hazards as well as the implementation of controls and policies to counter those threats/hazards. A safe working environment reduces stress and health-related illnesses, improves productivity, and helps reduce absenteeism and job turnover. In essence, workplace safety is necessary for all employees to work in a protected atmosphere. Every workplace setting has safety concerns — some more than others. Because this book focuses on professional issues for audiologists and speech-language pathologists (SLPs), this chapter’s focus will concern the safety issues surrounding a professional practice setting. For audiologists and SLPs, that practice setting may be a hospital, a private practice, a school, a freestanding clinic, a nursing home, a manufacturing agency, or any other practice setting in which these professionals might be employed. Because it would become too cumbersome to address the specific safety concerns in each and every practice setting, the content in this chapter will focus on broad themes: (a) regulatory agencies, (b) policies, procedures, and trainings, (c) personal and environmental hazards, (d) infection control, and (e) confidentiality and Internet safety. Workplace hazards have been categorized into several different classifications: chemical, radiation, mechanical, physical/health, psychological, biological, and ergonomic. Hazards can also be classified as acute or chronic, depending on how long the hazard is present in the worker’s environment (Anderson, 2018). The controls for these hazards are typically established by state or federal government standards, which necessitate the ongoing safety training and education of employees. It is the employer’s responsibility to see that safety policies and procedures are implemented in the workplace, yet it is the employee’s responsibility to abide by the policies and implement the procedures for the good of everyone in that environment. 357



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Workplace safety should be important to audiologists and SLPs. These professionals should not think of workplace safety as something required for only employees in industrial or manufacturing jobs. As professionals, audiologists and SLPs should be concerned about safety and well-being for themselves, their fellow workers, as well as their clientele. Audiologists and SLPs should know what safety concerns are important to their specific professional setting and to the people served within that setting. Knowing the policies and procedures within their own setting allows these professionals to carry out their responsibilities in a safe and effective manner. Knowing the correct way to handle a workplace safety concern may allow those involved to meet accreditation requirements, thwart hacking attempts, contain infections, or simply survive.

Regulatory Agencies Audiologists and SLPs should know which agencies regulate the safety concerns within their workplace environment. Knowing this information will assist in the development of that site’s policies and procedures for safety and security measures, especially as they apply to the employees of that site. The following are international or national agencies that put specific regulations or mandates into effect to ensure the best possible safety outcomes for employers, employees, and constituents (e.g., clients, family members) associated with a particular work setting.

Occupational Safety and Health Administration The U.S. Department of Labor has three supports responsible for enforcing laws passed to protect the safety and health of workers/employees in the United States:

the Occupational Safety and Health Administration (OSHA), the Mine Safety and Health Administration (MSHA), and the Fair Labor Standards Act (FLSA). OSHA is likely the only one of these three agencies to provide information and training guidelines relevant to the work environment of audiologists and SLPs. Therefore it is the only one further detailed in this chapter. Although OSHA is typically thought of as an agency that regulates industries outside of health care, as of the early 1990s, OSHA has been responsible for overseeing and enforcing infection control programs and other safety hazards in the workplace (OSHA, 2016). Random inspections of health care facilities are accomplished to ensure employees, as well as the clients/patients seen in those facilities, are kept safe through compliance with current regulations. Most recently, OSHA has included information about emergency preparedness and response on its website (OSHA, n.d.-a). However, audiologists and SLPs may obtain additional information from such websites as those found in Table 18–1.

Environmental Protection Agency Although the Environmental Protection Agency (EPA) is not responsible for the safety and health of employees in a workplace environment to the extent that OSHA is responsible, the EPA, as part of its mission statement, works to ensure “that chemicals in the marketplace are reviewed for safety” (EPA, n.d.-a). The EPA is responsible for ensuring that no significant risk is posed to the health and safety of those coming into contact with the chemicals used to clean, disinfect, and sterilize the equipment, probes, toys, and diagnostic/therapy items used by SLPs and audiologists. The EPA has created an informative site helpful to health care and school-based practitioners who need to determine the appropriate method of cleaning as well as when to clean and contact times needed for safe handling (EPA, n.d.-b). Of note,

Table 18–1. Occupational Safety and Health Administration Websites of Interest to Audiologists and Speech-Language Pathologists Informational Topic

Website

Healthcare (in general)

https://www.osha.gov/healthcare

Nursing home safety

https://www.osha.gov/nursing-home

Healthcare workplace violence

https://www.osha.gov/healthcare/workplace-violence

Emergency preparedness

https://www.osha.gov/emergency-preparedness

Coronavirus safety

https://www.osha.gov/coronavirus/ets/



hand sanitizers, which have become omnipresent in our practices, are regulated by the Food and Drug Administration (FDA).

Food and Drug Administration The FDA is a regulatory agency that has authority to regulate food, drugs, biologics (e.g., vaccines, gene therapies), medical devices (including surgical implants, such as cochlear implants, implantable middle ear hearing devices [IMEHDs], and osseointegrated hearing implants), electronic products that give off radiation, cosmetics, veterinary products, and tobacco products (FDA, n.d.). The role of the FDA is to protect and promote public health by ensuring the safety of products and food. The FDA ensures that the product labels and descriptions are accurate and specific enough for consumers to understand and use them properly. The FDA and EPA often work together to exchange information about the effects of chemicals, including the disinfectants and sterilization chemicals used by audiologists and SLPs.

U.S. Departments of Education and Homeland Security Because not all audiologists and SLPs work in hospitals, nursing homes, or other health-related settings, school regulatory agencies must be addressed here as well. It is important to understand that the U.S. Department of Education (USDE), per se, is not a regulatory agency for workplace safety in schools or local education agencies (LEAs). However, in 2018, the Federal Commission on School Safety was “charged with quickly providing meaningful and actionable recommendations to keep students safe at school” (USDE, n.d.). The commission was established to focus on different aspects of school safety, including preventing school violence, mitigating the threats of violence, and protecting students and teachers while working and learning in educational settings. Also, a website was “created by the federal government to provide schools and districts with actionable recommendations to create a safe and supportive learning environment where students can thrive and grow” (SchoolSafety.gov, 2022). This website is meant to provide interested readers with a collection of resource materials and infographics on “a variety of school safety topics, including cybersecurity, emergency planning, school climate, mental health, and more” (SchoolSafety​ .gov, 2022). The Cybersecurity and Infrastructure Security Agency (CISA) is an agency of the Department of Homeland Security (DHS) and was developed to “understand,

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manage, and reduce risk to the cyber and physical infrastructure Americans rely on every day” (CISA, n.d.). The CISA website contains information on school safety, including resources and tools related to bomb threats, cyberattacks, and active-shooter trainings.

Accrediting Agencies Audiologists and SLPs should know which agencies license and/or accredit their workplace environment. Knowing this information will also assist in the development of that site’s policies and procedures for safety and security measures, especially as they apply to the clients/ patients of that site. Accreditation (a process by which an impartial organization reviews a hospital or nursing facility’s operations to ensure the facility is conducting business in a manner consistent with national standards) includes review of the privacy and confidentiality of protected health information. The accreditation review process also addresses accountability for patient safety and provides opportunities for ongoing education and training of employees.

The Joint Commission The Joint Commission has both national and international branches, with the branch located in the United States being responsible for accrediting U.S. health care organizations and programs (Joint Commission, n.d.-a). State governments recognize accreditation and certification by the Joint Commission as a reflection on an organization’s commitment to maintaining certain performance standards. These standards often serve as a symbol of quality that consumers and third-party payers recognize for licensing and reimbursement purposes. The Joint Commission accredits hospitals, home health care, and nursing care centers, settings in which many audiologists and SLPs are employed. The Joint Commission regularly formulates national patient safety goals, which include goals and updates meant to improve patient safety (Joint Commission, n.d.-b). In addition, the Joint Commission’s website contains the Sentinel Event Alert and Quick Safety newsletters, which include articles developed by the commission that cover workplace violence prevention. Articles present information on topics such as using deescalation techniques as the first line of response to prevent potential violence and aggression toward health care providers, as well as the clients they serve (Joint Commission, n.d.-c). Audiologists and SLPs should rely on these sources to supplement information obtained by their professional and state organizations.

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The Commission on Accreditation of Rehabilitation Facilities (CARF) This international organization’s mission is to provide accreditation standards for organizations working in the human services professions, including services related to aging, behavioral health, child and youth services, employment and community services, medical rehabilitation, and opioid treatment programs (CARF, n.d.). The CARF is a system of rehabilitation facilities that monitors itself to maintain standards and state certifications/accreditations. Through accreditation, CARF assists service providers in improving the quality of their services and generating customized standards based on universal precautions for each department within a facility, such as rehabilitation (speech-language pathology, audiology, physical therapy, and occupational therapy), nursing, and nutrition services (CARF, n.d.).

Additional Health Care Accrediting Agencies Audiologists and SLPs usually think of the Joint Commission and CARF when they think about accreditation; however, there are other agencies that a hospital or nursing home may opt to turn to for accreditation purposes. The Utilization Review Accreditation Commission (URAC), the National Committee for Quality Assurance (NCQA), and the Council on Accreditation (COA) are three additional agencies audiologists and SLPs may come in contact with at some point in their careers. All agencies take workplace safety seriously, particularly where portability and accountability of protected health information is concerned. Refer to the BHM Healthcare Solutions website (bhmpc.com) for a comparison of the five health care accreditation organizations (BHM Healthcare Solutions, n.d.).

Policies, Procedures, and Trainings As described earlier, regulatory agencies help establish guidelines to be adopted and implemented by the employers/administrations within workplace settings in which audiologists and SLPs are employed. Each setting should have protocols and policies in place to describe the threats and hazards associated with that specific site. Those policies and procedures should include trainings provided at little or no cost to the employees to prevent or control the outcome of possible breaches in safety. The policies and trainings should allow an employee to implement the necessary controls to counter any safety threats with a minimal negative impact.

Facility- and department-specific safety training protocols should be a part of any workplace environment’s policies and procedures. Each workplace setting should have a set of operating procedures with a detailed plan for responding to emergencies, including trainings specific to the activities, threats, and population served within that facility. All facilities have the potential for threat from fire, power outage, gas or water leaks, explosions, inclement weather, and environmental impacts. Some facilities will also have potential for threat from chemical spills, radiation leaks, or biohazard contamination. For example, if an SLP is working in a hospital setting, they should know the emergency response plan for exposure to radiation or biohazardous materials. A plan should be accessible to all employees specifying how those hazards are to be communicated to the staff, how treatment for skin or eye contact should be handled, and how to dispose of the hazardous material appropriately (even if this means passing the responsibility off to another employee correctly). Likewise, if an audiologist is working in a school setting, they should know the emergency response plan for a bomb threat or gas leak. A plan should be accessible to all employees specifying how those hazards are to be communicated to the staff, how to account for and safely move away from the building with children under the audiologist’s care, and when it is safe to reenter the area or building and how that will be communicated. All plans, policies, and trainings should be in both written and electronic formats. The information contained in the documents should be included in any new employee’s orientation to the work setting. Knowledge of the information contained within the policies should be updated every 12 to 18 months, with trainings used to support and update past knowledge on the topics. To ensure employees are informed properly, employers and administrators should have a method for documenting when and how employees obtained the information, and some sort of dated/time-stamped information should be obtained and maintained in employee records. Audiologists and SLPs should always inquire about the standard operating procedures (SOPs) and emergency plans in any work setting they enter, especially if they have an itinerant position that dictates they move from one setting to another. For example, if an audiologist starts the day in an ENT office setting in Kansas City, the audiologist is responsible for knowing what is contained within that setting’s emergency plan, which may include a hazardous materials management plan, a biohazards management plan, and the code for a tornado response action. Then, when that audiologist later drives to the local university’s campus to teach a course on hearing aids, they become responsible for knowing the university’s policies on campus safety (includ-



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ing policies on sexual violence, harassment, and active shooter threats). There is a plethora of information from agencies and websites on the topic of workplace safety and trainings. Refer to Table 18–2 for a nonexhaustive collection of information on workplace safety websites. A topic not entirely related to policies, procedures, or trainings — yet one that needs to be addressed when discussing safety in the workplace — is the topic of background checks (clearances) necessary for professional practice. The physical and emotional safety of clients should be paramount for audiologists and SLPs. One way to ensure safety is with the utilization of background checks for potential new hires, students obtaining practical experiences, and current employees. The background checks should be appropriate for the job responsibilities and clientele, which may include children, youth, and/

or vulnerable adults. Many state and local regulatory credentialing agencies, including licensure boards, may require an applicant to disclose relevant issues related to criminal history, employment history, and licensure history. It is likely that a new hire would be expected to disclose any prior misdemeanor or felony convictions, and employers would expect new hires to disclose if they had been disciplined or discharged from a professional position or had a license suspended, denied, revoked, or annulled. However, some states are writing new laws that protect an individual’s rights, particularly when the infraction occurs during childhood or adolescence. An example of this is Connecticut’s Clean Slate law, which is to take effect in 2023 (Connecticut Public Act 21-32, 2021). This law restricts employers from obtaining information classified in Connecticut as “erased criminal history information.” This classification refers to any erased

Table 18–2. Examples of Available Online Workplace Safety Websites of Interest to Audiologists and Speech-Language Pathologists Topic

Safety Trainings and Other Resources

Active shooter

Agency

Website

ALICE Training Program

ALICE Training Institute

https://www.alicetraining.com (Healthcare and Education options)

Active shooter/ campus intruder

Active Shooter and Campus Intruder Response Training (ASRP)

C.O.B.R.A. Defense System

https://www.cobradefensesystem.com

Active shooter: Mass attacks in crowded and public spaces

Ready

Department of Homeland Security

https://www.ready.gov/public-spaces

Active shooter preparedness

Active Shooter Preparedness

Department of Homeland Security

https://www.dhs.gov/cisa/ active-shooter-preparedness

Emergency preparedness

Ready

Department of Homeland Security

https://www.ready.gov/severe-weather https://www.ready.gov/tornadoes https://www.ready.gov/ hazardous-materials-incidents

Workplace violence

Physical and Verbal Abuse Against Health Care Providers

Joint Commission

https://www.jointcommission.org/ workplace_violence.aspx

Workplace safety and health

Workplace Safety

Centers for Disease Control and Prevention

https://www.cdc.gov/niosh/

Diseases and Conditions Emergency Preparedness and Response

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criminal records, information relating to people granted “youthful offender” status, and/or any continuances of cases that have been ongoing for more than 13 months. These new laws have the potential to impact employers of audiologists or SLPs (as well as university educational programs) by not identifying people involved in abuse-, sex offense-, or drug/alcohol-related cases. It is also important for SLPs and audiologists (especially those in administrative roles) to keep updated on new privacy laws because states, such as California, Colorado, Virginia, and Utah, have passed privacy laws that protect medical information not covered by HIPAA. With increases in telehealth and teletherapy, clinicians must know the laws from the states in which they are treating clients. There are many types of background checks, each of which provide different information to the employer. Criminal background checks provide information on a person’s criminal record and can be completed using personal information, such as name, Social Security number, and/or fingerprints. These records can be obtained via the Federal Bureau of Investigations (FBI) database, state/local databases, and private vendor services. State and national sex offender and child abuse registries may also be checked for criminal activity. Employers may check criminal records at their discretion as long as they go about doing so in compliance with federal and state guidelines (Equal Employment Opportunity Commission [EEOC], n.d.). For some settings, employers may obtain criminal records annually, but oftentimes this is done only upon the initial hiring process. Other types of background checks that may be of interest to employers include driving histories, education record/academic degree verification, social media usage, and drug testing. The information from these types of background checks help to ensure that employees are providing services to clients safely and with competency. Again, these background checks must be done in a manner that meets federal and state guidelines, and employers must tell prospective hires that they are obtaining records in a stand-alone written document (not the job application itself ).

Personal and Environmental Hazards Physical Hazards The workplace has many physical hazards, depending on the environment or setting. Physical hazards include wet or slick floors, objects or obstructions in walkways, poor lighting, gas leaks, fumes, dust, vapors, and misused or unsafe machinery (e.g., sharp objects, exposed wires).

Audiologists and SLPs working in all settings, but particularly pediatric settings, must be aware of the dangers associated with toys left out in waiting areas and other tripping hazards, exposed electrical outlets, small toy parts that pose a choking risk, dangling cords from window treatments, or cleaning agents that are not stored in child-locked cabinets. Likewise, these professionals must be aware of the dangers associated with sidewalk and parking lot hazards (e.g., door access, snow, ice, excessive heat, ramps) in clinical settings, especially those that serve very young and/or elderly clients. Employees in all settings should be made aware of policies that prohibit the use of specific equipment in the building. For example, some settings prohibit the use of space heaters/fans, hot plates, coffee makers, or toaster ovens in individual offices due to the fire hazard risk they can create. Also, certain departmental safety procedure documents prohibit the use of extension cords or power strips that are piggybacked on each other because of the risk of fire and/or tripping or using unmounted furniture (such as bookshelves) due to the risk of it tipping/ falling over and injuring someone. Other regulations may be described more fully by the technology management team in a practice setting.

Ergonomic Hazards For their own safety, clinicians should be instructed about ergonomic hazards, or physical conditions that may pose a risk for muscle, ligament, or tendon damage usually resulting from awkward/extreme postures or repetitive movements. “Ergonomics” is a term used to refer to the design of the work environment with an intent for comfortably fitting workers’ body size and capabilities while supporting any limitations or restrictions (Claussen, 2011; OSHA, n.d.-b). The main objective of ergonomics in the workplace is to create a safe work environment that decreases fatigue, pain, and injury in workers (OSHA, n.d.-b). Audiologists and SLPs are at risk for eye strain, lower back problems, and carpal tunnel syndrome because of the nature of their jobs (e.g., sitting at a computer or desk, typing or writing for long periods of time). Other aspects of these professionals’ job responsibilities that could create physical distress might include carrying equipment (e.g., portable audiometers for screenings), lifting small children throughout the day, and transferring adults from wheelchairs or hospital beds. The workplace is responsible for training staff on the proper use of body mechanics and the use of any special equipment for transferring. An example of a special piece of equipment is a Hoyer lift, which can assist professionals in transferring clients from a wheelchair into a bed after therapy. Additional ergonomically designed equipment



that might be used to assist audiologists or SLPs include adjustable-height chairs, sit/stand desks, alternative mouse devices and keyboards, keyboard sleeves, antifatigue mats, and wrist rests.

Behavioral Management and Restraints Physical restraint may be necessary when a client’s behavior poses a threat to themselves, another person, or the professional working with them. If an audiologist or SLP finds themselves providing services to a client who becomes combative, confused, or irrational, having been trained in behavioral management and restraint may make the difference between emerging from the situation with resultant injuries or emerging injury free. Training instruction and videos (such as the one from Handle With Care, which provides crisis intervention and behavior management training services; https://han​ dlewithcare.com) may help to keep employees, clients, and others within the practice setting safe. Each practice setting should have detailed instructions included in protocols and safety documents for addressing the use of restraints and behavioral management techniques. If an audiologist or SLP is employed in a hospital or clinic setting, they must not only be knowledgeable of the codes for combative patients, but must also be able to use techniques for controlling the patient in a manner that allows both the clinician and the patient to maintain self-respect and emerge from the situation without harm (Gastmans & Milisen, 2006). This same scenario exists for SLPs and audiologists who work in school settings. Each school district should have operational plans and protocols established for behavioral management and/ or physical restraint for students whose actions present a safety risk for those around them. Regulations and policies exist at the local, state, and federal levels to protect individuals from being unnecessarily or inappropriately restrained (Crisis Prevention Institute [CPI], 2009; USDE, 2022). For example, audiologists and SLPs who work in public school settings should be familiar with state and federal guidelines regarding when restraint of a student can and cannot be used. In other practice settings, such as hospitals, the rules and regulations will be different for when and how restraint may be used with patients. Regardless of the workplace, the use of restraints should be implemented only when necessary to protect the immediate physical safety of the student/patient, staff, and others. Deescalation techniques are also important for audiologists and SLPs to become familiar with through trainings. Deescalation, also known as defusing, crisis or conflict resolution, or conflict management, can be described as a combination of strategies and techniques

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intended to reduce a patient’s distress and aggression (Joint Commission, 2019). Audiologists and SLPs should obtain training that includes proper use of assessment, communication, and actions to reduce the risk of harm to patients and themselves. Examples of commonly used trainings can be obtained on the CPI website (https://www.crisisprevention.com).

Workplace Violence Information on workplace violence and prevention has become more common, and anyone can access information about this topic on the internet (see Tables 18–1 and 18–2). For example, the ALICE Training Institute (an acronym for Alert, Lockdown, Inform, Counter, Evacuate) has listed 12 ways to prevent workplace violence (ALICE, 2020). The site stresses the need to make employees aware of what constitutes workplace violence, to establish training sessions to help employees act appropriately in cases of workplace violence, and to create policies that prevent threats, unacceptable behaviors, harassment, or retaliation. Audiologists and SLPs need to be encouraged to report all incidents to supervisors and employers. Being informed about workplace violence is not the only step necessary for preventing these events. Making physical changes to a practice setting can also help discourage would-be attackers. For example, placing privacy screening (darkening or mirroring) on windows makes it impossible to see into rooms. Essentially, keeping an attacker unable to see through windows eliminates what is known as the “fishbowl effect” (Wyllie, 2010). Establishing a system of internal notifications (e.g., email, text, phones, and/or codes) provides a method for alerting workers about the presence of an attacker. Making a plan and establishing protocols for all employees to follow is equally important. That plan must include what actions employees should take for clients with disabilities, access limitations, or other functional needs. Any time an audiologist or SLP enters a new work setting, they should identify the closest exits and visualize a path of escape should an active shooter or violent intruder enter the facility. Also, identifying a place to hide in any setting is prudent, should that be the only choice of action. In addition to general information found on the ALICE website, information and videos can be found on the Joint Commission’s website on the topic of workplace violence prevention resources for health care (Joint Commission, n.d.-b). For audiologists and SLPs who practice in a university clinic, there may be a plan for dealing with sexual violence, harassment, and theft. As with other places of employment, university employees typically must have proof of training completion on file

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with the human resources office. Every professional setting can tailor the recommendations and examples given on safety websites to accommodate employee and client needs. Additional information laid out in a variety of educational and literacy levels and found in an assortment of written information, online training modules, and location-based training programs can be found in Table 18–2.

Signage and Catchy Acronyms Every workplace setting should have highly visible emergency exits, along with signs, maps, and/or directions indicating the nearest exits. Emergency exits should lead directly out of the building. Other signage indicating additional dangerous conditions (e.g., what to do in the event of a chemical spill, an active shooter, or a dangerous weather event) should also be present and highly visible throughout hallways and areas in which employees and constituents are likely to congregate. Figure 18–1 provides an example of signage that must be located in all public areas. Many employers or safety departments have established catchy or memorable acronyms to help employ-

ees quickly remember specific protocol or processes for safety. For example, unless the hazard or threat is directly affecting an employee’s work area, the acronym SNOW may help hospital SLPs remember to “S — stay in place, N — notify the supervisor, O — operate normally, and W — wait for instructions.” Likewise, a school-based audiologist may safely respond to a fire in a school by remembering the acronym RACE (R — remove individuals from the immediate area, A — activate the alarm, C — contain the fire by closing all doors in the area, and E — extinguish the fire if it can be done safely or impedes evacuation/E — evacuate the area to your designated meeting location). Even active shooter trainings use a catchy, memorable phrase of “run, hide, fight” to help workers remember what to do in times of stress and danger.

Infection Control in Clinical and Educational Settings Minimizing and eliminating infectious disease contamination in the practice settings of SLPs and audiologists is another aspect of workplace safety. The pathogens

Figure 18–1.  An example of emergency signage that must be located in all public areas.



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commonly considered problematic in speech-languagehearing clinical settings include, but are not limited to, staphylococcus, influenza, common cold, tuberculosis, HIV, and the various forms of hepatitis. We have also just experienced a pandemic in which COVID-19 has entered our clinics, schools, and offices, and we now need to be knowledgeable about the virus and its variants. Audiologists and SLPs need to be trained to use appropriate infection prevention methodologies, including personal protective equipment (PPE) and disinfecting solutions. To learn more about these and other pathogens, go to the Centers for Disease Control and Prevention (CDC) webpage on infection control (CDC, n.d.). The CDC site, as well as book chapters written specifically on the topic of infection control in the speech-language-hearing clinical setting (e.g., Bankaitis & Kemp, 2008; Lubinski, 2013), will provide specific information for SLPs and audiologists to obtain knowledge and skills in the areas of (a) pathogen transmission, (b) infection prevention, (c) infection control plans for the specific settings, and (d) exposure protocols and reporting. Many workplaces have specific documents outlining infection prevention and control for that setting. The American Speech-Language-Hearing Association (ASHA) website also has information about hand hygiene, isolation precautions, PPE, needle/sharps handling, as well as information specific to school-based professionals and practice guidelines (ASHA, n.d.). The literature on infection control will enable professionals to become more knowledgeable about the various forms of pathogen transmission (e.g., contact, vehicle, airborne, and vector-borne transmission). Guidelines in

the literature will help professionals learn to prevent and control contamination on the surfaces of equipment, toys, and diagnostic/therapy items. Knowing which chemicals are appropriate for cleaning on a topical level versus those that disinfect or sterilize will allow audiologists and SLPs to protect themselves and their clients. In addition, protocols addressing the handling and disposal of chemicals used for infection control should be part of the orientation and annual trainings provided for SLPs and audiologists. Various resources on infection control can be found in Table 18–3. Another element that needs to be addressed in practice setting protocols (as they pertain to the protection of both professionals and constituents) is preemployment health screening documentation. New employees need to provide documentation of infectious disease immunizations/screenings (e.g., measles, mumps, rubella; tuberculosis tests) and/or clearance to work by a licensed physician. Additionally, many employers now require annual vaccinations, cardiopulmonary resuscitation (CPR) training, and defibrillator training as a condition for employment or continued employment. With respect to the topics discussed previously, some agencies have tried to summarize information that every employee should know to a short list of less than 10 workplace safety tips. These tips are meant to (a) keep people aware of their surroundings and emergency exits, (b) allow employees to identify and address sources of workplace stress, (c) allow employees to report unsafe conditions to supervisors/managers, (d) have workers use the correct tools with proper posture and ergonomically appropriate aids, and (e) make people aware of the

Table 18–3. Examples of Available Online Infection Control Sources of Interest to Audiologists and Speech-Language Pathologists Resource Type

Agency/Country

Website

Website

ASHA/U.S.

www.asha.org/practice/infection-control

Website

Northern Speech Services/​ U.S.

www.northernspeech.com/bf53/

Website

EPA/U.S.

www.epa.gov/pesticide-registration/list-ndisinfectants-coronavirus-covid-19

Educational videos

AudiologyOnline.com/​ U.S.

www.audiologyonline.com/articles/infection-control-inaudiology-1299

Educational videos

SpeechPathology.com/U.S.

www.speechpathology.com/articles/infection-control-forspeech-language-1736

Website with resources

Speech-Language and Audiology Canada/Canada

www.sac-oac.ca/infection-prevention-and-controlresources-audiologists/

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benefits of staying sober and taking appropriate breaks during the workday. For SLPs and audiologists, there is an additional component to workplace safety that needs to be included in the list of safety tips. This additional component centers on our clients, research participants, and family members.

right 2025. Plural Publishing, Inc. rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

Confidentiality of Client and Research Participant Information Another aspect of workplace safety for audiologists and SLPs is the safeguarding and protection of client information. Additionally, when these professionals are involved in research projects using human participants, professionals have both a legal and ethical obligation to protect the privacy of those participants (Department of Human and Health Services [HHS], 2018).

Safeguarding Client Information There are three things that professionals must keep in mind when considering the safeguarding of information for clients: confidentiality, privacy, and security. Audiologists and SLPs need to consider each of these aspects as they reflect on safeguarding client information. Confidentiality is the concept that the information a client reveals to a provider in a professional relationship is private and that there are limits on how and when the information may be disclosed to a third party (“Confidentiality,” n.d.). Information a patient shares with an SLP or audiologist in any format (i.e., written or verbal), as well as any documentation that results from the interaction between the patient and the professional, is confidential. Privacy is the right of the patient to make decisions about when and how confidential information should be shared with a third party (HHS, 2003). Audiologists and SLPs will want to become familiar with rules/laws/ regulations that affect their workplace and client population. These professionals must understand when and how they can release information on any given client. Many workplaces will have standardized forms for the client to sign that give explicit permission as to who can receive confidential information and what information is to be released. Figure 18–2 is an example of a release of information form (ROI) that can be used to protect a patient’s privacy. Security (as it relates to patient information) refers to the method used to ensure confidential information is protected, whether in paper or electronic format. For audiologists and SLPs who work in schools, hospitals, clinics, or large medical practices, decisions about secu-

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rity of client information may be made and enforced by administrators outside of their department. However, professionals who are in private practice may possess the decision-making powers for determining how to ensure security of client information.

Regulations Regarding Patient Confidentiality, Privacy, and Security Depending on their work settings and job responsibilities, audiologists and SLPs may be required to complete formal training regarding protection of client confidentiality, privacy, and security of data. Professionals working in hospital settings will most likely have annual trainings to ensure that they are aware of regulations and know how to report a data breach should it occur. For professionals involved in clinics, nursing homes, rehabilitation centers, and hospitals, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will very likely be among the regulations included in annual trainings. Regulations involving HIPAA required the HHS to adopt national privacy protection standards for electronic health care transactions because it was recognized that advances in electronic technology had the potential to create problems with maintaining privacy of health information (HHS, 2017). For professionals involved in educational settings, the Family Educational Rights and Privacy Act of 1974 (FERPA) will very likely be among the regulations included in annual trainings. Regulations involving FERPA apply to all schools that receive funds from the USDE, and these laws protect the privacy of educational records belonging to students (USDE, 2021). Audiologists and SLPs will find guidance concerning confidentiality, privacy, and security of patient information contained within their codes of ethics, state and federal regulations, and workplace-specific documents. According to ASHA (2018), if there is inconsistency between these different documents, the professional should follow the most restrictive rule. One example of this inconsistency might be if the law seems to allow an action, but the ASHA Code of Ethics (ASHA, 2023) seems to prohibit that action. In this case, the professional should follow the ASHA Code of Ethics (refer to Chapter 4 for more information on ethical practice). Similarly, if there appears to be a conflict between documents/sources, the professional should abide by the law (e.g., when a workplace policy conflicts with legal requirements for the confidential handling of records, the law will take precedence [ASHA, 2018]). Table 18–4 contains a list and short descriptions of several regulations and guidelines SLPs and audiologists should be familiar with when considering how to safeguard client information.

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TEXAS TECH UNIVERSITY



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AUTHORIZATION TO RELEASE HEALTH INFORMATION All elements are required prior to information being released Patient Name: ________________________________________________ Date of Birth: _____________ 1. Who is authorized to disclose the information: ________________________________________________ 2. Who is authorized to receive the information: Name: ___________________________________________________________________________ Complete Address: _________________________________________________________________ City: ___________________________________ State: ____________ Zip Code: _______________ 3. I understand that I will be charged for the costs of copying the information to be released. 4. The specific information to be requested or released is: List the dates of services: ____________________________________________________________ □ Clinic Report □ Operative Report □ Radiology Films □ Discharge Summary □ Physical □ ER Report □ Shot Record □ Lab □ X-Ray Report □ Medical Abstract □ Other: _________________________________________________ 5. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be redisclosed and no longer protected by these regulations. 6. I understand that the [NAME OF SITE] will be paid for the cost of copying the information released. 7. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits. I may inspect or obtain a copy of any information used/disclosed under this authorization. 8. I understand that I may revoke this authorization in writing at any time by delivering a copy of my revocation to [NAME OF SITE] except to the extent that action has been taken in reliance on this authorization. This authorization expires: 1 year from date signed 9. I understand that the information in my health record may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental services and/or treatment for alcohol and drug abuse. PLEASE INCLUDE A COPY OF A PHOTO ID _____________________________________ Signature of Patient or Representative

_____________________________________ Date

_____________________________________ Phone Number

_____________________________________ Relationship to Patient

Witness: ___________________________ Phone Number: __________________ Date: ________________

Figure 18–2.  Sample of a release of information. Source: Adapted from Arkansas Children’s (2019).

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Table 18–4.  Laws, Regulations, and Guidelines Regarding the Protection of Client Information Law/Regulation/Guideline Name

Description

American Speech-Language-Hearing Association (ASHA) Code of Ethics

This document reflects the values of ASHA members regarding scientific and clinical practice based on principles of duty, accountability, fairness, and responsibility. This code is modified, adapted, and updated as society and practices change. As of the writing of this chapter, the latest version of the ASHA Code of Ethics was published in 2023 (ASHA, 2016).

Health Insurance Portability and Accountability Act of 1996 (HIPAA; 1996)

This federal law was initially written to protect workers who changed jobs against the loss of health insurance or from encountering exclusions for preexisting conditions in new health insurance coverage. Currently, standards and rules for how protected health information (PHI) may be used, disclosed, stored, maintained, and transmitted gets the most attention in the Administrative Simplification section of this act.

Family Educational Rights and Privacy Act (FERPA; 1974)

This federal law protects the privacy of student education records. In addition, the document requires schools that receive funding from the U.S. Department of Education to obtain written permission from the parent (or student once they turn 18 years of age) to release information from a student’s education record. There are some exceptions and conditions that allow schools to share student education data without consent. See https:// www2​.ed.gov/policy/gen/guid/fpco/ferpa/index.html for those exceptions.

U.S. Department of Health and Human Services Policy for Protection of Human Research Subjects Title 45, Part 46 (2018)

This policy contains 45 CFR 46.111(a)(7), which provides guidance about how to protect the privacy of research subjects and maintain the confidentiality of data (45 CFR 46.111(a)(7).

State- and workplace-specific documents

These documents contain rules, regulations, and guidance on the protection of client information specific to each state and workplace. Speech-language pathologists and audiologists should make sure they are familiar with these documents. Claiming ignorance will not protect a professional in a legal or ethical conflict when it comes to patient confidentiality, privacy, and security of data.

Breaches of confidentiality and privacy may be due to carelessness, such as speaking about a patient in a public space or improperly safeguarding patient data around others. Breaches of this nature may also occur for malicious reasons, such as accessing the medical record of a patient who is well known when there is no relevant need to know that person’s status to complete the work assignment. Regardless of the reason, breaches of confidentiality and privacy can result in disciplinary actions that range from disciplinary action by the employer, to termination of employment, to criminal charges that

may include monetary fines and/or imprisonment. In addition, audiologists and SLPs may have their Certificate of Clinical Competence (CCC) or American Board of Audiology (ABA) certification suspended or revoked, which in turn could lead to the suspension or revocation of their state license. At the least, these professionals could be reprimanded or censured by the Board of Ethics, which would also mean the state licensing board would be notified of the lapse in professional ethics (ASHA, 2019). Therefore, these professionals are responsible for knowing and abiding by the laws and



regulations that govern confidentiality, privacy, and security in their workplaces.

Computer and Internet Safety In this digital age, most, if not all, workplaces have computers, other electronic devices (e.g., tablets, smartphones), and internet access. Processes and procedures need to be put into place to safeguard both employees and clients as they relate to computer and internet safety. Depending on which sources are read, today’s electronic medical records (EMRs; also known as electronic health records or EHRs) are full of safety and danger. It can be argued that EMR systems can contain mistakes created by the program’s clumsy or unintuitive design or by autocorrect functions that accidentally fill in information or change words that a professional might not notice (ZaggoCare, 2021). Even today, EMR systems do not communicate with each other the way they were intended. Each medical facility uses their own operating system so most facilities still rely on faxes and CDROMs to send information to medical providers not in their own system or network. However, most professionals will argue that electronic records are better than paper records for the following reasons: (a) electronic records grant access only to authorized users, (b) electronic records are encrypted to secure information, (c) electronic records leave trails that make auditing records easier, and (d) electronic records stored in the cloud secure information to another location in the case of disasters, such as fire, floods, or earthquakes (O’Connor, 2020). Knowing how to keep electronic records accurate and secure is important for SLPs and audiologists. In addition to following the security requirements outlined by HIPAA and FERPA, SLPs and audiologists need to be mindful of the use of computers and other electronic devices in public spaces. Guaranteeing that unauthorized people cannot access or view client data is critical. For example, if an SLP writes client reports on a computer in a public workspace, they will need to have a process for always logging out of that computer or locking the screen when away from that device to help ensure client information is safe from a breach of confidentiality. Employees in any workplace need to use some basic online safety rules. Larger organizations may have specific rules in place to protect employees and electronic data, which should be outlined in employee orientation sessions and updated during annual trainings. All audiologists and SLPs, no matter how large or small their practice settings may be, should learn and practice skills for minimizing computer and internet safety breaches at work. One example of practicing online safety is avoiding the creation of generic passwords or easily guess-

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able passwords. Avoid using a family name, birthdate, address, or even a pet’s name as a password. The more random a password, the stronger it will be. Safety experts recommend that employees not use the same password for every situation that requires one. Additionally, employees should never have their passwords written down, especially in a location close to their computers or devices. Lastly, email phishing scams often occur in the workplace. Suspicious-looking emails should not be opened. An email from an unknown source (especially one that promises quick money) should generate caution and cause a professional to think twice before looking at the contents. When the content of an email appears to be from someone known but contains suspicious or unusual requests, workers should follow protocol to first report and then dispose of those emails appropriately. Audiologists and SLPs should be made aware that sophisticated hackers and spammers will use email addresses that appear to be legitimate but that are not. An email that appears to have been sent from a supervisor and asks the viewer to “click on a link and enter your username and password” should always be approached with skepticism. Again, workers should have specific protocol for reporting and handling emails that appear to be phishing for personal information of both the worker and the client. Modern-day technology and access to information via the internet can be necessary and beneficial. However, with the benefits of technology comes the need to safeguard client confidentiality and privacy. Employees’ use of email and other data sources requires that precautionary measures be an element of today’s workplace safety — now more than ever.

Summary Workplace safety is not a new concern — it has been of interest since the 1700s — but identifying, managing, and mitigating the concerns are relatively new concepts to modern society. Approximately 14,000 workers were killed on the job in 1970, the same year the WilliamsSteiger Occupational Safety and Health Act was signed into law by President Nixon (OSHA, 1970). By 2009, the number of workers killed in the workplace dropped to under 4,400, yet the number of workers in the U.S. workforce had almost doubled (OSHA, 2010). We can thank OSHA, the National Institute of Occupational Safety and Health (NIOSH), and other agencies and policies dedicated to implementing safety practices for our modern workforce. But we are not done yet. According to Chia and colleagues (2019), we are entering a “fourth Industrial Revolution,” which they define as the merging of a set of disruptive technologies including

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autonomous robots, the Internet of Things (IoT) that connects physical objects to the internet and communicates with other devices, and 3D technologies that allow objects (such as guns or bombs) to be built without regulations. These authors believe that as the nature of work evolves, new hazards to well-being (e.g., burnout) are going to surface. They believe psychosocial stresses and uncertainty created by blurred work–life boundaries and a 24/7 digital work platform have the potential to affect workers now and in the future. Therefore, creating and fostering a culture of safety in the workplace is a must. A culture of workplace safety will lead to better performance within every organization and across all professions, including those of audiology and speech-language pathology, resulting in better productivity from happier and healthier employees and better patient outcomes.

accreditation-comparison-cta/AccreditationComparison-Tool.pdf Centers for Disease Control and Prevention. (n.d.). Infection control. https://www.cdc.gov/infection​ control/ Chia, G., Lim, S. M., Sng, G. K. J., Hwang, Y. J., & Chia, K. S. (2019). Need for a new workplace safety and health (WSH) strategy for the fourth Industrial Revolution. American Journal of Industrial Medicine, 62, 275–281. Claussen, L. (2011). Office safety: 25 steps to a safer office. https://www.safetyandhealthmagazine.com/ articles/recognizing-hidden-dangers-25-steps-to-asafer-office-2

References

Commission on Accreditation of Rehabilitation Facilities. (n.d.). CARF international. http://www​ .carf.org

ALICE Training Institute. (2020, June 17). How to prevent workplace violence in 12 ways. https:// www.alicetraining.com/resources-posts/blog/​ 10-ways-to-prevent-workplace-violence/

Confidentiality. (n.d.). In Miller-Keane encyclopedia and dictionary of medicine, nursing, and allied health (7th ed.). https://medicaldictionary.thefree​ dictionary.com/confidentiality

American Speech-Language-Hearing Association. (n.d.). Infection control resources for audiologists and speech-language pathologists. https://www.asha.org/ slp/infectioncontrol/

Connecticut Public Act 21-32 (2021). https://portal​ .mycertiphi.com/documents/CT_Public_Act_ No_21-32.pdf

American Speech-Language-Hearing Association. (2018). Issues in ethics: Confidentiality. https://www​ .asha.org/Practice/ethics/Confidentiality/ American Speech-Language-Hearing Association. (2019). How ASHA’s board of ethics sanctions individuals found in violation of the code of ethics. https://www.asha.org/practice/ethics/sanctions/ American Speech-Language-Hearing Association. (2023). Code of ethics. https://www.asha.org/policy/ et2016-00342/ Anderson, J. (2018, September 20). What is the difference between an acute hazard and a chronic hazard? Safeopedia. https://www.safeopedia.com/7/4109/ hazards/what-is-the-difference-between-an-acutehazardand-a-chronic-hazard Bankaitis, A. U., & Kemp, R. J. (2008). Infection control. In H. Hosford-Dunn, R. Roeser, & M. Valente (Eds.), Audiology practice management (pp. 215–245). Thieme Medical. BHM Healthcare Solutions. (n.d.). The big five healthcare accreditation organizations — side by side comparison. https://bhmpc.com/calltoaction/

Crisis Prevention Institute. (2009). Joint Commission standards on restraint and seclusion/nonviolent crisis intervention training program. https://www​ .crisisprevention.com/CPI/media/Media/Resources/ alignments/Joint-Commission-Restraint-SeclusionAlignment-2011.pdf Cybersecurity and Infrastructure Security Agency (CISA). (n.d.). School safety and security. https:// www.cisa.gov/school-safety-and-security Environmental Protection Agency. (n.d.-a). Our mission and what we do. https://www.epa.gov/ aboutepa/our-mission-and-what-we-do Environmental Protection Agency. (n.d.-b). What’s the difference between products that disinfect, sanitize, and clean surfaces? https://www.epa.gov/ coronavirus/whats-difference-between-productsdisinfect-sanitize-and-clean-surfaces Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. 1232g; 34 CFR Part 99 (1974). https:// www2.ed.gov/policy/gen/guid/fpco/ferpa/index​ .html Food and Drug Administration. (n.d.). https://www​ .fda.gov



Gastmans, C., & Milisen, K. (2006). Use of physical restraint in nursing homes: Clinical-ethical considerations. Journal of Medical Ethics, 32, 148–152. Health Insurance Portability and Accountability Act, Pub. L. No. 104-191, 45 CFR, Parts 160-164 (1996). https://www.hhs.gov/hipaa/for-profes​ sionals/index.html Joint Commission. (n.d.-a). We all deserve excellent healthcare. https://www.jointcommission.org Joint Commission. (n.d.-b). Workplace violence prevention resources. https://www.jointcommission.org/ workplace_violence.aspx Joint Commission. (n.d.-c). Sentinel Event Alert and Quick Safety newsletters. https://www.jointcommis​ sion.org/resources/patient-safety-topics/workplaceviolence-prevention/sentinel-event-alert-and-quick-​ safety-newsletters/ Joint Commission. (2019). De-escalation in health care. Quick Safety, 47. https://www.jointcommis​ sion.org/resources/news-and-multimedia/news​ letters/newsletters/quick-safety/quick-safety-47-​ deescalation-in-health-care/ Lubinski, R. (2013). Infection prevention. In R. Lubinski & M. Hudson (Eds.), Professional issues in speech-language pathology and audiology (pp. 460–476). Cengage. Occupational Safety and Health Act of 1970, 84 Stat. 1590, 29 U.S.C.A. § 651 et seq. (1970). Occupational Health and Safety Administration. (n.d.-a). Emergency preparedness and response. https://www.osha.gov/emergency-preparedness Occupational Health and Safety Administration. (n.d.-b). Ergonomics. https://www.osha.gov/SLTC/ ergonomics/ Occupational Safety and Health Administration. (2016). Bloodborne pathogens. CRF Title 29 Labor vol 6 part 1910.1030. https://www.osha.gov/ laws-regs/regulations/standardnumber/1910/1910​ .1030 O’Connor, S. (2020, January 15). 5 reasons why electronic health records are better than paper records.

CHAPTER 18   Safety in the Workplace

Advanced Data Systems Corporation. https://www​ .adsc.com/blog/reasons-why-ehr-software-is-moresecure-than-paper-based-records SchoolSafety.gov. (n.d.). Find resources to create a safer school. https://www.schoolsafety.gov United States Department of Education. (n.d.). Federal commission on school safety. https://www.ed.gov/ school-safety United States Department of Education. (2021). Family Education Rights and Privacy Act (FERPA). https://www2.ed.gov/policy/gen/guid/fpco/ferpa/ index.html United States Department of Education. (2022). Seclusion and restraints: States and territories summary. https://www2.ed.gov/policy/seclusion/seclusionstate-summary.html United States Department of Health and Human Services. (2003). Summary of the HIPAA privacy rule. https://www.hhs.gov/sites/default/files/privacy​ summary.pdf United States Department of Health and Human Services. (2017). Office of Civil Rights summary of HIPAA for professionals. https://www.hhs.gov/hipaa/ for-professionals/index.html United States Department of Health and Human Services. (2018). Subpart A of 45 CRF Part 46: Basic HHS policy for protection of human subjects. https://www.hhs.gov/ohrp/sites/default/files/ revised-common-rule-reg-text-unofficial-2018-​ requirements.pdf United States Equal Employment Opportunity Commission. (n.d.). Background checks: What employers need to know. https://www.eeoc.gov/laws/ guidance/background-checks-what-employersneed-know Wyllie, D. (2010, May 5). Active shooters in schools: The enemy is denial. Police1. https://www.police​ one.com/school-violence/articles/2058168Activeshooters-in-schools-the-enemy-is-denial/ ZaggoCare. (2021, July 18). 6 dangers of electronic health records. https://zaggocare.org/dangerselectronic-health-records/

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Appendix 18–A Acronyms ABA:  American Board of Audiology

HIV:  Human Immunodeficiency Virus

ALICE:  Alert, Lockdown, Inform, Counter, Evacuate

IMEHD:  implantable middle ear hearing devices

ASHA:  American Speech-Language-Hearing Association

LEA:  local education agency

CARF:  Commission on Accreditation of Rehabilitation Facilities CCC:  Certificate of Clinical Competence CDC:  Centers for Disease Control and Prevention

MSHA:  Mine Safety and Health Administration NCQA:  National Committee for Quality Assurance NIOSH:  National Institute of Occupational Safety and Health

CISA:  Cybersecurity and Infrastructure Security Agency

OSHA:  Occupational Safety and Health Administration

COA:  Council on Accreditation

PPE:  Personal Protective Equipment

CPI:  Crisis Prevention Institute

QCOSS:  Queensland Council of Social Service

CPR:  cardiopulmonary resuscitation

RACE:  R — remove individuals from the immediate area, A — activate the alarm, C — contain the fire by closing all doors in the area, and E — extinguish the fire if it can be done safely or impedes evacuation/​ E — evacuate the area to your designated meeting location

DHS:  Department of Homeland Security DOL:  Department of Labor EHR:  electronic health record EPA:  Environmental Protection Agency FBI:  Federal Bureau of Investigations

ROI:  release of information

FDA:  Food and Drug Administration

SARS-CoV-2:  Severe Acute Respiratory Syndrome Coronavirus 2

FERPA:  Family Educational Rights and Privacy Act of 1974

SNOW:  S — stay in place, N — notify the supervisor, O — operate normally, W — wait for instructions

FLSA:  Fair Labor Standards Act

SOP:  standard operating procedures

HHS:  Department of Human and Health Services

URAC:  The Utilization Review Accreditation Commission

HIPAA:  Health Insurance Portability and Accountability Act of 1996

U.S. DOE:  United States Department of Education

19 Overview of Interprofessional Practice and Interprofessional Education Alex F. Johnson

Introduction Interprofessional collaborative practice (ICP) occurs “when health workers from different professional backgrounds work together with patients, families (caregivers), and communities to deliver the highest quality of care” (World Health Organization [WHO], 2010). Interprofessional education occurs when students from two or more disciplines learn from and with one another (WHO, 2010). On the surface, these simple statements suggest a level of cooperation and collaboration that is expected in every health transaction. Longitudinal evidence, however, suggests that these simple goals are frequently not achieved. Although our health care expenses and advances in technology both continue to grow, errors in judgment, practice, and collaboration lead to significant problems and a growing cost of delivery of care. In the health care setting, the frequency of errors has led to the conclusion that failures in collaboration, communication, and teamwork provide an opportunity for resolution. A logical extension of this thinking is that improvement in these critical areas will improve the quality and cost of care. Because speech-language pathology and audiology are delivered in school settings as well as health care, it is important to acknowledge that similar patterns of professional behavior can also result in challenges in the K–12 educational setting. Failures in collaboration, communication, or teamwork result in delays or interruptions in needed services to children, conflicts with parents and educators, failures to achieve best outcomes, and costly litigation. It seems reasonable to conclude that the contexts, primarily health care and education, where speech-language pathology services are delivered can be risk prone, complex, and at times challenging to the client/family complex and to those providing services. Because these concerns apply to individuals across settings, the generic term “client” will be used in this chapter. Hopefully, the reader can substitute their own setting-specific terminology (e.g., patient, client, student) accordingly. Even though most clinicians strive to achieve the best quality outcomes, there are times when the needs of an institution or a provider can complicate the situation. Additionally, when the needs 373



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of the client are more complex, miscommunication or ineffective problem solving can lead to confusion and/ or conflict. To be honest, the opportunities for error, dissatisfaction, and frustration in client care are immense. In this brief chapter, we will focus on interprofessional collaborative practice (IPCP) as desirable for providing the best level of care, mitigating risk, keeping the patient at the center, and enhancing communication with the patient and the health care team. Additionally, we will consider interprofessional education (IPE) as an approach to learning to work collaboratively. Readers should consider this discussion an early primer on the topics of IPE and IPCP for two reasons. First, it is directed to an audience of new learners and graduate students and is organized to provide basic concepts. Second, there is a growing literature and extensive scholarship focusing on both IPE and IPCP. There are also numerous available resources available through websites and professional organizations. Interested learners are encouraged to dig deep into this information.

Interprofessional Practice To further clarify this topic, the reader is invited to consider clients from different settings. These cases highlight the types of issues that can arise when poor practices, miscommunication, or interpersonal conflict impact the care of the client. In preparation for addressing the concerns for each client, six key questions will be used for the reader’s consideration. First, the questions are provided as a cueing mechanism for the reader. The following questions will be used for each case. Note the brief rationale provided for each question. Consider these items as you review each case. 1. What are the risks? What could go wrong? (Iden­ tification of potential risks or errors allows the team to plan with prevention of these problems in mind.) 2. Can you identify any issues the health care team could have addressed in a more effective manner? (In reflection, learning about what might have been done better becomes a teaching and learning tool for the team of providers. The team can apply this learning to the next client with similar concerns.) 3. Who are the members of this client’s team? Have they all been included and aligned on the discussion of care? (Considering all the members of the team is critical. Aligning perspectives and goals for care and ensuring all the people providing care

have the client at the center are key to providing the best outcomes.) 4. What are the complicating factors in this situation? How do they contribute to the manner in which the client could have received care? (Anticipating factors that may affect care from the client’s perspective include personal characteristics and preferences of the client and their family. Some factors may be irrelevant to care, while others can be critical.) 5. Is there anything that could have been done to make this situation better from the client/family perspective? (It is possible that clinical goals of care are achieved, but what would have helped the client/family understand or participate more fully? What would have helped them see the benefit of the clinical activities being completed?) 6. What communication strategies could have been helpful? (Aligning communication with the client/ family preferences, styles, language, and culture can ensure the client’s needs are met. Bringing resources or tools into interaction can enhance communication and ultimately compliance and appreciation.)

Client 1:  Health Care Setting Mrs. Spinelli is an 88-year-old widow. She immigrated from Italy in her 30s, when she married her husband. Her primary language is Italian and while she understands common English terms and uses social language appropriately, her health literacy skills are weak. She was admitted to the hospital via the emergency department after suffering right-sided weakness, slurred speech, confusion, and difficulty speaking in either English or Italian. Her oldest daughter, Maria, has accompanied her mother and has been in the waiting room for several hours, hoping to see her mother soon. Maria has been gathering information via separate verbal reports from the emergency medicine physician, the neurologist, and the nurse practitioner. Her mother’s condition stabilized over the first 12 hours, and she is more communicative but still has weakness and some word-finding difficulties, and appears to have difficulty swallowing. Mrs. Spinelli is crying and says she just wants to go home. However, the team members think she should be admitted to the stroke unit at the hospital, as does her daughter. In the unit, Mrs. Spinelli is not allowed to eat or drink because of her apparent swallowing difficulty, and she is given intravenous fluids. She is complaining of being hungry and Maria doesn’t understand why her mother can’t eat. The nurse tells Maria that she can’t have food until the speech-language pathologist (SLP) evaluates her mother’s



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swallowing. However, it’s now 6 p.m. on Saturday. The SLP won’t be available until sometime Monday morning to do the needed evaluation. Maria is very angry and frustrated with this situation and decides to get some soft foods and go and give it to her mother. After one or two swallows, Mrs. Spinelli starts to cough violently. The nurse walks into the room and begins to scold the daughter for feeding her mother. Both mother and daughter are upset and crying. Consider this situation from the following perspectives and answer these six questions: 1. What are the risks? What could go wrong? 2. Can you identify any issues the health care team could have addressed in a more effective manner? 3. Who are the members of this client’s team? Have they all been included and aligned on the discussion of care? 4. What are the complicating factors in this situation? How do they contribute to the manner in which the patient could have received care? 5. Is there anything that could have been done to make this situation better from the client/family perspective? 6. What communication strategies could have been helpful?

Client 2:  Public School Setting Jamie is a 6-year-old boy who attends elementary school. At age 3, Jamie was assessed by an SLP and diagnosed with developmental stuttering. Her advice at that time was to wait and see if Jamie grew out of it. Over time, Jamie’s disfluencies became less frequent, but never totally disappeared. Now, in first grade, Jamie was placed on the caseload of the school-based SLP. His therapy has been focused on using fluency-facilitating techniques. He is seen for one, 30-minute session per week. The SLP lets the mother know that she doesn’t have a lot of experience with children who stutter, but she will give it a try. She also tells the mother that she has lots of children on her caseload with more complex speech and language problems, limiting the time available for Jamie. Recently, Jamie has become less willing to participate in class or to play with other children. His mother has noticed that he is quieter than usual at home, especially when his siblings are involved in conversing. Jamie’s teacher notes that he never volunteers to read aloud. She also notices that Jamie is starting to close his eyes when he speaks and seems to tense his shoulders and arms while speaking. The teacher suggests evaluation by the school psychologist. The SLP disagrees that this new referral is needed, saying these behaviors

are exhibited by lots of children as they begin to realize they stutter. She thinks she can work with him on better coping skills and wants to enlist the teacher’s support. The teacher is resistant and wants the referral. Jamie’s mother wonders why he can’t get more therapy at school or if another SLP might seem more comfortable dealing with Jamie’s problem. Again, consider the same six questions used in the previous case: 1. What are the risks? What could go wrong? 2. Can you identify any issues the team could have addressed in a more effective manner? 3. Who are the members of this client’s team? Have they all been included and aligned on the discussion of care? 4. What are the complicating factors in this situation? How do they contribute to the manner in which the patient could have received care? 5. Is there anything that could have been done to make this situation better from the client/family perspective? 6. What communication strategies could have been helpful?

Client 3:  Child With Hearing Loss Laura is a 4-year-old girl with severe speech-language and behavioral difficulties. Her mother brought her to the SLP for assessment and was referred by the pediatrician. At the evaluation, Laura engaged nicely in the speech and language assessment. When the SLP attempted to screen her hearing, Laura was uncooperative and exhibited loud crying and seemed inconsolable. Because she was going to be enrolled in therapy, the SLP decided she would attempt to rescreen hearing in an upcoming session. The SLP forgot to document this in the plan and subsequently failed to follow up on the hearing assessment. Over the next 6 months of therapy, Laura became slightly more intelligible, but her progress was slow and she exhibited problems with comprehension and with following directions. Laura’s pediatrician suggested a more comprehensive neurodevelopmental assessment. Laura was then seen by a neurologist and a psychologist. The psychologist determined that Laura was developmentally behind in a number of cognitive and language areas, but not in motor skills. He also noticed a number of behavioral difficulties. He indicated that a special education program might be needed, especially for these unexplained cognitive problems. The neurologist completed a thorough examination and indicated that she seemed neurologically intact but noted that a hearing assessment was not part of the record. He asked that she

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see an audiologist, who identified a significant hearing loss bilaterally. The team (neurologist, audiologist, psychologist) decided the best approach would be to secure amplification for Laura and see if her other problems were resolved and if this assisted her progress in speech and language therapy. Laura’s mother called the SLP and expressed her anger and frustration for the waste of time as a result of the missed hearing referral from the first examination. Also, Laura’s mother’s insurance required large copayments on all these medical appointments, which served as another trigger for her anger. She noted that she plans to pursue legal action. The SLP apologized and felt upset and embarrassed for her mistake. She is deeply concerned about the consequences. Again, consider the six questions used in the previous cases: 1. What are the risks? What could go wrong? 2. Can you identify any issues the health care team could have addressed in a more effective manner? 3. Who are the members of this client’s team? Have they all been included and aligned on the discussion of care? 4. What are the complicating factors in this situation? How do they contribute to the manner in which the patient could have received care? 5. Is there anything that could have been done to make this situation better from the client/family perspective? 6. What communication strategies could have been helpful?

Client 4:  Young Adult With Traumatic Brain Injury Jake is an 18-year-old college student who sustained a serious brain injury, along with multiple fractures, in a motor vehicle accident. He was with friends and one of them was killed during the accident. At the time of the accident his alcohol levels were quite high. Jake attends college on a football scholarship, which pays for his tuition and room and board. Jake was in the ICU for several weeks and as he became more stable was transferred to a medical-surgical unit. His cognitive and communication abilities were slow to improve, but he did benefit from therapy received from the occupational and physical therapists. Jake’s sessions with the SLP focused on language skills as well as work on memory and decision making. Once he was able to walk with assistance, Jake was moved to the rehabilitation unit, where he received physical therapy, occupational therapy, and speechlanguage pathology services for 1 hour each, 6 or 7 days per

week. Jake’s family was very supportive, visited daily, and participated in sessions with his therapists in anticipation of helping him at home after discharge. Jake indicated that he liked physical therapy because it seemed like his workouts, but he felt that the activities in the speech therapy sessions were childish and made him feel stupid. He was not compliant with following up with any of the activities his SLP left for him to work on between sessions. In one session, he tossed a notebook provided by the SLP across the room and started swearing at the clinician. While the SLP and the family were concerned that Jake was so upset, they also were aware he would need more therapy to regain necessary skills to return to college. It was also clear that it was highly unlikely he would be able to play college football again due to his physical injuries, which included some persistent mild paralysis in his leg. This was heartbreaking information for Jake and for his family. The SLP, a new graduate, was empathetic and wanted to know how to help Jake. She was also very frustrated because she felt unsure about how to get Jake’s trust and engagement in the therapy process. The complexity of Jake’s needs, his emotional status, and the SLP’s lack of experience all contributed to his parents’ decision to request a new SLP for his ongoing therapy. Again, here are the six questions: 1. What are the risks? What could go wrong? 2. Can you identify any issues the health care team could have addressed in a more effective manner? 3. Who are the members of this client’s team? Have they all been included and aligned on the discussion of care? 4. What are the complicating factors in this situation? How do they contribute to the manner in which the patient could have received care? 5. Is there anything that could have been done to make this situation better from the client/family perspective? 6. What communication strategies could have been helpful? Hopefully, these cases highlight the need for improved care, improved communication with the client/ family and within the team, the clarification of roles, and the best ways to manage disagreement or conflict. These are the core skills needed to effectively manage individuals in the context of health care or education and to collaborate interprofessionally. These skills do not replace the need or demand for clinical competency within a specific discipline, but rather complement good clinical skills. Importantly, when an element within the system fails, there is opportunity for correction and improvement.



CHAPTER 19   Overview of Interprofessional Practice and Interprofessional Education

There is an important caveat to this discussion. The cases mentioned above all present individuals with primary disorders of communication. Thus, the role of the audiologist or SLP in each discussion is quite clear and calls for a leadership perspective. It is not uncommon for SLPs and audiologists to be involved in clinical discussions and situations where the concerns of the patient’s communication disorder are secondary for another provider or family member. Consider the child in a school setting with a behavior disorder, complex health issues, social disadvantage, and a communication disorder. Or consider the patient in a skilled nursing facility (SNF) with hearing loss, dementia-related behavioral difficulties, language impairment, and an exhausted staff of caregivers. Understanding this larger context helps prioritize questions and resolve (or hopefully prevent) adverse outcomes. Case scenarios such as those described above represent situations familiar to most SLPs and audiologists. Interprofessional collaborative practice addresses these potential failures and attempts to prevent them. At its center, interprofessional practice acknowledges the important role of information and best practices from each relevant discipline in coordinating and connecting with other clinicians to meet the patient’s needs respectfully and with appreciation. To the public, it might seem logical that the patient’s health care or educational team would be coordinated, connected, orchestrated, and aligned. There is an expectation that professionals talk to each other regularly, always put the client’s issues first, and typically come to an agreement about the desired approach to care or the expected outcome of treatment. The public might also assume professionals educate each other, know (and appreciate) each other’s roles, and are responsible in ensuring a common set of health, education, or communication goals. Appreciation, respect, cooperation among providers would seem to be reasonable expectations. As previously mentioned, these interprofessional competencies align with individual professional skills and knowledge. While these goals are desirable and highly logical, they are often not fully achieved in today’s health and education environments. Notably, SLPs and audiologists can affect the environment of care beyond their own practice. The client benefits in many positive ways when their SLP or audiologist is fully engaged with other team members. Despite the aforementioned desired goals and perspectives, errors do occur. Understanding the types of errors and their associated consequences helps to prevent them. Anticipation of the likelihood of errors is a critical feature of effective clinical reasoning. Table 19–1 provides examples of common technical and communication errors and potential interprofessional solutions.

For purposes of this discussion, technical errors refer to errors carried out or observed by a professional that are tied to a mistake in judgment, inferior competence, or poor supervision. Communication errors are errors that occur among members of the team of providers caring for the client or between providers and the client/family. Fortunately, the possible risks, errors, and complications as a result of poor care by specialists in communication disorders are limited and usually not life threatening. While a small number of common procedures that are invasive (e.g., intraoperative monitoring, management of selected swallowing and voice issues) can produce serious complications when managed poorly, the consequences of errors in our discipline produce more long-term, insidious, and chronic challenges. Regardless of whether these errors are life threatening, their impact is significant in time, cost, quality of service, and communication. Many times, mistakes made by audiologists and SLPs are not uncovered until later in the trajectory of care. Delays in discovery of clinical errors in audiology or SLP practices do not reduce their significance or their impact on quality of life. On a more routine basis, colleagues in medicine, nursing, and pharmacy engage in procedures and decisions that contain greater risk and potentially more imminently dangerous outcomes than SLPs and audiologists do. Appreciation for this risk and for insight into the varied approaches and types of decisions being made can be helpful in building relationships with these providers. At the same time, insightful feedback about their patients, especially regarding any untoward consequences being observed, is usually greatly appreciated and can build trust and respect. Understanding and prioritizing the collaborative context in the client interaction is essential interprofessionalism. Helping other professionals understand and appreciate the patient’s communication, hearing, and swallowing needs provides an important foundation. Ensuring that practice is ethical, errors are avoided, and the patient’s needs are always at the center of the work contributes to quality care and to the effectiveness and excellence of the team. It is worth noting that there is no comprehensive, well-documented taxonomy of errors related to service delivery in speech, language, and hearing settings. When such a listing becomes available, the opportunity to understand and appreciate the impact of such errors will become useful in educating SLPs and audiologists. This has proven useful in other health fields and allowed for improved outcomes and quality (Clark et al., 2018; Cullen et al., 2010; Mu et al., 2006; Scheirton et al., 2007). In the shorter term, reliance on practice guidelines, clinical experience and risk mitigation approaches used by other professionals are necessary steps.

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Table 19–1.  Summary of Common Errors in Health Care and Education Settings: CSD Perspective Example

Description/Effect

Potential Solutions Informed by Interprofessional Practice

Technical Errors Misdiagnosis

Mislabeling of a condition; can lead to wrong treatment by another team member

When in doubt, get supervision and advice, and always use best evidence. Confirm likelihood of diagnosis using information from your own background but also from other team members.

Medication error

Client receives wrong medication or wrong dose; can cause serious risks or failure to improve

Ensure that patient and all providers understand; double check all medications; note any unexpected reactions or behaviors. When in doubt, speak up/ask. Circle back to team members when there is a question.

Child placed in wrong educational environment

Child fails to benefit from educational services being provided

Observation of progress and frequent reassessment; input from all team members including parent and child. When in doubt, speak up.

Preventable injuries in an elderly person

Patient falls or is otherwise injured

For high-risk persons, ensure all safety precautions are in place; involve appropriate professionals from other disciplines. Learn how to safely move patients. Know safety precautions made by others. When in doubt, ask.

Clinical competency errors

Errors in clinician judgment or skill cause unnecessary harm or inconvenience

Ensure supervision at appropriate level for all providers, but especially those who are early in their careers; provide processes for review and feedback with difficult or challenging cases; always use available evidence; provide a practice environment that encourages questions and feedback; use best practice resources and guidelines and document their use. Acknowledge and learn from errors.

Communication Errors Misunderstanding among providers

Providers fail to implement necessary actions to effect benefit

Avoid and challenge any assumptions by other providers that suggest misunderstanding; speak up with questions or clarifications as necessary; consider meaningful and efficient approaches to communicate about important issues

Misunderstandings by client/family

Client/family fails to comply with recommendations

Provide frequent opportunities and time for client/ family to understand recommendations; contribute to reduced complexity of communication; use strategies for assuring understanding and monitor compliance and follow-up

Ignoring important information

Provider chooses to ignore information that may have been beneficial

Use listening and reading skills to ensure recommendations and clinical information from other members of the team are understood and appreciated. Ask questions to assist with understanding. Know the effects of medicines, treatments, therapies, or educational approaches that might affect cognitive, communication or swallowing behaviors.



CHAPTER 19   Overview of Interprofessional Practice and Interprofessional Education

Table 19–1.  continued Example

Description/Effect

Potential Solutions Informed by Interprofessional Practice

Documentation failures

Provider fails to document an important finding or recommendation; can lead to unnecessary problems or expenses

Use best practices in documentation; develop mastery of the recording approach being used, particularly with electronic systems in common use; review before submitting final record. Check back to ensure recommendations are considered or followed.

Failure to appreciate client’s health literacy levels

Provider assumes client/ family understanding of health or educational information

Assess client’s health literacy based on overall language abilities, use of standard and/or professional English or other language. Deliver information using tools to assist comprehension and compliance (e.g., interpreter; written, spoken, recorded materials; diagrams; visuals)

Contributing to conflict or confusion in any way

Provider allows conflict with another provider or the family to impact care

Ensure any disagreements, even healthy ones, are resolved prior to communicating with client/ family. Avoid criticizing or second guessing another professional. When information seems confusing or conflicting, check in with other providers.

Interprofessional Education IPE occurs when “students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes” (WHO, 2010). This definition is now the goal for those who teach and supervise students in their graduate education programs. The learner focus of IPE differentiates it from the professional practice focus of IPCP. A supposition has been made that if students begin to learn together early in their professional formation, they may find it easier to practice interprofessionally as they enter their field. Interestingly, professional associations, academic institutions, and funders have gravitated to this approach in great numbers. The American Speech-LanguageHearing Association (ASHA) and the Council of Academic Programs in Communication Sciences and Disorders (CAPCSD) have taken a leadership role in the discipline of CSD. The ASHA website (http://www​ .asha.org) includes extensive resources providing basic information, ideas for infusion of IPE into the curriculum, videos, and links to other relevant sites. An ebook developed by ASHA Special Interest Groups (Johnson, 2016) provides a comprehensive overview of IPE and IPP in CSD and highlights several examples for educators and practitioners to consider. CAPCSD annual meetings regularly offer programming related to IPE, and the same organization offers extensive online continuing education. A special issue of Seminars in Speech-

Language Pathology (Johnson & Portney, 2017) included articles on a variety of topics related to interprofessionalism in CSD. Finally, the 2020 Council on Academic Accreditation (CAA) Standards encourages interprofessional education within SLP and audiology graduate programs. The expanding interest in interprofessionalism clearly resonates in CSD. A wide variety of approaches exist for including interprofessional education in communication disorders curricula. These models have been used in many health professions and the previously cited journals are filled with examples of a variety of novel approaches. Examples include shared practicum experiences with other professions, integration of core learning experiences within multiprofessional schools and colleges, short-term or intensive learning experiences, simulation exercises, and team- or problem-based learning activities within the classroom. New approaches are emerging that address the obvious challenges of time and place by instituting digital IPE opportunities. One of the obvious side benefits of these innovations in education has been the introduction of new active learning pedagogies in all health fields, including CSD. Table 19–2 provides a few examples of some of these new learning approaches that have been reported in the CSD literature. To support these innovative learning approaches, a wide variety of faculty development activities is being provided for instructors. Also, new approaches to assessment are being developed to determine the effectiveness of both teaching and learning. Finally, there is a growing

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Table 19–2. Examples of Reported Interprofessional Education Activities That Have Included Students From SLP and Audiology Topic

Brief Description

Author (References)

Shared media

Using popular media (e.g., films, books) to trigger a discussion with an interprofessional group about implications on care, roles, and communication

Doherty et al., 2018

IPE simulations

Using predeveloped scenarios and/ or standardized patient actors to elicit interprofessional discussions and decisions

Palaganas et al., 2014; Decker et al., 2015; Potter & Allen, 2013

Community service learning

Using joint needs of a community to engage learners in a problem-solving or hands-on activity

Bridges et al., 2010

Shared practicum — IPE focus

Using a “real” patient/client care environment to practice interprofessional skills

Palaganas et al., 2014; Hoover et al., 2017; Ker et al., 2003

Immersive day-long experience

Using a complex simulated experience to integrate clinical skills and IP skills (e.g., natural disaster)

Hall et al., 2011

Hackathon

Using opportunities for students to come together in a time-limited competitive experience to produce solutions to a health issue

Aungst, 2015

Digital IPE

Using technology and a common platform to allow students to interact regarding a clinical problem

Cain & Chretien, 2013; Carbonaro et al., 2008

Comprehensive approaches

Approaches that use a systematic approach to immersing IPE goals and activities across curricula and professions

Portney et al., 2017; Cahn et al., 2018; Knab et al., 2017

archive of scholarly work, allowing for critical evaluation of interprofessional activities. A recent and enlightening membership survey by ASHA highlights the educational needs of current ASHA members. The most recent Interprofessional Practice Survey (ASHA, 2021) provided important information regarding the penetration of interprofessionalism into practice for audiologists and SLPs across settings. In this survey, 73% of audiologists and 91% of SLPs reported engaging in interprofessional practice. Most respondents indicated that they were satisfied with the level of collaboration in their clinical setting, while about half indicated that they felt prepared to participate in interprofessional teams. As the trend toward acknowledging the impact of interprofessionalism on quality care is relatively new in the broad health care discussion, it is important to acknowledge resources developed both within CSD and

beyond. The opportunity to explore these resources presents a rich opportunity for those who wish to advance their understanding of interprofessionalism. Clinicians entering the field will benefit from the opportunity to become familiar with interprofessional collaborative practice. This will allow them to be prepared for the language and behaviors associated with interprofessional practice and in some cases to teach others. It is important to acknowledge that the purpose of IPE is to prepare students to work in clinical settings with colleagues from other professions, to place the client’s needs at the center of this work, and to improve outcomes (e.g., cost, efficiency, quality, satisfaction) in the health system. Again, these issues affect SLPs and audiologists in schools and health settings alike. It is not possible to list all the interactions for every clinical setting, but consider the SLP or audiologist in the schools. Engaging administrators, special and regu-



CHAPTER 19   Overview of Interprofessional Practice and Interprofessional Education

lar educators, psychologists and social workers, families, and other colleagues is essential to service delivery for most children on the caseload. Similarly, in a health care setting, interactions with both primary and specialty physicians, nurses, and rehabilitation specialists are all important. Working to appreciate the collective and unique goals with and for the client, determining obstacles to achieve outcomes, and addressing challenges are all parts of collaborative team practice.

National and International Organizations and Resources for IPE and IPCP As noted above, a wide variety of resources are available to support interprofessional practice among health professions. For the reader interested in learning more and in accessing resources, some brief descriptions follow.

World Health Organization The WHO (www.who.org) is a leader in the discussion of interprofessionalism. While a particular focus on global health has been at the center of this discussion (Gilbert et al., 2011), the model and principles described can be useful to all health providers. The WHO (2010) further explicates the details of its framework and is particularly useful in understanding the ways best practices can come to scale nationally and internationally.

Interprofessional Education Collaborative Interprofessional Education Collaborative (IPEC; www​ .ipecollaborative.org) was formed in 2009 when six educational associations in medicine, nursing, pharmacy, dentistry, and public health came together with the idea of collaborating across their varied education models. The focus was to improve and enhance teambased care of patients and improve health outcomes for populations. In 2019, IPEC membership was expanded to include 14 additional education members including ASHA. IPEC sponsors webinars and conferences to advance IPE.

American Interprofessional Health Collaborative American Interprofessional Health Collaborative (AIHC; www.aihc.org) is an individual membership organization focused on broad and boundary-spanning discussion of educational issues across professions. AIHC offers webinars and partners the with Canadian Interprofessional

Health Collaborative to jointly offer Collaborating Across Borders conferences biennially.

National Center for Interprofessional Practice and Education The National Center for Interprofessional Practice and Education (NEXUS; www.nexusipe.org) is the most comprehensive resource for both educators and practitioners. Resources include a large national conference (summit) held annually and a number of smaller conferences. NEXUS also sponsors webinars and publications to guide practice and education. It has a well-managed resource center that provides links to publications on a variety of related topics. The NEXUS platform includes an impressive learning system that provides extensive modules, webinars, and training materials. Faculty members and those interested in research in IPE/IPP may want to explore the extensive list of measurement tools provided. Additionally, several journals exist that are specifically dedicated to reporting research and scholarly discussion around IPCP and IPE. Examples of some of these journals include The Journal of Interprofessional Care, The Journal of Research in Interprofessional Practice in Practice and Education, The Journal of Interprofessional Education and Practice, and Health and Interprofessional Practice. In addition, several health profession-specific journals invite and publish articles on IPE and IPC. It is not uncommon to find audiologists and SLPs (and people with communication and swallowing disorders) represented in articles in these publications. Finally, two sources that focus on education in CSD include interprofessionally focused materials. Perspectives of the ASHA Special Interest Groups produces peer-reviewed articles related to the various specialty interests with the discipline. The April 2019 issue produced three articles (Hall & Gilliland, 2019; Ludwig & Kerins, 2019; Namazi et al., 2019). A relatively new journal in our field, Teaching and Learning in Communication Sciences and Disorders, also includes occasional papers on interprofessional activities involved in the education process. As both practice-focused and educational scholarship emerges in CSD, it is likely that important new resources will be forthcoming.

Summary The topics of interprofessional education and practice are emerging as important issues for all professionals in speech-language pathology and audiology. In this chapter, we have attempted to highlight some of the important features of IPE and IPCP. Additional resources and examples have been shared for readers who wish to pursue additional information on this topic.

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References American Speech-Language-Hearing Association. (2021). Interprofessional Practice Survey results. http://www.asha.org/uploadedfiles/2021-Inter​ professional-Practice-Survey-Results.pdf Aungst, T. D. (2015). Using a hackathon for interprofessional health education opportunities. Journal of Medical Systems, 3(5), 60. https://doi.org/10.1007/ s10916-015-0247-x Bridges, D. R., Abel, M. S., Carlson, J., & Tomkowiak, J. (2010). Service learning in interprofessional education: A case study. Journal of Physical Therapy Education, 24(1), 44.

interprofessional education: Interprofessional day, the four-year experience at the Medical University of South Carolina. Journal of Research in Interprofessional Practice and Education, 2(1). https://doi.org/​ 10.22230/jripe.2011v2n1a42 Hall, K., & Gilliland, H. (2019). Changing the long-term care culture through interprofessional practice: A speech-language pathologist-led initiative. Perspectives of the ASHA Special Interest Groups, 4, 313–321. https://doi.org/10.1044/2019​ _PERS-SIG2-2018-0005 Health Professions Accreditors Collaborative. (2019). Guidance on developing quality interprofessional education for the health professions.

Cahn, P. S., Tuck, I., Knab, M. S., Doherty, R. F., Portney, L. G., & Johnson, A. F. (2018). Competent in any context: An integrated model of interprofessional education. Journal of Interprofessional Care, 32(6), 782–785. https://doi.org/10.10​ 80/13561820.2018.1500454

Hoover, E. L., Caplan, D. L., Waters, G. S., & Carney, A. Communication and quality of life outcomes from an interprofessional intensive, comprehensive, aphasia program (ICAP). Topics in Stroke Rehabilitation, 24(2), 82–90. https://doi.org/10.1080/1074 9357.2016.1207147

Cain, J., & Chretien, K. (2013). Exploring social media’s potential in interprofessional education. Journal of Research in Interprofessional Practice and Education, 3(2). https://doi.org/10.22230/ jripe.2013v3n2a110

Johnson, A. F., & Portney, L. (2017). Interprofessional Education Issue. Seminars in Speech and Language, 38(05), 333–334. https://doi.org/10.1055/s-0037-​ 1607346

Carbonaro, M., King, S., Taylor, E., Satzinger, F., Snart, F., & Drummond, J. (2008). Integration of e-learning technologies in an interprofessional health science course. Medical Teacher, 30(1), 25–33. https://doi.org/10.1080/01421590701753450 Decker, S. I., Anderson, M., Boese, T., Epps, C., McCarthey, J., Motola, I., . . . Scolaro, K. (2015). Standards of best practice: Simulation standard VIII: Simulation-enhanced interprofessional education (Sim-IPE). Clinical Simulation in Nursing, 11(6), 293–297. https://doi.org/10.1016/j.ecns​ .2015.03.010 Doherty, R. F., Knab, M., & Cahn, P. S. (2018). Getting on the same page: An interprofessional common reading program as foundation for patient-centered care. Journal of Interprofessional Care, 32(4), 444–451. https://doi.org/10.1080/135 61820.2018.1433135 Gilbert, J. H. V., Yan, J., & Hoffman, S. J. (2011). Interprofessional education and collaborative practice. Journal of Allied Health, 39 (3, Pt. 2) (Special Issue). Hall, P. D., Zoller, J. S., West, V. T., Lancaster, C. L., & Blue, A. V. (2011). A novel approach to

Ker, J., Mole, L., & Bradley, P. (2003). Early introduction to interprofessional learning: A simulated ward environment. Medical Education, 37(3), 248–255. https://doi.org/10.1046/j.1365-2923.2003.01439.x Knab, M., Inzana, R. S., Cahn, P. S., & Reidy, P. A. (2017). Preparing future health professionals for interprofessional collaborative practice part 2: The student experience. Seminars in Speech and Language, 38(5), 342–349. https://doi.org/10.1055/s-0037-​ 1607069 Ludwig, D. A., & Kerins, M. R. (2019). Interprofessional education: Application of interprofessional education collaborative core competencies to school settings. Perspectives of the ASHA Special Interest Groups, 4, 269–274. https://doi.org/​ 10.1044/2018_PERS-SIG2-2018-0009 Mu, K., Lohman, H., & Scheirton, L. (2006). Occupational therapy practice errors in physical rehabilitation and geriatrics settings: A national survey study. American Journal of Occupational Therapy, 60(3), 288–297. Namazi, M., Holan, G. P., McKenzie, S. E., Anuforo, P. O., Pax, J. A., Knis-Matthews, L., & Marks, D. R. (2019). An exploratory survey study of grand rounds as an interprofessional education tool for



CHAPTER 19   Overview of Interprofessional Practice and Interprofessional Education

graduate students in the health professions. Perspectives of the ASHA Special Interest Groups, 4(2), 299–306. https://doi.org/10.1044/2019_ PERS-SIG2-2018-0007 Palaganas, J. C., Epps, C., & Raemer, D. B. (2014). A history of simulation-enhanced interprofessional education. Journal of Interprofessional Care, 28(2), 110–115. https://doi.org/10.3109/13561820.2013​ .869198 Portney, L., Johnson, A. F., & Knab, M. (2017). Preparing future health professionals for interprofessional collaborative practice part 1: The context

for learning. Seminars in Speech and Language, 38(5), 335–341. https://doi.org/10.1055/s-0037-​ 1607344 Scheirton, L. S., Mu, K., Lohman, H., & Cochran, T. M. (2007). Error and patient safety: Ethical analysis of cases in occupational and physical therapy practice. Medicine, Health Care, and Philosophy, 10(3), 301–311. (17310308) World Health Organization. (2010). Framework for action on interprofessional education and collaborative practice.

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20 Child Abuse and Elder Mistreatment/Abuse Carolyn Wiles Higdon

Introduction Your career as an audiologist or speech-language pathologist (SLP) may involve situations when you suspect that a child or elder client is a victim of abuse or neglect. Child abuse and neglect are defined in federal and state laws; each state may define child abuse and neglect in both civil and criminal statutes. Federal legislation lays the groundwork for state laws by identifying a minimum set of acts of behaviors that define child abuse and neglect. The federal Child Abuse Prevention and Treatment Act (CAPTA) (2018) defines child abuse and neglect as, at minimum, “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act which presents an imminent risk of serious harm.” CAPTA was most recently amended by the Victims of Child Abuse Act Reauthorization Act of 2018 (2019) This law reauthorizes section 106(b)(2) (B)(vii) of CAPTA to provide immunity from civil and criminal liability under federal, state, and local law for people who make good-faith child abuse or neglect reports or who provide information or assistance, including medical evaluations or consultations, in connection with a report, investigation, or legal intervention pursuant to a good-faith report of child abuse or neglect. CAPTA provides federal funding and guidance to states in support of prevention, assessment, investigation, prosecution, and treatment and provides grants to public agencies and nonprofit organizations, including Indigenous tribes and tribal organizations, for demonstration programs and projects. CAPTA identifies the federal role in supporting research, evaluation, technical assistance, and data collection; establishes the Office on Child Abuse and Neglect; and establishes a clearinghouse of information relating to child abuse and neglect. CAPTA confirms a federal definition of child abuse and neglect. In 2015, the federal definitions of “child abuse and neglect” and “sexual abuse” were expanded by the Justice for Victims of Trafficking Act (2015) to include a child who is identified as a victim of sex trafficking or severe forms of trafficking in persons (https://www.congress.gov/ bill/114th-congress/senate-bill/178). Additional amendments were made by the Comprehensive Addiction and Recovery Act of 2016 (2016)Title V, section 503 of the act modified the CAPTA state plan requirement for infants identified 385



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as being affected by substance use withdrawal symptoms or fetal alcohol spectrum disorders by adding criteria to state plans to ensure the safety and well-being of infants following their release from the care of health care providers, to address the health and substance use disorder treatment needs of the infant and affected family or caregiver, and to develop the plans of safe care for infants affected by all substance use (not just the use of illegal substances, as was the requirement prior to this change). As stated on the Child Welfare website (https://www​ .childwelfare.gov), child protection laws refer to cases of harm to a child caused by parents and other caregivers and generally do not include harm from other people. Some states include a child witnessing domestic violence as a form or neglect or abuse. Depending on the state in which you are employed, you will have either a professional and/or a mandated obligation to report incidences of suspected abuse. This chapter presents broad definitions and characteristics of various types of child abuse, possible causes for such mistreatment, the scope of the problem, and suggestions for what to do when indicators may be present. Similarly, various types of elder abuse and neglect are discussed. The information is intended to supplement and not replace individual state definitions, procedures, or requirements for coursework or certification on these topics. All 50 states, the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands provide civil definitions of child abuse and neglect in statute. Abuse is recognized by different states as physical abuse, neglect, sexual abuse, emotional abuse, parental substance use, and/or abandonment. The Child Welfare Information Gateway (2019) provides child abuse and neglect statute information for each state. The National Child Abuse and Neglect Data System (NCANDS) is a federal effort to organize annual data on child abuse and neglect. This national data collection and analysis effort was created as part of the CAPTA amendments, with the data submitted voluntarily by the 50 states, District of Columbia, and Commonwealth of Puerto Rico to the Children’s Bureau in the Administration on Children, Youth and Families, Administration for Children and Families of the U.S. Department of Health and Human Services (HHS).

Child Abuse and Neglect: How to Identify Clinicians should be able to identify the signs and symptoms of child abuse and neglect. In addition, you

need to be aware of the potential causes and factors that put a child at risk for these forms of maltreatment. Finally, you need to know who might act as an abuser and how common child abuse and neglect are in our society. Broadly defined, child abuse occurs when children under 18 years of age are physically, emotionally, or sexually harmed or neglected by a parent or other person legally responsible for their care. This may involve physical injury by other than accidental means, sexual offense against the child, or allowing the child to engage in such acts. In 18 states, the crime of human trafficking, including labor trafficking, involuntary servitude, or trafficking of minors, is included in the definition of child abuse. Physical abuse involves the use of force, such as striking, beating, pushing, shoving, shaking, slapping, kicking, pinching, or burning, that results in injury, pain, or impairment. The abuse may or may not be executed with an object. The unjustifiable use of drugs and physical restraints may also be considered physical abuse. Child abuse may also include other forms of neglect such as malnutrition, dehydration, psychological mistreatment, and failure to treat mental or physical ills that may impair growth and development (National Child Abuse and Neglect Data System, 2023). Emotional abuse, also called mental cruelty, emotional neglect, or emotional maltreatment, occurs when there is some type of nonphysical action toward a child that results in psychological stress and may lead to physical or psychological illness. Emotional abuse may entail threatening a child verbally or nonverbally, terrorizing, isolating or placing the child in a closed confinement, withholding nurturance and affection, and knowingly permitting the child’s maladaptive behavior. Parental substance abuse is an element of the definition of child abuse or neglect in some states. The following issues can be included for consideration: prenatal exposure of a child to harm due to the mother’s use of an illegal drug or other substance, manufacture of a controlled substance in the presence of a child or on the premises occupied by a child, allowing a child to be present where the chemicals or equipment for the manufacture of controlled substances are used or stored, selling/distributing/giving drugs or alcohol to a child, and use of a controlled substance by a caregiver that impairs the caregiver’s ability to adequately care for the child. Child Protective Services (CPS) will decide if the definition of abused or neglected child is met, and then, by federal law, must have provisions for a plan of safe care to address health and substance use disorder treatment needs for the child as well as for the affected parent or caregiver.



CHAPTER 20   Child Abuse and Elder Mistreatment/Abuse

Approximately 38 states and American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the Virgin Islands also include acts or circumstances that threaten the child with harm or create a substantial risk of harm to the child’s health or welfare (Child Welfare Information Gateway, 2016). The word “approximately” is used because state statutes change. As of April 2016, the states are Alabama, Alaska, Arkansas, California, Colorado, Florida, Hawaii, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, West Virginia, Wisconsin, and Wyoming. Seven states include human trafficking, labor trafficking, involuntary servitude, or trafficking of minors in the definition of child abuse: Hawaii, Illinois, Indiana, Louisiana, Mississippi, North Carolina, and Utah. Abandonment is also considered a type of neglect in many of the states. It is considered abandonment of the child when the parent’s identity or whereabouts are not known, the child has been left by the parent in circumstances in which the child suffers serious harm, or the parent has failed to maintain contact with the child or to provide reasonable support for a specified period. Table 20–1 describes potential types and indicators of child abuse and neglect.

Maltreatment and Neglect Maltreatment occurs when children under 18 years of age are neglected or have serious physical injury inflicted on them by other than accidental means. The parent or other person legally responsible for care fails to provide a minimum degree of care and the child’s physical, mental, emotional, or educational well-being has been or is in danger of being impaired. Neglect is defined as the failure of a parent or other person with responsibility for the child to provide needed food, clothing, shelter, medical care, or supervision to the degree that the child’s health, safety, and wellbeing are threatened with harm. Many states include the failure to educate the child as required by law in the individual state’s definition of neglect. Also, failure to provide specialized medical treatment or mental health care needed by the child is considered neglect. In some states, medical neglect may include withholding of med-

ical treatment or nutrition from disabled children with life-threatening conditions. Neglect, in some states, can include failure to provide adequate supervision appropriate for the child’s age, mental ability, physical condition, the length of the caregiver’s absence, and the context of the child’s environment. According to the HHS (2023), neglect can be categorized as physical, medical, inadequate supervision, environmental, emotional, and educational. Specific examples of neglect include when a responsible adult has not provided a child with adequate nutrition, clothing, shelter, protection from safety hazards, personal hygiene, nurturing or affection, or education, although financially able to or offered means to do so. Neglect also occurs when the responsible adult has not provided the child with proper supervision or guardianship. This may occur when this individual inflicts or allows harm to be inflicted, places the child at risk of harm, uses excessive corporal punishment, or uses substances that impair self-control. A child who has been abandoned by their parents or other legally responsible person is also considered neglected. Emotional neglect occurs when there is a “state of substantially diminished psychological or intellectual functioning in relation to, but not limited to such factors as failure to thrive, control of aggression or self-destructive impulses, ability to think and reason, or acting out and misbehavior” (Center for Development of Human Services at Buffalo State College, n.d., p. 17). Such neglect may cause children to be permanently damaged or may be responsible for more deaths per year than abuse. Per the Child Welfare government website, approximately 25 states (Arkansas, Colorado, Connecticut, Delaware, Idaho, Indiana, Kentucky, Maine, Minnesota, Mississippi, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Pennsylvania, South Carolina, South Dakota, Utah, West Virginia, Wyoming), the District of Columbia, American Samoa, Puerto Rico, and the Virgin Islands include failure to educate the child as required by law in the definition of neglect (Child Welfare Information Gateway, 2019a). Ten states (Arkansas, Florida, Mississippi, Iowa, North Dakota, Ohio, Oklahoma, Tennessee, Texas, West Virginia) and American Samoa define medical neglect as failing to provide any special medical treatment or mental health care needed by the child. Four states (Indiana, Kansas, Minnesota, Montana) define medical neglect as the withholding of medical treatment or nutrition from disabled infants with life-threatening conditions.

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Table 20–1. Types and Potential Indicators of Child Abuse and Neglect Possible Signs of Physical Abuse

n

Poor peer relationships

n

Unexplained bruises or welts in different places, in clusters, in various stages of healing, and/or in shape of instrument used

n

Unwillingness to change clothes; example: changing into gym clothing during gym period

n

Unexplained burns

n

Unusually sophisticated sexual knowledge and behavior

n

Unexplained lacerations or abrasions

n

Depressed, apathetic

n

Unexplained skeletal injuries, such as bites, fracture, bald spots, detached retina

n Suicidal

n

Inappropriate clothing for weather to conceal injuries

n

Extremes in behavior — aggressive to withdrawn

n

Easily frightened or fearful — for example, of parents, adults, physical contact, going home, or when other children cry

n

Sexually aggressive

n

Regression to earlier developmental stages

Possible Signs of Emotional Maltreatment n

Failure to thrive in infancy

n

Poor appearance

n Self-destructive

n

Infantile or regressive behavior

n

Hurts others

n

Developmental lags

n

Poor social relationships — craves attention, poor relationships with peers, manipulates adults

n

Extremes in behavior

n

Poor self-concept

n

Depressed, apathetic

n

Reports fear of parents, injuries, noncredible reasons for injuries

n

Poor academic performance

n

Short attention span

Possible Signs of Neglect

n

Language delays

n

Hunger and malnutrition, begs for or steals food

n Runaway

n

Poor hygiene, lice, body odor

n

n

Inappropriate clothing for weather and context

n

Unattended physical problems or medical needs

n

Lack of supervision especially in dangerous activities or contexts

n

Constant fatigue

n

Developmental lags

n

Extremes in behavior

n Pregnancy

n

Depressed, apathetic

n

Report of abuse

n

Seeks attention or affection

n

Drop in academic performance

n

Truancy or delinquency

Truancy and or delinquency

Possible Signs of Sexual Abuse n

Difficulty walking

n

Abnormalities in genital/anal areas — itching, pain, swelling, bruises, frequent infections, discharge, poor sphincter control

n

Venereal disease

Continuum of Abuse and Neglect Victims in their first year of life tend to have the highest rate of abuse; overall, boys of all ages tend to account for fewer abuse cases than girls of all ages, and White children account for more reports and cases than individuals of Hispanic or African American heritage. However,

n Suicidal

these demographics are unique to the exact time the data are collected and can vary over time in each category. There are more children who suffer from neglect than from physical and sexual abuse. Abuse and neglect range in severity from mild to moderate to severe (HHS, 2023). Severity is determined by such factors as degree of harm or risk and the chronic-



CHAPTER 20   Child Abuse and Elder Mistreatment/Abuse

ity of the problem. Keep in mind that one occurrence of abuse or neglect may be serious and warrant identification and intervention. The professions of speechlanguage pathology and audiology have not adequately addressed and educated peers about abuse and neglect over the years. In addition, many times we make excuses for situations we observe or are made aware of rather than identifying and intervening. The standards of reporting call for a report to be made when an individual knows or has “reasonable cause to believe or suspect that a child has been subjected to abuse or neglect” (HHS, 2023). For example, in certain states, when a person suspects a child is the victim of human trafficking, an abuse that is receiving much visibility in the legal and child protection arenas recently, a report is required. Generally, a report must be made when an individual designated as a mandatory reporter, while working in a professional capacity, knows or has reasonable cause to believe or suspect a child has been subjected to abuse or neglect. Individuals designated as mandatory reporters typically have frequent contact with children as part of their professional duties.

Prevention of Abuse:  Causes and Risks Children’s exposure to trauma has both immediate and lifelong impacts on the physical and mental health and cognitive functioning of those children. When trauma, and its impact on a child’s brain and body, goes unaddressed, the child’s life course is often altered, resulting in serious behavioral and emotional problems, cognitive difficulties, poor performance in school, and instability in life as both a child and adult. Preventing trauma, recognizing and properly responding to trauma when it occurs, building resilience in children and adults to manage trauma, and providing culturally competent treatment services to help individuals overcome trauma have all been themes in publications and grants to stop the increasing amount of child abuse and neglect. Informed care and practice, including the development of individual and family resilience, is a central theme in its support for families and for all family members — children, parents, and seniors. Trauma-informed principles support trauma-informed direct services and trauma-informed community networks. There are numerous, interrelated possible causes of and risk factors for child abuse and neglect. Table 20–2 lists four major categories, including parent/caretaker characteristics, parent–child relationship characteristics, child characteristics, and environmental factors. It should be noted that these are potential risk factors and that the presence of any one is not an absolute predictor of child abuse or neglect. Further, it is likely that these

factors are not mutually exclusive and do not all arise within the parent/caregiver. Finally, causes and risk factors must be considered within a framework of a cultural background of child-rearing practices and economic and political values. The origins of abuse and neglect should also be considered from a socioecological perspective. For example, poverty may contribute to a parent abusing a child, and thus, intervention would need to focus on both the parent and remediation of poverty (HHS, 2023). Several of these etiological factors bear more discussion. First, 40% of physical abuse of children is caused by people who themselves were abused as children (HHS, 2023). These adults were inadequately parented during their own childhoods and have carried over this negative child-rearing style to their own interactions with children. Second, younger parents, particularly teenagers, appear more at risk for committing child abuse. Teenagers may be emotionally immature to take on the responsibilities of parenting and have limited parenting, coping, and homemaking skills. Teen mothers may be at greater risk for not completing their education, have limited work options, and face financial stress (HHS, 2023). Third, substance abuse contributes to drug-exposed newborns and inappropriate parenting styles. Substance abuse frequently co-occurs with other problems. For example, young parents may also be involved with substance abuse. Substance abuse is also a major contributor to criminal activity. Fourth, parents under stress because of unmet internal needs, lack of support, unemployment, financial or familial crises, and their own health and emotional problems are more vulnerable to committing child abuse and neglecting their children. Fifth, children who have challenging needs may be more susceptible to abuse and neglect. Children with myriad chronic needs may stress parents/caregivers beyond their limits, particularly when parents or caregivers have limited education, support, and respite and may face financial concerns. Parents may not know how to deal with challenging behavioral characteristics such as noncompliance and may resort to inappropriate measures to gain control. Children with communication disabilities pose double challenges. Parents may become frustrated by lack of meaningful intelligible communication. Further, children with communication problems may not be able to report their own abuse to parents or other caregivers/educators. Statistics vary on the prevalence of child abuse among children with disabilities, but evidence indicates it may be at least 1.8 times greater than for children without disabilities (Hibbard & Desch, 2007; Sullivan & Knutson, 2000). As a comparison to the data reported in 2000, in

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Table 20–2.  Possible Causes of Risks for Child Abuse and Neglect Parent/Caretaker Characteristics

n

Twins or multiple births

n

Personal history of abuse

n

Premature baby

n

History of family violence

n

Baby born during time of family trauma

n

Single parenthood or absence of parent

n

n

Social isolation and lack of emotional support

Baby or young child who cries excessively (colicky), has feeding difficulties, resists being held

n

Parental/caregiver immaturity or lack of parenting knowledge

n Stepchild n

Child of unplanned or unwanted pregnancy

n

Marital problems of parents

n

n

Physical or mental health problems

Adolescence, teenager striving for independence, teenager’s dependency on teenage culture

n

Life crises such as financial problems, unemployment or underemployment, death of spouse

n

Substance abuse

n

Adolescent parents

n

Lack of knowledge in areas of housekeeping, nutrition, and medical care

n

Expectation that child acts like an adult (e.g., leaves young child alone or to care for other younger children)

n

Has low frustration tolerance and poor judgement; cannot delay gratification

n

Lack of motivation to learn productive childraising practices

n

Does not believe there is a problem, is unconcerned, or refuses to cooperate

Child Characteristics n

Infant/child with special needs (e.g., mental retardation, health problems, sensory impairments, learning difficulties, communication difficulties)

2012 more than 3.8 million children were the subjects of at least one report. This is a 3.5% increase from 2008, when an estimated 3.1 million children received a CPS investigation. There is some indication that children with behavior disorders are at greater risk for physical abuse and that those with speech/language disorders are at risk for neglect (Sullivan & Knutson, 2000). Finally, as noted earlier in this chapter, very young children are at the highest risk for abuse and death from abuse. According to the National Center on Child Abuse and Neglect, children less than 1 year old are more likely to be neglected than at any other time of their lives (HHS, 2023). The demands of infant care may tax parents or caregivers, particularly those with limited parenting skills, support, or patience.

Parent–Child Relationship Characteristics n

Parent’s unrealistic expectations for development, achievement, or responsibility

n

Lack of nurturing child-rearing skills

n

Use of violence as an accepted means of personal interaction

n

Inadequate bonding between parent and child

n

Delay or failure to seek needed health care

n

Perception that child is evil or different

Environmental Factors n

Lack of social support

n Homelessness n

Poor or inadequate housing 

n

Large family in crowded housing

n Poverty n

Withdrawal of governmental social, housing, and economic support

Child fatalities are the most tragic outcome of neglect and abuse. The HHS (2018) reports the following data: The national rate of child fatalities was 2.20 deaths per 100,000 children. Nearly three-quarters (70.3%) of all child fatalities were younger than 3 years of age. Boys had a higher child fatality rate than girls at 2.54 boys per 100,000 boys in the population. Girls died of abuse and neglect at a rate of 1.94 per 100,000 girls in the population. Nearly 90% (85.5%) of child fatalities were comprised of [sic] White (38.3%), African-Americans (31.9%) and Hispanic (15.3%) victims. Four-fifths (80%) of child fatalities were caused by one or both parents.



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Trauma-informed care is a critical component of any CPS program, from prevention through intervention. Understanding the ways in which trauma can impact the condition and behavior of children and adults is critical to successful investigations, service provision, and the ultimate resolution of the cases. Trauma-informed principles also apply to the support of CPS workers, who regularly confront cases of child abuse or neglect in which the damage done to the children involved is traumatizing to discover and confront. CPS workers often deal with parents who are angry, despairing, and threatening as the workers try to investigate, protect these children, and help these families. In addition, agencies need to recognize that internal agency issues such as lack of resources and bad management also contribute to staff trauma. Munchausen by Proxy.  Munchausen syndrome is a disorder in which an individual deliberately creates fictitious physical and/or mental health symptoms to gain attention and sympathy, particularly from medical personnel. When this pattern of exaggeration, fabrication, and inducement is applied to the symptoms of others (usually children), it is called Munchausen by Proxy (MBP). This is a recognized type of maltreatment that may involve physical, sexual, or emotional abuse; neglect; or a combination (Lasher, 2004). MBP perpetrators are usually mothers who appear to be good caretakers, may have extensive health care knowledge and experience, and are convincing in their concerns. Some may change health care providers frequently to avoid suspicion and subject their child to unneeded medical tests and procedures. Some may inflict injury to magnify the symptomatology. Most will deny the maltreatment even when confronted with evidence. Possible indicators of MBP include some combination of the following: frequent emergency room admissions, recurrent episodes of the same complaint, treatment that does not produce expected results, a pattern of the problem arising in the perpetrator’s presence and disappearing in his or her absence, and recurrences when the child goes home after treatment. The parent exhibits characteristics commensurate with the pattern described (Lasher, 2004). Confirmation of this diagnosis is difficult but necessary because of the potential for serious harm to a child. SLPs and audiologists who work in medical settings should be alert to this category of child abuse.

Who Is an Abuser? Child abuse occurs when a child under the age of 18 is mistreated or neglected by an adult, resulting in harm, the potential for harm, or the threat of imminent harm.

The adult may be a relative, caregiver, stepparent, religious figure, coach, or babysitter, although most perpetrators are parents of the child. Child abuse or neglect occurs at the rate of 8.9 per 1000 children and is considered an adverse childhood experience that can have longterm impacts on an individual’s health and well-being. Child abuse can occur in a single instance or in several instances, but falls within four main categories: emotional abuse, sexual abuse, physical abuse, and neglect. Child abuse spans all ethnic, social, economic, and racial lines. Abusers may be parents, guardians, relatives, or friends. Eighty percent of abusers are parents, and women (53.8%) are the majority of abusers (HHS, 2023). In 2009, a typical profile of an abuser was a young adult in their mid-20s, with limited education, living at or below the poverty level, and depressed. In 2012, the data remained fairly consistent, although our measures continued to be more refined if reporting is reliable. Fifty states reported unique perpetrators, meaning data were tallied only once regardless of the number of times the perpetrator was identified. Four-fifths of the perpetrators were between the ages of 18 and 44 years. More than half were women (53.5%), 45.3% were men, and 1.1 % were of an unknown sex. Four-fifths of the perpetrators were parents (80.3%) and of those, 88.5% were the biological parents (HHS, 2018). Nearly all child abusers were inadequately parented in their own childhood, and most were abused as children (Andrews University, 1999). It should be noted that child-on-child abuse also occurs, such as adolescent-on-child sexual abuse, sibling incest, and cousin-on-cousin incest.

Types of Abuse and Neglect There are different types of child abuse and neglect, each with unique characteristics. Some children have multiple types of maltreatment, which together may affect them to a greater degree (Child Welfare Information Gateway, 2019b). The types and examples are explained through this section. Emotional Abuse. Psychological, verbal abuse, or emotional abuse is persistent, nonphysical abuse that makes a child believe they are unwanted, unloved, worthless, or only valuable in meeting their perpetrator’s needs. Words and actions manipulate or control a child, causing emotional harm that may result in low selfesteem, hostility, anxiety, depression, or delinquency. Types of emotional abuse may be difficult to recognize but can include: n

Name calling or criticizing

n

Setting unreasonable expectations

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n

Threatening or terrorizing

n

Tying a child up

n

Ignoring boundaries

n

n

Demeaning or belittling

Depriving a child of air or holding them underwater

n

Bullying or cyberbullying

n

Dismissing or invalidating the child and their feelings

n

Degrading or objectifying the child

n

Isolating the child

Sexual Abuse.  By law, children cannot consent to sexual acts of any kind, and any sexual activity that occurs between an adult and a minor is considered sexual abuse. In more than 90% of child abuse cases, the child or family knows the perpetrator. A perpetrator doesn’t have to touch a child to abuse them sexually. Types of sexual abuse include: n

An adult exposing their genitalia to a child

n Molestation n

Sexual intercourse of any kind, including vaginal, oral, or anal

n

Sexual assault incidents involving an object

n

Masturbation in the presence of a child

n

Phone calls, text messages, or other interactions that are sexual in nature

n

Forcing a child to perform sexual acts

n

Producing, owning, or distributing pornographic images or videos of children

n

Sex trafficking

n

Female genital mutilation

n Incest

Physical Abuse.  Any act of harm committed against a child that results in injury is physical abuse, even if it is unintentional. This type of abuse can cause physical and mental health problems in adulthood and is a common cause of child morbidity and mortality. Types of physical abuse include: n

Severely shaking a baby, also known as shaken baby syndrome

n

Hitting or beating a child with a fist or an object

n

Burning the child with hot water, a cigarette, or an iron

n Kicking

A harmed child may exhibit physical signs, such as bruises, burns, scarring, hair loss, bone fractures, or other injuries. They may hide certain body parts with clothing, or they may blame the injury on a sibling. Their explanation of the injury may change or may not match the injury itself. They may also delay seeking medical care, change primary care providers frequently, or have a long history of visiting the emergency department. Neglect.  Neglect occurs in 61% of child abuse cases. It is the most common form of child maltreatment in the United States. Child neglect occurs when a parent or caregiver fails to provide food, shelter, clothing, medical care, or supervision to maintain or protect the child’s health, safety, and well-being, resulting in harm or the threat of harm. Types of neglect include: n

Failing to give a child medical care or treatment when needed

n

Denying a child food, clothing, or shelter

n

Abandoning or locking a child in a room for hours on end

n

Leaving a young child at home alone without a caregiver or with neglectful caregivers

n

Exposing a child to domestic abuse

n

Failing to enroll a child in school or denying them educational access

Unfortunately, neglect can occur with or without intention. A parent or caregiver may not have the financial resources to buy food, maintain shelter, or clothe their children. Still, this maltreatment can result in developmental problems, cognitive impairments, and emotional, social, and behavioral problems. Neglect can lead to sexual promiscuity, substance abuse, visual hallucinations, cognitive delays, antisocial personality disorder, dysthymia, and other mental health conditions (Mather & Kilduff, 2020).

Recognizing Signs of Child Abuse In 2019, CPS received 4.4 million referrals for the alleged mistreatment of 7.9 million children. Most reports come from professionals, such as education workers, legal and law enforcement workers, medical personnel, and social services staff members. However, friends, neighbors, and relatives reported 15.7% of the time (Jackson & Hafemeister, 2016).



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Every child is susceptible to child abuse and, unfortunately, if a child is experiencing one form of abuse, they may be experiencing another. If the child is exhibiting the following signs and symptoms, they may be experiencing some form of abuse: n

Constantly hungry or exhausted

n

Showing signs of deteriorating health or mental health

n

Missing school repeatedly

n

Dressing in dirty or inappropriate clothes for the weather

n

Experiencing severe changes in mood and behavior

If you have reasons to believe child abuse is happening, immediately report to an official agency. Depending on the state, only select members of society, such as medical professionals and early childhood education teachers, can and are required to report child abuse suspicions, but you should never withhold your worries. A child’s life may be in danger. Extent of the Problem.  Each year, the HHS Children’s Bureau (2023) publishes data on child maltreatment that are collected and analyzed by the National Child Abuse and Neglect Data System (NCANDS). Note that these data are aggregate, as a child may be reported as a victim of one or more types of abuse or neglect. In 2012 there were about 3.3 million referrals to CPS in the United States involving the alleged maltreatment of 6 million children. About one-quarter of these were found to be victims with substantiated cases. Children from birth to 1 year had the highest rate of victimization. Boys presented as 48.2% of the victims and girls 51.1%. Whites accounted for 44% of the cases; African Americans, 22.3%; and Hispanics, 20.7%. Neglect accounted for the highest percent of maltreatment (78.3%), followed by physical abuse (17.8%), sexual abuse (9.5%), and psychological maltreatment (7.6%). Eighty-one percent of abuse cases were committed by parents, and women constituted 53.8% of perpetrators as compared with 44.4% men. Four-fifths of perpetrators were between the ages of 20 and 49 years. The national data estimate that 1,770 children died from abuse or neglect. Most of these child fatalities involved children younger than 4 years and boys and were attributable to neglect or multiple maltreatments. Table 20–3 lists some signs and signals of the presence of child abuse or neglect. The table does not list all the signs of abuse or neglect, so it is necessary to be vigilant about any behaviors that appear to be unusual or concerning.

More details specific to signs of physical abuse, neglect, sexual abuse, and emotional maltreatment are discussed at the following website of Child Welfare Information Gateway (2019).

Effects of Child Abuse and Neglect Child abuse and neglect have numerous negative effects that may be obvious immediately or may be more covert and manifest themselves later in life. There may be some combination of social, emotional, behavioral, academic, and physical consequences. Each of these negative effects may in some way influence communicative and cognitive development. For example, child neglect has been associated with the failure of the brain to develop and impoverished cognitive and social skills (HHS, Children’s Bureau, 2018). The Children’s Bureau states: Children who are neglected early in life may remain in a state of “hyperarousal” in which they are constantly anticipating threats, or they may experience dissociation with a decreased ability to benefit from social, emotional, and cognitive experiences. To be able to learn, a child’s brain needs to be in a state of “attentive calm,” which is rare for maltreated children.

The brains of abused or neglected children may be as much as 20% smaller than those of nonabused children. Abuse particularly affects the development of language skills. Effects in the education realm include lower IQ; poorer scores on reading, language, and math skills; and overall lower academic performance. Children who are abused or neglected may be diagnosed with oppositional defiant disorder, conduct disorder, posttraumatic stress disorder, depression, anxiety, and sexual abuse of others. They also may be at a higher risk for health problems as an adult. It is important to note that child abuse and neglect have long-term implications for victims even after the physical wounds heal, and that a child’s or youth’s ability to cope and to even thrive after trauma relates to the child’s resilience. With identification and help, these children can overcome the negative experiences. The estimated annual financial costs are extremely high, totaling more than $103.8 billion (Fang et al., 2012). Direct costs are estimated to be at least $33 billion and include costs for hospitalization, chronic health problems, mental health services, child welfare, and law enforcement and judiciary. The remaining indirect costs are related to special education, mental health, juvenile delinquency, lost productivity to society, and adult criminality. Societal consequences go beyond the financial. Indirect effects include increased child and adult criminal

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Table 20–3.  Signs and Signals of the Presence of Child Abuse or Neglect In the Child n

Child demonstrates sudden changes in behavior or school performance

n

Parents, although notified (sometimes repeatedly), have not obtained help for physical or medical problems

n

Child demonstrates potential learning or attention problems without specific physical or psychological causes

n

Child demonstrates anxiety about something bad happening, leading to continual hypervigilance

n

Lack of adult supervision when it would be normal for supervision at the particular chronological age

n

Child is noted to be overly compliant, passive, or withdrawn

n

Child does not want to go home, is resistant to leave a safe environment

n

Child shows reluctance to be around a particular parent, rarely touching or looking at parent

n

Child reports problems or maltreatment at home or reports parent does not like the child. Sometimes the comments are subtle and infrequent because the child is embarrassed about the differences between themself and peers.

In the Parent n

Parent blames the child for problems at school or home

n

Parent expects teachers or caregivers to administer harsh physical punishment if child misbehaves

n

Parent does not see the child’s value or indicates the child is a burden

n

Parent demands levels of academic or sports performance the child cannot achieve

n

Parents’ emotional needs are primarily dependent on the success of the child

n

Parent has no real concern for the child, sees the relationship as negative, states dislike for the child

n

Parent rarely touches the child

activity, mental illness, substance abuse, and domestic violence. The fact that one-third of neglected children are likely to maltreat their own children creates a vicious cycle that affects generations (HHS, Children’s Bureau, 2023).

What to Do if You Suspect Abuse In 2022, the most recent compilation of data we could locate, professionals (i.e., people who had contact with the child as part of their job) made three-fifths (58.7%) of the reports of alleged child abuse and neglect. Professionals include teachers, police officers, lawyers, social service workers, therapists, education administrators, and clergy. Nonprofessionals (e.g., friends, neighbors, relatives) submitted one-fifth of the reports (18%), per the data prepared by the Children’s Bureau of the HHS (2023).

You cannot ignore signs of abuse. First, you must know if you are a mandated reporter of abuse in your state. You must also know what constitutes abuse in your state, what reasonable cause is, and what to do when you suspect abuse. Your confidentiality will be protected if you make the report in good faith. If you work in a larger organization, policies and procedures will guide you in the steps to take when reporting abuse. You are advised to inform your supervisor of your suspicions.

Who Is a Mandated Reporter of Abuse? Each state has specific people who are required by law to report suspected child abuse or neglect. In approximately 48 states, the District of Columbia, American



CHAPTER 20   Child Abuse and Elder Mistreatment/Abuse

Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the Virgin Islands, specific professionals are mandated to report child abuse and child neglect. This list includes social workers, teachers, principals, other school personnel, physicians, nurses, other health care workers, counselors, therapists and other mental health professionals, childcare providers, medical examiners or coroners, and law enforcement officers. In some states, other specific professionals are also mandated to report, such as commercial film or photograph processors; substance abuse counselors; probation or parole officers; directors and/or employees of camps, youth centers, and recreation centers; domestic violence workers; animal control or humane society officers; court-appointed special advocates; and clergy. Recently, some states have designated faculty, administrators, athletic staff, and other employees at private and public colleges, universities, and vocational and technical schools as mandatory reporters. Some states have started to require anyone suspecting child abuse or child neglect, without specifying professions, to report. For example, according to New York State Law Chapter 544, Identification and Reporting of Child Abuse and Maltreatment (1989), SLPs and audiologists are not specifically named in this category. They may, however, be considered under some other mandated personnel category such as school officials, daycare center workers, or members of hospital personnel engaged in the admission, examination, care, or treatment of patients. It is best to review your school’s, hospital’s, or agency’s policy and procedure manual for precise guidelines in your facility, locality, and state. Note that if you are a mandated reporter, you can face criminal and civil liability for not reporting suspected abuse (HHS, 2023). It is your responsibility to know the reporting laws in the state in which you practice (Child Welfare Information Gateway, Children’s Bureau (2019a) however, even if you are not a mandated reporter, you have an ethical responsibility to document possible signs of abuse or neglect in writing and report these to your supervisor or immediate superior.

What Is Reasonable Cause? Circumstances for making a report may vary from state to state. The key words for the need to report in any official capacity are “suspects” or “has reason to believe” a child has been abused or neglected. Another benchmark is if the reporter has “knowledge of ” or “observes a child being subjected to conditions that would reasonably result in harm to the child.” The facts and circumstances are reported without the burden of providing proof that the neglect or abuse has occurred. This is true for anyone who is reporting.

When and to Whom to Report Suspected child abuse or neglect should be reported immediately by telephone, at any time of day, 7 days a week. Each state, on its state human services or Department of Children and Family Services websites, will have a phone number to report child abuse or child neglect. If additional information is needed, call the Child Help 800 number (800-422-4453). Depending on the state, a written report may be required within a specified time limit — typically 24 to 48 hours after the initial phone report. In addition, national phone numbers are listed in the Resources section at the end of this chapter. Your agency, hospital, or school will have specific guidelines for policies and procedures regarding reporting of possible child abuse.

Immunity and Confidentiality When reporting, you will need to provide the name, address, and age of the child, the names and addresses of the parents or guardians, and the nature of the abuse. If possible, the name of the perpetrator and that person’s relationship to the child are helpful but not mandatory. If you are a mandatory reporter by your state laws, you will need to provide your name; however, this information is typically confidential and protected by law. You have immunity from any civil or criminal liability if you or your agency has reported a suspected case of child abuse or neglect in good faith. Most mandatory reporting laws specify how and when communication is privileged. “Privileged communications” are the right, by law, to maintain confidential communication between professionals and clients and patients. At the time of this writing, all but three states and Puerto Rico address the issue of privileged communication, affirming the privilege or denying it (i.e., not allowing privilege to be grounds for failing to report) per Child Welfare Information Gateway (2019a). Connecticut, Mississippi, and New Jersey do not currently address privileged communication within their reporting laws, but this information may be in rules of evidence dealing with other statutes in these states. It is wise to know the definitions and laws pertaining to privileged communication in your state, but not knowing this information does not protect you from reporting child abuse or child neglect.

Consequences for Failing to Report As noted earlier in the chapter, if you are a mandated reporter and willfully fail to report a case of suspected child abuse or maltreatment, you may be guilty of a misdemeanor and have civil liability for damages caused by

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such failure. More importantly, failure to report your suspicion may result in continued and/or traumatic harm to a child.

Elder Mistreatment and Neglect This is a time of sweeping change and opportunity in the field of aging, health, and long-term care. Significant progress in the technology available to improve health care, increased focus on prevention strategies, and the growing importance of home- and community-based care are just three key factors transforming the landscape of health and long-term care delivery. As retirement is frequently postponed, physiological aging is delayed compared to a century ago. With advances in medical treatment, people are living longer and healthier into the sixth, seventh, and eighth decades, with greater periods of time in what is considered old age. Aging is often compounded by the onset of chronic illnesses and disabling conditions, bringing with it the increased likelihood of functional loss and disability. As a result, costs for care and services increase. One study reported that approximately 20% of communitydwelling older adults have some difficulty with activities of daily living, and this percentage doubles for persons who are more than 85 years old (Cohen et al., 2006). All of this makes elders among the most vulnerable members of our society. There are 75 million baby boomers who will eventually retire, and for the next 20 years an average of 10,000 people per day will reach 65 years of age, moving into the retirement phase of their lives. Around 1 in 60 people who are 60 years and older experienced some form of abuse in community settings during this past year. Rates of abuse in older people are high in institutions such as nursing homes and longterm care facilities, with two in three staff reporting they have committed abuse in the past year. Rates of abuse of older people have increased during the COVID-19 pandemic. Abuse of older people can lead to serious physical injuries and long-term psychological consequences. Abuse of older people is predicted to increase as many countries are experiencing rapidly aging populations. The global population of people aged 60 years and older will more than double, from 900 million now to about 2 billion in 2050. People aged 85 and older are predicted to almost triple, from 6.7 million currently to 19 million by 2060. For the first time, in 2034, it is anticipated that older Americans will outnumber children. Declining rates of fertility and the aging of the baby boom generation are believed to contribute to the increasing ranks of older adults nationwide. Aging is one of the most important demographic trends in the United States (Supporting Older Ameri-

cans Act of 2020 (2020). In 1965, the Older Americans Act (OAA) was signed into law to meet the diverse needs of an aging population. This law had specific objectives for maintaining the dignity and welfare of older individuals. In 2016, the Older Americans Reauthorization Act was approved by Congress. The Supporting Older Americans Act (2020) reauthorizes programs for fiscal year 2020 through fiscal year 2024. It includes provisions that aim to remove barriers to the aging population, increase business acumen and capacity building, provide states and localities with the flexibility of deciding the allocation of national family caregiver services among the populations served, and extend authorization of the RAISE Family Caregiver Act and the Supporting Grandparents Raising Grandchildren Act by one additional year (Supporting Older Americans Act, 2020). The Supporting Older Americans Act of 2020 reauthorizes services and strengthens the law by providing better protection for vulnerable elders, promoting evidence-based support, improving nutritional services, and aligning senior employment services with the workforce development system. Aging can be complicated by the onset of chronic illnesses and disabling conditions, which can increase the likelihood of functional loss and disability. Elderly persons’ ability to protect themselves may be hampered by physical, cognitive, and communication problems. As with child abuse, you need to be aware of the signs and symptoms of elder abuse and what to do if you suspect such maltreatment. Remember that elder abuse or neglect can take place in the home or in formal care settings.

Elder Abuse Elder abuse is a general term that describes intentional and neglectful actions by a trusted person or caregiver who causes harm to an elder (National Center on Elder Abuse, 2010). A second definition of elder abuse is “the willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment with resulting physical harm, pain, or mental anguish; or deprivation by a person including a caregiver, of goods or services that are necessary to avoid physical harm, mental anguish, or mental illness” (Supporting Older Americans Act of 2020, 2020). For an action to be classified as elder abuse, a person either does something or fails to do something that harms an elder. Elder abuse may occur in the home or in institutional settings, or it may be self-imposed. In 2002, Weinrich stated that a research agenda and community awareness are needed because elder abuse is now considered a serious health concern for the older population. The most common forms of elder abuse include physical abuse, sexual abuse, emotional or psychologi-



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cal abuse, neglect, abandonment, financial or material exploitation, and self-neglect. Many types of elder abuse are similar to those of child abuse, including physical abuse involving injury, pain, or impairment, and sexual abuse, whereby individuals receive inappropriate and unwanted sexual activities imposed on them. Several other types of abuse are particular to elders or have different characteristics and are described in the following sections. The following list provides a summary of the major types of elder abuse and potential signs of treatment of each type. Physical Abuse.  This type of abuse involves the nonaccidental use of force that results in pain, injury, or impairment (Helpguide, 2010). Physical abuse may also include the inappropriate use of drugs, restraints, or confinement. Emotional or Psychological Abuse. Elders who experience undue emotional pain or distress are said to be emotionally abused. A common type of emotional abuse is administered verbally through verbal attacks, insults, threats, intimidation, humiliation, or harassment or by giving the elder the silent treatment. Nonverbal abuse involves ignoring or terrorizing the older person. Other forms of emotional abuse include infantilizing of the elder and isolation from people and activities of choice. Neglect.  Elder neglect is defined as “an act of omission, of not doing something, of withholding goods or services” (Quinn & Tomita, 1986). Neglect involves deliberately ignoring the needs of an elder and may take the form of financial neglect by failing to attend to financial obligations, and physical neglect, when the elder receives inadequate food, water, clothing, shelter, personal hygiene, medicine, comfort, or personal safety. Neglect can be intentional (active), characterized by a conscious effort to inflict harm, or unintentional (passive), which is associated with laziness or lack of knowledge (Cicirelli, 1986). Self-Neglect.  Self-neglect occurs when elders harm themselves. For example, elders may improperly or inadequately care for their own health, safety, clothing, nutrition, hygiene, or shelter. Potential factors that lead to self-neglect include long-term chronic self-neglect through adulthood, dementia, illness, malnutrition, overmedication, depression, substance abuse, poverty, and isolation (Woolf, 1998). Abandonment.  Abandonment is the deliberate desertion of an elder by a person who has responsibility for that elder. Abandoned elders are left alone frequently and for extended periods in their homes or other settings

by caregivers. This is particularly dangerous for elders who cannot provide for their own daily needs such as food, personal care, and medications. In addition, the loss of socialization opportunities may have a deleterious effect on the elder and contribute to cognitive and emotional decline. Financial or Material Exploitation. This type of abuse occurs when an elder’s funds, property, or material assets are illegally or improperly used, usually without authorization or permission. Examples of financial or material exploitation include fraudulent check cashing or use of a credit card; forgery of a signature; misuse or theft of money, property, or other possessions; coercion into signing a document (e.g., a will); identity theft; or the improper use of conservatorship, guardianship, or power of attorney (Helpguide, 2010).

Decision-Making Ability and Risk of Elder Mistreatment Changes in the brain and cognition and social functioning affect the decision-making ability of older people, including the ability to pay bills, drive, follow recipes, adhere to medication schedules, or refuse medical treatment (IOM, 2015). Individuals can show lack of decision-making ability in one area while retaining ability in other areas. Impaired ability may lead to an increased risk for abuse in older people (Spreng et al., 2016). The natural process of aging, including cognitive aging, and the social aspects of decision making may be the first consideration. Psychosocial factors such as depression, reduced feelings of well-being, less social support, and increased risk of financial vulnerability also lead to higher risk of elder abuse. Cognitive aging (e.g., memory, decision making, processing speed, wisdom, and learning) includes structural and functional brain changes that may impact daily tasks. Cognitive aging may not be able to be avoided, but there is evidence that effects can be reduced with physical exercise, reducing and managing cardiovascular disease risk factors, and managing medication (IOM, 2015). Cognitive aging may be associated with the potential for financial fraud and abuse and poor consumer decision making (IOM, 2015). Decisions that require a person to understand their decisions and take responsibility for the consequences of the decision (Falk et al., 2014) may be affected by situations that involve new learning or stressful situations. Moye and Marson (2007) identified medical and financial decision-making capacity as two major clinical domains of capacity fundamental to personal autonomy and independent functioning that have received the most research attention. A person’s ability to make

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decisions regarding their medical treatment is a fundamental aspect of autonomy. Moye and Marson (2007) identify the four core abilities associated with consent capacity as understanding, appreciation, expressing a choice, and reasoning. Understanding is the ability to comprehend diagnostic and treatment-related information that may include risks and benefits of proposed treatments. Appreciation is the ability to relate medical information and associated consequences to one’s own personal situation. Expressing a choice is the ability to convey relatively consistent treatment choices. Reasoning is the ability to rationally evaluate and compare treatment alternatives. Although these four core abilities are not just used in medical decision-making capacity, SLPs and audiologists may be the first to see changes occurring in these areas and should be vigilant when working with the elderly. If changes are noticed in an older person’s decisionmaking ability, it is important to seek further evaluations to assess an individual’s physical and psychological status to identify any conditions that may require therapy or medical treatment. SLPs are trained in assessment processes to analyze information and make recommendations that will allow an older person to maintain independence and decision-making abilities, protecting the individual against abuse and exploitation. A trusted support team is critical in supporting the individual at this stage.

Who Is Mistreated? The aging population is becoming increasingly racially and ethnically diverse. In 2018, minority populations accounted for 23% of all Americans aged 65 and older. Approximately 9% were non-Hispanic African Americans, 5% Asian, 0.5% American Indian and Alaska Native, 0.1% Native Hawaiian/Pacific Islander, and 0.8% of identified as being two or more races. Individuals of Hispanic origin constituted 8% of older Americans. The percentage of diverse Americans is projected to rise to 34% by 2040. Life expectancy has risen from 68 years in the mid20th century to the current average of about 81 years for women and 76 years for men. In 2018, there were 29.1 million older women in the United States, compared with 23.3 million older men. However, these numbers started to fall slightly based on a Harvard Report by Lachs and Pillemer (2015) stating women averaged 79.1 years and men averaged 73.2 years. COVID-19, drug overdoses, and accidental injury accounted for about two-thirds of the decline in life expectancy, and other reasons included heart and liver disease and suicides. The good news is there were decreases in deaths

from chronic lung disease, pneumonia, influenza, and Alzheimer disease. Approximately 28% of older people live alone and more than 25% of those who live by themselves are older women aged 65 to 74, 39% are women aged 75 to 84, and 55% are women over the age of 85. It is expected that by 2030, there will be a 50% increase in the number of elders over the age of 65 who require nursing home care. The number of older Americans with medical complications such as Alzheimer disease will likely more than double from 5.8 million to 13.8 million in 2050. These statistics and influences are important to consider when we address the picture of elder abuse in the United States. According to the National Center on Elder Abuse (2022), the majority of elder abuse victims are female (67.3%), with about 1 in 6 elders becoming the victims of elder abuse in 2022. The prevalence of this abuse differs across studies, but includes psychological, physical, financial, neglect, and sexual abuse. National data indicate that there may be between 1 million and 2 million older Americans who have been abused or neglected. The median age of elders abused by others is 77.9 years, compared to 77.4 years for elders who neglected themselves. Two-thirds of the victims of domestic abuse are White, 18.7% are African American, and 10% are Hispanic. For every incident of abuse reported to authorities, nearly 24 additional cases remain undetected. Underreports occur because of the older person’s fear of retaliation by the offender, reluctance to disclose the incident because of shame and embarrassment, concern they will be institutionalized, dependency on the offender, and an inability to report because of physical or cognitive limitations. Financial abuse tends to be the most commonly reported form of mistreatment, while physical abuse commonly occurs with another form of abuse; family members were the most identified offenders. The unfortunate consensus is that although there is agreement on the core components of elder mistreatment, the field has not adopted a universally accepted definition of abuse. Different professional disciplines use distinct approaches to classifying elder abuse, and conceptual understandings may also vary based on differing cultural and social norms among communities. Faith, family, circumstances, context, community, legal definitions, and variation both between and within other countries make it challenging to measure, define, and identify trends in elder mistreatment. Table 20–4 discusses common definitions of elder mistreatment. The World Health Organization (WHO, 2022) estimates that 15.7% of the individuals 60 years or older (around one in six people) may have experienced elder abuse. The number may be higher for people in at-risk categories, including older people with physical or men-



CHAPTER 20   Child Abuse and Elder Mistreatment/Abuse

Table 20–4.  Definitions of Elder Mistreatment Centers for Disease Control and Prevention (2023): Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. An older adult is someone age 60 or older. The abuse often occurs at the hands of a caregiver or person the elder trusts. World Health Organization (2019): Elder abuse can be defined as “a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person.” Elder abuse can take various forms such as financial, physical, psychological, and sexual. It can also be the result of intentional or unintentional neglect. National Research Council (2023): Elder abuse is (a) an intentional act that causes harm or creates a serious risk of harm to a vulnerable elder by a caregiver or other person in a trust relationship to the elder, or (b) failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm” (http://www.nationalacademics.org).

tal incapacity and people living in institutional settings. Abuse within institutions is more likely to occur where standards for health care are low, staff are poorly trained or overworked, the physical environment is deficient, and policies prioritize institution needs over resident needs. WHO (2022) states that rates of elder abuse are high in nursing homes and long-term care facilities, with two in three staff reporting they have committed abuse in the past year (WHO, 2019). As the global population of people aged 60 and older will more than double to about 2 billion in 2050, elder abuse is predicted to increase in many countries, leading to serious physical injuries and long-term psychological consequences. These data are considered gross underestimations of the true number of cases but are much higher in institutions than in community settings. It is predicted that for every reported incident of elder abuse, five go unreported. Reliable statistics on elder abuse and neglect are difficult to find but as more agencies collect data, there will be an improved accounting of elder abuse cases.

Who Is at Risk? Any elder is at risk for abuse, although those who have mental or physical disabilities are at the greatest risk. Overall, elder abuse is becoming an important public health problem that is underreported and underestimated. Recent data (2022) indicate that about 67% of elders with substantiated reports of abuse were female, 43% were over age 80, and 77% were Caucasian; 89% of incidents occurred in the home (National Center on Elder Abuse, 2022). Elders are at risk when their caregivers over- or underestimate their abilities and thus have unreasonable expectations for performance. Elders are

also at risk if there is a history of domestic abuse in their family or in that of a professional caregiver. The likelihood of abuse increases when caregivers have difficulty with temper control; physical, mental, or substance abuse problems; and immature personalities. Elders themselves may increase their risk for abuse if they verbally insult or psychologically taunt their caregivers, especially with threats of withholding inheritances (Quinn & Tomita, 1986). Other factors that place elders at risk include dependency and isolation, family conflict, and financial stress. Elders with dementia and mental disorders are at significant risk for abuse, as care for these individuals is particularly stressful and time consuming (National Center on Elder Abuse, 2022). The WHO (2019) has identified risk factors as individual risks, relationship risks, community risks, and sociocultural risks. Table 20–5 lists possible risk factors in each of these categories. Table 20–6 gives readers a list of types and potential indicators of elder abuse, neglect, and exploitation. The author would refer readers to the Journal of Elder Abuse and Neglect (Taylor & Francis, Online) for current research in the area of elder abuse, neglect and exploitation.

Signs of Mistreatment The most frequently observed signs of mistreatment are referenced below. Please note that indicia of abuse may present differently based upon multiple factors, including the type, degree, duration, and context of abuse experienced (Neuhart & Carney, 2020). Manifestations of abuse may also be impacted by the older adult’s physical and cognitive condition, social connectedness, and emotional state.

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Table 20–5.  Individual, Relationship, Community, and Sociocultural Risk Factors Individual Risk Factors n

Poor physical health of the individual

n

Mental health problems of the individual

n

Mental health disorders of the abuser

n

Substance abuse of the abuser

n

Gender of the victim

n

Shared living situation of individual and abuser

n

Inferior social status of women in some cultures

n

Marriage status of women in some cultures

Relationship Risk Factors n

A shared living situation between two parties

n

An abuser who is financially dependent on the elderly person

n

A history of challenging family relationships

n

Female or male family members’ expectation but inability to care for older family members

Community Risk Factors, Specifically Toward Social Isolation n

Caregivers and older persons’ social isolation

n

A person’s loss of physical or mental capacity

n

The loss of close family and friends

Sociocultural Risk Factors n

Older adults depicted as frail, weak, or dependent, promoting ageist stereotypes

n

A breakdown in the bonds in and between generations in the family

n

Situations affecting distribution of power and goods in families, specifically affecting plans for inheritance or land rights

n

In societies where older persons were traditionally cared for by their children, adult childrens’ attitudes and migration plans leave older parents alone.

n

Older adults are realizing a lack of personal funds, changes in funding of medical care, and changes in funding for long-term care, affecting individuals’ ability to pay for the needed care and services.



CHAPTER 20   Child Abuse and Elder Mistreatment/Abuse

Table 20–6. Types and Potential Indicators of Elder Abuse, Neglect, and Exploitation Possible Signs of Physical Abuse

n Denial

n

Cuts, wounds, punctures, choke marks

n

Helplessness, hopelessness

n

Unexplained fractures, broken bones, skull fractures

n

Severe anxiety or agitation

n Anger

n

Bruises, welts, discolorations on face or body

n

Bedsores or significant skin problems

n

Detached retina, hematomas

n

Injuries left untreated or improperly cared for

n

Poor skin hygiene or condition

n

Dehydration without illness-based cause

n

Malnourishment without illness-based cause

n

Loss of weight

Possible Signs of Financial or Material Exploitation

n

Cigarette or rope burns

n

n

Soiled clothing or bed

Improper signatures on financial documents or unusual activity in bank accounts

n

Broken eyeglasses, hearing aids, other assistive devices

n

Identity theft

n

n

Signs of being restrained

Financial statements do not come to elder’s home without explanation

n

Sudden change in elder behavior

n

n

Elder report of physical abuse

Power of attorney given or changed without explanation

n

Death or murder

n

Changes in will or other documents without explanation

n

Financial mismanagement of funds, including unpaid bills

n

Elder states that they have been signing papers without understanding the content

n

Missing personal items

n

Heightened concern by elder regarding financial management

Possible Signs of Sexual Abuse n

Bruises around breasts or genital area

n

Unexplained sexually transmitted diseases

n

Unexplained vaginal or anal bleeding

n

Torn, stained, or bloody underclothing

n

Inappropriate display of affection by caregiver

n

Elder report of sexual abuse

n Confabulations n

Elder report of verbal or emotional mistreatment

n

Extreme withdrawal

n

Elder becomes noncommunicative, especially in presence of caregiver

n

Attempted suicide

n

Possible Signs of Psychological/ Emotional Abuse

Lack of amenities, including appropriate clothing, entertainment, and so on that elder could afford

n

Promises of care by caregiver or family

n

Hesitancy to express feelings in public

n

n

Ambivalence, deference to others, passivity, cowering

Provision of unnecessary services or purchase of items

n

n

Lack of eye contact

Unauthorized withdrawal of funds using an ATM or credit card

n

Clinging, trembling

n

Elder receives eviction notice from house they owned

n

Elder report of financial or property mismanagement

n

Caregiver concerned that too much money is spent on the elder

n Depression n

Confusion or disorientation

n Fear n Withdrawal

continues

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Table 20–6.  continued Possible Signs of Abandonment

Possible Signs of Self-Neglect

n

Desertion of an elder at a hospital, nursing home, or other institution

n

Inability to handle activities of daily living, including personal care and meal preparation

n

Desertion of an elder at a public location

n

Suicide attempts

n

Report by elder of being abandoned

n

Inadequate financial management

Possible Signs of Neglect

n

Dirty, unsafe living environment

n

Dirty environment

n Homelessness

n

Fecal or urine smell

n

Refusing medical or personal care

Environmental safety hazards

n

Willful isolation

n

Rashes, sores, lice, or other infestation

n

Alcohol or other drug abuse

n

Untreated medical condition

n

Slovenly appearance

n

Malnourishment or dehydration

n

Malnourishment or dehydration

n

Inappropriate or inadequate clothing and grooming

n

Not keeping medical or other important personal appointments

n

Psychological Abuse n

Emotional distress or agitation

n

Withdrawal from activities of daily life

n

Uncommunicative or nonresponsive

n

Unusual behaviors commonly attributed to dementia (e.g., sucking, biting, rocking)

n

Lack of self-care

n

Lower self-esteem, feelings of despair, or a sense of worthlessness (Neuhart & Carney, 2020)

Physical Abuse n

Bruises, abrasions, welts, lacerations, or rope marks

n

Head trauma and/or bone fractures

n

Open wounds, cuts, punctures, or untreated injuries in various stages of healing

n

Sprains, dislocations, and internal injuries/ bleeding

n

Bite, strangulation, or burn marks, or patterns of injury

n

Falls, including broken eyeglasses or frames

n

Physical indicia of punishment, including evidence of physical restraints

n

Medication overdose or chemical restraints

n

Sudden behavioral changes (Heisler, 2017; Rosen et al., 2020; Yonashiro-Cho et al., 2019)

Financial Abuse n

Sudden changes in bank account or banking practices, including an unexplained withdrawal of large sums of money or the addition of signatories to an older person’s bank signature card

n

Abrupt changes to a will or other financial documents

n

The unexplained disappearance of funds or valuable possessions, or sudden transfer of assets

n

Substandard care provision, unpaid bills, or eviction proceedings

n

The provision of unnecessary services

n

Depression or anxiety

n

Evidence of poor financial decision making

n

Malnutrition (Lachs, 2015)

Neglect n

Dehydration or malnutrition

n

Untreated bed sores

n

Poor personal hygiene

n

Unattended or untreated health problems



CHAPTER 20   Child Abuse and Elder Mistreatment/Abuse

n

Unsafe living conditions

n

Violence as a problem-solving strategy

n

Unsanitary living conditions (Friedman et al., 2017)

n

Individual problems of the abuser

n

Society’s negative portrayal of the elderly

n

Greed (Quinn & Tomita, 1986)

Sexual Abuse n

Bruises, abrasions, or lacerations around the breasts or genital area

n

Unexplained sexually transmitted disease or genital infection

n

Unexplained vaginal or anal bleeding or incontinence

n n

Victim risk factors include: n

Chronic medical conditions and poor physical health

n

Functional disability and dependence

n

Mental health problems

Increased anxiety or depressive symptoms

n

Cognitive deficits

Sleep disturbances, agitation, or restlessness (Heisler, 2017)

n

Financial dependence

n

Lower socioeconomic status

n

Substance misuse

n

High levels of stress and poor coping mechanisms

n

Prior exposure to trauma

n

Limited social support

n

Poor relationship between the victim and the perpetrator (Pillemer, 2016; Storey, 2020)

Who Is an Abuser? Those who abuse elders come from all racial, economic, educational, and socioeconomic strata (Quinn & Tomita, 1986). In 2004, the National Center on Elder Abuse reported that 52.7% of alleged perpetrators of abuse were female and three-quarters were under the age of 60. It also found that adult children are the most frequent abusers of the elderly (34.6%), followed by other family members (21.5%). Formal caregivers who have poor working conditions, low salary, and limited education are at higher risk for becoming abusers.

Most Common Types of Abuse The most common types of elder maltreatment are, in decreasing order of frequency, neglect (49%), emotional/ psychological abuse (35%), financial/material exploitation (30%), physical abuse (27%), abandonment (4%), sexual abuse (3%), and other (1.4%). These frequency data are not mutually exclusive, as more than one type of abuse may be reported for an incident.

Why Does Elder Abuse Occur? Elder abuse and neglect are generally attributed to the following factors: n

Physical and mental impairment of the elder

n

Psychological abuse

n

Financial abuse

n Neglect n

Sexual abuse

n

Caregiver stress

Other victim-centric variables that have been correlated with a potential increased risk of abuse include: n

Gender (women)

n

Race (one study cited support for the proposition that, compared with Caucasians, older African Americans may be at increased risk of financial abuse and psychological abuse; Pillemer, 2016)

n

Younger older age

n

Health care insecurity (Hamby et al., 2016; Rosay & Mulford, 2017)

Perpetrator risk factors include: n

Chronic medical conditions and poor physical health

n

Mental health problems

n

Cognitive deficits

n

Financial dependence

n

Substance misuse

n

High levels of stress and poor coping mechanisms

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n

Negative attitudes toward the older adult

n

Early childhood abuse (Storey, 2020)

It is likely these hypothesized causes work in tandem rather than individually. Meeting the needs of frail and physically and/or mentally challenged elders takes time and effort, especially for caregivers with limited personal resources and reduced or immature psychological stamina. In some cases, a triggering crisis may instigate an incident of abuse. In other cases, long-term, unrelieved stress and physical fatigue may result in an explosion of violence. Some families may routinely use abuse as a problem-solving strategy. Some elders may purposely antagonize their caregivers, whereas others with reduced cognitive abilities may not understand or appreciate the care received. Finally, society stigmatizes the disabled and their caregivers. Limited financial or social incentives are available for caregivers, who may sacrifice career and social lives for their elder family members. Some caregivers may deliberately hasten the progression of decline because it will result in a greater or earlier financial inheritance. Reinharz (1986) commented that elder abuse is not a modern problem and represents “twin cultural themes of honor and contempt” toward the elderly. Certain caregiving contexts appear to trigger abuse, and many of these are related to the stress involved. For example, feeding, incontinence, interrupted sleep, and incessant vocalizations are all extremely stressful for caregivers, especially when they occur repeatedly and without respite. These situations become even more problematic if the caregiver is an alcohol or drug abuser or has a history of being abused or abusive. Elders may be afraid to report abuse because of their fear of what will happen to them if their caregiver is removed. Many elders greatly fear they will be forced to leave their home and relocate to an institutional setting where there will be less independence, loss of control, and loss of familiar surroundings and property. Thus, many elders refrain from mentioning incidents of abuse because they perceive the alternative of institutionalization to be worse than the abuse they receive in their home. Polyvictimization is the intersection of multiple cooccurring or sequential forms of abuse that result in cumulative and compounding harms for older adults. The concept of polyvictimization recognizes that past traumas over the life course can heighten the negative impact of mistreatment in older age. Early childhood adversity, both experiencing and witnessing mistreatment, can also exacerbate later life abuse (Hamby et al., 2016). One study reported that approximately 1.7% of older people experienced prior polyvictimization. Elder abuse occurs across racial, ethnic, gender, and sexual domains. Older people with dementia are par-

ticularly susceptible to abuse. Though there is a paucity of studies assessing elder abuse in diverse communities, emerging research reflects that perceptions of mistreatment are often culturally construed and contextually determined. Elder abuse is recognized globally as a significant public health problem impacting older adults worldwide (Li & Dong, 2021). International bodies from the WHO to the United Nations and the International Network for the Prevention of Elder Abuse, among other agencies, have noted the individual and societal harms caused by elder mistreatment.

Elder Abuse in Long-Term Care Facilities Working with elders in long-term care facilities can be challenging, particularly when residents have demanding physical and psychological needs, salary, and societal regard are low and training is minimal. The list of examples of abuse is long and growing longer to include physically restraining patients; depriving them of their dignity (e.g., not meeting bathroom needs, leaving them in dirty clothes); not allowing them to make decisions within their ability levels about daily activities or decisions about personal affairs; not providing sufficient care, which then results in medical issues such as pressure sores, infections, torn skin, broken bones, dehydration, or loss of weight; over- or undermedicating or withholding medications, and emotional neglect and abuse, leading, at times, to psychological consequences including depression, anxiety, or premature death. Pillemer and Moore (1990) state that possible risk factors for staff abuse of elders in long-term care settings include patient aggression and provocation, staff burnout, staff age, and conflict regarding daily routines. In their confidential interviews of 577 nurses and aides, Pillemer and Moore found that more than 75% of staff had observed psychological abuse, 41% admitted to committing such abuse, about 33% had observed physical abuse, and 10% had committed physical abuse. Physical abuse is the most commonly reported abuse against elders in nursing homes, followed by sexual abuse, neglect, and monetary abuse. Male nursing aides committed two-thirds of the reported cases of abuse. Prevention undoubtedly lies in higher qualifications for staff, more staff training, and enforcement of mandatory abuse reporting (Quinn & Tomita, 1997).

What to Do? The WHO (2022) has identified strategies to prevent or react quickly to take action against elder abuse, but attention and support come primarily from higherincome countries. Prevention steps include caregiver



CHAPTER 20   Child Abuse and Elder Mistreatment/Abuse

training on dementia, school-based intergenerational programs, awareness programs for the public and professional communities, screening of potential victims and abusers, support interventions for caregivers including respite and stress management, and improving residential care policies to define and improve standards of practice and care. To prevent or respond in a timely manner to reports of abuse, procedures for reporting abuse to authorities and helplines to provide information and referrals need to be clearly defined and accessible to all. Self-help groups, safe houses, and emergency shelters should be highly visible and available to all individuals. Caregiver support interventions and psychological programs for abusers should be available to all who need these resources. In addition, the courts, legal system, and medical community need to be better educated and quicker to react to potential problems to avoid serious outcomes as well as to establish legal, financial, and housing support. The WHO (2019) also shows evidence that adult protective services and home visitation by police and social workers for victims of elder abuse may in fact increase elder abuse. There is a five-step approach to dealing with elder abuse. The guidelines for action are listed below. Although these steps appear to be linear, they can occur simultaneously. 1. Identify whether abuse is taking place.  Ask questions to find out further information such as “Is someone hurting you?” or “Are you frightened by anyone?” If this appears to be an emergency, jump to Step 3. Responding to an emergency such as serious assault or ongoing criminal act should be the first priority to protect the older person. 2. Provide emotional support.  Listen, acknowledge, and validate. Listen to and acknowledge what the person is saying. Validate their feelings. 3. Assess risk and plan safety.  Determine the level of response needed. Is it an emergency? Call 911. Follow procedures by notifying managers and administrators, and take safeguards to protect the older person and others. 4. Refer.  Contact the appropriate service or agency with reference to the level of risk to the older person and others. If it is not an emergency, obtain the person’s consent and

make appropriate referrals. If the person does not want assistance, attempt to provide them with contact information for services. 5. Document.  Record concerns, communication with the person, and whatever actions have been taken.

Table 20–7 is a list of intervention steps to consider based on the Alliance for Prevention of Elder Abuse: Western Australia publication (Elder Abuse Protocol, 2017). Several factors increase the risk that an older person will be abused, including dependency, family dynamics and living arrangements, social isolation, health and cognitive impairments, addictions, caregiver stress, language and cultural barriers, and ageism. Each state determines whether audiologists and SLPs are mandated to report child or elder abuse. If you suspect elder abuse, it is best to document in writing the indicators and discuss the policy and procedure of your setting for reporting these potential signs of elder abuse. In most states, the Adult Protective Services (APS) agency is responsible for both investigation of reported cases of elder abuse and for providing help to victims and their families. This agency is often contained within the county department of social services. Other organizations that have primary roles in investigation and followup of elder abuse referrals include the Area Agency on Aging, county departments of social services, local law enforcement agencies, the medical examiner/coroner’s office, hospitals, the state long-term care ombudsman’s office, mental health agencies, and facility licensing or certification organizations. Investigations may lead to provision of community supportive services, financial or legal assistance, counseling referrals, or guardianship. Alleged perpetrators may face criminal investigations and prosecution. There are services available that can focus on any of the concerns, with more information available from APS. These include financial management help, restorative justice, trauma-informed responses, service advocates, elder mediation, elder shelters, social supports, APS, long-term care, ombudsman services, forensic centers, and general awareness, education, and training for any individuals. Several screening tools have been developed to aid providers in the detection of abuse: n

Brief Abuse Screen for the Elderly (BASE; Reis & Nahmiash, 1998)

n

Caregiver Abuse Screen (CASE; Reis & Nahmiash, 1995)

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Table 20–7.  Intervention Principles n

Do no harm.

n

Accept what the elder person is saying.

n

Do not escalate action unnecessarily.

n

Assess safety and risks and implement safety management plans.

n

Uphold the older person’s rights in all actions and interactions and respect their right to autonomy and self-determination.

n

If you have doubts about the older person’s decision-making ability, make appropriate referrals.

n

Recognize the importance of preserving family relationships where possible.

n

Responses should consider the needs of the older person in relation to disability, culture, language, religion, gender, sexuality, and historical abuse and reporting experiences.

n

Know your organization’s policies and procedures, including duty of care responsibilities.

n

Be aware of the potential for conflict of interest, especially in small communities or within service settings.

n

Be clear about your role in supporting the older person and do not be co-opted into other people’s agendas.

n

Be informed about elder abuse and engage in training where available.

n

Detection of Elder Abuse Through Emergency Care Technicians (DETECT; Cannell et al., 2020)

n

ED Senior Abuse Identification (ED Senior AID) tool (Cannell et al., 2020)

n

Elder Abuse Suspicion Index (EASI) Kurkurina et al., 2018)

n

Elder Assessment Instrument (EAI; Fulmer, 2003)

n

Elder Mistreatment Screening and Response Tool (EM-SART; Platts-Mills et al., 2020)

n

Emergency Department Elder Mistreatment Assessment Tool for Social Workers (ED-EMATS; Elman et al., 2020)

n

Older Adult Financial Exploitation Measure (OAFEM; Phelan et al., 2017)

n

Responding to Elder Abuse in Geriatric Care — Self-administered (REAGERA-S; Simmons et al., 2020)

n

Vulnerability to Abuse Screening Scale (VASS; Schofield & Mishra, 1996)

The following tools have been identified for use by APS and other caseworkers in aging: n

California Undue Influence Screening Tool (CUIST; Quinn et al., 2017)

n

Elder Abuse Risk Assessment and Evaluation tool (EARAE; Dauenhauer et al., 2019)

n

Expanded Indicators of Abuse (E-IOA; Cohen et al., 2006)

n

Elder Abuse Decision Support System (EADSS; Conrad et al., 2017)

n

Geriatrics Mistreatment Scale (GMS; GiraldoRodriguez & Rosas-Carrasco, 2013)

n

Weinberg Center Risk and Abuse Prevention Screen (WC-RAPS; Teresi et al., 2019)

n

Hwalek–Sengstock Elder Abuse Screening Test (H-S/EAST; Neale et al., 1991)

n

Indicators of Abuse (IOA; Reis & Nahmiash, 1998)

n

Lichtenberg Financial Decision Rating Scale (LFDRS-SF; Lichtenberg et al., 2020)

What to Report When reporting suspected abuse, the reporter should have as much information as possible. The purpose of an investigation is to determine if abuse occurred and how/ if the case will be prosecuted for abuse. The following



CHAPTER 20   Child Abuse and Elder Mistreatment/Abuse

information is needed when reporting abuse: the supposed abused person’s name, address, date of birth, and gender as well as the same information of the alleged abuser; a description of the incident; name, address, and phone number of next of kin, guardian, or representative payee; names and information of any parties with whom the older person resides; and any information that adds further clarity to the cause or how the abuse has been occurring. It is important to remember that you should first report the suspected abuse to your supervisor, but any individual is able to report directly to the state APS department. It is not wise for a reporter to attempt to intervene in cases of suspected abuse, and you need to keep in mind that the older person may be traumatized or may not want the abuse reported. Neither, however, alleviates you of your legal responsibility to report the suspected abuse (WHO, 2022). Individuals who have lived with abuse over time may believe it is better to put up with the abuse than to leave their environment and possessions at their age. This can create a very sad and negative lifestyle for this person, as well as the danger of something more serious occurring. If the alleged abuser is made aware of the identification of abuse or the reporting of abuse, the abuse may escalate. Confidentiality and anonymity are important considerations, but it is never alright not to report suspected abuse. The practice of speech-language pathology and audiology has increased in settings and with individuals in the aging and elder population, thus increasing the likelihood of identification of individuals who are being abused. With life expectancies increasing; with our evidence-based research showing more need for speech, language, swallowing, hearing assessments, and interventions in treatment with the aging population; and with the establishment of longer-term relationships with these individuals, SLPs and audiologists have more opportunities to be watchdogs for elder abuse. The WHO adopted, in 2019, a global strategy and action plan on ageing and health that provides guidance for coordinated action to prevent elder abuse through the following initiatives that help to identify, quantify, and respond to the problem (WHO, 2019). These include building evidence on the scope and types of elder abuse in different settings to understand the magnitude and nature of the problem at the global level with an emphasis on low- and middle-income countries where there are little data, developing evidence and providing prevention guidance to member states, supporting national efforts to prevent elder abuse, and collaborating with international agencies and organizations to deter the problem globally. There are three case studies in Appendices 20–A, 20–B, and 20–C to represent child neglect and elder

abuse issues that occur. Although these are real cases, the names and events have been altered to protect the anonymity of the individuals.

Palliative Care and Hospice This chapter is about resources to help individuals along the continuum of life. At the end of life there is also a need for resources. We conclude this chapter with a discussion of how to manage end-of-life issues for chronic illness or advanced-stage disease. Choosing palliative care or hospice care often allows a patient to live longer and to live life in their own way. Palliative care and hospice care are reasonable considerations for individuals, families, and/or health professionals. It is about making meaningful decisions about care by truly understanding the specifics of the individual’s clinical needs. The modern hospice movement started in 1967 in London (Saunders, 2000). The intent was to address the multifaceted areas that occur during the progression to end of life, including physical, emotional, social, and spiritual aspects. The main parameter in all of this is pain, because pain is universal but also unique to each individual who experiences it. Pain is complex because it can simultaneously be physical, emotional, and spiritual in nature. Elizabeth Kubler-Ross, a University of Chicago psychiatrist, developed and taught about the five stages of grief (denial, anger, bargaining, depression, and acceptance) in her 1969 book, On Death and Dying. She acknowledges that although death and dying are interrelated, they are also distinct. Each person approaches the death and dying process in unique ways, not always following a step-by-step process once acknowledging that it is going to occur. In 1974, the hospice movement arrived in the United States with the opening of services in Connecticut (National Hospice and Palliative Care Organization [NHPO], 2014), growing across all 50 states. The primary goal of hospice is to provide noncurative pain control and symptom management utilizing a patient-centered, community-based, multidisciplinary approach that seeks to avoid inappropriate prolongation of the dying process (Singer et al., 1999). Hospice philosophy supports the fact that each person has a right to determine the location of their death, to die with dignity while free of pain, and to have their families receive support during the dying process. In 1983, a national Medicare hospice benefit was established in the United States to provide Medicare beneficiaries with access to end-of-life care. The United States Congress codified the concept of self-determination as a primary ethical cornerstone of service in the Patient Self-Determination Act of 1990

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(Ulrich, 1998), which requires any health care institution receiving Medicare or Medicaid funding to provide individuals in their care with written notification of patient rights (e.g., right to refuse, rights of advanced directives, and any specific institutional policies concerning withholding life-sustaining treatments). Communicating with individuals considering hospice or just receiving a terminal diagnosis is difficult, and health care providers in the day-to-day routines often are not specifically trained in this type of communication. Providers must be respectful of the individual’s wishes when explaining the process following a poor prognosis and limited treatment options. As counselors say, “it is important to meet the patient where they are.” This can vary with each individual as they advance, with some individuals never achieving final closure during the grieving process.

Palliative Care Palliative care is often the first step in the end-of-life process (NHPO, 2014). Palliative care is specialized medical care focused on providing individuals with expert support, care coordination, prognostication, and relief from the symptoms often accompanied by serious illness. Palliative care is beneficial for patients pursuing curative treatments as well as those who are not. Palliative care typically offers a physician, nurse practitioner, social worker, and counselor to address all palliative needs as a team. The team members collaborate with the individual and their physicians to provide the best individualized care plan options consistent with what is important for the individual. Chronic illnesses may include cancer, heart disease, respiratory disease, renal disease/failure, HIV/AIDS, chronic liver disease, multiple sclerosis, stroke, amyotrophic lateral sclerosis, and/or other progressive neurological diseases. Symptoms to be addressed in palliative care may include but are not limited to pain, shortness of breath, nausea/vomiting, diarrhea, constipation, loss of appetite, fatigue, depression, delirium, difficulty sleeping, anxiety, and emotional and/or spiritual distress. While all palliative care is not hospice care, all hospice care includes palliative care.

Hospice Care Hospice care is an advanced level of care and expertise for all individuals of any age facing a limited life expectancy of 6 months or less. If an individual lives longer than 6 months, they must be clinically reassessed for continued hospice eligibility. There are no limits on the number of recertifications an individual may receive if the individual continues to meet the hospice criteria. Hospice care can occur in personal homes, nursing

homes, residential facilities, inpatient hospice facilities, or acute care hospitals. The room and board fees are not part of the covered hospice services. Hospice focuses on managing an individual’s physical and emotional symptoms and spiritual needs. Hospice also supports families through the end-of-life progression and empowers everyone to continue to live, love, laugh, and give. The care team typically includes a physician, nurse, home health aide, social worker, chaplain, bereavement specialist, and volunteers to offer more support and specialized care. Individuals and families have the right to choose their hospice provider and to change providers one time during the benefit period. The Medicare hospice benefit period is two consecutive 90-day periods, and each 60 days thereafter. If an individual is discharged from hospice care because of no longer meeting the requirements, the person remains eligible to reenter at a later date, even if reentry is needed after a short time period (Hospice, 2014). Hospice is not a permanent fixture in an individual’s life. Plans are tailored to the needs of the individual experiencing end-of-life planning, starting with weekly visits and increasing as the individual moves closer to actively dying. Acceptance of hospice is challenging as families and individuals struggle to accept a terminal diagnosis. Assessing the individual’s needs and assisting the family can involve many of the following factors: n

Physical and psychological stages of the dying process

n

Physical and psychological manifestations of pain

n

Range of psychosocial interventions that can alleviate discomfort

n

Biopsychosocial need of clients and their family members

n

Impact of ethnic, religious, and cultural differences on the dying and death experience

n

Disparities across cultures in gaining access to palliative and end-of-life care

n

Range of settings for palliative and end-of-life care, including home care and hospice settings

n

Available community resources and how to gain access to them

n

Impact of financial resources on family decision making at the end of life

n

Development, use, support, and revision of advanced directives throughout the progression of the illness



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n

Communicating the client’s psychosocial needs to the interdisciplinary team

Hospice care in the United States can occur in one of four categories that will be assigned to an individual at the beginning of the hospice plan; the individual can move through the categories or can remain in one category while under hospice care. These four categories are routine care, general inpatient care, continuous nursing care, and respite care. Each level of care allows the individual to have access to certain services with specific team members and number of visits. Routine care is for the individual who lives at home or a long-term care facility and does not have uncontrolled symptoms. General inpatient care is for an individual who is in a facility setting (e.g., nursing home, inpatient hospice, or hospital) and needs facilitated symptom control and a plan of care that will maintain symptom control if the patient returns to a home setting. Continuous nursing care is provided to an individual at home who has uncontrolled symptoms. Respite care is for the individual (usually in a facility) who has controlled symptoms, to give a caregiver some relief. Each of these levels of care are defined in detail by the NHPO (2014) and others who continue to educate rehabilitation professionals on how to possibly predict appropriate entry points for hospice (Stuart, 1999).

Grief There is grief in child abuse and elder mistreatment. We experience grief in death also. Simply defined, grief is the normal and natural reaction to a significant change or emotional loss of any kind. While we never compare losses, any list would include death as an obvious painful loss. The range of emotions associated with grief are as varied as there are people and personalities. There is no list of feelings that would adequately describe one’s emotions. Grief is normal and natural, but many ideas we have been taught about dealing with grief are not helpful. While some emotions are common, grief does not always come in stages or follow textbook definitions. Mourners will experience a wide and unique range of feelings, mental reactions, physical effects, spiritual struggles, and behavioral or social difficulties throughout the course of their grief journey. Other incorrect ideas about dealing with loss can be summed up in the following six myths: n

Time heals all wounds

n

Don’t feel bad

n

Grieve alone

n

Replace the loss

n

Be strong

n

Keep busy

Just looking at the myth that time heals implies that if the person waits, they will feel better. It is not the quantity of time that heals, but rather what you do over time to work through your loss. Without proper resources and tools, people can wait many years and still not feel whole. Grief may be a blend of emotional, behavioral, intellectual, and physical reactions to a loss. Appendix 20–D lists common reactions in the grief process that should be acknowledged. Additionally, many medical treatment organizations have developed hospice guidelines with resources, talking points, and pocket cards available to be used when working with families and individuals in the discussion of palliative care, hospice care, and end-of-life planning. Examples of these materials can be found in NHPO (2014), University of Texas Health Science Center at Houston (n.d.), and Visiting Nurse Hospice Service (n.d.). Palliative care and hospice care are strange topics to end a discussion of child abuse and elder mistreatment, but the psychosocial aspects of all three have some similarities. There is nonacceptance, loss, grief, loss of control, family dynamics, and varying needs. It is important for readers to acknowledge the need for an interprofessional team of experts to assist with each of these areas as needed. Obviously the interprofessional team changes in composite depending on the need (e.g., child abuse, elder mistreatment, and end of life) but many emotions and needs may overlap and have similarities.

Summary When providing intervention services in home, community, or institutional settings, audiologists and SLPs need to be vigilant for signs of abuse. Young children and elders with communication problems and other disorders are particularly vulnerable to abuse because of their high-intensity needs. Abuse can take a variety of forms, including physical, psychological, sexual, financial, or neglect. Abuse or neglect can occur in any age, ethnic, or economic group; in urban, suburban, or rural settings; and in any type of setting by paid caregivers, family members, or others. Globally, too little is known about child and elder abuse, how to prevent it, and consequences; evidence of what works to prevent both is very limited. SLPs and audiologists need to know their individual state regulations regarding mandated reporting of child or elder abuse and should know their agency’s particular guidelines for reporting suspected cases of

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child abuse. Identification of abuse against those with whom we work may help prevent further abuse and provide abusers with the help they need to refrain from this type of dangerous and humiliating behavior.

Child Welfare Information Gateway. (2019c). Child maltreatment. https://www.acf.hhs.gov/programs/ cb/research-data-technology/statistics-research/ child-maltreatment

References

Child Welfare Information Gateway. (2019d). State statutes. https://www.childwelfare.gov/topics/ systemwide/laws-policies/state/

Administration on Aging. (2017). The national elder abuse incidence study: Final report September 1998. https://acl.gov/about-acl/administration-aging Administration for Community Living. (2023). National Center on Elder Abuse. https://acl.gov/ programs/elder-justice/national-center-elder-abuse Andrews University. 2019). Child abuse. https://www​ .andrews.edu/riseup/about/index.html Cannell, B., Livingston, M., Burnett, J., Parayil, M., & Reingle Gonzalez, J. M. (2020). Evaluation of the detection of elder mistreatment through emergency care technicians project screening tool. Journal of the American Medical Association, 3(5), e204099. https:// doi.org/10.1001/jamanetworkopen.2020​.4099 Center for Development of Human Services at Buffalo State College. (n.d.). Identification and report of child abuse and maltreatment: A course for mandated reporters. Centers for Disease Control (CDC). (2023). https:// www.cdc​.gov Centers for Medicare and Medicaid Services (CMS). (2012). Medicare benefit policy manual, Chapter 9. http://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/downloads/bp102c09.pdf Check, W. (1989). Child abuse. Chelsea House. Child Abuse Prevention and Treatment Act (CAPTA) (2018). Section 3. General Definitions [42 U.S.C. 5101]. https://www.acf.hhs.gov Child Welfare Information Gateway. (2016). Children’s Bureau/ACYF/ACF/HHS. https://www.childwelfare​ .gov Child Welfare Information Gateway. (2019a). Mandatory reporters of child abuse and neglect. https://www​ .childwelfare.gov/topics/systemwide/laws-policies/ statutes/manda/ Child Welfare Information Gateway. (2019b). Fact Sheets. https://www.childwelfare.gov/search/?822E9 8A70CACF462191B3E33F9A34910=58C4CB2C 897972335277EC60BB69FDC9D4B12790&adds earch=Fact+sheets

Child Welfare Information Gateway. (2019e). About CAPTA: A legislative history. U.S. Department of Health and Human Services, Children’s Bureau. Cicirelli, V. (1986). The helping relationship and family neglect in later life. In K. Pillemer & R. Wolf (Eds.), Elder abuse conflict in the family (pp. 49–66). Auburn House. Cohen, M., Halevi-Levin, S., Gagin, R., & Friedman, G. (2006). Development of a screening tool for identifying elderly people at risk of abuse by their caregivers. Journal of Aging and Health, 18(5), 660–685. Committee on Diagnostic Error in Health Care, Board on Health Care Services, Institute of Medicine; The National Academies of Sciences, Engineering, and Medicine. (2015). In E. P. Balogh, B. T. Miller, & J. R. Ball (Eds.), Improving diagnosis in health care. National Academies Press. https://www.ncbi.nlm​ .nih.gov/books/NBK338596/ and http://doi.org/​ 10.17226/21794 Comprehensive Addiction and Recovery Act of 2016. (2016). Publ.L.No.114-198, 130 Stat 695. https:// www.congress.gov/114/plaws/publ 198/PLAW-114​ publ198.pdf Conrad, K. J., Iris, M., & Liu, P. J. (2017). Elder abuse decision support system: Field test outcomes, abuse measure validation, and lessons learned. Journal of Elder Abuse & Neglect, 29(2-3), 134–156. Dauenhauer, J., Heffernan, K., Caccamise, P., Granata, A., Calamia, L., Siebert-Konopko, T., & Mason, A. (2017). Preliminary outcomes from a communitybased elder abuse risk and evaluation tool. Journal of Applied Gerontology.,38. 073346481773310. https://doi.org/10.1177/0733464817733105 Elder Abuse Protocol. (2017). Alliance for Prevention of Elder Abuse (APEA): Western Australia publication. https://www.advocare.org.au/aged-care-sector/ apeawa/ Elman, A., Rosselli, S., Burnes, D., Clark, S., Stern, M. E., LoFaso, V. M., & Rosen, T. (2020). Developing the emergency department elder mistreatment assessment tool for social workers using a modified



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Delphi technique. Health & Social Work, 45(2), 110–121. Falk, N. H,, Norris, K., & Quinn, M. G.. (2014). The factors predicting stress, anxiety and depression in the parents of children with autism. Journal of Autism Development Disorder, 44(12), 3185–3203. https://doi.org/10.1007/s10803-014-2189-4 Fang, X., Brown, D. S., Florence, C. S., & Mercy, J. A. (2012) The economic burden of child maltreatment in the United States and implications for prevention. Child and Abuse Neglect, 36(2), 156–165. https://doi.org/10.1016/j.chiabu.2011.10.006 Friedman, L. S., Avila, S., Liu, E., Dixon, K., Patch, O., Partida, R., & Meltzer, W. (2017). Using clinical signs of neglect to identify elder neglect cases. Journal of Elder Abuse & Neglect, 29(4), 270–287. Fulmer, T. (2003). Elder abuse and neglect assessment. Journal of Gerontological Nursing, 29(6), 4–5. Giraldo-Rodríguez, L., & Rosas-Carrasco, O. (2013). Development and psychometric properties of the Geriatric Mistreatment Scale. Geriatrics & Gerontology International, 13(2), 466–474. Hamby, S., Smith, A., Mitchell, K., & Turner, H. (2016). Poly-victimization and resilience portfolios: Trends in violence research that can enhance the understanding and prevention of elder abuse. Journal of Elder Abuse and Neglect, 28(4-5), 217–234. https://doi.org/10.1080/08946566.2016​.1232182 Heisler, C. J. (2017). Elder abuse forensics: The intersection of law and science. In X. Dong (Ed.), Elder abuse. Research, practice and policy (pp. 387–416). Springer International Publishing AG. https://doi​ .org/10.1007/978-3-319-47504-2_18 Helpguide. (2010). Elder abuse and neglect. https:// www.helpguide.org/articles/abuse/elder-abuse-andneglect.htm Hibbard, R., & Desch, L. (2007). Maltreatment of children with disabilities. Pediatrics, 119, 1018– 1025. Hospice 42 CFR § 418. (2014). GPO — Electronic code of federal regulations. https://www.ecfr.gov/cgi-bin/ text-idx?rgn=div5;node Institute of Medicine, National Institute of Aging (2015). Cognitive Aging: Progress in understanding and opportunities for action. http://nia.nih.gov/ news/institute-medicine-releases-report-cognitiveaging

Jackson, S. L., & Hafemeister, T. L. (2016). Theorybased models enhancing the understanding of four types of elder maltreatment. International Review of Victimology, 22(3), 289–320. Justice for Victims of Trafficking Act (2015). Public Law No: 114-22 (2015), 227 STAT (S178). https://www.congress.gov/bill/114th-congress/ senate-bill/178 Konopko, T., & Mason, A. (2019). Preliminary outcomes from a community-based elder abuse risk and evaluation tool. Journal of Applied Gerontology, 38(10), 1445–1471. Kubler-Ross, E. (1969). On death and dying. Scribner. Kurkurina, E., Lange, B. C., Lama, S. D., Burk-Leaver, E., Yaffe, M. J., Monin, J. K., & Humphries, D. (2018). Detection of elder abuse: Exploring the potential use of the Elder Abuse Suspicion Index© by law enforcement in the field. Journal of Elder Abuse & Neglect, 30(2), 103–126. Lachs, M., & Pillemer, K. (2015). Elder abuse. New England Journal of Medicine, 373, 1947–1956. http://doi.org/10.1056/NEJMra1404688 Lasher, L. (2004). MBP overview and definitions. http://www.mbpexpert.com/ Li, M., & Dong, X. (2020). Association between different forms of elder mistreatment and cognitive change. Journal of Aging Health, 33(3-4), 249–259. https://doi.org/ 10.1177/0898264320976772 Lichtenberg, P. A., Gross, E., & Campbell, R. (2020). A short form of the Lichtenberg financial decision rating scale. Clinical Gerontologist, 43(3), 256– 265. Mather, M., & Kilduff, L. (2020, February 19). The U.S. population is growing older, and the gender gap in life expectancy is narrowing. Population Reference Bureau. https://www.prb.org/the-u-spopulation-is-growing-older-and-the-gender-gapin-life- expectancy-is-narrowing/ Moye, J., & Marson, C. (2007). Assessment of decision-making capacity in older adults: On emerging area of practice and research. Journal of Gerontology Series B Psychological Sciences and Social Sciences, 62(1), P3–P11. National Center on Elder Abuse. (2022). Why should I care about elder abuse? https://ncea.acl.gov/ncea/ media/publication/ncea_whycare.pdf National Child Abuse and Neglect Data System. (2023). https://www.acf.hhs.gov/cb/data-research/nacands

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National Hospice and Palliative Care Organization. (2014). History of hospice care. http://www.nhpco​ .org/ National Research Council (U.S.) Panel to Review Risk and Prevalence of Elder Abuse and Neglect (2003). In R. J. Bonnie & R. B. Wallace, Elder mistreatment: Abuse, neglect, and exploitation in an aging America.National Academies Press (U.S.). https://www.ncbi.nlm.nih.gov/books/NBK98788/ National Research Council of the National Academies. (n.d.). https://www.nationalacademies.org Neale, A. V., Hwalek, M. A., Scott, R. O., Sengstock, M. C., & Stahl, C. (1991). Validation of the Hwalek-Sengstock elder abuse screening test. Journal of Applied Gerontology, 10(4), 406–418. Neuhart, R., & Carney, A. (2020). Psychological abuse. Elder Abuse, 163–182. New York State Education Department. (1989). Identification and reporting of child abuse and maltreatment —  explaining reporting requirements —s​ tudy requirements for licensing. https://www.op.nysed​ .gov/about/training-continuing-education/ mandated-training-related-child-abuse NIH Workshop. (2015). Multiple approaches to understanding and preventing elder abuse and mistreatment. Proceedings of the Cross Disciplinary National Institute of Health Workshop. N.Y. Connects. (n.d.). Visiting nurse hospice service. https://www.nyconnects.ny.gov/providers/visitingnurse-hospice-and-palliative-care-doh-ag-3505 Phelan, A., Fealy, G., & Downes, C. (2017). Piloting the older adult financial exploitation measure in adult safeguarding services. Archives of Gerontology and Geriatrics, 70, 148–154. Pillemer, K., Burnes, D., Riffin, C., & Lachs, M. S. (2016). Elder abuse: Global situation, risk factors, and prevention strategies. The Gerontologist, 56(Suppl. 2), S194–S205. Pillemer, K., & Moore, D. (1990). Highlights from a study of abuse of patients in nursing homes. Journal of Elder Abuse & Neglect, 2, 5–29. Platts-Mills, T., Sivers-Teixeira, T., Encarnacion, A., Tanksley, B., & Olsen, B. (2020). EM-SART: A scalable elder mistreatment screening and response tool for emergency departments. Generations, 44(1), 51–58. Quinn, M. J., Nerenberg, L., Navarro, A. E., & Wilber, K. H. (2017). Developing an undue influ-

ence screening tool for adult protective services. Journal of Elder Abuse & Neglect, 29(2-3), 157. Quinn, M. J., & Tomita, S. (1986). Elder abuse and neglect. Springer. Quinn, M. J., & Tomita, S. (1997). Elder abuse and neglect (2nd ed.). Springer. Reinharz, S. (1986). Loving and hating one’s elders: Twin themes in legend and literature. In K. Pillemer & R. Wolf (Eds.), Elder abuse conflict in the family (pp. 25–48). Auburn House. Reis, M., & Nahmiash, D. (1995). Validation of the caregiver abuse screen (CASE). Canadian Journal on Aging, 14, 45–60. Reis, M., & Nahmiash, D. (1998). Validation of the indicators of abuse (IOA) screen. The Gerontologist, 38(4), 471–480. Rosay, A. B., & Mulford, C. F. (2017). Prevalence estimates and correlates of elder abuse in the United States: The national intimate partner and sexual violence survey. Journal of Elder Abuse & Neglect, 29(1), 1–14. Rosen, T., LoFaso, V. M., Bloemen, E. M., Clark, S., McCarthy, T. J., Reisig, C., . . . Lachs, M. S. (2020). Identifying injury patterns associated with physical elder abuse: Analysis of legally adjudicated cases. Annuals of Emergency Medicine, 76(3), 266– 276. https://doi.org/10.1016/j.annemergmed​ .2020.03.020 Saunders, C. (2000). The evolution of palliative care. Patient Education & Counseling, 41(1), 7–13. https://www.ecfr.gov/current/title-42/part-418 Simmons, J., Wiklund, N., Ludvigsson, M., Nägga, K., & Swahnberg, K. (2020). Validation of REAGERA-S: A new self-administered instrument to identify elder abuse and lifetime experiences of abuse in hospitalized older adults. Journal of Elder Abuse & Neglect, 32(2), 173–195. Singer, P. A., Martin, D., Schofield, M. J., & Mishra, G. D. (1996). Vulnerability to Abuse Screening Scale (VASS). University of Iowa, Roy J. and Lucille A. Carver College of Medicine. Singer, P. A., Martin, D. K., & Kelner, M. (1999). Quality-of-life care: Patient’s perspectives. Journal of the American Medical Association, 281(2), 163–168. Spreng, R., Karlawish, J., & Marson, D. (2016). Cognitive, social, and neural determinants of diminished decision making and financial exploitation risk in ageing and dementia: A review and new



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model. Journal of Elder Abuse & Neglect, 28(4–5), 320–344.

STAT 5467 (S2961). https://www.congress.gov/ bill/115th-congress/senate-bill/2961/titles

Storey, J. E. (2020). Risk factors for elder abuse and neglect: A review of the literature. Aggression and Violent Behavior, 50, 101339.

Weinrich, D. (2002). Elder abuse: A hidden tragedy. Perspectives on Gerontology, 7(1), 5–10. https:// pubs.asha.org/doi/10.1044/gero7.1.5

Stuart, B. (1999). The NHO medical guidelines for non-cancer disease and local medical review policy: Hospice access for patients with diseases other than cancer. Co-published simultaneously in The Hospice Journal, 14(3/4), 139–154; and The hospice heritage: Celebrating our future (pp. 139–154). Haworth Press.

Woolf, L. (1998). Elder abuse and neglect. http://faculty​ .webster.edu/woolflm/abuse.html

Sullivan, P., & Knutson, J. (2000). Maltreatment and disabilities: A population-based epidemiological study. Child Abuse and Neglect, 24, 1257–1273. Teresi, J. A., Ocepek-Welikson, K., Ramirez, M., Solomon, J., & Reingold, D. (2019). Methodological approaches to the analyses of elder abuse screening measures: Application of latent variable measurement modeling to the WC-RAPS. Journal of Elder Abuse & Neglect, 31(1), 1–24. Supporting Older Americans Act of 2020 (2020). PLAW 116-publ131, Section 102 [13][A][B]. https://www.congress.gov.plaws/publ131 Ulrich, L. P. (2001). The Patient Self-Determination Act: Meeting the challenges in patient care. https:// academic.udayton.edu/lawrenceulrich/psda.htm University of Texas Health Science Center at Houston. (n.d.). Geriatric education. https://www.uth.edu/ aging/geriatric-education U.S. Department of Health and Human Services. (2021). Children’s Bureau. https://www.acf.hhs.gov/ cb/focus-areas/child-abuse-neglect U.S. Department of Health and Human Services, Administration for Children and Families. (2006). Child neglect: A guide for prevention, assessment, and intervention. U.S. Government Printing Office. U.S. Department of Health and Human Services, Children’s Bureau. (2023). Child maltreatment reports from 1995 to 2023. https://www.acf.hhs.gov/ cb/data-research/child-maltreatment U.S. Department of Health and Human Services, National Center on Child Abuse and Neglect. (1994). Child maltreatment 1992: Reports from the states to the National Center on Child Abuse and Neglect. U.S. Government Printing Office Victims of Child Abuse Act Reauthorization Act of 2018 (2019) Public Law No. 115-424 (2019), 132

World Health Organization. (2022). Elder abuse. https://www.who.int/news-room/fact-sheets/detail/ abuse-of-older-people Yonashiro-Cho, J., Gassoumis, Z. D., & Homeier, D. C., University of Southern California, & United States of America. (2019). Forensic markers of physical elder abuse: Establishing a medical characterization and identifying the criminal justice approach to investigation and prosecution.

Resources Note:  The web addresses and phone numbers of these resources are fluid and should be checked for accuracy at time of use. Administration on Aging U.S. Department of Health and Human Services 330 Independence Avenue, SW Washington, DC 20201 Telephone: 202-401-4634 Website: https://acl.gov Adult Protective Service (APS) Call directory assistance and request the number for the department of social services or aging services in your county. American Academy of Pediatrics Check this website for information on what to know about child abuse. Website: https://www.aap.org Area Agency on Aging Look in the government section of your telephone directory under the terms “aging” or “elderly services.” This agency can provide the phone number for the local ombudsman for long-term care in your area. Website: https://www.usaging.org/ Child Help U.S.A. Hotline Telephone: 800-422-4453 (24 hours) Website: https://www.childhelp.org Elder Abuse Resources Website: https://www.cdc.gov/violenceprevention/ elderabuse/index.html

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Eldercare Locator For those who want to identify aging services in specific communities, call this Administration on Aging agency. Telephone: 800-677-1116 Website: https://eldercare.acl.gov/Public/Index.aspx. Health and Human Services Check this website for information on how to report the maltreatment of children with disabilities. Website: https://www.hhs.gov/

Website: https://archrespite.org/caregiver-resources/ respitelocator/ Youth Crisis Hotline Helps individuals reporting child abuse of children ages 12 to 18. Telephone: 800-448-4663 Website: https://www.stopitnow.org/ohc-content/ crisis-hotlines-for-youth

Other Websites

Medicaid Fraud Control Units (MFCU) Every State Attorney General’s office has an MFCU to prosecute Medicaid provider fraud and patient abuse in long-term care or home health care settings. Website: https://oig.hhs.gov/fraud/ medicaid-fraud-control-units-mfcu/

AARP: Coping With Grief and Loss: https://www.aarp.org/griefandloss

Mental Help Net Provides information and referral numbers for numerous national hotlines. Website: https://mentalhelp.net/

AGS Foundation for Health in Aging: https://www.healthinagingfoundation.org/

National Center for Missing and Exploited Children Helps families and professionals. Telephone: 800-843-5678 Website: https://ojjdp.ojp.gov/programs/ national-center-missing-and-exploited-children National Center on Elder Abuse State directory of help lines, hotlines, and elder abuse prevention resources. Website: https://ncea.acl.gov; https://www.napsanow.org/ National Committee to Prevent Child Abuse Website: https://preventchildabuse.org/ National Domestic Violence Hotline Helps children, parents, friends, and offenders of family violence. Telephone: 800-799-7233 Website: https://www.thehotline.org/ National Parent Hotline Call for support from trained persons. Part of Parents Anonymous. Telephone: 855-4APARENT Website: https://www.nationalparenthelpline.org National Respite Locator Service Helps parents, caregivers, and professionals caring for children with disabilities, terminal illnesses, or those at risk of abuse. Telephone: 800-677-1116

Agency for Health Care Research and Quality: https://www.ahrq.gov Aging Life Care Association: https://www.aginglifecare.org

Alzheimer’s Association: https://www.alz.org Alzheimer’s Disease Education and Referral Center at the National Institute of Aging: https://www.nia.nih.gov/alzheimers American Association of Homes and Services for the Aging: https://leadingage.org/ American Association of Retired Persons (AARP): https://www.aarp.org American Geriatrics Society: https://www.americangeriatrics.org American Society on Aging: https://www.asaging.org Association for Gerontology in Higher Education: https://www.aghe.org Benefits Checkup: https://www.benefitscheckup.org Brookdale Center for Health and Longevity: https://www.brookdale.org Caregiver Survival Resources: https://www.caregiver.com Caregiving Online: https://www.caregiving.com Careguide@Home — Elder Care: https://www.eldercare.com



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The Eldercare Directory: https://www.eldercaredirectory.org

National Hispanic Council on Aging: https://www.nhcoa.org/

ElderCare Online: https://www.ec-online.net

National Association of Area Agencies on Aging: https://www.N4A.org

Eldercare Workforce Alliance: https://eldercareworkforce.org/

National Association of State Units on Aging: https://www.nasua.org

Elderweb — Center for Eldercare: https://www.seniorliving.org

National Caregivers Library: https://www.caregiverslibrary.org

Family Caregiver Alliance — National Center on Caregiving: https://www.caregiver.org

National Center on Addiction and Substance Abuse: https://www.centeronaddiction.org/

Fisher Center for Alzheimer’s Research Foundation: https://www.alzinfo.org Gerontology Society of America: https://www.geron.org GriefNet: https://www.rivendell.org Health and Age: https://www.healthandage.com Health Care Financing Administration: https://www.federalregister.gov/agencies/ health-care-finance-administration Healthfinder: https://www.healthfinder.gov Hospice Foundation of America: https://www.hospicefoundation.org Jewish Family and Children Agencies: https://www.jfcsaz.org Marcus Institute for Aging Research, Harvard Medical School Affiliate: https://www.marcusinstituteforaging.org

National Council on the Aging: https://www.ncoa.org National Institutes of Health: https://www.nih.gov/ National Institute on Aging: https://www.nia.nih.gov/ National Rehabilitation Information Center: https://www.justiceinaging.org Senior Link: Innovation in Care Collaboration: https://www.seniorlink.com SeniorNet: http://www.seniornet.org Social Security Administration Online: https://www.ssa.gov USDA Nutrition, U.S. Department of Agriculture. https://www.Nutrition.gov

Videos Related to Palliative Care and Hospice

National Academy of Elder Law Attorneys: https://www.naela.org

https://www.youtube.com/watch?v=FOQhUcfZ9kk

National Asian Pacific Center on Aging: https://napca.org

https://www.youtube.com/watch?v=rfeqVGf_PB0

https://www.youtube.com/watch?v=5A6B-2ZEWbs https://www.youtube.com/watch?v=xO8OqQkXEfQ

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Appendix 20–A Case 1:  Joshua Joshua lived with his father. The father’s then-wife informed the county police that the father was physically abusing Joshua, who was around 3 years old at the time. The county department of social services investigated the claim, but the father denied the allegations, and the inquires stopped. A year later, Joshua presented to the hospital with multiple bruises and abrasions covering his body, leading the treating physician to suspect child abuse and report the injuries to the department of social services. The hospital was then granted temporary custody of Joshua, and a multidisciplinary team examined the case. The team concluded there was not enough evidence to keep Joshua away from his father’s custody but required the father to enroll Joshua in a preschool program and participate in counseling services. Joshua was returned to his father. The department of social services started making monthly visits to the home and noted suspicious injuries on Joshua’s head and observed he was not enrolled in school as was previously agreed upon. Despite all of this, the department of social services took no further action. When Joshua was 4 years old, his father beat him so badly that Joshua suffered a massive brain hemorrhage and fell into a coma. The child underwent emergency neurosurgery, which revealed older brain hemorrhages consistent with shaken baby syndrome. Given his permanent brain damage, Joshua was expected to live the rest of his life institutionalized.

The father pled no contest to felony abuse charges and was sentenced to 4 years in prison. The mother, on behalf of Joshua, filed a lawsuit against the county and the department of social services, claiming a lack of intervention to protect Joshua. The legal decision was in favor of the individual state laws, allowing each state to determine liability in cases where the state has failed to act. However, the Supreme Court saw this case otherwise. The state was not the agent who physically beat Joshua into a coma, but the state did play an indirect role in the child’s fate. A state is to be held accountable because under the current structure, mandated reporters’ responsibility is to report the suspected child abuse. A state assumes a special relationship with child abuse victims since it is the epicenter for dealing with mandated reporters, alleged child abuse victims, and suspected abusers. Mandated reporters are compelled to report suspected child abuse cases to state entities and would be held accountable for failing to report; therefore, states should be held accountable for what happens after the report is made. The author’s reason for including this case is to show that all parties need to take reporting suspected abuse very seriously, and that even then, there is a series of steps in the justice system, creating complex outcomes. The first and very necessary piece is to watch for and report suspected abuse, initiating the system responses.



CHAPTER 20   Child Abuse and Elder Mistreatment/Abuse

Appendix 20–B Case 2:  Sam Sam Smith is an adult with an intellectual disability and mental health problems. He lived with his grandmother, who managed his life for him until her death a year ago. Sam’s only time away from his grandmother was the couple of years he spent in a vocational training program. After Sam’s grandmother died, he moved into a licensed board and care home. The owner of the facility made Sam clean the house and do all the yardwork without receiving adequate food and nutrition. When the neighbors reported this to the proper agency, the agency discovered the inadequate care the residents were receiving and the facility’s license was revoked. The agency tried to help Sam move to a safer, better environment, but he was fearful and declined to move at that time. The agency continued to contact and work with Sam for the next year before Sam was willing to relocate to another facility. The agency assisted by: n

Locating an assisted living facility that could provide a healthy and safe living environment for Sam

n

Assisting Sam in moving to his new home

n

Helping Sam apply for medical benefits and attendant care benefits, and assisting him in completing applications for caregiving services

n

Arranging primary medical care for Sam, as he hadn’t seen an MD in a decade

n

Transporting Sam to all follow-up medical appointments

n

Arranging for Sam to participate in an arts program to enhance his social activities

After 3 months, Sam had adjusted nicely to his new home. He had made friends with many of the other residents and was participating in new activities through the arts program. He had started to attend his local church, participate in outings offered by the assisted living program, and engage with the other residents.

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Appendix 20–C Case 3:  Miriam The local elder care agency received a report on Saturday afternoon from a hospital regarding Mrs. Miriam Wiles, a frail 95-year-old female. On Thursday, the hospital determined that Mrs. Wiles was ready to be discharged following a fall in her home. She had remained in inpatient and skilled rehabilitation care in the facility for 5 months. At the point of discharge from therapy and the facility, she was weak, had difficulty lifting her weight from sitting to standing, and had trouble maintaining her balance. The hospital recommended that Miriam move to a rehabilitation center to regain her strength. Miriam refused, so the hospital discharged her to her home. She lived in an accessible one-level home, with a son and daughter living within a 5-mile radius of the home. She accepted home health services with providers coming for an hour at breakfast, lunch, and dinner to assist with meals and dressing. On Saturday following the week of her discharge from the hospital, the hospital telephoned Miriam to monitor her medications but could not get an answer to their call. They called the local elder care agency to investigate. The agency worker was unable to reach Miriam by telephone, so he went directly to her home. There was no answer despite repeated knocking on her door and ringing the doorbell. The agency worker called a family member who was unable to come, so the agency worker called emergency

services and the police were dispatched. When the police arrived, the agency worker entered with the police and located Miriam sitting in her recliner chair, where she had been stationary for 6 hours because she was too weak to stand up by herself. Mrs. Wiles was overjoyed that someone had discovered her, because she did not have her emergency alert button in a location that she could access and call for help, and was otherwise too isolated for anyone to hear or come to assist her. The agency assisted by: n

Calling the paramedics to transport Miriam to the hospital for further evaluation

n

Following Miriam to the hospital and making sure she was readmitted there

n

Working with the hospital to ensure adequate home care services were in place before Miriam was discharged home

n

Advocating to make sure that Miriam accepted the in-home care services and that they addressed her needs

Miriam was very thankful for the agency’s help and was happy to be safe in her home.



CHAPTER 20   Child Abuse and Elder Mistreatment/Abuse

Appendix 20–D Common Reactions in the Grief Process Grief:  Experiencing the blend of emotional, behavioral, intellectual, and physical reactions to a loss.

n Tearfulness

Physical Changes

n

Urinating frequently

n

Vomiting/dry heaves

n

Weakness, especially in legs

n

Weight gain or loss

n

Appetite — loss or increase

n

Breathing difficulties n Hyperventilation n

Shortness of breath

n Trembling

Behavioral Changes

n

Chest tightness

n

Dizziness or fainting spells

n Absentmindedness

n

Dry mouth

n

Accident proneness

n Fatigue

n

Appetite changes

n

GI upset

n

Fingernail biting

n Constipation

n

Grinding teeth

n Diarrhea

n

Hair twisting

n

Hypermobility — can’t sit still

n Nausea

n

Hands cold

n Headaches n

Hives, rash, itching

n Indigestion

n Nightmares n

Searching/calling out

n

Treasuring objects of deceased

Flare-Ups

n

Insomnia — sleeping changes

n

Low resistance to infection and minor illness

n Allergies

n

Muscle tightness in face, jaws, back of neck, shoulders

n Arthritis

n

Numbness or tingling extremities

n

Pounding or rapid heartbeat

n Sighing n

Skin pale

n

Sleeping too much/too little

n

Speech slowed, stuttering

n

Stomach butterflies

n

Stomach gas

n Sweating

n Asthma n Colitis n Herpes n

Canker sores

n

Cold sores

n Migraines

Emotional or Social Changes n Ambivalence n Agitation

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n

Anger or angry outbursts

Sense of Presence

n Anxiousness

n

Feelings that the deceased is still with you

n

Blaming others

n

n

Critical of self

Thinking you hear them in the driveway, smell their perfume, even see them in public

n Crying n Depression n Dread n Emancipation n

Fear of groups or crowds

n

Fear in general

n

Guilty feelings

Intellectual (Cognition) n

Concentration difficulties

n Confusion n Disbelief n

Errors in judging distance, grammar, pronunciation, use of numbers

n

Fantasy life increased/decreased

n Helplessness

n

Lack of attention to details

n Hyperexcitability

n

Lack of awareness to external events

n

n

Loss of creativity

n Indecisiveness

n

Loss of productivity

n Irritability

n

Mental blocking

n Jealousy

n

Overattention to details

n Loneliness

n

Past-oriented rather than present or future.

n

Loss of interest in living

n

Preoccupation with the decreased

n

Loss of self-esteem

n

Worrying about everything

n

Moodiness or mood swings

Impulsive behavior

n Relief n Restlessness n Sadness n Suspiciousness n

Withdrawal from relationships

n Worthlessness n Yearning

Spiritual n

Questioning divine will

n

Difficulty trusting in self

n

Increase/decrease in faith; searching for meaning

n

Feeling connected/disconnected with others

n

Struggling with/searching for Creator/images of God

21 Working With Culturally and Linguistically Diverse Populations Shirley Huang and Pui Fong Kan

The views expressed in this chapter are those of the authors and do not necessarily represent those of the National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, the U.S. Department of Health and Human Services, or the University of Colorado–Boulder.

Introduction In the last few years, exposure to COVID-19 inequities, national dialogue about racism, and hate crimes against minority populations have pushed forward the importance of addressing systemic racism that exists in health care. Systemic racism continues to permeate every level of society that affects our health care service and delivery — from educational institutions that train the next generation of clinicians to research enterprises that support evidence-based practice (e.g., Ellis & Kendall., 2021; Martinez-Acosta & Favero, 2018; Wingfield, 2020). Dr. Martin Luther King, Jr. said it best: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane” (King, 1966). Members of the American Speech-Language-Hearing Association (ASHA), including speech-language pathologists (SLPs), audiologists (AuD), speech-language pathology and audiology assistants, and scientists, all serve to uphold ASHA’s vision in “making effective communication, a human right, accessible and achievable for all” (ASHA, n.d.-e). We as a discipline have a collective responsibility to eliminate cultural and linguistic barriers in accessing and navigating the health care system, correct the power imbalances embedded in educational and health care systems and among different racial and ethnic communities, and identify implicit and explicit biases to create an equitable, accessible, and inclusive health care system for all. Our antiracist work in providing culturally responsive care to diverse populations, training minority students in clinical settings, or conducting inclusive research with underrepresented communities does not occur in a vacuum. Rather it occurs within the context of a larger ecosystem that includes the social environment, politics and policies, natural disasters, economic factors, pandemics, wars, globalization, and human migration — all of which are subject to change over time. At the level of clinicians 421



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or researchers, these factors may seem far removed or indirectly related to our daily work, yet they have influential and cascading effects on the work we do with culturally and linguistically diverse populations — populations that have historically been considered vulnerable. For example, political priorities can affect governmentfunded programs such as head start programs that often serve low-income families, and health care policies can affect our service provision for those with limited health insurance. Whether we work with children or adults in public schools or skilled-nursing facilities, we all must be informed consumers of current events and understand how these systems impact our practice and research with culturally and linguistically diverse populations. In this chapter, we will cover the following topics: n

Cultural and language differences, including language characteristics in bilinguals

n

Updated demographic data on the U.S. population and ASHA members

n

Cultural and linguistic competency in service delivery with children and adults

n

Systems-level barriers that perpetuate health care inequities

n

Strategic actions to dismantle racism in health care and improve quality of life for all

Demographic Landscape in the United States The latest 10-year demographic data collected by the U.S. Census Bureau in 2020 revealed that the U.S. population’s racial and ethnic diversity increased since last measured in 2010, such that more than 40% of Americans now identify as people of color (Frey, 2021; Jenson et al., 2021). As the racial, ethnic, and language diversity in the United States increases, clinicians and researchers must be prepared to work effectively and competently with individuals and families as well as with their colleagues, who come from culturally and linguistically diverse backgrounds. ASHA’s Scope of Practice (ASHA, 2016) states that we “are committed to the provision of culturally and linguistically appropriate services and to the consideration of diversity in scientific investigations of human communication and swallowing.” Clinicians and researchers in the speech, language, and hearing sciences field are likely to work with someone whose racial and ethnic background are different from their own and therefore must learn how to navigate these cultural and language differences.

Population Estimates and Projections Data from the U.S. Census provides population estimates and projections to inform us on how to best allocate resources and services to people from different backgrounds across the United States. The U.S. population is now over 330 million people composed of 61.2% White, 18.8% Hispanic or Latino, 12.1% Black or African American, 5.8% Asian, 1% American Indian and Alaska Native, 0.2% Native Hawaiian and other Pacific Islander, 7.2% of another race, and 12.6% of two or more races (U.S. Census Bureau, 2021). In the coming decades, the racial and ethnic composition of the United States is projected to grow and change even further (Vespa et al., 2020). The fastest-growing population, of people who are mixed race (i.e., two or more races), is projected to grow by 200% by 2060. The nextfastest growth will be the Asian population, whose count is projected to double, followed by the Hispanic population, which will nearly double in the next 4 decades. It is important to remember that there are subgroups within a larger racial and ethnic group. For example, Asian is a large ethnic group that can include Vietnamese, Japanese, Korean, Indonesian, and many others. Each ethnic subgroup may speak a different language or dialect or have cultural values and beliefs that are different from another subgroup. Therefore, clinicians and researchers working with different ethnic groups must be cautious not to overgeneralize about someone’s cultural experiences simply because they belong to a larger ethnic group.

Language Use In addition to racial and ethnic growth and changes, language profiles in the United States have also changed over time. Based on the latest U.S. Census Bureau report, nearly 68 million people (21.6%) who are 5 years or older speak a language other than English in the home, which is broadly divided into four major language groups: Spanish (13.2%), other Indo-European languages (3.8%), Asian and Pacific Island languages (3.5%), and other languages (1.2%; Figure 21–1). Between 1980 and 2019 (Dietrich & Hernandez, 2022), the largest language growth increase was for Spanish speakers (30 million increase), followed by Chinese speakers (2.9 million increase). More recently in the 21st century, several language groups have shown remarkable growth between 2000 and 2019. For example, the Indian languages group (e.g., Gujarati, Hindi, Urdu, Punjabi, Bengali, Telugu, Tamil) grew between 82.2% and 351.5%, the African languages group (e.g., Amharic, Igbo, Swahili, and Yoruba) grew by 321.2%, and the other Asian languages group (mostly South Asian languages) grew by 201.8%. This growing and changing language diversity

Figure 21–1.  U.S. map of language spoken by individuals age 5 or older by state. Source: American Community Survey. (2021). https://data.census.gov/

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is part of our national fabric, so clinicians and researchers should view multilingual populations in clinical and research settings as part of the norm rather than as the exception.

Refugee and Immigrant Populations Increased refugee resettlement and immigration have contributed to the changes and gains in the language, as well as racial and ethnic, composition in the United States. A refugee is someone who is forced to flee from their home country because of persecution, war, violence, or famine to cross an international border and is unable to return home because they are afraid to or it is not safe to do so (United Nations, 1967). Data collected by the Office of Immigration Statistics in the Department of Homeland Security showed that a total of 11,454 people were admitted to the United States as refugees during 2021 (Baugh, 2022). The three leading countries of nationality for refugees during this period were the Democratic Republic of the Congo, Syria, and Afghanistan, followed by Ukraine, Burma, Sudan, Iraq, El Salvador, Somalia, and Eritrea. Unlike refugees, immigrants choose to leave their country of origin and settle in a foreign country. The United States is the leading country in the world with nearly 51 million immigrants in 2020 (Natarajan et al., 2022). The top three languages other than English spoken by U.S. immigrants ages 5 years and older were Spanish (42%), Chinese (6%), and Hindi (5%; Budiman, 2020). Taken together, refugees and immigrants add to our nation’s makeup of children and adults who are multilingual. Despite the growing cultural and linguistic diversity in our nation, as we will learn in the next section, the population we serve is not reflected in the demographic profiles of ASHA clinicians.

Speech, Language, and Hearing Clinicians and Scientists: Demographic Profiles Every year, ASHA updates its member and affiliate profile, which presents its annual demographic data. In this section, we summarize the latest data at year-end of 2021 and highlight data trends and patterns over the past 10 years. At year-end of 2021, ASHA had a total of 213,115 audiologists, SLPs, speech-language-hearing scientists, and clinical support personnel (ASHA, 2022b). Only 17,373 (8.2%) of the ASHA constituents self-identified as multilingual service providers, which is up slightly from 8% in 2020. There were a total of 83 spoken languages other than English reported by

those who indicated they were multilingual providers. The top five languages that had the most multilingual service providers were Hindi (615 people, 3.5%), Russian (656, 3.7%), American Sign Language (ASL; 803, 4.6%), Chinese dialects (875, 5%), and Spanish (11,559, 66.5%). The majority of ASHA multilingual service providers were White (78.3%), while 15% were Asian, 3.3% were Black or African American, 2.4% were multiracial, 0.8% were American Indian or Alaska Native, and 0.2% were Native Hawaiian or other Pacific Islander (ASHA, 2022a). Almost half (46%) of the multilingual service providers were of Hispanic or Latino ethnicity, which is only 6.2% of ASHA’s total membership and affiliation. Not only is there a small number of ASHAcertified multilingual service providers, but they are also predominantly located in New York (12.6%), Florida (15.6%), California (16.3%), and Texas (17%). Of the multilingual clinicians, many of those are Spanish-language service providers concentrated in Arizona (9.3%), California (10%), Florida (13.7%), New Mexico (15%), Texas (15.7%), and Puerto Rico (79.7%). Therefore, individuals and families who have limited English proficiency face major barriers (e.g., transportation, insurance network, scheduling) in assessing culturally and linguistically responsive health care services if they do not live in or near these states. Figure 21–2 presents a U.S. map of ASHA’s multilingual service providers by state based on year-end 2021 demographics. ASHA also summarized the demographic profiles of its members over the past 21 years (ASHA, 2022c). From year-end 2001 to 2021, ASHA constituents who identified as Hispanic or Latinos increased by 2.5% and those who identified as either American Indian/Alaska Native, Asian, Black or African American, Native Hawaiian or other Pacific Islander, or multiracial increased by 5%. Data showed a small increase in the number of different racial and ethnic groups in the past 21 years. So far, the data we summarized focused on ASHAcertified clinicians, but the lack of racially or ethnically and linguistically diverse clinicians extends to scientists in the speech, language, and hearing sciences field. The year-end 2021 report showed that out of the 4,475 ASHA members and affiliates who hold a PhD, 83.7% were White, 7.4% were Asian, 7.1% were Black or African American, 4.2% were Hispanic or Latino, 1.4% were multiracial, 0.2% were American Indian or Alaska Native, and 0.2% were Native Hawaiian or other Pacific Islander (ASHA, 2022d). Many ASHA members and affiliates with PhDs conduct research to contribute to evidence-based practice, shape the national scientific agenda and landscape, and/or evaluate science and health care policies — all of which have cascading effects on the individuals and families we serve. Therefore, the

Figure 21–2.  U.S. map of ASHA’s bilingual service providers by state. Source: Based on data from American Speech-Language-Hearing Association. (2022b). 2021 demographic profile of ASHA members providing multilingual services. https://www.asha.org

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lack of culturally and linguistically diverse ASHA constituents with PhDs may cause biases in both science and health care. When the individuals and families we serve are from diverse racial and ethnic and linguistic backgrounds but data from the past 20 years persistently show that majority of ASHA clinicians and scientists are White and/or monolingual (ASHA, 2022a, 2022b), this is not just a gap in services but rather a chasm in the speech, language, and hearing sciences field. We need more clinicians and scientists from diverse backgrounds who understand the cultural and linguistic nuances, traditions, social norms, and expectations, as well as for White-majority clinicians to develop cultural and linguistic competency skills to provide quality services and reduce systemic racism. While we strive for the racial and ethnic profiles of ASHA constituents to reflect the culturally and linguistically diverse populations we serve, recruiting more people from diverse backgrounds cannot and should not be the only solution to addressing this multidimensional problem. As we will learn in later sections, cultural and linguistic competency, cultural humility, and cultural responsiveness are critical when working with individuals whose ethnicity, race, or language spoken are different from our own.

of cultural diversity (e.g., gender identity, neurodiversity, different abilities). ASHA recognizes that “some of the cultural variables that may influence the perceptions and behaviors of both individuals and clinicians are age, disability, gender, occupation, religious beliefs, race, sexual orientation, socioeconomic status . . . ” (ASHA, n.d.-a). In this chapter, we will use the term CLD people instead of Black, Indigenous, and People of Color to more broadly include different cultural and linguistic groups who may not be racially or ethnically diverse (e.g., Deaf population who use sign language). Linguistic diversity may include people who understand and use more than one language in different language communities (i.e., bilingual/multilingual), speak with an accent, or use different language dialects (e.g., African American Vernacular English [AAVE]). It is important that clinicians working with populations from linguistically diverse backgrounds understand that a language difference is not a disorder and do not misdiagnose or develop inappropriate and ineffective treatment plans. Awareness of our own and others’ cultural and language backgrounds and community belonging is important when providing clinical services or conducting research that is culturally and linguistically responsive.

Cultural Differences

Defining Cultural and Linguistic Diversity The broad term “culturally and linguistically diverse (CLD) populations” is used to describe people or communities from different backgrounds, including race, ethnicity, language, religion, and nationality. The UNESCO Universal Declaration on Cultural Diversity defined culture as The set of distinctive spiritual, material, intellectual and emotional features of society or a social group . . . [that] encompasses, in addition to art and literature, lifestyles, ways of living together, value systems, traditions and beliefs . . . [and] a source of exchange, innovation and creativity. (UNESCO, 2001)

The United Nations established an annual World Day for Cultural Diversity for Dialogue and Development to continue promoting respect for cultural diversity, advancing commitment to human rights, and learning about intercultural exchanges. Culture is not static but rather dynamic, evolving with changes in demographics, politics and policies, economics, or globalization. While the majority of this chapter will focus on racial and ethnic diversity, accompanied by different language backgrounds, we will also address other characteristics

Culture is not exclusively defined by groups of people who share the same racial, ethnic, or religious background or come from the same country of origin. There are also cultural groups that developed based on their shared neurodiversity, sexual and/or gender orientation, or linguistic backgrounds (e.g., sign language). The term neurodiversity is broadly defined as the infinite variations in neurocognitive functioning in humans and is often used in the context of the autistic community. The neurodiversity paradigm seeks to depathologize and see these differences as natural and valuable factors in human diversity (e.g., Chapman, 2020). Indeed, some members of the autistic community believe autism is a developmental disability that is a natural part of human diversity and strive to increase access and inclusion in society so they can reach their full potential (e.g., Autistic Self Advocacy Network, n.d.). Another culturally distinct group is the LGBTQIA+ community that brings together individuals with diverse sexual orientations or gender identities. Transgender persons may seek gender affirmation services, including voice therapy, from SLPs to safely modify their voice or other aspects of their communication style to align more closely with their gender identity or expression. It is within our scope of practice to provide our clinical expertise on the oral mechanism, vocal anatomy, and verbal and nonverbal communication skills to help meet



CHAPTER 21   Working With Culturally and Linguistically Diverse Populations

the client’s goals (ASHA, 2017, n.d.-b; Lee, 2002; Matthews et al., 2020). Clinicians and researchers working with this cultural group should stay informed of news related to LGBTQIA+ persons because changes in federal and/or state laws and regulations could impact our service provision or research and scholarly activities. For example, state-level policy changes can affect health insurance coverage for gender-affirmative services and congressional priorities about the LGBTQIA+ community can influence federal agencies’ research funding priorities. In the Deaf community, the term “big D deaf ” acknowledges deafness as a distinct culture with its own values, traditions, history, origins, and social norms, rather than as a disability. The shared communication system in Deaf culture is ASL (in North America) and is commonly used by Deaf and hard-of-hearing individuals, as well as by some hearing people. ASL is an autonomous language separate from English, with all the fundamental properties of language, including phonology, morphology, syntax, and pragmatics, and is expressed by hand movements and facial expressions (ASHA, 2019; Holcomb, 2023; National Institute of Deafness and Communication Disorders [NIDCD], 2020). Members of the Deaf community may view deafness as part of their cultural identity rather than as a disability that needs to be cured. According to ASHA demographic data (2022), there are 803 ASHA members who indicated that they communicate using ASL. However, there is no reported information on whether these ASHA members are Deaf or hard of hearing themselves and identify as being a part of Deaf culture. SLPs and audiologists who work with Deaf or hard-of-hearing individuals should collaborate with ASL interpreters, educate themselves about Deaf culture and the language, and/or make referrals to health care professionals who have specialized knowledge and skills in this cultural and language area. There are many differences in what people from racial and ethnic diverse backgrounds experience compared to what those in the neurodiverse, LGBTQIA+, and Deaf communities experience — or even the intersectionality of these different cultural groups — but they all belong to a community with shared values, beliefs, lifestyle, and social norms.

Language Differences There are over 350 minority languages in the United States (U.S. Census Bureau, 2015) as well as a diverse range of dialects, including mainstream American English, nonstandard American English, AAVE, English with foreign accents, and ASL (Benítez-Barrera et al., 2023; Dietrich & Hernandez, 2022; Stockman, 2010). It is important to note that language differences should not be mistaken for language disorders. Despite the stigma surrounding nonstandard English dialects and

foreign accents, these are not signs of linguistic incompetence. Their linguistic abilities should be respected and valued in the classroom and in society as a whole. As clinicians, we need to be aware that language diversity is not always respected or valued in the United States. Individuals who speak a nonmainstream English dialect (e.g., AAVE) or English with accents often face significant barriers to accessing clinical services (Hamilton et al., 2018; Pope et al., 2022). The individuals who speak a nonmainstream dialect or language may struggle to communicate effectively with service providers due to linguistic and cultural differences, leading to misunderstandings. Furthermore, people who speak nonmainstream dialect or language may be subjected to discrimination. The fear of being treated unfairly can lead to mistrust and reluctance to seek medical care, even in severe circumstances. These challenges might be compounded by systemic inequalities and exacerbate disparities (Ellis & Kendall, 2021). Addressing language barriers in health care and promoting cultural competence among health care providers is essential for equitable and effective health outcomes. In the following sections, we describe the language characteristics in typically developing bilingual children as an example to illustrate the potential differences in individuals learning nonmainstream language. These differences should not be mistaken as disorders.

Language Characteristics in Typical Bilinguals This section focuses on the general language characteristics of typical bilinguals with different language experiences. Bilingual individuals are heterogeneous and diverse in many aspects, such as the timeline of learning two languages, proficiency levels, and language attitudes toward their two languages (Anderson et al., 2018; Giguere & Hoff, 2020; Grosjean, 1998). For example, simultaneous bilinguals learn two languages from birth, while sequential bilinguals learn one language first and then learn a second language (L2; e.g., English) later during childhood. Many sequential bilinguals are also heritage bilinguals who grew up in a home environment learning a minority language their family speaks. Some bilinguals might have a good understanding of a language (e.g., Spanish) but may not be able to speak it fluently. Because of bilinguals’ unique languagelearning experience in each language, bilinguals’ language knowledge fluctuates over time (Hiebert & Rojas, 2021; Kohnert, 2010). As a result, bilinguals’ language skills in each language might look different from their monolingual peers (Anderson et al., 2018; Bialystok et al., 2010; Bialystok & Luk, 2012). Specific characteristics in typically developing children who are learning

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two languages or bilingual adults from diverse language backgrounds might potentially be confused with symptoms of language disorders (Ebert et al., 2014; Kohnert et al., 2020; Muñoz & Marquardt, 2003). In the following sections, we describe five general characteristics of typically developing bilingual children: (a) unique communication strategies at the beginning stage of learning a second language, (b) using two languages in a given context, (c) distributed language knowledge across two languages, (d) language attrition, and (e) cross-language interference and transfer. It is crucial for clinicians to understand these characteristics when making clinical decisions and not confuse them with a language impairment. Unique Communication Strategies at the Beginning Stage of Learning a Second Language. In the United States, many children learn a minority language at home and start to learn English (L2) in school settings. For early sequential bilinguals from minority families, early school experience involves transitioning from first language (L1) interactions in homes to L2 instructions in school settings (Duursma et al., 2007; Pearson, 2007). This period has been called the silent period, silent stage, or silent phase (Bligh, 2014; Roberts, 2014). Children receiving instructions in L2 in school settings may appear to be unwilling to interact or speak (Siraj-Blatchford & Clarke, 2000). Some typically developing bilingual children might be mistakenly thought to have a language delay or selective mutism (Clarke, 2009). However, it is important to note that not being able to communicate in English at the early stage of learning L2 is not a sign of a disorder. Recent research has shown that early L2 learners are not completely silent (Roberts, 2014). Rather, early L2 learners use multiple strategies, such as body language and L1, to express their thoughts (Bligh & Drury, 2015; Kan et al., in review; Roberts, 2014). For bilinguals, language impairment does not present only in their L2 (Bedore & Peña, 2008). To determine whether an L2 learner has a language disorder, clinicians should focus on their communication strategies in L2 settings and the external support (e.g., teacher’s use of scaffolding) they receive. Using Two Languages in a Given Context. Code switching and translanguaging are related concepts that refer to bilinguals’ use of two languages (García & Wei, 2015; Grosjean, 1995). Both concepts allow bilinguals to make sense of the world, communicate more effectively, and navigate different social contexts. Code switching refers to alternating two languages (or dialects) in the same conversation or discourse (Grosjean, 1995; Miccio et al., 2009; Paradis et al., 2011). Code switch-

ing serves many communicative functions, such as facilitating comprehension, avoiding miscommunication, expressing specific language concepts, and establishing membership in a social group (Hughes et al., 2006; Pavlenko, 2009). The amount of code switching depends on many contextual factors (e.g., communicative contexts and partners), language input, and language proficiency in each language (Beatty-Martínez & Dussias, 2017; Gutiérrez-Clellen & Simon-Cereijido., 2008). Bilinguals with language disorders do not use more atypical code-switching patterns than their typically developing bilingual peers (Gutiérrez-Clellen et al., 2009). Thus, code switching should not be considered a symptom of language deficits (Kohnert et al., 2005; Miccio et al., 2009). Translanguaging, on the other hand, is a theoretical framework and pedagogical approach that values the use of two languages by bilinguals (MacSwan, 2017; Otheguy et al., 2015). It views the use of multiple languages not as a deficit or a problem but as a natural and dynamic aspect of communication. Distributed Language Knowledge Across Two Languages.  Bilinguals use their two languages with different partners (parents versus teachers; spouse versus coworkers) in other contexts (home versus school; home versus workplace). Because of their unique language experience in each language (Kan et al., 2020), they are likely to have uneven and distributed language knowledge across two languages (Kohnert, 2010; Oller, 2005; Pavlenko, 2009). At the word level, some concepts are lexicalized in one language, some in the other, and some in both languages. Clinically, language input and the distributed nature of bilingual knowledge may explain the low language scores in bilinguals (Bedore et al., 2016; Muñoz & Marquardt, 2003; Pearson et al., 1993). Thus, when assessing language skills in bilinguals, clinicians should determine bilinguals’ linguistic knowledge in both languages as well as their opportunities to use two languages. Language Attrition.  Language attrition (or language loss) in bilinguals is the nonpathological gradual loss of language knowledge (Ecke, 2004; Köpke & Schmid, 2004). Language loss could occur in either L1 or L2, depending on the language context and the individual’s level of proficiency in each language. For example, L1 attrition is documented in immigrant children who do not have frequent opportunities to use L1 (Karayayla & Schmid, 2019) and in internationally adopted children who are adopted by a family who does not speak their L1 at home (Anderson, 2001). Language attrition could be at the phonological, morphological, lexical, syntactic, and/or semantic levels (Ecke, 2004). Language loss is not



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a disorder. Many factors are associated with language attrition, including the age of L1 and L2 acquisition, infrequent use of one language (e.g., the L1 of immigrant children), and language proficiency (Fillmore, 1991; Karayayla & Schmid, 2019; Nicoladis & Grabois, 2002; Proctor et al., 2010). Thus, when assessing children or adults from diverse language backgrounds, clinicians should examine their language knowledge holistically by considering various factors, such as language input and sociolinguistic variables. Cross-Language Interference and Transfer. Crosslanguage interference and transfer refer to how one language influences the use of another language in bilinguals. Interference is the negative effect of cross-language interaction, and transfer involves a facilitative effect of one language on performance in another (Grosjean, 2012; MacWhinney, 2005). Cross-linguistic interference and transfer have been observed in bilinguals in phonology, lexical–semantics, and morphosyntax (Goldstein & Bunta, 2012; Kaushanskaya & Marian, 2007; Nicoladis, 2006). For example, Goldstein and Bunta (2012) reported that a typical bilingual preschooler transferred Spanish phonemes such as /u/ to English (e.g., [bʊk] → [buk]). Adult L2 learners (e.g., adult immigrants) may exhibit L1 interference when speaking English (Flege et al., 2006), such as accents. The patterns resulting from interference or transfer are not indicators of language impairment. Clinicians should work with the interpreter to determine if specific error patterns in L2 are influenced by the individual’s L1 or vice versa.

“An Inconvenient Truth” Our previous sections discussed the increasingly diverse racial, ethnic, and language demographics in the United States, and our next section will address the importance of cultural and linguistic competency in clinic and eliminating systemic barriers for minority populations. However, before we do so, we want to acknowledge the reality that we work in a health care system that was not set up to include people who do not fit the mainstream (e.g., disabilities, neurocognitive differences, racial and ethnic diversity, minority languages). Activist and former presidential nominee Al Gore coined the term “An Inconvenient Truth” in his documentary and book of the same titles (Gore, 2007; Guggenheim, 2006). Gore was referring to how changing our human behaviors and thinking can address global warming issues, but people often do not want to do so because it requires effort and can be inconvenient. We borrow this phrase and adapt it here to explore the

inconvenient truths for health care providers working in a growing culturally and linguistically diverse society. It feels inconvenient to work with a translator to translate written clinical documents when we have a deadline. It feels inconvenient to conduct culturally and linguistically appropriate language assessments on bilingual children when bilingual measures do not exist in the minority language. The following sections of this book chapter strive to shift our thinking from inconvenient behaviors that continue to perpetuate exclusion and discrimination to strategic actions that dismantle barriers for people from diverse backgrounds. We as a society and as a health care field have a collective responsibility to change our behaviors to create an inclusive and equitable world for all.

Cultural Competence, Responsiveness, and Humility The terms “cultural competence,” “cultural responsiveness,” and “cultural humility” are often used interchangeably, but they each carry different meanings. Cultural competence involves the understanding of different cultural variables and/or their unique combinations and how they contribute to our perspectives and social interactions. It is not a final product, but rather a dynamic and complex process that requires continuous self-assessment and lifelong learning (ASHA, n.d.c). Cultural responsiveness is a practice of taking into consideration others’ cultural beliefs, perspectives, behaviors, and attitudes that are different from our own and then actively and effectively responding by creating spaces where those cultural variables are valued and respected (Hopf et al., 2020; Hyter & Salas-Provence, 2019). Cultural humility requires self-reflection and selfevaluation to acknowledge one’s biases and how those affects our interactions, decision making, or beliefs. It also involves a willingness to admit what one does not know followed by the drive to seek that knowledge (Lekas et al., 2020; Riquelme, 2022). Cultural competence, responsiveness, and humility in the speech, language, and hearing profession is critical, especially as the racial, ethnic, and linguistic diverse makeup grows rapidly in the U.S. population relative to its slow growth in the profession. In the following sections we first address our cultural lens as it applies to our service delivery in children and adults. While we mainly address service delivery in speech and language areas, it is important that our lens also be applied to every scope of our practice, including disorders in feeding, swallowing, fluency, hearing, and voice. Next, we apply a wider cultural lens when examining inequities in larger systems within our field, including health care and education.

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Service Delivery for Children and Adults Assessment and Diagnosis Early identification of communication disorders is critical for providing effective intervention and reducing negative long-term consequences (Durán et al., 2016). However, culturally and linguistically minority children may be at risk of over- or underidentification of a speech-language disorder (Cooc, 2019; Counts et al., 2018; Morgan et al., 2015). Overidentification refers to the phenomenon where bilingual children are incorrectly identified as having a language disorder. At the same time, underidentification occurs when an individual’s language impairment has not been captured in the assessment process. Failure to differentiate language differences and language disorders delays intervention for bilingual children and could lead to a long-term negative impact on their development. Several factors, listed in the following sections, might contribute to the inaccurate diagnoses of bilingual children. The Lack of Valid Assessment Tools.  When assessing the language skills of bilinguals, both languages should be taken into consideration. One critical issue is the lack of valid and reliable bilingual standardized tests. To date, only a handful of tests report normative data of Spanish– English bilingual children (e.g., Spanish versions of the Preschool Language Scales‒5; Zimmerman et al., 2012; and the Clinical Evaluation of Language Fundamentals‒4; Wiig et al., 2006). Although there are published tests in various languages (e.g., Spanish, Chinese), many of these tests are merely translations of measures from English, with a questionable construct or content validity (McLeod & Verdon, 2014; Soto et al., 2015). Shortage of Clinicians Who Are Knowledgeable About Culturally Linguistically Diverse Populations.  Bilingual children are exposed to language and social cues from homes that might use cultural practices different from the mainstream practices. Carrying out and interpreting assessments for bilingual children requires a deep understanding of the linguistic and cultural factors that influence language development in bilinguals. Many clinicians might not feel well prepared for working with bilinguals and their families (Parveen & Santhanam, 2021; Roseberry-Mckibbin et al., 2005). Limited Data on Bilingualism.  There are over 350 minority languages other than English spoken in U.S. homes (U.S. Census Bureau, 2015). Limited data on bilingualism, especially for specific languages, can make it challenging to interpret assessment results and make

appropriate recommendations for instruction and support. It is possible that some formal and informal assessment results are inadvertently interpreted through a monolingual bias (Counts et al., 2018; Morgan et al., 2015). Language Proficiency of Bilinguals’ Two Languages. It is well documented that children’s language skills may fluctuate in relation to the use of and exposure to two languages (Cheung et al., 2019; Jackson et al., 2014; Vagh et al., 2009). For example, some children may start to lose their skills in their home language (L1), while some maintain their L1 while learning L2 (Kohnert, 2010). Thus, it can be challenging to determine a bilingual child’s language proficiency in each language, as they may be more proficient in one language than the other. ASHA adopted the International Classification of Functioning, Disability, and Health (World Health Organization [WHO], 2001) as the framework for assessment and intervention in its Scope of Practice (ASHA, 2016), which contains components of health conditions (e.g., body functions and structures; activity and participation) and contextual factors. In the context of identifying language impairment in CLD populations, clinicians need to have a clear understanding of typical and atypical language performance under diverse circumstances. Using a one-size-fits-all assessment approach may not accurately reflect bilinguals’ language abilities and may lead to underestimating or overestimating their skills. Thus, adopting a linguistically and culturally responsive assessment strategy is vital when evaluating bilingual clients (Karem & Washington, 2021). A linguistically and culturally responsive assessment approach considers a person’s cultural and linguistic background and uses appropriate assessment tools and materials (Buac & Jarzynski, 2022). This approach can help ensure that the assessment is culturally unbiased and that the results accurately reflect bilinguals’ language abilities. It also allows for more accurate identification of language disorders and can inform treatment decisions tailored to the individual’s needs. Additionally, using a culturally responsive assessment approach can help build trust and rapport with bilingual clients, improving the therapeutic relationship and ultimately leading to better outcomes. Four areas should be considered in the assessment process: (a) general knowledge and functional skills in both languages, (b) verbal and nonverbal processing skills, (c) learnability, and (d) diverse language learning environments. Measuring General Knowledge and Functional Skills in Both Languages.  Several assessment tools (e.g., language sample analysis and criterion-referenced assessments) can be used to measure general knowledge



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and functional skills in both languages. Speech and language samples in both languages (conversation or narrative) are helpful in assessing bilinguals (Kapantzoglou et al., 2017), allowing clinicians to analyze bilinguals’ morphological, syntactic, phonological, and lexical systems in both languages (Ebert & Pham, 2017). Criterion-referenced assessments such as Spanish-English Language Proficiency Scale (SELPS; Smyk et al., 2013) are helpful for examining bilinguals because the tests provide a clear and objective measure of a specific skill or knowledge area rather than comparing bilinguals’ performance to that of their peers. Therefore, criterionreferenced assessments are well suited for evaluating the progress of bilingual clients, who may be at different stages of language development and may have different language backgrounds. Additionally, criterion-referenced assessments can help identify areas of strength and weakness in bilinguals’ language skills, which can inform and support children’s ongoing development or patients’ ongoing progress. It is important to note that formal and informal testing procedures could be biased and affect the performance of individuals who have not been exposed to mainstream educational contexts. Thus, clinicians should document the clients’ verbal and nonverbal responses and consult with cultural brokers about the responses. Assessing Verbal and Nonverbal Processing Skills. Processing tasks can be another component for evaluating children and adults with language disorders (Elin Thordardottir & Brandeker, 2013; Park et al., 2020). There are two main types of processing tasks: languagebased and nonlinguistic processing tasks. Languagebased processing tasks such as nonword repetition (Elin Thordardottir & Brandeker, 2013) or sentence repetition (Archibald & Joanisse, 2009) assess an individual’s ability to hold and manipulate information in their mind over a short period — an ability considered critical for a wide range of cognitive tasks (e.g., language comprehension). Probing Learnability.  “Learnability” measures focus on the difference between the learner’s current independent functioning level and the level of functioning when a communicative partner supports his/her performance (zone of proximal development; Vygotsky, 1978). Unlike traditional tests, dynamic assessment emphasizes the learner’s learning process. Dynamic assessment involves three components: pretest, teach, and posttest. The mediated learning experiences consist of the examiner’s effort to teach, observe the child’s responses, and adjust teaching strategies (Peña et al., 2014). Recent research showed that dynamic assessment — focusing on the learning process rather than knowledge — could

effectively identify diverse children with a language disorder (Kapantzoglou et al., 2017; Peña et al., 2014; Petersen et al., 2020). Gather Information About Bilinguals’ Diverse Language Environments.  Bilinguals’ language environments play a critical role in their language skills in each language. Including community stakeholders, such as their family members and teachers, is vital in making clinical decisions. Their language environments and other contextual factors can be examined using questionnaires and ethnographic interviews. Questionnaires (e.g., parent questionnaires) with open-ended questions are helpful tools for obtaining information about the individual’s communication characteristics (AbbotSmith et al., 2018; Anderson, Mak, et al., 2018). Ethnographic observations and interviewing are effective ways to learn about the culture of the family, such as their worldview, values, and beliefs, and about the strengths and needs of the client and their family (Soto & Yu, 2014; Westby et al., 2003; Westby, 1990).

Intervention After a communication disorder or hearing loss diagnosis is confirmed, an intervention plan is developed in conjunction with other members of the intervention team. The plan includes intervention outcomes, approaches, methods, and settings. According to the International Classification of Functioning, Disability, and Health (WHO, 2001), the intervention should involve health conditions and contextual factors (ASHA, 2016). For CLD clients/patients, planning intervention requires the consideration of their history with both languages, their current and future needs for using each language across settings, and the family’s values, cultures, and needs (Dyches et al., 2004; Westby & Washington, 2017). Many existing intervention approaches have been developed based on mainstream cultural practice (van Kleeck, 1994) and may not be appropriate for all cultures. Recent research showed that linguistically and culturally responsive intervention positively affects the outcomes of bilinguals. Linguistically and culturally responsive intervention focuses on using strategies and techniques that consider a client’s cultural and linguistic background in the treatment of their language disorder (Larson et al., 2020; Mendez et al., 2015; Orosco & O’Connor, 2014). Such an intervention approach has the potential to build on cultural and linguistic strengths and maximize intervention success with the support of their families. Treatment Goal Setting.  When considering cultural responsiveness in setting treatment goals for bilingual

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children with language disorders, clinicians should consider bilinguals’ primary language, cultural background, language proficiency, and unique personal needs (Larson et al., 2020; Rivera Pérez et al., 2022). For example, dysphagia can negatively affect the pleasure of eating and thus impact the quality of life. The effects can be further influenced by patients’ cultural views about disease and disorder (Sharp & Genesen, 1996). In setting a treatment plan consistent with the client’s culture, clinicians need to include the family’s input about their communication needs, their views on the patient’s communicative functions, and their culture about family involvement (ASHA, 2013; Mendez et al., 2015). The Language of Intervention. There is growing evidence supporting intervention in bilingual children’s home language (Durán et al., 2016; Lim et al., 2019). Supporting home language is important for improving communication outcomes and helping children and adults maintain communication with their families, who may primarily speak a minority language (Durán et al., 2016; Yu, 2013). In a systematic review, Lim and colleagues examined 18 studies on treatment outcomes for individuals with neurodevelopmental disorders. Interventions delivered in the home language led to better outcomes than those delivered solely in the majority language (Lim et al., 2019). Two approaches have been proposed to provide intervention to bilinguals: the bilingual approach and the cross-linguistic approach (Kohnert, 2010; Kohnert et al., 2005). The bilingual approach focuses on cognitive processing skills common to both languages. The intervention emphasizes the aspects shared by the two languages (e.g., cross-linguistic cognates) and the metalinguistic processing skills. The cross-linguistic approach targets linguistic features or communicative functions in L1 and L2. Kohnert (2010) suggested working with the interpreter or recruiting parents or siblings to mediate interactions with the clients in their home language for the SLP who does not speak both the child’s languages. Cultural Considerations in Intervention. Clinicians serving CLD populations may or may not share the language or culture of their clients/patients/families. Due to the shortage of bilingual and bicultural clinicians, a mismatch between clients and professionals will likely be expected. One challenge is facilitating the knowledge and skills of a language the clinician does not speak. Another challenge is asking the family members to complete tasks that are not consistent with their cultural practice. To overcome these limitations, clinicians can recruit family members, peers, and paraprofessionals to implement specific facilitation strategies in the client’s home language (Kohnert et al., 2020). This pro-

cess should consider the patient’s cultural background. For example, in some cultures, play-based child–parent interaction is not common (Dyches et al., 2004; van Kleeck, 1994). Thus, it is important to gather information about the level of involvement with which the family members feel comfortable and consider the daily activities they are familiar with.

Systems-Level Inequities Going beyond cultural competency, responsiveness, and humility in our individual role as a health care provider, we as a discipline must acknowledge deeply rooted systemic issues that disrupt health equality. Culturally and linguistically diverse populations, especially racial, ethnic, and linguistic minority groups, have a long history in the United States of experiencing disparities when accessing and navigating the health care or special education system. To fully understand why, one must first understand that systemic racism is embedded in every aspect of the health care system. The goal of reducing health disparities in the United States was first acknowledged in the Healthy People 2000 initiative, and every iteration since then — Healthy People 2010, 2020, and our current iteration 2030 — has sought to eliminate health disparities all together (Office of Disease Prevention and Health Promotion, n.d.). The speech, language, and hearing sciences field, as well as the general health care profession, still have a long way to go in achieving this goal, but it is our collective responsibility to make progress in identifying and dismantling barriers and work toward health equity. We highlight only a few systems-level barriers that are directly related to our service provision — health insurance coverage, language access, and bilingual education — but clinicians and researchers should continue to learn about how other barriers show up in the systems in which they work. See Chapter 15 for further discussion.

Limited or No Health Insurance Coverage Prevents Timely Access In the United States, many racial and ethnic minority groups persistently have low rates of health insurance coverage compared to the White population. In 2021, American Indian and Alaska Native was the highest group without health insurance at 18.8%, followed by the Hispanic or Latino group at 17.7%, the Native Hawaiian and Pacific Islander group at 10.1%, the Black or African American group at 9.6%, the Asian group at 5.8%, and then the White group 5.7% (Branch & Conway, 2022). Major barriers to obtaining health insurance included paying for the cost, navigating the health



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insurance market, limited health literacy, accessing technology or internet, completing the enrollment process, or understanding eligibility criteria (Office of the Assistant Secretary for Planning and Evaluation, 2021). These barriers are especially exacerbated for those with limited English proficiency. Lack of or limited health insurance coverage can severely impact timely access to speech, language, and hearing services. For example, lack of health insurance was found to be a primary factor related to underuse of hearing aids in Hispanic-Latino adults (e.g., Arnold et al., 2019). SLPs, audiologists, and speech-language pathology and audiology assistants can explore the resources on ASHA’s webpages (www .asha.org), Billing and Reimbursement, Essential Health Benefits: Audiology and Speech-Language Pathology Services, and Advocacy Toolkit, to learn about health insurance changes in our field, how to protect health insurance access and coverage, and ways to advocate for our clients/patients, especially those from underrepresented backgrounds who may struggle to navigate the health insurance system.

Language Access Is Critical to Obtaining Quality Health Care Communication is a human right, but access to language necessary for successful communication — either written, spoked, or signed — is not always easy. An interpreter refers to someone who interprets spoken or signed language from one language to another “faithfully, accurately, and objectively . . . taking the cultural and social context into account” (National Council on Interpreting in Health Care, 2005). A translator does the same but through written language. Title VI of the Civil Rights Act of 1964 and the Americans With Disabilities Act (ADA) are federal laws that requires health care providers who receive federal funding from the Department of Health and Human services (e.g., Medicare, Medicaid) provide spoken or signed interpreters and/or translated written materials to limited English proficiency and Deaf or hard-of-hearing clients/patients. However, even after obtaining language access, linguistically diverse populations face another barrier of getting culturally and linguistically appropriate and accurate translations and interpretations (Dyches et al., 2004; Larson et al., 2020; Lim et al., 2019; Mendez et al., 2015; Orosco & O’Connor, 2014; Rivera Pérez et al., 2022; Sharp & Genesen, 1996; van Kleeck, 1994; C. Westby & Washington, 2017; Yu, 2013). Dialectal differences within a language may complicate the interpreting process if the client/patient speaks a language dialect that is different from that of the interpreter. For example, while Arabic is the official language for 28 nations, there are more than 25 different dialects of Arabic, including Leba-

nese, Moroccan, and Egyptian Arabic. Dialectal differences can influence the interpreters’ semantics, syntax, and pragmatics of language. Translating written documents is also a complex and sensitive process that must take into consideration cultural and linguistic nuances between languages. This should go without saying, but solely using a computer translation program (e.g., Google translator) is not a culturally and linguistically responsive way of translating highly sensitive documents such as special education (e.g., Individualized Education Plan [IEP]) or clinical (e.g., diagnostic reports, therapy progress notes) reports. As an example, for one of the families with whom I worked, the school used a computer program to translate the entire IEP and the parents said that none of it made sense so the IEP was rendered useless to them. Health care professionals, interpreters, and clients/ patients should work together: Clinicians can teach interpreters about commonly used terms in the health field, interpreters can educate us on the linguistically equivalent terms or phrases, and families can feel empowered to speak up when something does not make sense. Importantly, cultural brokers are knowledgeable about the sociocultural norms and expectations in a cultural group within the community, and they can be an invaluable resource for translation and interpretation services.

Policies and Politics Influence Bilingual Education Programs Bilingual students’ education has been the focus of many educational policies and political platforms — at the national, state, local, and tribal levels and in all three branches of the U.S. government. The oversimplified term “bilingual education” ranges across a spectrum from immersion programs (AKA “sink or swim”) that immerse students in English-only classrooms to maintenance/heritage language programs that use the home language to support classroom instruction (Baker & Wright, 2021). In 1968, Title VII of the Elementary and Secondary Education Act, known as the Bilingual Education Act, established a federal goal of providing limited-English speaking students with adequate education. Since then, there have been many legal battles in the United States over defining equitable education for emergent bilinguals — from Supreme Court cases such as Lau vs. Nichols (1970), which promoted bilingual instruction, to state legislative actions such as Ron Unz’s English for Children Initiative (1998), which banned the use of the home language in classrooms. Bilingual education is not just about education. This system has a steeped history of racial, political, and economic issues in the debate over the provision of bilingual education (García & Kleifgen, 2010).

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Moreover, the COVID-19 pandemic and remote learning led to unprecedented and rapid changes in the language-learning environment of emergent bilinguals. While bilingual children showed growth and maintenance of their home-language skills because they spent more time at home during COVID-19, they also showed slower English-language development because they spent less time in school (e.g., Sheng et al., 2021). Minority children with limited English proficiency, particularly newly arrived immigrants and refugee children or children of immigrants and refugees, were disproportionately affected by COVID-19 (Mengesha et al., 2022; Rafieifar et al., 2021). SLPs and audiologists working with bilingual children in the school system should be aware of how current events and educational policies and politics influence bilingual education programming and decision making in their school districts. Additionally, researchers studying bilingual children in schools should know the type of bilingual education programs (e.g., immersion or home-language maintenance programs) to better understand the language-learning environment of bilinguals, which has implications for how to best support them in the classroom.

Advocacy and Leadership Roles Maybe you are a student reading this chapter thinking, “I’m just trying to finish my coursework, clinical clock hours, and graduate!” or maybe you are a clinical supervisor thinking, “How much can I do if I only supervise one student?” You do not have to be the chief of a hospital, president of ASHA, or chancellor of a school district to lead or advocate. Advocacy and leadership are part of our everyday work in various positions as health care providers, educators, supervisors, and advisors, and developing these skills begins as early as your undergraduate and graduate training and continues as a lifelong process. There is a multitude of ways you can develop and practice your advocacy and leadership skills (see Chapters 17 and 25 to learn more about developing leadership and advocacy skills).

Contribute Your Voice to ASHA’s Multicultural Constituency Groups.  In addition to the National Student Speech Language Hearing Association (NSSHLA) and Student Academy of Audiology (SAA), the voices of students from culturally and linguistically diverse backgrounds are especially valued in ASHA’s multicultural constituency groups: Asian Pacific Islander Speech-Language-Hearing, Disability, Haitian, Hispanic, L’GASPAction Is Long Overdue: LGBTQ, Middle East and North Africa, National Black Moving the Field Forward Association for Speech-Language and Hearing, Native In the past few years, the COVID-19 pandemic and American, and South Asian Caucus. The multicultural racial justice uprisings have commanded our society’s constituency groups aims to “recruit professionals; proattention, forcing us to acknowledge systemic racism mote cultural competence and improvement in the that continues to perpetuate inequities in health care ​ quality of speech, language, and hearing services; pro— ​and this includes the speech, language, and hearing mote research and knowledge related to identification, sciences health field. Action in dismantling racism and diagnosis, and treatment; support students; advocate eliminating health disparities is long overdue; we can at the local, state, and national levels for consumers; no longer afford for progress in our discipline to be left encourage leadership and engagement in professional to chance. This section discusses some actions we can and related issues, provide professional support and take to advance the field at the systems level, including networking opportunities; and disseminate informastepping up to advocacy and leadership roles, collaborat- tion and resources’’ (ASHA, n.d.-d). In addition, these ing with communities in decision making, and chang- groups provide a space for ASHA constituents to address ing our graduate program practices. When we move issues affecting their communities, increase culturally beyond increasing cultural competency skills and shift and linguistically responsive clinical care, and advance our approach to addressing systems-level issues, we can awareness of systemic racism in health care. reduce racism in higher education, graduate training, clinical practice, and scientific contributions, which will Be There When Decisions Are Being Made. Stuconsequently improve quality of life in all the popula- dents, clinicians, or faculty members with lived experitions we serve (see Ellis & Kendall, 2021). In Supreme ences need to be at the table when important decisions Court Justice Sonia Sotomayor’s book, My Beloved are being made. When opportunities arise for a represenWorld, she wrote, “if this was the system, maybe I should tative to be at departmental meetings, student governbe working to improve it rather than simply enforcing it ment organizations, hospital grand rounds, university on the front lines” (Sotomayor, 2013, p. 237). Our title assemblies, or hiring or admissions committees, be as SLP, audiologist, or scientist does not fully capture there at the table. People from culturally and linguistiour multifaceted roles and responsibilities as advocates, cally diverse backgrounds and lived experiences can offer leaders, community partners, consumers, educators, unique perspectives and initiatives without which these issues may not have been even considered in the deciantiracists, and allies.



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sion-making process. In addition, clinical supervisors and faculty/staff who already have a seat at these tables can leverage their power and advocate for inviting more diverse voices. When we increase inclusivity, equitability, and diversity at the decision-making level, we can end the cycle of perpetuating White production of knowledge and White-centered culture that can harm minority students, faculty, clients, service delivery, and research. Provide Good Mentorship to Students From Underrepresented Backgrounds.  Mentorship at different stages of your academic, clinical, and research career is important for a successful career and well-being. Mentorship can happen whether you are a graduate student mentoring a prospective undergraduate or a professor emeritus mentoring young scientists. It is especially important that mentees from underrepresented backgrounds are paired with mentors who share and understand their cultural backgrounds and experiences to create an inclusive and safe learning environment. Mentors at all levels of their career should continue to develop their mentorship skills, including practicing their listening skills, self-reflecting on their cultural biases, and practicing flexibility to meet the mentee’s needs rather than imposing their own ideas. Communicate Your Experiences to Policymakers. At the national, state, and regional levels, ASHA constituents can voice support or opposition for various legislation that affects health care and service provision. ASHA’s annual Capitol Hill Day is an opportunity for ASHA constituents to educate members of Congress about the speech, language, and hearing sciences field and our work. On the ASHA Advocacy webpage (ASHA, n.d.-f ), you can follow a list of current legislative actions and take part in voicing your support or concerns. In addition, the ASHA State-by-State webpage (ASHA, n.d.-f ) allows you to filter your search to your state’s legislative priorities, resources, or policy changes. See Chapter 10 for further information.

CCC:  Collaborations with Community Constituents We know that the CCC in CCC-SLP or CCC-AuD stands for Certificate in Clinical Competence, but one may also consider it as an acronym for Collaborations with Community Constituents. After all, our job is to provide clinical services to communities or conduct research with communities to inform our evidencebased practice; therefore, working with communities should be a part of our job description. Community members can include local organization leaders, teachers, and parents — all of whom are acutely aware of the current events and top concerns in the community. Col-

laboration with community members can be defined in many ways. In science, it could mean seeking their input and ideas in the formulation of a research question, the feasibility of data collection, ethical interpretation of the results, and disseminating knowledge to individuals and families within that cultural group. In clinics, community collaboration could mean learning from cultural brokers and liaisons who are highly knowledgeable about the sociocultural norms, expectations, and values within a cultural group and a community. In addition, engaging in local parent support groups, town hall meetings, or community programs are informal ways to learn from the communities. Establishing a trusting and meaningful relationship with community members and leaders in clinical and research work is key to addressing systems-level issues in health care.

Graduate Programs Graduate programs in speech-language pathology and audiology serve as an important gateway for students from underrepresented racial and ethnic backgrounds to enter the field and contribute to serving the diverse populations in the U.S. However, students from culturally underrepresented backgrounds were significantly less likely to receive offers of admission than students from mainstream backgrounds. According to the Communication Sciences and Disorders education survey, conducted by ASHA (2022e), only 26.5% of first-year students in the SLP programs and 25.5% in the Audiology programs identified as racial and ethnic minorities in the academic year 2021–2022. Graduate school admission requirements, including grade point averages and GRE requirements, remain barriers for students from diverse backgrounds (Kovacs, 2022). In addition, a common issue is the lack of cultural diversity in the curricula of the graduate programs in speech-language pathology (Stockman et al., 2008). To address the challenges, graduate programs in speech-language pathology can consider several steps to create a more inclusive and culturally responsive environment and prepare students to work effectively with individuals from culturally and linguistically diverse backgrounds. Developing Strategies to Recruit Students From Underrepresented Backgrounds. The admission process can be made more inclusive by reaching out to students from underrepresented backgrounds, making the application process accessible and culturally responsive, and using holistic measures in the admission review process (Guiberson & Vigil, 2021). Incorporating Cultural Responsiveness Into the Curriculum. The graduate program can incorporate culturally diverse resources and materials into existing

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courses, invite guest speakers from the community, and provide an opportunity for students to provide culturally responsive services to clients and families (Gregus et al., 2020; Guiberson & Vigil, 2021). In addition, the program should prioritize cultural responsiveness by providing ongoing professional support for faculty and staff.

that requires ongoing self-reflection, awareness of our implicit biases, motivation to fill the learning gaps, and most importantly the driving belief that high-quality health care for all populations begins with creating an inclusive and equitable society.

Provide Information About External Resources to Students From Underrepresented Backgrounds. The program can provide information about national resources for underrepresented students, such as the ASHA Minority Student Leadership Program, Minority Scholarship Program from American Speech-LanguageHearing Foundation (ASHFoundation), and other professional development opportunities and resources (Stewart & Mishra, 2022). In addition, the program can partner with the ASHA Multicultural Constituency Groups (e.g., Hispanic Caucus) to provide mentorship and networking opportunities. Faculty can encourage students to attend conferences and events hosted by national minority organizations (e.g., National Black Association for Speech-Language and Hearing Convention; Asian Pacific Islander Speech-Language-Hearing Caucus meetings and events).

References

Evaluating and Improving the Program.  The program can conduct ongoing evaluations to assess its curriculum. For example, the program can regularly gather feedback from students, faculty, and clients; conduct needs assessments; and update the curriculum as needed to ensure it is culturally responsive and linguistically diverse.

Summary As the U.S. landscape continues to grow more culturally and linguistically diverse, our profession must be prepared to work with individuals, families, and communities whose cultural and language backgrounds are likely to differ from our own. In this chapter, we have learned the importance of cultural competency, responsiveness, and humility when conducting assessments, making a diagnosis, and providing intervention in clinical settings. Going beyond cultural competency at the individual level, we also learned that addressing systemslevel inequities in health care can dismantle barriers that minority populations often face. This profession is not for the faint hearted. There is so much to learn about the world, about ourselves, and about the people and communities we serve. There is so much work we still need to do in our commitment to eliminate health disparities, racism, and systemic barriers and increase cultural competency, responsiveness, and humility. Developing cultural and linguistic competence, antiracist thinking, and leadership and advocacy skills is a lifelong process

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Muñoz, M., & Marquardt, T. (2003). Picture naming and identification in bilingual speakers of Spanish and English with and without aphasia. Aphasiology, 17(12), 1115–1132. https://doi.org/10.1080/0268​ 7030344000427 Natarajan, A., Moslimani, M., & Lopez, M. H. (2022, December 16). Key facts about recent trends in global migration. Pew Research Center. https://www​.pewresearch.org/fact-tank/2022/12/ 16key-facts-about-recent-trends-in-globalmigration National Council on Interpreting in Health Care (NCIHC). 2005. National standards of practice for interpreters in health care. https://www.ncihc.org/ assets/z2021Images/NCIHC%20National%20 Standards%20of%20Practice.pdf National Institute of Deafness and Communication Disorders (NIDCD). (2020). American sign language. NIDCD fact sheet, hearing and balance. No. 11-4756. https://www.nidcd.nih.gov/health/ american-sign-language National Institute of Deafness and Communication Disorders (NIDCD). (2021). American sign language. NIDCD fact sheet, hearing and balance. National Institutes of Health, No. 11-4756. https://www.nidcd.nih.gov/health/american-signlanguage Nicoladis, E. (2006). Cross-linguistic transfer in adjective–noun strings by preschool bilingual children. Bilingualism, 9(01), 15. https://doi.org/10.1017/ S136672890500235X Nicoladis, E., & Grabois, H. (2002). Learning English and losing Chinese: A case study of a child adopted from China. International Journal of Bilingualism, 6(4), 441–454. https://doi.org/10.1177/13670069 020060040401 Office of Disease Prevention and Health Promotion. (n.d.). Diabetes. Healthy People 2030. U.S. Department of Health and Human Services. https:// health.gov/healthypeople/objectives-and-data/ browse-objectives/diabetes Office of the Assistant Secretary for Planning and Evaluation. (2021). Issue Brief No. HP-2021-21 “reaching the remaining uninsured: an evidence review on outreach & enrollment strategies. U.S. Department of Health and Human Services. https://aspe​ .hhs.gov/sites/default/files/documents/b7c9c6db8b​ 17c6fbfd6bb60b0f93746e/aspe-remaining-unin​ sured-outreach-enrollment.pdf

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22 Supervision and Mentoring Melanie W. Hudson and Mary Sue Fino-Szumski

Introduction This chapter is written by supervisors for both supervisees and supervisors in audiology and speechlanguage pathology. The information in this chapter is based on both the literature and personal experiences in supervising and in training supervisors in a variety of professional contexts. Good sources for more in-depth discussion of supervision in general and in speech-language pathology and audiology in particular include Anderson (1988) and McCrea and Brasseur (2003). The chapter begins with an overview of the foundations of the supervisory process, including a description of the Dreyfus Model of Skill Acquisition (Dreyfus & Dreyfus, 1986) and Anderson’s Continuum Model (Anderson, 1988). It includes a model of supervision that can be applied across all levels of experience and settings and moves to practical issues discussions. Specific discussion is directed to current issues such as the clinical fellowship (CF) experience and the audiology externship; ethics; cultural, linguistic, and generational differences; technology; training; accountability; and research needs.

A Brief History of Supervision and Mentoring An appreciation of the history of supervision and mentoring is as important to the preprofessional as it is to the seasoned clinician. Supervision and mentoring have been integral parts of both professions from their beginnings. It is safe to state that each member of the professions of speech-language pathology and audiology has participated in the supervisory process during their clinical training, certainly as a supervisee and perhaps also as a supervisor. In her book Science of Successful Supervision and Mentorship, Carozza (2011) explains the importance of knowledge of the history of supervisory education and research and how such knowledge relates to providing effective supervision. As interest in supervision and mentoring increases, and as they continue to play such a significant role in professional growth and development, it is helpful to understand the evolutionary progress of this distinct area of practice. It was not until the last quarter of the 20th century that a true understanding of supervision as a process in clinical education was established. Anderson (1988), Farmer and Farmer (1989), and Ulrich (1985) provide informative summaries of the early development of the supervisory process when the professions of speech pathology and audiology were in their infancy. During the 1960s and 445



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1970s, conferences and publications devoted exclusively to issues pertaining to supervision began to appear on the professional horizon (Anderson, 1970; Halfond, 1964; Kleffner, 1964). In 1970 the Council of College and University Supervisors was established, expanding in 1974 into the Council of University Supervisors in Speech-Language Pathology and Audiology (CCSPA). In 1975 the American Speech and Hearing Association Committee on Supervision was established and some communication science disorders (CSD) programs began course offerings in supervision. In 1985 the American Speech-Language-Hearing Association (ASHA) adopted a position statement describing competencies associated with appropriate supervision, with an emphasis on supervision of students (ASHA, 1985). As interest continued to grow, there were several national conferences devoted to the topic resulting in more publications, along with major books that continue to define the knowledge base (Anderson, 1988; Casey et al., 1988; Crago & Pickering, 1987; Farmer & Farmer, 1989). During the 1990s, there was a move toward combining theory and practice in supervision, and the ASHA Certification and Membership Handbook was revised to document the requirements for the CF year (CFY; ASHA, 1997). At the beginning of the new millennium, there was more emphasis placed on quality clinical education for audiologists and speech-language pathologists (SLPs). ASHA developed new standards for students’ courses of study that required documentation of knowledge and skills, including both formative and summative assessment in addition to new standards for academic program accreditation and certification of personnel (ASHA, 2000). Further research on the topic of merging theory and practice in supervision led to the publication of two major books (Dowling, 2001; McCrea & Brasseur, 2003). With the publication of these books, supervisors had a better understanding of how to implement effective supervisory practices supported by evidence and research. Several factors during the 2010s stimulated interest in supervision, including expanded scope of practice, personnel shortages, and sustained influx of new professionals (O’Connor, 2008). For example, supervisors may find themselves in situations where they do not feel qualified to provide supervision because an individual case is out of their scope of practice or beyond their specific skill set. Or, due to a shortage of qualified clinicians in a facility, a supervisor may not have the appropriate amount of time to provide the required supervision and mentoring, thus jeopardizing the supervisee’s ability to meet certification and/or licensure requirements. These and other types of similar situations may also

present ethical dilemmas for both the supervisor the supervisee. In keeping with some of these variables, ASHA revised its certification guidelines for the CF experience (Council for Clinical Certification, 2005). You will note that this revision includes discontinuing the “Y” designation for “year” to denote the adjustment in the length of time to complete requirements. These revised guidelines also include replacing the term “supervisor” with “mentor” to reflect the higher degree of autonomy now placed on the clinical fellow or audiology extern. Policy documents regarding CF mentoring (ASHA, 2007) and ethical issues pertaining to supervision of student clinicians (ASHA, 2010), a technical report (ASHA, 2008a) and a document addressing knowledge and skills for clinical supervision (ASHA, 2008b) were also published. During this same time period, ASHA audiology certification standards were updated in response to the transition to the doctoral degree as the entry-level degree to the profession. The 2007 audiology certification standards specified that the clinical experience required for certification was included in the educational program. There was no longer a postgraduation CF required for audiology certification and the minimum number of supervised clinical practicum hours was increased to the equivalent of 1 year of full-time experience (1,820 hours). The 2007 audiology standards also removed the minimum percentage of supervision requirement and gave discretion to supervisors on this based on a student’s training, education, experience, and competence (Allen et al., 2008). In more recent years, many professionals involved in the supervisory process have used the terms “clinical educator” and “clinical instructor” to more accurately reflect their work (CAPCSD, 2013). The term clinical educator is typically used in conjunction with the clinical training, education, and supervision of audiology and speech-language pathology graduate students. The term “preceptor” most commonly refers to audiologists who supervise audiology students in their final externship. The role of the clinical educator is to integrate theoretical, evidence-based knowledge with clinical practice to prepare student clinicians to provide quality services (ASHA, 2013a). In 2013, ASHA’s Ad Hoc Committee on Supervision (ASHA, 2013c) acknowledged that supervision is a distinct area of practice and discounted the faulty assumption that competency in clinical service delivery translates into effective clinical supervision. Experts in clinical education have long recognized that effective supervision requires a unique set of knowledge and skills and, as such, individuals must receive training to gain competence before engaging in the activity. The com-



mittee identified five constituent groups for supervision including clinical educators of graduate students, preceptors of audiology externs, mentors of clinical fellows, supervisors of support personnel, and supervisors of those in transition, with each of these groups requiring specific knowledge and skills in supervision. In 2016, ASHA’s Ad Hoc Committee on Supervision Training (AHCST) identified topics for supervision training for each of these constituent groups (ASHA, 2016). The 2020 ASHA certification standards for audiology (Council for Clinical Certification, 2018a) and speech-language pathology (Council for Clinical Certification, 2018b) recognize the need for training and experience for supervisors/clinical educators working with students, CFs, and audiology externs. The 2020 ASHA certification standards require the equivalent of a minimum of 9 months of full-time clinical experience after securing ASHA certification as a prerequisite for being involved in clinical education/supervision. In addition, 2 hours of professional development in topics related to supervision/clinical education must be completed. Many states now have specific supervision requirements in place to ensure appropriate levels of supervision and/or mentoring for the beginning clinician working toward being fully credentialed. In some states, licensing boards have enacted regulations regarding supervision of audiology externs. Further guidance related to the roles and responsibilities of an audiology preceptor is provided in the position statement on clinical education guidelines for audiology externships that resulted from the American Academy of Audiology (AAA) Taskforce on Supervision (AAA, 2006). The Council on Academic Accreditation in Audiology and SpeechLanguage Pathology (CAA) sets specific standards for clinical education for training programs (CAA, 2017) and the Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC) has established standards that incorporate supervision requirements for individuals seeking certification (CFCC, 2018a, 2018b). Individuals who enter a supervisory or mentoring relationship need to become familiar with regulations and guidelines applicable to their specific circumstances. Whether you are a supervisor, mentor, preceptor, clinical fellow, or audiology extern or hold a provisional certificate or license, the success of the experience depends on assuming this responsibility. Regulations, standards, and guidelines will be covered in more detail later in this chapter. Supervision and mentoring have played significant roles in the development of speech-language pathology and audiology since the early history of both professions. Over the years, research and evidence have demonstrated how effective supervision and mentoring support service

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delivery and positive outcomes. As a result, university programs, professional organizations, and government agencies have learned to recognize the value of effective supervision and mentoring of new clinicians. Their attempts to address this need by establishing regulations, guidelines, and training for clinical supervisors and mentors are evidence of this belief.

The Supervisory Process Supervision as a process is more easily understood when presented in the context of learning or acquiring clinical skills and knowledge in audiology and speech-language pathology. The insightful student of supervision will be able to draw a parallel between supervisee performance and supervisor expectations when such a process is taken into consideration.

The Dreyfus Model of Skill Acquisition The Dreyfus Model of Skill Acquisition (1980) describes a learning process consisting of five stages: novice, advanced beginner, competent, proficient, and expert. It is used as a means of assessing and supporting progress in the development of skills. It also provides a definition of acceptable level for the assessment of competence. Similar in its design to a developmental continuum, the learner or supervisee progresses from one stage to the next as the level of clinical knowledge and skills increases. At the novice stage, the learner has minimal knowledge connected to practice. Because supervisees at this stage have no experience in the application of rules, behavior is predictably inflexible. The novice needs to be closely supervised and cannot be expected to use discretionary judgment. The supervisor would naturally need to incorporate a more direct style of supervision, such as modeling behaviors for supervisees. At the advanced beginner stage, supervisees are able to demonstrate marginally acceptable performance, but with limited situational perception. They are beginning to treat knowledge in context, but still treat attributes and aspects separately and with equal importance. For example, they may not perceive the relationship between a hypernasal vocal quality and restricted movement of the mandible, thus viewing them as distinct areas for treatment. At the competent stage, supervisees are able to plan with more independence, deliberately using analytical assessment to treat problems in context. Competent supervisees can view actions in long-term goals and incorporate conscious, deliberate planning to achieve those goals. These supervisees are also able to use

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standardized and routine procedures while recognizing their relevance to a given situation. For example, after conducting pure-tone audiometric testing, supervisees would be able to assess the necessity of impedance testing or the use of a bone oscillator to help determine type of hearing loss. At the proficient stage, supervisees are able to see the situation as a whole in long-term goals. This holistic understanding improves decision making, as maxims are used for guidance, and they are now able to modify plans in what should be expected. Proficient supervisees perceive deviations from what is typical and, as a result, can make clinical judgments more easily. These supervisees can also see what is most important in a situation and take responsibility for their own decisions. If working with a nonverbal child with autism, for instance, these supervisees would recognize the value of joint attention training before attempting to initiate a system of picture exchange for communication. At the expert stage, clinicians are able to make decisions not only based on a set of rules, but also using their experience to manipulate these rules to achieve the end goal. Expert clinicians have an intuitive grasp of situations and only rely on an analytical approach to problem solving when unfamiliar situations occur. Expert clinicians can see the end goal and know just how to achieve it. They see the big picture and consider various alternatives, possibly going beyond existing standards to achieve the end result. The goal of a supervisor is to ensure the supervisee progresses from one stage to the next while employing effective strategies that promote increasing levels of independence. Implementation of models of the supervisory process that utilize such strategies will help achieve this goal.

Anderson’s Continuum of Supervision Jean Anderson’s book The Supervisory Process in SpeechLanguage Pathology and Audiology (1988) had a major impact in supervision. The profound influence of her work is seen in the fact that her approach to the supervisory process is reflected in the current accreditation standards for academic programs in CSD (ASHA, 2023). Anderson (1988) defines supervision as “a process that consists of a variety of patterns of behavior, the appropriateness of which depends on the needs, competencies, expectations and philosophies of the supervisor and supervisee and the specifics of the situation (tasks, client, setting, and other variables)” (p. 12). This definition supports flexibility, self-evaluation, and critical thinking. It also promotes collaboration, a key component of the process. Prior to the publication of this book, supervisory style was characterized by stricter control and higher levels of direction on the part of the supervisor. There

was very little, if any, collaboration between the supervisor and the supervisee. Anderson’s Continuum of Supervision (1988) is the most widely recognized supervision model in speechlanguage pathology and audiology (Dowling, 2001). This continuum model was influenced by the theoretical framework of Cogan (1973), whose ongoing cycle of supervision was designed to improve the performance of teachers. Anderson employs different strategies and styles that may be incorporated at different stages of the supervisory process, depending on the situation. The continuum model allows for the eventual competent independence of the supervisee while the degree of involvement of both the supervisor and supervisee shifts as they move along the continuum. The continuum consists of three stages: evaluationfeedback, transitional, and self-supervision (Figure 22–1). It is important to understand that the stages are not time bound, but allow for the supervisee to be at any given stage or point along the continuum, depending on circumstances, including knowledge and skills. An important feature of this model is that it also promotes the professional growth of the supervisor. As the supervisee progresses along the continuum, the supervisor learns to adjust their supervisory style according to the needs of the supervisee. The supervisor may choose to become more or less directive as appropriate, according to the knowledge and skills of the supervisee. Students and entry-level clinicians with minimal knowledge and skill work closely with their supervisors at the evaluation-feedback stage of the continuum. The supervisee who is a marginal student or who is working in a new setting would most likely be seen in this stage where the supervisor has a dominant role and employs a more direct style of supervision. The goal at this initial stage is for the supervisee to move as quickly as possible from a level of dependence on the supervisor to one that is more consultative in nature (McCrea & Brasseur, 2003). As the student or new clinician begins to demonstrate the ability to employ critical thinking skills and principles of reflective practice (self-evaluation), movement to the transitional stage is appropriate. At the transitional stage, supervision is a shared process and the supervisee is moving toward more independence. Supervisors now use a less direct style of supervision and employ methods that include the supervisee as an active participant in the supervisory process. Supervisors encourage the development of problemsolving skills, critical thinking, and reflective practice to guide the supervisee to higher levels of independence and competence. Individual circumstances and situations will necessitate a fluidity of movement within this stage as dictated by experience, comfort level, and skill of the supervisee (McCrea & Brasseur, 2003).



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Stages

EvaluationFeedback

Styles Direct/Active

Transitional

SelfSupervision

Collaborative

Consultative

Supervisor

Supervisee

Peer

Figure 22–1.  Anderson’s continuum of supervision. Source: McCrea, E. S., & Brasseur, J. A. (2003). The supervisory process in speech-language pathology and audiology (p. 27). Allyn & Bacon. Reprinted with permission.

We learn from Anderson’s continuum (1988) that an effective supervisory model should have a framework for systematic development of the process of supervision. The key components of such a framework should include collaborative planning, observation and data collection, analysis of data, and evaluation and feedback. Each of these elements should support principles of reflective practice that lead to self-supervision. Although professional demands and responsibilities may vary from setting to setting, these key elements are universal and not specific to any setting or profession.

pants, including the client, the clinician, the supervisee, and the supervisor. When setting goals, the needs of each of these participants should be considered and addressed appropriately. Thus, supervisors must balance helping supervisees plan for their clients and for their own clinical and professional growth. In all cases, goals should be measurable, serve as a guide for action, and serve as a source of motivation. The supervisee will more likely achieve specified goals if the supervisor offers continued support and recognizes effort and success. There have been studies supporting the use of contracts to structure the practicum experience. Christodoulou (2016) cited research in occupational therapy that recommended the use of contracts to determine practicum objectives and methods of evaluation and feedback and to identify supervisor and supervisee expectations. This approach allows for clarification of roles and responsibilities and serves to enhance the supervisory relationship. A systematic plan should provide clear expectations, strategies to facilitate interpersonal communication, and opportunities for problem solving and critical thinking on the part of the supervisee. Lulai and DeRuiter (2012) developed such a plan for new clinical supervisors working with graduate students in medical settings.

Planning.  Supervisors need to consider more than just the relationship with the supervisee as part of the planning process. McCrea and Brasseur (2020) describe the concept of careful systematic “fourfold planning” (p. 108) to achieve professional growth for all partici-

Observation and Data Collection.  The purpose of observation is to collect data on some aspects of the clinical work being done. Anderson (1988) described observation as the point at which supervision changes from being solely an art to more of a science and stressed that

The self-supervision stage is attained when supervisees no longer rely upon the feedback of their supervisors to analyze their work but can self-analyze their clinical behavior. The relationship between supervisor and supervisee becomes more of a peer interaction. At this stage, supervisees are truly competent, independent clinicians, having assumed complete responsibility for their own professional development, although they still desire peer interaction (McCrea & Brasseur, 2003).

Key Elements of the Supervisory Process

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it must be an active process if it is to be of value. She also stated that “observation without data is a waste of time” (p. 123). Objectivity in the supervisory process is achieved through clinical observation and data collection. A supervisor may want to gather information about the supervisee’s communication skills or monitor a specific clinical activity to assess quality of service delivery. Data may also be collected by the supervisees themselves, depending on the objectives set as part of the planning process. These data would typically be centered on client or patient behavior and organized in such a way that they can be related to actions of the supervisee. In any case, data collection should correspond to the goals established in relation to expected clinical activities and professional growth. There are a variety of tools used to observe and collect data in audiology and speech-language pathology. Casey et al. (1988) identified seven types of data collection including verbatim recording, selective verbatim, rating scales, tally, interaction analysis, nonverbal analysis, and those that are individually designed. To facilitate self-supervision, or reflective practice, the Kansas Inventory of Self-Supervision (Mawdsley, 1987) is an excellent example of an individually designed system for collecting specific data. New clinicians should become familiar with several data collection tools to diversify their clinical skills. Whichever methods are employed, the resulting data are analyzed so they become logical and meaningful and have a specific purpose. Analysis.  Analysis of collected data allows supervisees to observe the relationship of their behavior to that of the client. It also affords an opportunity for supervisors to observe how their actions may influence the behavior and performance of their supervisees. As cited in McCrea and Brasseur (2003, p. 193), Cogan (1973) listed the purposes of analyzing data: n

Determining if objectives from the planning stage were met

n

Identifying salient patterns in the teacher’s (supervisee’s) behavior

n

Identifying unanticipated learning by the student (client/patient)

n

Identifying critical incidents in the interaction (behavior that significantly affects the learning or relationship between teacher and student)

n

Organizing the data to determine what was learned

n

Determining if what was planned was carried out

n

Developing a database for the rest of the super­ vision program

The results of analyzed data may yield information that provides an opportunity for supervisors to improve their interactions and become more effective at their job. The results may also yield information that informs the clinician whether certain clinical procedures are effective. Objective data must be collected so that events can be reconstructed for accurate analysis (Goldhammer et al., 1980). The reconstruction of the collected data also promotes accountability and thus maintains compliance with codes of ethics for both professions. Before an objective evaluation of performance or effectiveness can occur, data must be carefully examined and interpreted. The process of analysis also provides supervisors with an opportunity to examine and interpret their own behavior to see how it influences the supervisory relationship. For instance, if the supervisor has been employing a more direct style of supervision, the supervisee may not have demonstrated sufficient confidence in determining if a certain clinical procedure would be appropriate in treatment for the client. In this situation, the supervisor would need to move from a direct style of supervision to a more flexible one that affords the supervisee more input in the decision-making process. Evaluation.  The importance of collection of objective data is underscored when an evaluation component is being considered. Literature on supervisor accountability discounts the acceptability of a totally subjective evaluation on the part of the supervisor (Anderson, 1988). When the supervisory relationship is based on a collaborative and consultative model, the effective supervisor relies on the results of analysis of objective data as part of the evaluation process. Objective data support the observations the supervisor shares with the supervisee. Dowling (2001) states that “if supervisees are truly self-evaluating, they are aware of their levels of performance and assessment becomes a joint sharing of known information” (p. 227). The process of evaluation is ongoing, and the supervisee always understands their strengths and weaknesses. The effective supervisor assists the supervisee in describing and measuring their own progress and achievement as part of this ongoing process (ASHA, 2008b). In other words, there would be no surprises at a prescribed evaluation conference with the supervisor using a collaborative model that employs tools for self-assessment. Principles of active learning support engaging students in written self-analysis of their discrete and nonverbal clinical behaviors (Gillam et al., 1990). Many university CSD programs have developed their own tools for self-assessment of clinical knowledge and skills to support these principles. Weltsch and Crowe (2006) studied the effectiveness of a supervisory approach designed to facilitate self-analysis by graduate clinicians.



They concluded that having student clinicians complete written self-analyses of recorded target intervention behaviors may lead to greater clinical competency. The Supervisee Performance Assessment Instrument (SPAI; Fall & Sutton, 2004) is an example of an instrument used for self-assessment by the supervisee. Its design supports collaboration by allowing the supervisor and supervisee to target specific areas for evaluation that can be tailored to certain individuals or groups. The format uses a nonhierarchical type of scaling and many evaluation criteria. Professionals in both educational and health care settings have developed a variety of self-assessment tools, including rating scales and performance checklists. Many of these may be adapted for use by audiologists and SLPs. Dowling (2001) discusses the importance of evaluation but states that overemphasis on this component of the process may be destructive to the supervisory relationship. The use of self-assessment tools may place the evaluation component of the supervisory process in the proper context to support a collaborative supervisory relationship.

CORE Model of Supervision and Mentoring Hudson (2010) describes the CORE Model of Supervision and Mentoring incorporating these key elements of the supervisory process. Based on the combined works of individuals who have made significant contributions to the knowledge base of the supervisory process, including Anderson (1988), McCrea and Brasseur (2003), Cogan (1973), and Dowling (2001), the model is a cycle comprising four major components: collaboration, observation, reflection, and evaluation. The goal of the first component of this model, collaboration, is to establish an effective and trusting working relationship between supervisor and supervisee, emphasizing the joint nature of the supervisory relationship. ASHA (2008a) describes supervision as a collaborative process, with shared responsibility for many of the activities throughout the supervisory experience. This is where the supervisor sets the stage for growth in relation to the supervisory process by explaining policies and procedures, performance expectations, and assessment procedures, including data collection. In addition, the supervisor guides the supervisee in establishing performance goals and objectives to promote clinical knowledge, personal improvement, productivity, and self-directed learning. The observation component allows the supervisor to record data that will be used during the processes of analysis and evaluation. McCrea and Brasseur (2003)

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state that observation is the place where real objectivity begins in the supervisory process. The observation and data collection are based on the goals and objectives that were established during the collaboration component of the model. The supervisor should specify the purpose for each observation, and on what, supervisee behavior data will be collected. For instance, the supervisor may be collecting data on the number of times the supervisee uses the phrase “good job” when the goal was to use appropriate positive reinforcement consistent with client performance of targeted skills. The reflection component is where evidencesupported strategies to promote reflective practice are specifically identified to promote self-supervision and independence. These strategies may include the use of journals, portfolios, and self-evaluation checklists (Hudson, 2010). As in Anderson’s model, the ultimate goal of this component is for the supervisee to engage in critical thinking for solving professional problems as an independent, competent clinician (McCrea & Brasseur, 2003). The supervisor plays an important role in supporting guided reflection as the supervisee implements predetermined goals, tackles new situations, embraces challenges, and meets expectations. The purpose of the evaluation component is to provide the supervisee with feedback that is objective, data based, verifiable, and systematic. It is designed to confirm or reinforce behavior, correct behavior, and to motivate and enhance performance (Nottingham & Henning, 2014). Dowling (2001) states that managing feedback is a fundamental issue in building constructive supervisory relationships. Self-assessment tools that support principles of reflective practice are an important ingredient of this component. As specific skills in need of improvement are identified, or as new situations occur as part of this process, they are addressed by rotating to the collaboration component and then proceeding through the remaining components of the cycle.

Supervisory Style and Communication Skills What do you think of when you hear the word “style”? In the context of supervision, definitions that have been offered include “A distinctive manner of responding to supervisees” (Ladany et al., 2001, p. 263) and “The way in which the personality and convictions of the supervisor are demonstrated in the supervisory relationship” (Leighton, 1991; Long et al., 1996, p. 589). Anderson (1988) discusses the influence of personal characteristics and interpersonal style on the type of supervisory style chosen by the supervisor. She also refers to supervisory style as it applies to stages of her continuum model:

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direct-active style at the evaluation-feedback stage, collaborative style at the transitional stage, and consultative style at the self-supervision stage. In a study of supervisory styles in nursing, two styles were revealed by clinical nurse supervisors: emotional style and cognitive style (Severinsson, 1996; Severinsson & Hallberg, 1996). Research tells us that supervisors tend to use one style even when they think they do not (McCrea & Brasseur, 2003) and that supervisors must be aware of their own behavior (McCrea & Brasseur, 2020). Experience tells us that certain styles are more effective in some situations than in others. Phillips (2009) discusses the importance of determining a supervisee’s level of independence to allow supervisors to adjust their style accordingly. Supervisors should be aware of the supervisory style they choose and develop an appreciation of how various styles affect the supervisory relationship. Most of us recognize the role that communication style can play in our interpersonal relationships. The influence of interpersonal communication skills on the supervisory process has been widely studied, and research demonstrates that the communication skills of the supervisor play a key role in the clinical performance of the supervisee and the overall success of the supervisory relationship (McCrea & Brasseur, 2003). Essential components of effective communication may include active listening, asking purposeful questions, and responding appropriately to questions when asked. Each of these has both verbal and nonverbal aspect. Verbal behaviors that support active listening include saying “fine,” “I see,” “good,” “mmm,” or “uh-huh” (Shipley, 1997). Nonverbal behaviors that support active listening include facing the listener, maintaining eye contact, and using appropriate facial expressions and head movements. Purposeful questions are well thought out and formulated to encourage the supervisee to think creatively and develop problem-solving skills. In a study on questioning behaviors of supervisors, Smith (1979) found that when supervisors dominated the questioning process by asking for factual information, they deprived supervisees of the opportunity to problem solve, selfanalyze, and self-direct their own behavior. This type of communication style on the part of the supervisor would certainly present a challenge for the new clinician who is striving for independence. The effective supervisor promotes self-supervision as the supervisee grows toward competence and independence. Strategies that encourage critical thinking and self-reflection on the part of the supervisee are an important part of this growth. Mormer and Messick (2016) present an approach for the use of reflective journal writings, an effective tool for self-supervision. Tools that guide supervisees in the process of self-reflection comply with the 2017 CAA standard: “the ability

to use self-reflection to understand the effects of one’s actions and to make changes accordingly” (Std. 3.1.1A —  Professional Practice Competencies/ and 3.1.1B  Accountability). The clinical educator must not only teach critical thinking skills but also nurture the disposition toward critical thinking (Gavett & Peapers, 2007), and knowing how to ask questions is an essential communication skill for the supervisor when facilitating these skills. Cunningham (1971) developed a category system for questioning by dividing questions into broad and narrow categories. The narrow category includes cognitive memory questions (recall, identify/observe, yes/no, define, name, designate) and convergent questions (explain, state relationships, compare, and contrast). The broad category includes divergent questions (predict, hypothesize, infer, reconstruct) and evaluative questions (judge, value, defend, justify, choice). Supervisors need to consider the types of questions they employ when facilitating critical thinking as part of the supervisory process. The way the supervisor responds to questions also plays an important role in interpersonal communication style and affects the supervisory relationship. Carin and Sund (1971) stress the importance of a diplomatic reply to questions that are answered incorrectly by redirecting, helping the respondent move closer to a better answer, and not blocking communication by responding negatively. In a study of classroom teacher behavior, they reported that when wait time was extended for students to reply to questions, it resulted in longer responses, fewer “I don’t know” answers, more whole sentences, and increased speculative thinking. Supervisors should learn to adjust their wait time when asking questions to afford the supervisee the opportunity to reflect and formulate considered responses. Providing feedback is a key element of supervision and mentoring, typically linked to the evaluation component of the supervisory process. Supervisors and supervisees alike may even consider supervising and providing feedback as synonymous, but no matter how much of a role feedback may play, it is a fundamental expectation of both parties in the supervisory relationship. In a traditional supervisory model, feedback is usually provided in written form, or it may be spontaneous or unscheduled verbal interaction (Anderson, 1988). Feedback may also be provided as a scheduled conference, either in person, by telephone, or other real-time electronic method. These sessions typically consist of the supervisor giving suggestions, reviewing expectations, and discussing overall performance while the supervisee listens and perhaps provides clarification and asks questions. In a collaborative/consultative model, supervisors should encourage supervisees to seek feedback as part of an ongoing process, thereby reducing the number of



formal feedback sessions. Feedback-seeking behavior is an important educational strategy and can facilitate an individual’s adaptation, learning, and performance (Bose & Gijselaers, 2013; Crommelinck & Anseel, 2013). Ashford and Cummings describe such behavior as a conscious effort to determine the correctness and adequacy of one’s own behavior for the purpose of attaining a goal (1983). The supervisee is more likely to be receptive to feedback if it is constructive. Pfeiffer and Jones (1987, p. 121) list 10 characteristics of constructive feedback: 1. It is descriptive rather than evaluative. 2. It is specific rather than general. 3. It is focused on the behavior rather than the person. 4. It takes into account the needs of both the receiver and the giver of the feedback. 5. It is directed toward performance rather than personal characteristics. 6. It is well timed. 7. It involves sharing of information rather than giving advice. 8. It involves the amount of information the receiver can use, rather than the amount of information we would like to give. 9. It is checked to insure clear communication. 10. It is checked to determine the degree of agreement of the receiver. To be effective, feedback should be part of an ongoing process, supported by careful analysis of data and related to the goals developed as part of the initial collaborative planning phase of the supervisory process. Feedback should always promote critical reflection on the parts of both the supervisor and the supervisee. It should enable both parties to explore why some strategies worked and others did not. To respect the supervisee’s privacy and promote dialogue, it should be delivered in a confidential, nonconfrontational way. This will naturally lead to the collaboration involved in outlining specific, measurable, action-oriented, realistic, and time-bound goals for improvement. Both supervisors and supervisees need to recognize how their individual communication styles affect the supervisory relationship. There is a great deal of literature pertaining to communication style among the realms of counseling, education, self-improvement, career development, management, and others. There are also course offerings available at professional conferences on this topic, sometimes with an emphasis on the influ-

CHAPTER 22   Supervision and Mentoring

ence of cultural, linguistic, and generational issues on communication skills in the professional setting. Taking advantage of professional development opportunities in this area will enhance not only the supervisory relationship, but also any other professional relationships that occur in the work setting.

Transition:  Supervisor to Mentor/Preceptor As students, you have come to expect a certain degree of dependency on your clinical supervisor for most if not all aspects of your clinical activities. Your supervisor reads your reports, reviews your audiograms, observes you counseling family members, watches how you fit a hearing aid, sees you perform an oral-peripheral examination, helps you introduce a new therapy activity to a client, and so on. There is very little you have done as a student clinician that was not observed and/or evaluated by a supervisor. It is no wonder that as your knowledge and skills develop, and your supervisor naturally becomes less directly involved in your clinical activities, that you may, on occasion, develop a sense of uncertainty and/or panic. As you approach graduation and your first professional employment, you are told you will have a mentor or preceptor instead of a supervisor. Now, the sense of panic may really begin to set in. You were accustomed to working with a supervisor as a student and were familiar with your role as a supervisee. So, just what is the difference between a supervisor and a mentor/preceptor? Consider this fact: As a paid professional, your employer has rightfully assumed your clinical knowledge and skills are worth whatever you are being paid. If that is the assumption, why would the employer feel the need to assign someone to work closely beside you, watching you perform daily tasks that your resumé indicates you know how to do independently? On the other hand, you just graduated and are new to the job, so it is understandable that some sort of coaching or even some direction on occasion would be necessary. Hence, the mentor or preceptor is put in place, and you are now entering into a special relationship that will assist you in your quest for further professional growth through learning. This relationship is a valuable resource in your commitment to lifelong learning. Shea (1997) describes the mentor as someone whose role is to gently guide the new clinician by offering knowledge, insight, perspective, or wisdom. ASHA (2008) describes mentoring as a collaborative process of shared responsibility. This concept of shared responsibility sets the stage for a relationship that offers more give and take, more exchange of ideas, and more working

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as a team than was the case in the student–supervisor relationship. If your previous supervisory relationships were truly collaborative, and you were guided in the art of reflective practice, the transition from supervisor to mentor/preceptor will feel quite natural. Mentors/ preceptors are expected to lead by example, and their example should facilitate your professional growth and learning. As role models, they will demonstrate ethical conduct, responsibility, and perspective taking and have knowledge of strategies that foster self-evaluation. They will appreciate how you learn and your personality type and consider how race, culture, gender, and age may influence personal interactions. Your mentor/ preceptor will guide you to proficiency, where you will obtain a greater understanding and appreciation of the big picture or the holistic view of a situation. You and your mentor/preceptor will discuss why some strategies worked and some did not as you continue to develop confidence in your current knowledge and skills and to take the initiative to try new strategies on your own. In this strategic partnership, you will feel empowered to explore new territory and stretch your skills with the knowledge that you have a foundation of support, your mentor/preceptor.

Regulations, Standards, and Guidelines At the preprofessional level, the CAA standards state that academic programs are required to demonstrate that “the type and structure of the clinical education is commensurate with the development of knowledge and skills of each student” (Standard 3.7A & 3.7B; CAA, 2023). Before providing direct services in any setting, supervisors, mentors, preceptors, student clinicians, clinical fellows, and audiology externs need to be aware of professional association standards for certification, state licensure laws, and federal/state reimbursement programs such as Medicaid and Medicare. State licensure boards and state boards of education have their own regulations and requirements, and supervision requirements may not match those of certification bodies. Thus, it is important to refer to all applicable sources. Each state has information that is readily available on requirements for certification and licensure and is easily obtainable on their websites. ASHA has information on its website on the certification process for SLPs and audiologists (www.asha.org). The American Board of Audiology (ABA) also has information available on its website regarding board certification (www.audiology​ .org). For audiologists, ASHA and ABA certification do not require membership in a professional organization.

Supervisors and mentors/preceptors are fully responsible for the behavior, clinical services, and documentation of their supervisees. This means supervisors and mentors/preceptors must be aware of the professional competence of the supervisee in specific area/scope of practice, not only to protect themselves but also to protect the welfare of the clients and to foster the growth of the supervisee (ASHA, 2008b). If you find yourself in a situation where you do not feel qualified, competent, physically or emotionally safe, or if you are in a situation that involves an ethical dilemma, it is imperative that you inform your supervisor or mentor/preceptor of the situation. If the supervisor or mentor/preceptor has placed you in this situation, contact your university program, professional association, or employer for direction and guidance.

Clinical Fellowship Experience and Audiology Externship Upon completion of the required academic coursework and clinical practicum experiences and after the graduate degree has been conferred, SLPs advance to the next stage of their professional career development by beginning a CF experience in accordance with the ASHA standards for certification for speech-language pathology. Since the change in entry-level degree to a doctorate, most audiology students complete an extended externship, usually 10 to 12 months, after completion of coursework and prior to graduation, instead of a CF experience postgraduation. This long practicum placement is often called the fourth-year externship, because it takes place in the final year of the graduate program. The ASHA certification standards for both professional areas of practice are defined by members of the CFCC, a semiautonomous body of ASHA. ABA also offers a certification avenue for audiologists. Because the clinical experiences of SLPs and audiology students diverge at this point, they will be addressed separately in this chapter.

Speech-Language Pathology Clinical Fellowship (SLPCF) ASHA (2018) describes the CF experience as a transition between being a student and being an independent provider of clinical services that involves a mentored professional experience. The purposes of the CF experience are: n

to promote excellence in the practice of the professions of audiology and speech-language



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pathology through the development and implementation of standards; n

to identify individuals who meet standards established as necessary to provide clinical services; and

n

to protect and inform the public by recognizing individuals who meet the certification standards.

It is the responsibility of the clinical fellow to identify a mentor who holds a current Certificate of Clinical Competence (CCC) that meets mentor requirements (e.g., experience, continuing education in supervision) and, if applicable, state licensure. States may not require the completion of a CF experience but have their own provisional licensure requirements that include supervision by a licensed SLP who may or may not be required to hold a CCC. In those instances, the CF will need to determine if the supervisor can also serve as a CF mentor. If not, the ASHA website has information on how to find a CF mentor. The CF should find out what the requirements are for the state in which they are going to be working and verify this information before the start of the CF experience. This may be done by contacting the ASHA national office and by checking with state licensure boards, as appropriate. It is important that both the CF and the CF mentor are familiar with the ASHA Code of Ethics, Scope of Practice in Speech-Language Pathology, and the ASHA Certification and Membership Handbook, all of which are available on the ASHA website, and any applicable state licensure/certification requirements so as not to jeopardize the certification or licensure status of the CF. The CF and the CF mentor need to discuss at the very beginning of the CF experience how the monitoring activities will be completed, including frequency and method of documentation, and how their performance will be evaluated. Both parties should maintain copies of all written feedback and other documentation, including the required forms submitted to ASHA and the state. The specific requirements for completion of the CF may be found on the ASHA website. Finally, the CF and the mentor need to be aware of possible ethical misconduct on the part of the CF mentor. Although these events are not typical, they may include arbitrary termination of the mentoring relationship, failure to complete and sign the required paperwork in a timely manner, failure to provide the required amount and type of mentoring, or recruitment of the CF as an independent practitioner. Should any of these or other unfortunate situations occur, the CF should consult with a certification manager at the ASHA national office immediately.

Audiology Externship The profession of audiology has gone through changes in recent years that impact credentialing requirements. There are two professional certifications available to audiologists: ASHA (CCC-A) and ABA (ABA Certified or ABAC). Both are voluntary and do not require membership in a professional organization. Certification reflects a higher standard of professional practice and may be required as a minimum job qualification for certain employers or in certain settings. In addition, individual states continue to have their own requirements for licensure that may or may not mirror either of the professional certification programs available to audiologists. Audiology students should carefully consider the requirements for certification early in their graduate career to ensure they are on a path to meet all requirements prior to graduation or within the time frame specified by the credentialing body. More information about requirements for ASHA certification and ABA board certification is provided in Chapter 3. The audiology externship has been adopted by many academic training programs to provide students with an extended clinical experience where they can further develop their knowledge and skills and prepare for independent practice. Accredited academic training institutions are not specifically required to include an externship as part of their curriculum, but many have elected to do so. Externships are offered in many work settings and locations. A preceptor plays a key role in the externship experience. The academic institution and the student extern should ensure clinical supervision provided by the preceptor meets all credentialing requirements at an externship site. This includes certification and licensure requirements. Securing an externship is usually the result of a competitive process where students complete applications and submit transcripts, cover letters, and resumés. Interviews are also commonly part of this process. Students should check externship postings and ask questions during the application process to verify their assigned preceptor will meet credentialing requirements. Licensure and certification in almost all cases can be verified online through the website of the credentialing body. These sites will also indicate if the preceptor is in good standing and meets any requirements necessary for providing supervision. Externship preceptors/supervisors and externs are responsible for completing all licensure requirements in a timely manner. This may include registration with the appropriate licensing boards or securing temporary or provisional licensure. If a state has hearing aid dispenser and audiologist requirements that are handled separately by different regulatory bodies, all requirements must

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be investigated and met. Requirements vary from state to state. Finally, the audiology extern and the preceptor need to be aware of possible ethical misconduct on the part of the externship preceptor. Although this is not common, it may include failure to complete evaluations and verify clock hours, failure to complete required licensure paperwork related to the extern in a timely manner, failure to provide the required amount and type of supervision, treating the extern as an independent practitioner, or failure to maintain their professional credentials. Should any of these or other unfortunate situations occur, the extern should consult with their academic training institution immediately.

Supervision Postcertification Now that you have earned your Certificate of Clinical Competence or board certification, what can you expect in the way of supervision? The answer to that question will depend on your individual circumstances, including your work setting and the nature of your assigned duties. You should expect to have someone to whom you report directly, perhaps a rehabilitation director, clinic or private practice owner, service coordinator, school principal, or regional supervisor. This individual may or may not share your professional credentials. This supervisor’s main goal is to ensure the well-being of the patients, clients, or students you serve and to ensure the quality of the services you provide in that setting. As such, you can expect to have some type of supervision and receive an evaluation of your performance by someone in a supervisory capacity. A more detailed discussion of the employee evaluation process is provided in Chapter 8, but the employee evaluation process bears some mention in this chapter as you will most likely continue to be in a supervisory or mentoring/preceptor-type of relationship. The fundamental principles of supervision and mentoring still apply, so you may want to review those principles at this next stage of your career. You may also be asked to provide supervision to a graduate student or an assistant (support personnel). Now you become the supervisor.

Supervision of Students and Support Personnel Graduate programs require students to accrue clinical practicum hours in a variety of settings to prepare them for the professional work environment. You may be asked very early in your postcertification career to supervise a student in your work setting. If that is the

case, remember above all other considerations that you are a role model to this individual. You need to keep in mind that your opinions and impressions may carry a great deal of weight, and that this student will look to you for guidance and direction in many areas, including clinical skills, ethical behavior, interpersonal skills, and work habits. Typically, the student’s university program director or clinic director will have made the necessary arrangements between the university and your work site for the student placement. Determine who your contact at the university will be and what type of documentation is expected of you as the student’s supervisor. You should also discuss your professional liability with your worksite supervisor and verify that your current licensure and certification will meet the needs of the university. It is both a responsibility and a privilege to play a part in the early professional growth of a student clinician. The rewards of creating the professional climate in which a student can thrive are well worth the challenges that this unique supervisory relationship will present to you. The opportunity this relationship will provide will also make a significant contribution to your own professional growth and development. Supervision of support personnel, including speechlanguage pathology assistants (SLPAs) and audiology support personnel, presents a unique challenge, particularly for the new clinician who may just be learning how to do their first job. One of the most important issues has to do with the amount of supervision required and the documentation associated with that supervision. Typically, the more complex cases will necessitate increased levels of supervision. As in any supervisory relationship, the basic principles apply to the supervisor of the SLPA and audiology support personnel, particularly in the areas of ethical behavior, communication, and documentation. ASHA (2013a) developed a Scope of Practice for Speech-Language Pathology Assistants to provide guidance for SLPAs and their supervisors regarding ethical considerations related to the SLPA practice parameters. The document addresses how SLPAs should be utilized and what specific responsibilities are within and outside their roles of clinical practice. This information served as a valuable resource for many years. In late 2020, ASHA implemented the Assistants Certification Program, and for the first time, national certification became available for assistants in speech-language pathology and audiology. Through this new voluntary certification program, successful applicants may achieve SLPA certification (C-SLPA) or audiology assistant certification (C-AA). These assistant certification programs have a code of conduct that was introduced in June 2020 (ASHA, 2020) and a scope of practice for each program (ASHA, 2022a, 2022b). These documents provide guidance



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on appropriate use of assistance, ethical practice, and day-to-day decision making. Note that the ASHA Assistants Certification Program is a voluntary program with national standards. Each state may have rules and regulations that vary from this national credential. Supervisors of assistants and support personnel must investigate state requirements to verify compliance with state regulation when working with assistants. Assistants are required to have the necessary skills to work in a support position, and their duties are performed under direct supervision of an ASHA-certified SLP or audiologist. The topic of support personnel in speech-language pathology and audiology is covered extensively in Chapter 9.

under their supervision, and they shall inform those they serve professionally of the name, role, and professional credentials of persons providing services.

Ethical Issues Professional codes of ethics are established to provide the standards of conduct that guide the behavior of members of the professions of speech-language pathology and audiology. Both ASHA and AAA have codes of ethics that serve this purpose, and supervisors have the responsibility to ensure they and their supervisees adhere to ethical principals in every aspect of their clinical activities. The ASHA Code of Ethics (2023) specifies compliance with certification and licensure for members and certificate holders as required by their employers, their states, governmental agencies, and by ASHA in the area of their clinical or supervisory work, regardless of the work setting. The primary responsibility of ASHA-certified individuals who are engaged in supervision is to hold paramount the welfare of persons they serve professionally and to ensure services are provided competently by individuals under their supervision. Whether the title used is supervisor, clinical educator, mentor, or preceptor, each of these individuals exercises professional authority or power over the supervisee and ensures the trust that is an integral part of any supervisory relationship. There are several sections in the Code of Ethics that pertain to supervision: n

Principle I:  Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or who are participants in research and scholarly activities.

n

Principle I, Rule A:  Individuals shall provide all clinical services and scientific activities competently.

n

Principle I, Rule D:  Individuals shall not misrepresent the credentials of aides, assistants, technicians, support personnel, students, research interns, clinical fellows, or any others

n

Principle I, Rule E:  Individuals who hold the Certificate of Clinical Competence may delegate tasks related to the provision of clinical services to aides, assistants, technicians, or any other persons only if those persons are adequately prepared and are appropriately supervised. The responsibility for the welfare of those being served remains with the certified audiologist or SLP.

n

Principle I, Rule F:  Individuals who hold the Certificate of Clinical Competence shall not delegate tasks that require the unique skills, knowledge, judgment, or credentials that are within the scope of their profession to aides, assistants, technicians, or any nonprofessionals over whom they have supervisory responsibility.

n

Principle I, Rule G:  Individuals who hold the Certificate of Clinical Competence may delegate to students tasks related to the 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.

n

Principle II, Rule A:  Individuals who hold the Certificate of Clinical Competence shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their certification status, education, training, and experience.

n

Principle II, Rule E:  Individuals in administrative or supervisory roles shall not require or permit their professional staff to provide services or conduct research activities that exceed the staff member’s certification status, competence, education, training, and experience.

n

Principle II, Rule F:  Individuals in administrative or supervisory roles shall not require or permit their professional staff to provide services or conduct clinical activities that compromise the staff member’s independent and objective professional judgment.

n

Principle IV, Rule F:  Individuals who mentor clinical fellows, act as a preceptor to audiology

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externs, or supervise undergraduate or graduate students, assistants, or other staff shall provide appropriate supervision and shall comply — fully and in a timely manner — with all ASHA certification and supervisory requirements. n

Principle IV, Rule I:  Individuals shall not engage in sexual activities with persons over whom they exercise professional authority or power, including persons receiving services, other than those with whom an ongoing consensual relationship existed prior to the date on which the professional relationship began.

n

Principle IV, Rule J:  Individuals shall not knowingly allow anyone under their supervision to engage in any practice that violates the Code of Ethics.

n

Principle IV, Rule M:  Individuals shall not discriminate in their relationships with colleagues, members of other professions, or individuals under their supervision on the basis of age; citizenship; disability; ethnicity; gender; gender expression; gender identity; genetic information; national origin, including culture, language, dialect, and accent; race; religion; sex; sexual orientation; socioeconomic status; or veteran status.

Supervisors also need to be aware of the issue of vicarious liability that describes the supervisor’s responsibility concerning the behavior of the supervisee (Newman, 2001). The legal and ethical responsibility for persons served remains with the certified individual, so responsibility for clinical decision making and management should not be delegated to the supervisee. However, as part of the educational process, supervisees should be encouraged to make clinical recommendations and decisions that are commensurate with their knowledge, experience, and competence and that fall within the scope of practice for their specific profession. Supervisors also need to be aware of the dual relationship that can develop between the supervisor and the supervisee (Newman et al., 2009). When the relationship between the supervisor and the supervisee becomes more personal than professional, it can compromise the integrity of the supervisory process. For example, if a supervisor and a supervisee develop a personal friendship, will the supervisor be able to maintain objectivity when evaluating the supervisee’s ability to assume responsibility? This new relationship now presents its own set of problems that can adversely affect the supervisory relationship. Supervisors assume the responsibility of maintaining the proper balance in the relationship

and of setting and maintaining appropriate boundaries as needed. Situations involving ethical misconduct, including abuse of power, may also occur on the part of the supervisor. For example, a supervisor may fail to provide a sufficient amount of supervision based on the performance of the supervisee, fail to educate and monitor the supervisee’s protection of patient confidentiality, fail to verify appropriate competencies before delegating tasks to supervisees, fail to demonstrate benefit to the patient based on outcomes, and fail to provide self-assessment tools and opportunities to supervisees (King, 2003).The astute supervisee will learn to recognize possible ethical misconduct on the part of the supervisor and should seek appropriate consultation. Good sources of reference are ASHA’s Issues in Ethics statements of Supervision of Student Clinicians (2017) and Issues in Ethics: Responsibilities of Individuals Who Mentor Clinical Fellows in Speech-Language Pathology (ASHA, 2017). Adherence to principles of ethical conduct transcends all aspects of clinical practice and professional behavior. The supervisory relationship provides the supervisor with the opportunity to model behaviors necessary for lifelong ethical practice. See Chapter 4 for a more indepth discussion of ethical issues.

Cultural, Linguistic, and Generational Issues As we become more diverse as a nation, supervisors will have more and more opportunities to work with individuals from backgrounds different from their own. Because values, behaviors, and beliefs may vary according to age, disability, ethnicity, gender identity, national origin, race, religion, sex, and sexual orientation, supervisors will need to learn to appreciate the effect these factors have on communication, behavior, and learning. Linguistic diversity can accompany cultural diversity (ASHA, 2017), and supervisors and mentors should encourage an understanding of linguistic differences. They are also obligated to prevent discrimination against persons who speak with an accent and/or dialect in educational programs, employment, or service delivery (ASHA, 1998). Coleman (2000) noted that differences in cultural values have an impact on the nature and effectiveness of all aspects of clinical interventions, including supervisee relationships. He added that for interactions with supervisees to be successful, supervisors must consider learning styles and culturally based behaviors of their supervisees. Researchers who have studied clinical intervention strategies related to cultural issues (Anderson, 1992; Battle, 1993; Langdon & Cheng, 1992) promote the use of



self-inventory of cultural competence awareness and sensitivity. Munoz et al. (2011) state that the roles and responsibilities of the supervisor can still be met even when observing sessions in a language one doesn’t speak, while ASHA (2008b) recommends that supervisors provide culturally appropriate feedback to supervisees. It is also important to know when it may be appropriate to use a cultural mediator or advisor concerning effective strategies for interactions with individuals (clients and supervisees) from specific backgrounds. Development of self-awareness on the part of the supervisor sets the stage for increased sensitivity and understanding of situations that may occur during the supervisory process that are solely related to cultural differences. Cornish and White (2016) explore the critical need for cultural proficiency in mentoring relationships with our students and clinical fellows and Carozza (2011) offers a cogent discussion of cross-cultural issues in supervision. McCready (2007) reviewed the research on generational differences in the workforce and noted that the disparities between generations are more complex today than in the past. The experiences of each generation shape the values, beliefs, attitudes, and behaviors that may have a significant effect on the supervisory relationship. For example, a 22-year-old audiology student is in a meeting with his 56-year-old clinical supervisor to discuss a patient with unilateral Meniere’s disease. The student checks his cell phone several times and begins replying to a text message while the supervisor is describing the testing and how the pattern of results relates to the patient’s condition. The supervisor is rather offended, believing the student is not listening, and decides to stop speaking until the student has finished looking at his phone. The student looks up suddenly, and asks the supervisor to continue the discussion, quite surprised that they appeared to be offended. The supervisor believes the student should give them undivided attention, assuming the student can only focus on one thing at a time, while the student believes that multitasking is typical behavior and that their texting while listening should be no reason for the supervisor to take offense. To bridge this type of generation gap, McCready suggests the formation of smaller study groups within the work setting to investigate the research in this area that can then be presented to the larger group as a whole. She also suggests that the supervisor engage in discussions about generational differences pertaining to a particular work setting or situation and how those differences may or may not apply to that specific setting. In the scenario provided, the supervisor could use the situation to explain the philosophical differences between her generation and that of the audiology student regarding perceptions of multitasking. Where cultural, linguistic,

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and generational issues are considered, supervisors have a responsibility for their own professional development to increase their knowledge and sensitivity. Demonstration of this desire to learn may also motivate the supervisee to develop a plan for their own growth in this area.

Supervision of Challenging Supervisees In graduate CSD programs, there are students who may present special challenges during the supervisory process (Shapiro et al., 2002) and are often referred to as marginal students. Dowling (1985, as cited in Dowling, 2001) described marginal students as individuals who “cannot work independently, are unable to formulate goals and procedures, have basic gaps in conceptual understanding, and cannot follow through with suggestions” (p. 162). Understanding how to work effectively with marginal students deserves serious and systematic consideration (Shapiro et al., 2002). By the time these marginal students have graduated, they have completed the necessary requirements in their academic courses and clinical work to begin employment. However, new clinicians who experienced some of these challenges as students may need to be carefully monitored by their supervisors once they are in the work setting. In particular, these new clinicians may have difficulty evaluating their skill level accurately (Kruger & Dunning, 1999, as cited in McCrea & Brasseur, 2003). The initial collaborative planning phase of the supervisory process should address this and any other potential areas of concern and goals should be developed to target those areas specifically. Mandel (2015) discusses how being aware of the perceptions and expectations of supervisees allows supervisors to target areas of need in supporting professional growth. Schober-Peterson and O’Rourke (2008) describe using a formative assessment when working with the at-risk student and describe how this type of ongoing assessment encouraged students to take responsibility for their learning and to actively participate in the assessment of their knowledge and skills. This type of ongoing assessment, including providing specific feedback based on objective data collection, can support these new clinicians as they achieve the ultimate goal of self-supervision.

Technology and Supervision The use of technology in supervision, referred to as telesupervision, is not necessarily a new concept, although the variety of forms to support the supervisory process has expanded significantly in recent years. The internet

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has made it possible for supervisors to use email, instant messaging, social networks, and videoconferencing to communicate with supervisees in real time. Webinars, blogs, and podcasts can store information for later access and may be shared with a large number of individuals. The use of audio and video recordings will likely reveal behaviors that supervisors and supervisees may use for the development of goals for improvement (McCrea & Brasseur, 2003). For example, the supervisor and supervisee may view a video-recorded treatment session to verify data, review and discuss subtle behaviors that were not easily observable in real time, or evaluate the success of a treatment technique. The ability to self-analyze behaviors after they have occurred is extremely effective in promoting reflective practice. Although many universities use videoconferencing routinely for course delivery, it is also an effective technology to support required supervisory visits that may be challenged by time factors and/or geographical distance. It should not, however, be used solely for the convenience of the supervisee or the supervisor. Dudding (2002) described distance supervision, or telesupervision, as the use of two-way interactive videoconferencing technology for supervision of graduate students. Dudding (2006) reports that in a later study she found that there was no significant difference in graduate student perceptions of the effectiveness of the traditional versus distance supervision models. She reports that the graduate students “indicated that they felt more in charge of the session and less distracted than when the supervisor was physically in the therapy room” (p. 17). Tellis et al. (2010) described a novel video-capture technology, the Landro Play Analyzer, to supervise clinical sessions and to train students to improve their clinical skills. They observed four clinical sessions simultaneously from a central observation center. In addition, speech samples were analyzed in real time; saved on a CD, DVD, or flash/jump drive; viewed in slow motion; paused; and analyzed with Microsoft Excel. The use of this technology for clinical supervision allowed the authors to monitor multiple sessions and provide their student clinicians with specific feedback. Students indicated that they improved their clinical skills because they had the opportunity to review their sessions. Clinicians also reported using this technology successfully with their clients. Advances in technology have played an important role in supervision and are likely to continue to do so. The opportunities, as well as the challenges, technology presents and the role it will continue to play are important issues for supervisors and supervisees alike. ASHA (2008a) stresses the importance of following regulatory guidelines involving confidentiality when using technology in supervision (e.g., videoconferencing). The

integral concerns related to ethics, etiquette, access to technical support, licensure board rules, state and federal laws and regulations, university and/or clinical setting policies, and capital resources should also be considered in any discussion of technology and its application to the supervisory process. See Chapter 23 for a more in-depth discussion of technology.

Training in Supervision Achieving clinical competence does not necessarily mean one has the ability to be an effective supervisor. All too often, clinicians are placed in a supervisory role with limited or no supervisory experience. They may be clinically experienced and available, but they do not necessarily have an interest or the knowledge and skills to be effective supervisors. Both ASHA (2013c) and the Council of Academic Programs in Communication Sciences and Disorders (CAPCSD) recognize that clinical supervision is a distinct area of expertise and practice, and, as in other distinct areas, individuals must receive training to gain competence before engaging in the activity (ASHA, 2013c; CAPCSD, 2013). The ASHA Ad Hoc Committee on Supervision (2013c) identified the knowledge and skills required of supervisors.

Overarching Knowledge and Skills n

Knowledge of clinical education and the super­ visory process, including teaching techniques, adult learning styles, and collaborative models of supervision

n

Skill in relationship development, including the creation of an environment that fosters learning

n

Ability to communicate, including the ability to define expectations and engage in difficult conversations

n

Ability to collaboratively establish and implement goals, give objective feedback, and adjust clinical education style when necessary

n

Ability to analyze and evaluate the student clinician’s performance, including gathering data, identifying areas for improvement, assisting with self-reflections, and determining if goals are being achieved

n

Skill in modeling and nurturing clinical decision making, including (a) using information to support clinical decisions and solve problems and (b) responding appropriately to ethical dilemmas



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n

Skill in fostering professional growth and development

n

Skill in making performance decisions, including the ability to create and implement plans for improvement and to assess the student’s response to these plans

n

Ability to adhere to the principles of evidencebased practice and conveying research information to student clinicians

Knowledge and Skills Specific to Student Training in the University Clinic or Off-Site Setting n

Ability to connect academic knowledge and clinical application

n

Ability to sequence the student’s knowledge and skill development

Knowledge and Skills Specific to the Clinical Educator Working With Students in the Culminating Externship in Audiology n

Ability to provide a multifaceted experience across the scope of the profession

n

Ability to serve as a liaison between the facility, student, and university

n

Skill in guiding the student in reflective practice

n

Skill in facilitating the development of workplace navigation skill (e.g., being part of a team and adhering to policies and procedures)

The Ad Hoc Committee also noted the importance of early education in the supervisory process, including an introduction to the subject as part of the graduate curriculum and more advanced training for practicing and aspiring supervisors (ASHA, 2013b). ASHA certification standards for audiology and speech-language pathology are established by the CFCC, a semiautonomous credentialing body of ASHA. Both ASHA (2013c) and CAPCSD (2013b) suggested the need for systematic approaches to the training and preparation of clinical educators. As a result of these recommendations, the 2020 Standards and Implementation Procedures for the Certificate of Clinical Competence require clinical supervisors to have a minimum of 2 hours of professional development (training) in supervision and 9 months of full-time clinical experience

postcertification before serving as a clinical supervisor or CF mentor. ABA requires that preceptors for externs hold a state license and may be a certified ABA audiologist. However, some states (e.g., California) or settings may require specific coursework or credentials before being granted supervisory status. Although the availability for training in the form of coursework and continuing education (CE) in supervision may not always meet the demand, there are opportunities for continuing education in supervision. ASHA and CAPCSD provide CE sessions at their annual convention as well as webinars and teleconferences on supervision. Many state associations and related professional organizations also provide CE sessions on supervision. ASHA Special Interest Groups 10‒Higher Education and 11‒Administration and Supervision publish Perspectives throughout the year and afford opportunities to earn CE credit. There are also several noteworthy books available to those who have an interest in learning more about supervision (Carozza, 2011; Dowling, 2001; McCrea & Brasseur, 2020).

Supervisor Accountability The evaluation of a supervisor should be based on the demonstration of skills and competencies associated with the supervisory process. Supervisees are often asked to participate in the evaluation process of their supervisors. Do most supervisees know what to expect from a supervisor if asked to provide feedback? Even if they did, would they provide feedback that is honest and objective? The answers to these questions support selfevaluation by the supervisor relative to the supervisory process (ASHA, 2008). However, there are no validated guidelines for the outcomes achieved by supervisors, thus making it necessary for supervisors to use informal measures to evaluate their own supervisory skills and competencies (McCrea & Brasseur, 2003). Supervisors may consider using items from a selfassessment guide developed by Casey et al. (1988) to assist their effectiveness in acquiring the 13 tasks and 81 associated competencies contained in the ASHA position statement (ASHA, 1985). Supervisors may also consider using the more recent ASHA (2016) Self-Assessment of Competencies in Supervision developed by the 2016 ASHA AHCST to assess supervisory knowledge and skills identified by the Ad Hoc Committee on Supervision (ASHA, 2013c). This tool is used to rate competencies and to develop goals for training for clinical educators, preceptors, mentors, and supervisors. A performance appraisal that employs multiple sources of input is referred to as a 360-degree assessment (U.S. Department of Personnel Management, 1997). This appraisal includes

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self-assessment, and some aspects of a supervisor’s performance may also be evaluated by professional peers, support staff, and an administrator to whom the individual reports. This type of performance appraisal focuses on subjective impressions of global aspects of supervisor behavior and will not necessarily provide insight into the efficiency and effectiveness of an individual supervisor’s practice (McCrea & Brasseur, 2003). The results of a successful evaluation of one’s own behavior present an opportunity for quality assurance to ensure accountability. Deciding to improve as a supervisor promotes job satisfaction, self-fulfillment, and ethical behavior and prevents burnout (Dowling, 2001). Self-assessment is a key ingredient of reflective practice, and the supervisor who engages in this activity is also providing the supervisee an effective role model.

Future Needs in Supervision and Mentoring Supervision and mentoring are required components of clinical training and credentialing for professional organizations in speech-language pathology and audiology. Because of its pervasive nature in the professions, supervision is universally recognized as a distinct area of practice. What research is needed to ensure evidencebased practices in the distinct area of supervision? Data collection and analysis as part of the supervisory process provide the foundation for research and evidence to support effective supervisory practice. Anderson (1988) stated, “When the clinical supervision process proceeds as inquiry, personal discoveries have the potential for becoming collective discoveries” (p. 298). These discoveries are made after careful examination of the effects of certain supervisory practices, forming the basis of research. In recent years, audiologists and SLPs have been involved in interdisciplinary research, training, and practice examining how workers from a variety of professional backgrounds work together with clients, students, patients, families, caregivers, and communities to provide the highest quality and most comprehensive services possible. However, the final report of ASHA’s (2013b) Ad Hoc Committee on Interprofessional Education noted that the focus on interprofessional education to increase value in health care delivery has primarily involved the disciplines of medicine, nursing, pharmacy, and public health. Interprofessional education (IPE) is an essential first step in preparing professionals to work collaboratively in response to client/ student/patient needs, and clinical educators play a key role in reinforcing best practices in this area. Supervisors of audiologists and SLPs should examine their own com-

petencies in this area and learn how to facilitate learning on the part of the supervisee as part of a collaborative service delivery model that centers on the individual and the family/caregivers. There are several resources available for clinical educators and CF mentors in this area including Core Competencies for Interprofessional Collaborative Practice, a report published by an expert panel of the Interprofessional Education Collaborative (IPEC, 2011), as well as ASHA’s IPE: Final Report from the Ad Hoc Committee on Interprofessional Education (ASHA, 2013b). Both supervisors and supervisees alike have the responsibility to learn about issues in clinical supervision. The most effective supervisors will approach the supervisory relationship with the understanding that each supervisee brings not only certain skills, knowledge, and clinical experience to a situation, but also their own individual talents, perceptions, and life experiences. They will also appreciate how each of these factors can influence both the supervisory relationship and the overall clinical experience itself. For supervisees to develop critical knowledge and skills leading to competency, they must also learn to analyze their own behaviors to see how their actions influence the supervisory relationship and their clinical experiences. This shared responsibility for supporting the principles of reflective practice will lead to self-supervision of the independent clinician who is committed to lifelong learning and professional growth.

Summary Supervision plays a major role in speech-language pathology and audiology because of its pervasive nature. This chapter presented a model of skill acquisition that forms the basis of successful models of supervision, including a continuum model and a model composed of four key components of the supervisory process. It also provided an overview of regulations and guidelines leading to professional certification in both speechlanguage pathology and audiology. Current issues in supervision that are relevant across settings, including professional ethics, cultural competence, technology, training, and accountability, were also discussed. Finally, it set the stage for further exploration of research and training, particularly in interprofessional education and practice, in this essential area within the scope of practice in the professions.

References Allen, R., Cosby, J., Figueroa, C. M., & Allen, R. L. (2008). Differences between the 1993 and 2007



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standards for the certificate of clinical competence in audiology. Perspectives on Administration and Supervision, 18(2), 44–49. American Academy of Audiology. (2006). American Academy of Audiology clinical education guidelines for audiology externships. Audiology Today, 18(2), 29–31. American Board of Audiology. (2011). Board certification in audiology. http://www.americanboardofaud iology​.org/.../faqs_board_certification.html American Speech-Language-Hearing Association. (1985). Committee on Supervision in SpeechLanguage Pathology and Audiology: Clinical supervision in speech-language pathology and audiology. A position statement. ASHA, 27, 57–60. American Speech-Language-Hearing Association. (1996). Guidelines for the training, credentialing, use, and supervision of speech-language pathology assistants. ASHA, 38(Suppl. 16), 21–34. American Speech-Language-Hearing Association. (1997). ASHA membership and certification handbook. American Speech-Language-Hearing Association. (1998). Students and professionals who speak English with accents and nonstandard dialects: Issues and recommendations. https://www.asha.org/policy/ ps1998-00117/ American Speech-Language-Hearing Association. (2000). Background information and standards for implementation for the certificate of clinical competence in speech-language pathology. ASHA, Council on Professional Standards in Speech-Language Pathology and Audiology. American Speech-Language-Hearing Association. (2007). Responsibilities of individuals who mentor clinical fellows. http://www.asha.org/policy American Speech-Language-Hearing Association. (2008). Clinical supervision in speech-language pathology [Position statement]. https://www.asha​ .org/policy/ps2008-00295/ American Speech-Language-Hearing Association. (2008a). Clinical supervision in speech-language pathology [Technical report]. https://www.asha.org/ policy/tr2008-00296/ American Speech-Language-Hearing Association. (2008b). Knowledge and skills needed by speechlanguage pathologists providing clinical supervision. https://www.asha.org/policy/ks2008-00294/

American Speech-Language-Hearing Association. (2010a). Supervision of student clinicians. https:// www.asha.org/practice/ethics/supervision-ofstudent-clinicians/ American Speech-Language-Hearing Association. (2010b). Certification. SLP Graduate Student Supervision. http://www.asha.org/about/membershipcertification/ American Speech-Language-Hearing Association. (2013a). Scope of practice for SLPAs. https://www​ .asha.org/policy/slpa-scope-of-practice/ American Speech-Language-Hearing Association. (2013b). Report of the Ad Hoc Committee on Interprofessional Education. http://www.asha.org/ uploadedFiles/Report-Ad-Hoc-Committee-onInterprofessional-Education.pdf American Speech-Language-Hearing Association. (2013c). Knowledge, skills and training considerations for individuals serving as supervisors [Final report, Ad Hoc Committee on Supervision]. http://www​ .asha.org/uploadedFiles/Supervisors-KnowledgeSkills-Report.pdf American Speech-Language-Hearing Association. (2016). A plan for developing resources and training opportunities in clinical supervision [Final report, Ad Hoc Committee on Supervision Training]. https:// www.asha.org/siteassets/reports/ahc-on-supervisiontraining.pdf American Speech-Language-Hearing Association. (2017a). Issues in ethics: Ethical issues related to clinical services provided by audiology and speech-language pathology students. https://www.asha.org/Practice/ ethics/EthicalIssues-Related-to-Clinical-ServicesProvidedby-Audiology-and-Speech-LanguagePathologyStudents/ American Speech-Language-Hearing Association. (2017b). Issues in ethics: Responsibilities of individ­ uals who mentor clinical fellows in speech-language pathology. https://www.asha.org/Practice/ethics/ Responsibilities-of-Individuals-Who-MentorClinical-Fellows-in-Speech-LanguagePathology/ American Speech-Language-Hearing Association. (2017c). Issues in ethics: Cultural and linguistic competence. https://www.asha.org/Practice/ethics/ Cultural-and-LinguisticCompetence/ American Speech-Language-Hearing Association. (2018). 2018 Speech-language pathology certification handbook of the American Speech-Language-Hearing Association. https://www.asha.org/uploadedFiles/ SLP-Certification-Handbook.pdf

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American Speech-Language-Hearing Association. (2020). Assistants code of conduct. https://www.asha​ .org/policy/assistants-code-of-conduct/ American Speech-Language-Hearing Association. (2022a). Scope of practice for audiology assistants. https://www.asha.org/policy/scope-of-practice-foraudiology-assistants/ American Speech-Language-Hearing Association. (2022b). Scope of practice for SLPAs. https://www​ .asha.org/policy/slpa-scope-of-practice/ American Speech-Language-Hearing Association. (2023). Code of ethics. https://www.asha.org/policy/ et2016-00342/ Anderson, J. (Ed.). (1970). Proceedings of conference on supervision of speech and hearing programs in the schools. Indiana University. Anderson, J. L. (1988). The supervisory process in speech-language pathology and audiology. Pro-Ed. Anderson, N. B. (1992). Understanding cultural diversity. American Journal of Speech-Language Pathology, 1, 11–12. Ashford, S. J., & Cummings, L. L. (1983). Feedback as an individual resource: Personal strategies of creating information. Organizational Behavior and Human Performance, 32, 370–398. Battle, D. (1993). Communication disorders in multicultural populations. Butterworth-Heinemann. Bose, M. M., & Gijselaers, W. H. (2013). Why supervisors should promote feedback-seeking behaviour in medical residency. Medical Teacher, 35(11), e1573–e1583. Carin, A., & Sund, R. (1971). Developing questioning techniques. Charles E. Merrill. Carozza, L. (2011). Science of successful supervision and mentorship. Plural Publishing. Casey, P. (1985). Supervisory skills self-assessment. University of Wisconsin. Casey, P., Smith, K., & Ulrich, S. (1988). Selfsupervision: A career tool for audiologists and speechlanguage pathologists (Clinical Series No. 10). National Student Speech-Language-Hearing Association. Christodoulou, J. (2016). A review of expectations of speech-language pathology externship student clinicians and their supervisors. Perspectives on Administration and Supervision, 1(Part 2), 45–53. https:// doi.org/10:1044perspl.SIG11.42

Cogan, M. (1973). Clinical supervision. Houghton Mifflin. Coleman, T. J. (2000). Clinical management of communication disorders in culturally diverse children. Allyn & Bacon. Cornish, N., & White, M. (2016). Cultural proficiency: Supporting the development of cultural competence in mentoring relationships. Perspectives on Administration and Supervision, 1(14), 104–115. https://doi.org/10.1044/persp1.SIG14.104 Council of Academic Programs in Communication Sciences and Disorders. (2013). Preparation of speech-language pathology clinical educators [White paper]. http://scotthall.dotster.com/capcsd/wpcontent/uploads/2014/10/Preparation-of-ClinicalEducators-White-Paper.pdf Council on Academic Accreditation in Audiology and Speech-Language Pathology. (2004). Standards for accreditation of graduate education programs in audiology and speech-language pathology programs. http:// www.asha.org/policy Council on Academic Accreditation in Audiology and Speech-Language Pathology. (2023). Standards for accreditation of graduate education programs in audiology and speech-language pathology (2017). https:// caa.asha.org/siteassets/files/accreditation-standardsfor-graduate-programs.pdf Council for Clinical Certification in Audiology and Speech-Language Pathology. (2005). Membership and certification handbook of the American SpeechLanguage-Hearing Association. https://www.asha .org/about/membership-certification/handbooks/ slp/slp_standards.htm Council for Clinical Certification in Audiology and Speech-Language Pathology of the American Speech-Language-Hearing Association. (2018a). 2020 standards for the certificate of clinical competence in audiology. https://www.asha.org/certifi cation/2020-Audiology-Certification-Standards/ Council for Clinical Certification in Audiology and Speech-Language Pathology of the American Speech-Language-Hearing Association. (2018b). 2020 standards for the certificate of clinical competence in speech-language pathology. https://www.asha. org/certification/2020-SLP-Certification-Standards Crago, M., & Pickering, M. (Eds.). (1987). Supervision in human communication disorders: Perspectives on a process. Little Brown-College Hill Press.



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Crommelinck, M., & Anseel, F. (2013). Understanding and encouraging feedback-seeking behaviour: A literature review. Medical Education, 47, 232–241.

Kleffner, F. (Ed.). (1964). Seminar on guidelines for the internship year. American Speech and Hearing Association.

Cunningham, R. (1971). Developing question-asking skills. In J. Weigand (Ed.), Developing teacher competencies. Prentice Hall.

Ladany, N., Walker, J. A., & Melincoff, D. S. (2001). Supervisory style: Its relation to the supervisory working alliance and supervisory self-disclosure. Counselor Education and Supervision, 40, 263–275.

Dowling, S. (2001). Supervision: Strategies for successful outcomes and productivity. Allyn & Bacon. Dreyfus, S. E., & Dreyfus, H. L. (1980). A five-stage model of the mental activities involved in direct skill acquisition. https://apps.dtic.mil/sti/pdfs/ ADA084551.pdf Dudding, C. (2002). The use of videoconferencing in supervision of graduate clinicians. Perspectives on Administration and Supervision, 12(1), 8–12. Dudding, C. C. (2006). Distance supervision: An update. Perspectives on Administration and Super­ vision, 16(1), 16–18. Fall, M., & Sutton, J. M. (2004). Clinical supervision: A handbook for practitioners. Pearson Education New Zealand. Farmer, S., & Farmer, J. (1989). Supervision in communication disorders. Merrill. Gavett, E., & Peapers, R. (2007). Critical thinking: The role of questions. Perspectives on Issues in Higher Education, 10, 3–5. Gillam, R. B., Roussos, C. S., & Anderson, J. L. (1990). Facilitating changes in supervisees’ clinical behaviors: An experimental investigation of supervisory effectiveness. Journal of Speech and Hearing Disorders, 55(4), 729–739. Goldhammer, R., Anderson, R., & Krajewski, R. (1980). Clinical supervision (2nd ed.). Holt, Rinehart, and Winston.

Langdon, H. W., & Cheng, L. (1992). Hispanic children and adults with communication disorders. Aspen. Leighton, J. (1991). Gender stereotyping in supervisory styles. Psychoanalytic Review, 78, 347–363. Long, J., Lawless, J., & Dotson, D. (1996). Supervisory styles index: Examining supervisees’ perceptions of supervisory style. Contemporary Family Therapy, 18(4), 589–606. Lulai, R., & DeRuiter, M. (2012). The new clinical supervisor: Tools for the medical setting. Perspectives in Administration and Supervision, 22(3), 85–96. https://doi.org/10.1044/aaa22.3.85 Mandel, S. (2015). Exploring the differences in expectations between supervisors and supervisees during the initial clinical experience. Perspectives on Administration and Supervision, 25, 4–30. http://sig11​ perspectives.pubs.asha.org/article.aspx?articleid=23 815133&resultClick=3 Mawdsley, B. (1987). Kansas inventory of selfsupervision. In S. Farmer (Ed.), Clinical supervision: A coming of age. Proceedings of a national conference on supervision held at Jekyll Island, GA: Las Cruces, New Mexico State University. McCrea, E., & Brasseur, J. (2003). The supervisory process in speech-language pathology and audiology. Allyn & Bacon.

Halfond, M. (1964). Clinical supervision-stepchild in training. ASHA, 6, 441–444.

McCrea, E., & Brasseur, J. (2020). The clinical education and supervisory process in speech-language pathology and audiology. Slack Incorporated.

Hudson, M. W. (2010). Supporting professional performance in the clinical workplace. Proceedings of a short course for the American Speech-LanguageHearing Association, Philadelphia, PA.

McCready, V. (2007). Generational differences: Do they make a difference in supervisory and administrative relationships? Perspectives in Administration and Supervision, 17(3), 6–9.

Hudson, M. W. (2010). Supervision to mentoring: Practical considerations. Perspectives on Administration and Supervision, 20, 71–75.

Messick, C. & Mormer, E. (2016). Setting ourselves up for success: strategies for effective clinical learning partnerships. Proceedings of a short course, University of Pittsburgh.

King, D. (2003). Supervision of student clinicians: Modeling ethical practice for future professionals. The ASHA Leader, 8, 26.

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clinicians: Challenges and opportunities. ASHA Leader, 16, 5. Newman, W. (2001, June/July). The ethical and legal aspects of clinical supervision. CSHA (California Speech-Language-Hearing Association) Magazine, 30(1), 10–11, 27.

right 2025. Plural Publishing, Inc. rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

Newman, W., Victor, S., & Zylla-Jones, E. (2009). Tools for the first-time supervisor. Proceedings of a session of the American Speech-Language-Hearing Association, New Orleans, LA. Nottingham, S., & Henning, J. (2014). Feedback in clinical education, Part I: Characteristics of feedback provided by approved clinical instructors. Journal of Athletic Training, 49(1), 49–57. O’Connor, L. (2008). A new focus on supervision: Looking to the future. Perspectives on Administration and Supervision, 18, 17–23. Pfeiffer, J. W., & Jones, J. E. (1987). A handbook of structured experiences for human relations training. University Associates. Phillips, D. (2009). Supervisory practices in speechlanguage pathology: Pre-practicum assessment of clinicians in graduate training programs. Perspectives on Administration and Supervision, 19, 107–113. https://doi.org/10.1044 aas/19.3.107 Schober-Peterson, D., & O’Rourke, C. (2008). Identifying and assisting at-risk graduate students: Process and outcome factors. Perspectives on Administration and Supervision, 18, 94–98. Severinsson, E. (1996). Nurse supervisors’ views of their supervisory styles in clinical supervision: A hermeneutical approach. Journal of Nursing Management, 4, 191–199. Severinsson, E., & Hallberg, I. (1996). Clinical supervisors’ views of their leadership role in the clinical supervision process with nursing care. Journal of Advanced Nursing, 24, 151–161. Shapiro, D. A., Ogletree, B. T., & Brotherton, W. D. (2002). Graduate students with marginal abilities in communication sciences and disorders: Prevalence, profiles, and solutions. Journal of Communication Disorders, 35, 421–451. Shea, G. F. (1997). Mentoring: A practical guide (2nd ed.). Crisp Publications. Shipley, K. (1997). Interviewing and counseling in communicative disorders — principles and procedures (2nd ed.). Allyn & Bacon.

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Smith, K. (1979). Supervisory conferences questions: Who asks them and who answers them [Paper presentation]. Annual convention of the American Speech and Hearing Association, Atlanta, GA. Tellis, G., Cimino, L., & Alberti, J. (2010). Advanced digital technology for supervising graduate clinicians. Perspectives on Administration and Supervision, 20, 9–13. Ulrich, S. (1985). Continuing education model of training. In K. Smith (Moderator), Preparation and training models for the supervisory process [Short course presentation]. Annual convention of the American Speech-Language-Hearing Association, Washington, D.C. U.S. Department of Personnel Management. (1997). 360 degree assessment: An overview. http://www.opm​ .gov/perform/wppdf/360asess.pdf Victor, S. (2010). Coordinator’s column. Perspectives on Administration and Supervision, 20(3), 83–84. Weltsch, B. R., & Crowe, L. K. (2006). Effectiveness of mediated analysis in improving student clinical competency. Perspectives on Administration and Supervision, 16, 21–22. Williams, A. L. (1995). Modified teaching clinic: Peer group supervision in clinical training and professional development. American Journal of SpeechLanguage Pathology, 4, 29–38.

Resources Bartlett, S. (2003). In E. McCrea & J. Brasseur (Eds.), The supervisory process in speech-language pathology and audiology (pp. 154–156). Allyn & Bacon. Council of Academic Programs in Communication Sciences and Disorders eLearning Courses: https:// www.capcsd.org/elearning-courses/ Hurst, B., Wilson, C., & Cramer, G. (1998). Professional teaching portfolios. Phi Delta Kappan, 79(8), 578–582. Knowles, M. (1975). Self-directed learning: A guide for learners and teachers. Association Press. McCarthy, M. P. (2009, November). Promoting independence through self-evaluation and formative assessment in clinical education [Conference presentation]. Meeting of the American SpeechLanguage-Hearing Association, Chicago, IL.

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Pultorak, E. G. (1993). Facilitating reflective thought in novice teachers. Journal of Teacher Education, 44(4), 288–295. Rahim, M. A. (1989). Relationships of leader power to compliance and satisfaction with supervision:

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Evidence from a national sample of managers. Journal of Management, 15, 495–516. Schon, D. A. (1996). Educating the reflective practitioner: Toward a new design for teaching and learning in the professions. Jossey-Bass.

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23 Technology for Service Delivery, Professional Practice, and Student Training Carol C. Dudding and Rachel A. Ritter

“Technology is nothing. What’s important is that you have faith in people, [sic] if you give them tools, they’ll do wonderful things with them.” — Steve Jobs, Apple cofounder, 1994 interview, Rolling Stone magazine

Scope of Chapter This chapter provides you with an introduction to technologies as they are used by speech-language pathologists (SLPs), audiologists, researchers, and educators in communication sciences and disorders (CSD). It offers insights into the technologies themselves as well as ways in which they impact how we diagnose, treat, and interact with the clients; operate within our practice settings; and train future professionals. The chapter includes best practices and guidelines for effective and appropriate use of the technologies. Examples of real-world applications will be presented.

The Digital Revolution We are living in a time known as the digital revolution. The internet, smartphones, text messaging, and viral videos are likely to have always been part of the lived experience of millennials and Gen Z. For this reason, these individuals are known as digital natives (Prensky, 2001). This is contrasted to digital immigrants, those who have been exposed to these technologies later in life. Existing stereotypes suggest that digital natives are fluent in the use of technologies with little or no training, have short attention spans, and possess the ability to multitask (Jones et al., 2010; Prensky, 2001). It is thought that digital natives view relationships and institutions differently from digital immigrants. Digital natives have expectations for how they receive and share information, acquire knowledge, 469



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and interact with other people. Digital natives hold the view that learning is best achieved through action and exploration within a given context (Shtepura, 2018; Smith et al., 2020). Researchers and tech giants such as Steve Jobs, cofounder of Apple, and Bill Gates, cofounder of Microsoft, remind us that technologies are just tools and that it is up to the users of these tools to effectively adopt and utilize new technologies for the benefit of society. Digital natives and digital immigrants were all plunged into a world of technologies for our social, occupational, and educational needs because of the COVID-19 global pandemic of 2020. Due to massive shutdowns of our institutions, we were forced to rely on the internet, web-conferencing tools, and videoconferencing for all aspects of our lives. We quickly learned to interact with colleagues in boxes arranged on a computer screen as we engaged in meetings using Zoom®. We ordered our groceries, pizzas, and entertainment using the internet and digital apps on our smartphones. We reconfigured bedrooms to serve as offices, upgrading our internet services so we could continue to engage with others via web conferencing and digital conferencing. Family members of all ages came to rely on FaceTime® to check in and keep up with our friends and family. We connected with our health care professionals through cameras on our phones. University programs, such as graduate programs in CSD, pivoted to telepractice and telesupervision in place of on-site clinical training of students. As our world moves beyond the shutdowns imposed on us by the pandemic, it is clear that how we do our jobs, build and maintain relationships, and educate students is forever changed in ways that were only possible by embracing emerging technologies such as those discussed in this chapter.

Technology for Service Delivery Communication disorders professionals use technology in a myriad of ways across clinical and professional settings. SLPs and audiologists have access to imaging technologies, electronic assessments, software programs, electronic games, virtual simulations, and web-based applications to utilize in assessment and treatment of communication and swallowing disorders. Assistive technology devices can benefit clients with speech, language, and hearing disorders. Secure web-based videoconferencing platforms allow for clinical services to be provided through telepractice. It is beyond the scope of this chapter to discuss all the technologies in detail, but an effort is made to provide an overview of the current applications and best practices. Refer to Figure 23–1 for a partial listing of technologies employed in service delivery in CSD.

Telepractice for Service Delivery Telepractice has expanded dramatically in recent years, particularly since the start of the COVID-19 pandemic. As such, new professionals should expect to be involved either professionally or personally in telepractice. Telepractice, also referred to as telehealth and teletherapy, is a term used to describe connecting clients to clinicians, educational, or health care professionals using internet technology for service provision (American SpeechLanguage-Hearing Association [ASHA], n.d.-a). It can be effectively used for assessment, intervention, and/or education. The development and acceptance of telepractice has improved access to services for clients with geographic limitations, mobility or health concerns, and/or access to a qualified professional (Bolden, 2022). There is a growing number of communication disorders professionals who work exclusively via telepractice in school and private practice settings. Models of Telepractice Delivery.  There are various models of telepractice including synchronous, asynchronous, and hybrid models. Synchronous services are the most used model of telepractice. The provision of synchronous or face-to-face services occur when a clinician and client interface using digital videoconferencing technology to provide services in real time. An example of a synchronous delivery model would be a licensed SLP providing speech services to an adult who has aphasia. The clinician can elicit and monitor language production much like they would in an in-person session. A benefit of synchronous methods of telepractice is that they allow for immediate feedback to the client. Asynchronous services include the secure exchange of information, images, video, or data that are viewed or interpreted later. Asynchronous services are most often used in conjunction with synchronous delivery, making it a hybrid delivery model. For example, an audiologist may electronically receive test results from an otolaryngologist (asynchronous) and then schedule a video chat (synchronous) with a patient to discuss treatment approaches. Hybrid models are frequently used to facilitate generalization of skills through use of remote patient monitoring. Several digital apps allow clinicians to assign and check progress on home exercises. For example, an SLP may assign a home exercise program and then check in on client progress through a website or app. With the COVID-19 pandemic, reimbursement for telepractice services has increased among many insurance providers, though reimbursement is still typically limited to synchronous services. Clinician Guidelines.  Clinicians new to telepractice should seek out established best practices. Telepractice



CHAPTER 23   Technology for Service Delivery, Professional Practice, and Student Training

Figure 23–1.  Technology for service delivery in CSD.

services should be cost-effective, meet requirements for reimbursement and licensure, remain in compliance with state and national standards for best practice, and follow privacy and security laws. Clinicians must remain up to date with state and national regulations regarding telepractice. While state laws vary, generally, clinicians must be licensed in the state in which they are physically located as well as in the state in which they are providing services or the state in which their client is located (ASHA, n.d.-a). A nationwide compact or agreement is being developed among states in the United States to ease the burden of multistate licensing requirements. Government and regulatory agencies have created documents and resources to ensure services provided through telepractice meet the same standards as those provided in face-to-face delivery. The American Telemedicine Association (ATA) is an excellent resource. ASHA’s practice portal (ASHA, n.d.-a) also provides an overview of telepractice as well as resources for clinicians. Those interested in engaging in telepractice should seek out networking opportunities with other telepractitioners. They can do so by joining an organization dedicated to telepractice, such as ATA, or a special interest group as part of their professional organization.

Clinicians must always adhere to privacy and security standards regardless of the method of service delivery. This especially applies when using digital technologies for service delivery. It is the responsibility of the licensed professional to ensure telepractice platforms and documentation systems are HIPAA compliant; meaning they meet the requirements of the Health Care Insurance Portability and Accountability Act (HIPAA) of 1996 (HIPAA, 1996). HIPAA is a federal law that seeks to improve continuity of health coverage as well as privacy of information (Department of Health and Human Services [HHS], 2021). Specifically, HIPAA laws require that health care providers, health information organizations, and subcontractors working with protected health information (PHI) take measures to protect patients (HHS, 2021). Examples of PHI include medical test results, patient names, patient addresses, medical history, and diagnosis. As CSD professionals, we must follow HIPAA requirements to protect patient privacy for provision of in-person and telehealth services. When selecting telepractice platforms, clinicians might want to contemplate availability of certain features such as screen sharing, captioning, whiteboards, text chat, and remote-control access to ensure sessions

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are interactive and engaging for clients. For example, during a speech-language therapy session, a clinician can give remote-control access to a client so the client can control the mouse and interact with computer games. Remote control also can allow clinicians and clients to interact with other web-based video platform features, such as the whiteboard. On a whiteboard, clients and clinicians could write notes, draw pictures, play games such as tic-tac-toe or hangman, and more. Many of the same activities clinicians would use to deliver face-toface services can be adapted to telepractice with some creativity. Figure 23–2 shows an SLP preparing for a telepractice session working on speech and language skills using picture scenes and games. Client and Family Guidelines.  Several considerations must be addressed when considering the use of telepractice. First, clinicians must determine if telepractice is appropriate for each client. For some clients, telepractice is not the most appropriate format of service delivery. Clinicians should consider client and family commu-

nication skills as well as physical, sensory, and cognitive needs and abilities of their client before proceeding with telepractice. Is the client able to physically access the technology? What positioning devices, if any, are required? Can the client adequately view the screen, either with or without eyeglasses? Does the client have adequate attention span to engage in activities? Is the audio component, if any, adequate for individuals with hearing loss? Clients or their caregivers must also have access to resources such as a tablet or computer with videoconferencing abilities as well as high-speed internet. It is also important for clinicians, clients, and facilitators to

Figure 23–2.  Image of speech-language pathologist preparing for a telepractice session working on speech and language skills using picture scenes and games. Used with permission.



CHAPTER 23   Technology for Service Delivery, Professional Practice, and Student Training

possess basic technological knowledge to troubleshoot as issues arise. Telefacilitators.  Telepractice frequently requires the use of a telefacilitator, someone who is present during the session to assist the client or clinician in implementation of session objectives. Many children need a parent or caregiver present to act as a facilitator during sessions to help with activities and/or to provide feedback to the client or clinician. Oftentimes a classroom aide or someone already employed by the school with experience working with children is employed as a facilitator in school settings. Alternatively, some adult or geriatric clients benefit from the use of facilitators as well. Professionals serving as telefacilitators should be adequately trained and possess minimum competencies. Table 23–1 outlines minimum competencies in technology, interpersonal skills, policy, and administrative procedures for telefacilitators. These competencies can be adapted to the needs of family members and nonprofessionals serving as facilitators.

Technology Used in Assessment and Intervention SLPs and audiologists use various types of technology for assessment and intervention of people with communication, hearing, and swallowing disorders. Technologies can be categorized as instrumentation technology, digital apps, games, virtual simulations, and specialized software. These technologies can be used in provision of face-to-face assessment and intervention services or in combination with telepractice technologies. Instrumentation Technology.  Technological advancements in instrumentation have aided in the accurate diagnosis of communication disorders. For audiologists, instrumentation technologies such as audiometry (puretone air/bone conduction and speech recognition), otoscopy, immittance testing, otoacoustic emissions (OAEs), auditory brain stem responses (ABRs), and electrocochleography are the mainstays of audiological assessment. Audiometers are used to assess hearing acuity in children and adults. OAEs and ABRs have made screening the hearing of newborns/infants possible. Audiologists use instrumentation technologies including videonystagmography (VNG), vestibular evoked myogenic potential (VEMP), and rotational chair assessment in assessing vestibular disorders. SLPs rely on various forms of instrumentation technologies for diagnosis and treatment of communication and swallowing disorders. Imaging technologies including modified barium swallow studies (MBSS), flex-

ible endoscopic evaluation of swallowing (FEES), and laryngoscopy are integral to the assessment of pediatric and adult clients with swallowing concerns. The use of ultrasound and electromyography (EMG) can be used to aid in diagnosis and provide biofeedback to clients. Additionally, SLPs rely on web-based assessments, such as the Clinical Evaluation of Language Fundamentals– Fifth Edition (Wiig et al., 2013) and the GoldmanFristoe Test of Articulation–Third Edition (Goldman & Fristoe, 2015), which allow for digital administration, scoring, and reporting for common pediatric speech and language assessment measures. Specialized software also serves as crucial instrumentation technology for communication sciences and disorders professionals. Audiologists rely on specialized software for programming hearing aids and mapping cochlear implants. Available technology includes free or low-cost software programs that conduct voice, sound, and language analysis. This software is invaluable to the clinician in both assessment and treatment of a variety of communication disorders. Programs such as Waveforms Annotations Spectrograms and Pitch (WASP), WaveSurfer, and PRAAT provide basic spectral analysis of the client’s speech and in some cases may be used to provide feedback to clients with speech and voice disorders. Recordings of client language samples can be further analyzed using a computer-assisted language sample analysis software package such as Systematic Analysis of Language Transcripts (SALT). This specialized software has allowed practitioners to provide in-depth analysis and feedback that was formerly only possible in research laboratories. Virtual Simulations.  Simulations are another application of technology. Simulations represent a wide range of technologies from low to high, with varying levels of immersion. Advantages of simulations include opportunities for meaningful contextual learning and exposure to real-life challenges without risk of harm to actual clients. A specialized category of simulation, known as virtual simulations (VS), are well suited for assessment and intervention within CSD. Virtual simulations provide clients with an opportunity to practice targeted skills within a virtual reality (VR) practice environment (Lee, 2019). The VR environment is developed to imitate or estimate how events might occur in real-world situations. For example, a person with autism may practice engaging with virtual people in a virtual coffee shop. Audiologists may engage patients in virtual worlds developed to invoke vertigo as part of vestibular rehabilitation. Clients can experience varied levels of immersion and interaction within VR environments. For example, some VR environments may contain a single preprogrammed

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Table 23–1.  Minimal Competencies for Telefacilitators In-Session Management Competencies  n

Prepares, organizes, and maintains therapeutic materials for use during the session.

n

Ensures access to and functioning of all necessary technology, including mouse, cameras, pointers, and printers. 

n

Manages the environment to maximize audio and video quality with attention to lighting and noise levels. 

n

Uses behavior management strategies as directed by the clinician.

n

Administers prompts, scaffolding and reinforcement as directed by the clinician.

n

Clarifies client responses if necessary.

n

Uses email, telephone, and web-based materials in a matter compliant with privacy and confidentiality standards.

n

Cleans equipment between clients.

Interpersonal Competencies n

Effectively communicates with the client, family members, and other professionals in a manner that recognizes the needs, values, preferred mode of communication, and cultural/linguistic background of all individuals. 

n

Accurately transmits information between the clinician and client, teachers, family, administrators, and /or other professionals.

n

Accurately describes telepractice to clients, teachers, family, administrators and /or other professionals.

Technology Specific Competencies n

Establishes video and audio connections for the telepractice session.

n

Manages and troubleshoots telepractice equipment and peripheral devices such as external camera, printer, and document camera.

n

Maintains a list of resources for assisting with troubleshooting technical problems (e.g., IT personnel, video-conferencing platform, web resources, etc.)

n

Troubleshoots local issues with technology and secures technical support as needed. 

n

Maintains a log of technical difficulties encountered and requests assistance with recurring problems.

n

Uses annotation features of video-conferencing software as indicated (e.g., highlighter, arrow, text boxes).

n

Records session as needed. 

Policy and Procedural Competencies n

Adheres to licensing and certification regulations regarding telepractice and tele-facilitation. 

n

Adheres to policy regarding confidentiality and privacy (e.g., HIPAA and FERPA)

n

Follows general operating policies and procedures for the local site, including infection control policies.

Administrative Competencies n

Manages documentation related to diagnostics and intervention, including documentation related to consent, billing and compliance. 

n

Assists with scheduling therapy sessions and make-up sessions as required.

n

Schedules meetings between the clinician and clients. 

n

Escorts the client to and from therapy room as needed. 

Source:  Adapted from Douglass et al. (n.d.).



CHAPTER 23   Technology for Service Delivery, Professional Practice, and Student Training

avatar while others may have multiple users in real time with whom clients can interact. Figure 23–3 outlines the various depths of VR as it applies to learning environments. Some clinicians hypothesize that the sense of immersion with VR may facilitate transfer or generalization of skills to real-world environments (Bryant et al., 2020). Virtual simulations don’t have to be expensive and require a great deal of equipment and technical expertise. While highly immersive technologies such as highfidelity manikins and immersive VR caves may be out of reach for most practitioners, there are a number of computer and web-based simulations that are at low or no cost and can be readily adapted for CSD. Augmented reality (AR) is an affordable and accessible form of VR. AR refers to the use of VR imposed upon the real-world environment through use of goggles and/or smartphones. Consider the companies that allow you to virtually try on clothing using a photo from your smartphone. These types of AR could allow clinicians to add a level of realism and interactivity to traditional intervention materials. Consider how a storybook using AR technologies would allow a child with language disorders to engage with the 3D characters and images on the pages as a way of enhancing language skills. As VR goggles become less expensive and more readily available, the opportunities for intervention are seemingly endless. Ultimately, the use of VR for assessment and intervention within CSD is still developing and will likely continue to grow. Augmentative and Alternative Communication. Augmentative and alternative communication (AAC) is a specialized clinical area that employs a range of technologies to supplement or compensate for impairments in spoken and written modes of communication. Communication systems are considered augmentative when they add to someone’s speech and considered alternative when used in place of speech. AAC systems can help a variety of clients with congenital (i.e., present at birth) or acquired communication disorders. According to the United States Society of Augmentative and Alternative Communication (USSAAC), more than 2 million people in the United States use some form of AAC to communicate (National Institute on Deafness and Other Communication Disorders, 2022). AAC falls under the broader category of assistive technology but will be treated as a separate topic area in this chapter. AAC encompasses a wide range of communication devices, systems, strategies, and tools that replace or support natural speech. These tools range from low/no tech to high tech. Examples of AAC include any combination of:

n

manual signs, finger spelling and gestures;

n

tangible objects;

n

written words and drawings;

n

picture communication boards and letter boards; and

n

speech-generating devices (ASHA, n.d.-b).

AAC systems can be unaided, meaning they do not require any type of external technology or tool. Unaided forms of AAC can include use of body language, manual signs, verbalizations, and gestures. Alternatively, AAC systems can be aided, meaning an external tool is required. Aided AAC systems are generally divided into two categories: low tech and high tech, where lowtech systems include pictures, objects, visual schedules, writing, single switches, or communication boards and high-tech systems can include communication apps, tablets, and speech-generating devices (SGDs). SGDs allows a user to create a message that is then turned into voice output. An SGD is an example of a dedicated device that is created solely for use as an AAC device. AAC devices can be accessed in a variety of ways by the user including direct touch to the device, through use of eye gaze technology, and via voice. Artificial phonation devices (e.g., electrolarynx devices and speech valves for individuals with tracheostomies or ventilators) are also considered high-tech devices to augment speech. Figure 23–4 provides an overview of the categories and types of AAC devices. AAC devices have evolved from expensive and cumbersome dedicated devices that required special mounting on wheelchairs to small, compact, and powerful communication aids. Apple’s iPad technology is increasingly popular as a nondedicated AAC device due to its affordability, cultural acceptance, and the emerging number of apps being developed for this specific purpose. While iPads and tablets can be an affordable option for AAC, it is important to trial multiple AAC systems and ensure clinicians and families understand the pros and cons of dedicated devices compared to nondedicated devices. An AAC device should always be chosen because of its functionality for each specific client. Like any client SLPs work with, there is no onesize-fits-all approach to AAC. Websites, Games, and Digital Apps.  Today, several web-based commercially available websites exist, such as Teachers Pay Teachers and Boardmaker, that allow clinicians to find and customize materials for clients. Websites and blogs such as Home Speech Home and Eat, Speak, & Think offer listings of activities and provide

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Figure 23–3.  Depths of VR for learning. Source: Steve Banbury https://www.virtualiteach.com/post/the-depths-of-vr-model-v2-0  continues

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Figure 23–3.  continued



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Figure 23–4.  Augmentative alternative communication modalities.

suggestions for incorporating games into treatment programs. Several websites are designed specifically for SLPs to utilize during intervention. For example, UltimateSLP allows clinicians to select multiple therapy targets that become incorporated into fun and interactive games for individual or group sessions. Additionally, social media platforms, such as Etsy or Pinterest, also provide resources and activity ideas for clinicians. Through the development of digital apps on mobile devices, nondedicated touchscreen technologies such as the iPhone and iPad have made their way into intervention services in CSD. There are numerous advantages of integrating apps in intervention including increasing motivation, monitoring progress, serving as support

tools, and addressing specific communication targets such as written language and literacy (Hutchins, 2021). Children with speech sound disorders may benefit from use of the Articulation Station or the StaRt apps (Biofeedback Intervention Technology, n.d.) developed specifically to provide biofeedback for clients working on /r/ production. The LAMP Words for Life language system is useful for clients with language-based disorders. Many apps and games also exist for adult clients including Constant Therapy, which was designed for clients poststroke or traumatic brain injury (TBI) or for people living with aphasia, dementia, or other neurological conditions. Certain interactive games target skills such as word retrieval, memory practice, and language



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comprehension. Applications such as calendars or planners can also be used as external memory aids when working with adults. Audiologists make use of apps that allow for hearing screenings, act as sound-level meters and hearing loss simulators, and allow for practice of listening skills (Mashima, 2010). Websites and apps also facilitate the transfer of communication skills gained within the therapy setting to other contexts, known as carryover or generalization of skills. To facilitate carryover of skills, clinicians should create individualized home exercise programs (HEPs) for clients. Vayo et al. (2018) found the use of an app, HP Reveal, helpful in facilitating the transfer of speechlanguage goals for children from the clinic setting to the home environment using customized HEP. The app allows clinicians to create videos that are subsequently launched by trigger images on mobile devices. The videos remind parents and clients of the therapy goals, provide verbal and visual prompts to encourage accuracy, and provide activities to facilitate sound production and language use at home. Similar apps for skill transfer include Seesaw, Constant Therapy, and Bitsboard. Additionally, several electronic medical record (EMR) systems allow for assignment of a HEP that can be sent to clients directly. While a multitude of free and accessible apps and websites exist, clinicians should always adapt resources or materials found online to fit each client’s unique goals and needs by considering interactivity, specific feedback provided, and motivation to the user. This access to online materials is a wonderful resource; however, clinicians must remember that resources never take the place of skilled services. Imagine an SLP working with a child on vocabulary development. The SLP performs an online search and finds a simple, printable board game with vocabulary question cards. As the SLP reviews the game, it becomes clear that the vocabulary targeted in the game is not age appropriate or functional for this child. The SLP decides to generate their own vocabulary cards for use with the game board. This simple adaptation by the SLP ensures the client has a fun and interactive session that is customized to meet their unique goals.

Assistive Technology Assistive technology (AT) includes equipment, systems, or products to improve or enhance daily living for an individual with a disability (Assistive Technology Industry Association, n.d.). The use of AT spans the scope of multiple professions including audiologists, SLPs, occupational therapists, and physical therapists. Communication disorders professionals regularly inter-

act with clients using AT devices such as hearing aids, cochlear implants, hearing assistive technology systems (HATS), and augmentative and alternative communication (AAC) devices, to name a few (ASHA, n.d.-c). Hearing Aids and Implantable Devices.  A prime example of AT devices is hearing aids. The audiology profession has experienced rapid growth in hearing aid technologies since 1987, when the first digital hearing aids were manufactured. Hearing aids are used to amplify sound for individuals with hearing loss. Current hearing aids offer advantages in wireless technology, feedback cancellation, directional microphones, and improved environmental noise control. According to the ASHA 2018 Audiology Survey (ASHA, 2019), more than 80% of audiologists fit and dispense hearing aids on a daily or weekly basis. Many individuals with hearing loss do not have or use hearing aids due to a variety of barriers including cost, stigma, and low priority in addressing hearing loss by health care providers (McKee et al., 2019). In October 2022, the Food and Drug Administration (FDA) approved a new class of hearing aids to be purchased over the counter (OTC). Access to OTC hearing aids is intended to increase the availability and affordability for adults aged 18 and over with perceived mild to moderate hearing loss (Coco, 2022; Food and Drug Administration [FDA], 2023). The introduction of OTC hearing aids will involve a great deal of change and opportunity for audiologists to reach a larger population of clients (Coco, 2022). Perhaps no technology has impacted the profoundly deaf and hearing-impaired community more than the development of the cochlear implant. A cochlear implant is a surgically embedded device for individuals with profound sensorineural hearing loss that stimulates the auditory nerve directly, providing a sensation of sound. Cochlear implants are not a quick fix for hearing loss but rather a tool that some clients and/or families choose to utilize. Following cochlear implant surgery, individuals typically need extensive speech-language therapy (Cooper, 2019). Professionals in CSD should seek to understand perspectives of Deaf culture and ensure clients and families understand the benefits and drawbacks of cochlear implants. While cochlear implants serve those with sensorineural hearing loss, osseointegrated devices are treatment options for individuals with conductive, mixed, or single-sided deafness or unilateral sensorineural hearing loss. These implants are surgically embedded to the outside of a person’s skull, behind the ear, and transmit sounds to the inner ear through skull vibrations. Osseointegrated implants are indicated for children over the age of 5 with mixed or conductive hearing loss or for

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adults with single-sided deafness (Sigfrid, 2011). Outcomes with osseointegrated devices are generally successful, depending on the severity of the hearing loss. Hearing Assistive Technology Systems.  HATS are perhaps less familiar to the public than hearing aids and cochlear implants in spite of the fact that a majority of audiologists (68%) demonstrate, fit, or dispense hearing assistive technology on a daily or weekly basis (ASHA, 2019). HATS are technology devices that provide additional support in specific listening situations, particularly loud locations. HATS can be integrated with hearing aids or cochlear implants or used independently. HATS include altering systems to produce loud tones, flashing lights, or vibrations to alert people with hearing loss to various environmental sounds such as doorbells and fire alarms. Personal amplifiers can be used for amplification in conversations or when listening to television or music. Other HATS assist users in the use of telephones and smartphones through the use of Bluetooth, captioning, and relay services. There are several text-based devices designed to allow individuals with hearing and/or speech-language impairment to use telephone services to communicate directly with one another via speech and/or text or via live relay operator. These technologies include TeleTYpe (TTY), Telecommunications Device for the Deaf (TDD), and Text Telephone (TT). Imagine an individual with hearing loss who does not speak who wants to call to schedule a haircut. They can call a relay operator using TTY, where the operator and individual communicate through typed messages. The operator calls the hair salon and the individual with hearing loss can type the message to request an appointment and the operator reads it to the salon. Many people who use American Sign Language (ASL) to communicate now use video relay services (VRS). VRS works in a similar way to TTY but allows people who use ASL to communicate instead of typing messages (Gallaudet University, 2010). Frequency modulation (FM) systems and audio induction (i.e., hearing loops) systems are designed to assist people with hearing loss in large public and educational settings. FM systems are wireless devices that, when combined with the use of hearing aids and cochlear implants, can assist a person in hearing over distance and in noisy environments. FM systems can also benefit hard-of-hearing individuals who do not wear hearing aids. FM systems vary but in general, the speaker wears a microphone and the listener wears a receiver. The speech signal is transmitted using radio waves to the receiver, allowing for the speaker’s voice to come directly to the individual with hearing loss. Audio induction loops are designed to work with hearing aids in large settings. A wire that conducts an electrical current is generally

installed under flooring or in a ceiling. The loop wire, microphone, and hearing aids work together to pick up and convert sound signals. An infrared system is like the FM system except that it uses light waves instead of radio waves to send sound signals across a space. Infrared systems are generally used at home with televisions. This allows for users to increase the volume without turning the volume too high for others in the home. Assistive technologies have expanded and will undoubtedly continue to expand in the digital age. As the U.S. population ages, elderly people with cognitive and language disabilities may benefit from signaling devices to alert others of their needs; identification aids to convey biographical information; voice amplifiers to increase speech loudness; and alerts, environmental organizers, and memory books to serve as external memory aids. Technological advances continuously improve AAC devices and allow for additional modes of access to communication, such as eye gaze technology for clients with limited mobility. AT is constantly changing, and SLPs and audiologists should work to remain knowledgeable about advances in AT to best serve clients.

Considerations for Technology Usage in Service Provision Technological advances have facilitated improved diagnostic and intervention outcomes for patients and clients in CSD. While digital games and ready-made materials offer benefits to both clinicians and clients, you are cautioned to carefully evaluate the claims of any program employed in treatment. It is important to consider the population the program was designed to address (e.g., age, diagnosis, prerequisite skills, motor, and intellectual ability). A single digital assessment, game, program, or material cannot address the needs of all clients, nor does it replace skilled assessment or intervention provided by an SLP or audiologist. The professional should be guided by evidence-based practice in assessing the efficacy of technology employed in any client interaction. Refer to Figure 23–5 for an overview of considerations when integrating technologies into practice.

Professional Practice Settings SLPs and audiologists are employed in a variety of work settings including early intervention, health care, schools, and/or private practice. Each of these settings is greatly influenced by technology trends. In addition to the need for electronic billing and reporting functions, practice settings rely on technology to offer collaboration tools and to provide services to patients at a distance.



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Figure 23–5.  Barriers and facilitators of implementing and delivering technology-based interventions aimed at supporting professional practice change. Keyworth et al., 2018. Licensed under Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/).

The health care arena is seeing a surge in health information technologies, such as electronic health records (EHRs) or electronic medical records (EMRs), electronic billing, and clinical point of care technologies. Eighty-one percent of health care payer executives indicate their company is investing in technology to improve member experience (CDW Health Care, 2018). Personalized health care is a phrase used to describe a movement to provide health care individualized to the needs and history of a patient. This is possible, in part, due to a health information technology known as clinical decision support system (Morris et al., 2022). This technology allows physicians and other health care workers to access information and health care records to aid in clinical decision making. Another way that medical care is becoming more personalized is with the inclusion of tablets, smart TVs, and interactive digital whiteboards in patients’ rooms aiming to improve patient satisfaction/ participation, quality of care, and lower readmission rates (CDW Health Care, 2018). Hospitals and health care clinics are not the only work settings to be impacted by technology. Public and private schools have certainly been affected by educational technologies used in teaching (e.g., SMART Board•, n.d.), data management systems that assist tracking student progress, online and web-based therapy portals, computerized assessments and analysis programs, various assistive technologies including AAC systems, hearing aids and cochlear implants, and service delivery through telepractice.

Through several commercially available programs, SLPs and audiologists based in public schools can access scheduling calendars and student records. They can share information with family members and other professionals and track and report progress toward goals. Many public school systems use dedicated, password-protected online programs such as IEP Online (PCG Education, n.d.) to create, track, and share students’ Individualized Education Programs (IEPs), thereby streamlining the cumbersome documentation process and securing educational records. When sharing educational records and/or medical information, it is paramount to follow the employment setting’s policies and procedures related to information security. In addition to the HIPAA Privacy Rule governing health care information, clinicians should be familiar with the regulations protecting educational records as outlined by the Family Educational Rights and Privacy Act (FERPA) of 1974. Failure to comply with these safeguards may result in civil penalties and fines and criminal charges (FERPA, 1974). Breaches of information security may also result in loss of employment. Safeguarding of information will be addressed later in this chapter and is more fully detailed in Chapter 4 on ethics. It is no longer prudent or best practice to provide services in isolation from other professionals. Indeed, interprofessional practice and collaboration are becoming mandates of many professions, including audiology and speech-language pathology. Consider the use of web conferencing software programs such as Zoom®, WebEx,

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and Google Meet® for collaborating on a research project or discussing a challenging case. These applications, and others like them, allow for real-time communication through use of text, voice, and/or video communication. Desktop sharing allows all participants to view and modify shared documents and applications in real time. With the use of these technologies, practitioners can consult with an expert located across the country or across the world. They can virtually meet in real time to discuss a client, view videos of a client’s performance, and/or share test results. Now imagine the same expert is researching a rare or complex condition but has access to a limited number of clients. Once again, with web conferencing technologies, the professionals can now collaborate and share information to advance research in this area. Another way professionals and students can collaborate and share information is through peer-to-peer (P2P) file-sharing programs, document-sharing websites, and cloud applications. Cloud computing allows users to store electronic files on a password-protected site on the internet. Cloud computing provides users access to files and applications through browsers without housing software or files on a computer. There are several weband cloud-based applications to support professional collaboration. Current examples of cloud applications are Google Drive™, Google Calendar™, OneDrive, and Dropbox™. Some applications have meeting schedulers, shared calendars, and web conferencing capabilities for members to discuss the project. This type of technology is particularly useful for students and professionals working as a team to create a research paper, procedure manual, or other text-based project. These technologies, used individually or together, support and enhance collaboration and research for practicing professionals, students, and researchers in speech-language pathology, audiology, and the speech-hearing sciences. No doubt you can imagine any number of scenarios in which the sharing of information among professionals would be beneficial not only to the clients but also to the advancement of the professions.

about higher education. Institutions are compelled to be flexible and adopt innovative technologies to meet the changing demands and remain viable in a rapidly changing environment. Universities are committed to enhancing student interactions through digital admissions processes, virtual real-time support systems and new ways of learning (Siddiqi, 2022). Digital transformation goes beyond upgrading technology infrastructure and aims to reimagine vision and strategic objectives. Figure 23–6 represents states of institutional reform leading to digital transformation.

Classroom Technologies Digital technologies in higher education are focused on increasing student engagement in the learning process. Learning management platforms such as Canvas and Blackboard, cloud sharing, web conferencing, and electronic response systems have transformed the way we teach and learn at the university level. Learning platforms allow students to access course content, communicate with the instructor, and interact with the instructor and other learners. Synchronous technologies such as web meetings (e.g., Zoom, Webex, and Google Meet) have become ubiquitous following the COVID-19 pandemic. Learners interact in real time through screen sharing, online polling, and breakout rooms for small group discussion. Faculty create and post prerecorded lectures using multimedia technologies. Cloud-based technologies such as Google Drive™ and Dropbox™ allow for file storage and access to shared documents. These technologies collectively allow for remote working and learning. Emerging technologies such as artificial intelligence (AI), VR and AR, and big data analytics enable innovative teaching methods and transformation of learning. The transformation of learning is precipitated by changes in delivery methods as much as by the technologies themselves. Students can participate in learning through a combination of synchronous and asynchronous methods. The Digital Transformation in Higher Education (n.d. 2022) describes the following modalities:

Education and Training

n

Digital Transformation of Institutions of Higher Education

On-campus technology enhanced:  In-person teaching enhanced by technology

n

Hybrid/blended:  Combination of online and in-person learning

n

Asynchronous online:  Teaching and learning without live meetings

n

Synchronous online:  Instructors and learners interact online in real time

n

Bichronous online:  Combination of asynchronous and synchronous online modalities

Institutions of higher education, like other businesses and industries, are undergoing a digital transformation because of cultural, workforce, and technological changes (Unosquare, 2020). These changes are closely related to the rapid expansion in digital technologies, along with reduced public funding, student expectations of technology, and political and public skepticism



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Figure 23–6.  Digital transformation in context. Source: Brooks, D. C., & McCormack, M. (2020). Defining digital transformation. Educause (https://www.educause.edu/ecar/research-publications/drivingdigital-transformation-in-higher-education/2020/defining-digital-transformation). Licensed under Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/).

n

Hyflex:  Flexibility in attendance options based on need or preference

The rapid emergence of collaborative technologies, apps, and instruction modalities has university information technology (IT) and help desks struggling to keep pace. BYOD (bring your own device) is a term referring to the technologies students bring into the classroom including the hardware (e.g., smartphones, tablets, and laptops) and countless apps and software programs.

Online Learning The rise in online learning since the 2020 pandemic is not news to anyone but the rate of growth and its lasting impact is worth considering. In the 2 years from 2018–2020, the number of undergraduate students in the United States enrolled in at least one online course more than doubled from 31.6% to 75% of all students (Seaman et al., 2018). While enrollment in traditional degree programs continues to decline, online learning is projected to increase. Global growth in online learning is projected to reach $336 billion by 2026 (Global E-Learning Market Analysis 2019, n.d.). The disciplines of speech-language pathology and audiology are experiencing similar growth rates in the use of distance education technologies in the academic and clinical training of future professionals. A search

using ASHA’s EdFind (ASHA, n-d.-d) revealed that 26 institutions offer fully online degree programs, while 98 programs offer prerequisite coursework online. These numbers do not include graduate courses that are offered as hybrid or blended; that is, courses that employ both face-to-face and online delivery methods. Previous versions of this chapter included detailed descriptions of the kinds of technologies used in online learning (e.g., chatrooms, discussion boards, web conferencing, electronic gradebook) and key terms (e.g., synchronous, asynchronous, and hybrid). These technologies and terms are commonplace not only in higher education but also in preschool and elementary school classrooms. Online learning has been fueled by the ability to provide access to millions who could not attend traditional courses on a brick-and-mortar campus. Massive open online courses (MOOCS) spiked in numbers and popularity in 2020 as a way of offering access to high-quality education free of cost. This initiative was wildly successful in enrolling 220 million students in 3,100 courses and 500 microcredentials (Shah, 2018). Initially MOOCS were offered free by universities, but today many offerings are being offered by companies such as Coursera, edX, Udacity, and FutureLearn. In addition to the education and training of future professionals, online and distance technologies have impacted professional development and training in both audiology and speech-language pathology. Professionals

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certified by ASHA are required to obtain 30 hours of continuing education activities each 3-year certification period (Council for Clinical Certification [CFCC], 2018). A recent trend in online learning and professional development is in micro-credentialing. The National Education Association offers microcredentialing as a competency-based recognition of mastery in a particular area of practice (National Education Association, n.d.). Microcredentialing can take the form of certificates, digital badges, licensing, and apprenticeships. Microcredentialing offers personalization and flexibility in closing the gap between education and workplace skills and has the potential to increase diversity by improving access for underrepresented groups (Caballero et al., 2022). As microcredentialing continues to increase, the impact on traditional degree programs could be significant.

Telesupervision for Supervision and Mentoring Graduate programs in speech-language pathology and audiology recognize the significance of supervision as a means of producing quality clinicians. Bernard and Goodyear (1992) state the importance of supervision as a means of transmitting the skills, knowledge, and attitudes of a particular profession. It also is an essential means of ensuring that the clients receive a certain minimum of quality of care while trainees work with them to gain their skills. (p. 2)

Many state licensing boards and professional organizations such as the American Board of Audiology (ABA) and ASHA require student clinicians to complete practicum requirements under the supervision of accredited and/or licensed professionals. Graduate programs in audiology and speech-language pathology are facing dwindling availability of clinical placements for their students. This is a result, in part, of workplace demands, productivity quotas, and restrictions handed down from insurance companies that greatly limit the ability of a working professional to supervise a student, even if motivated to do so (Dudding et al., 2017). The rise in the number of nontraditional graduate students, including those enrolled in online programs, requires substantial resources to provide supervision to students at a distance from the campus (Dudding & Justice, 2004; Carlin et.al., 2013). Telesupervision, also referred to as e-supervision, provides a means for students at geographically distant sites to be supervised by clinical educators located at a college campus or selected base sites. Telesupervision offers many benefits, including cost-effectiveness and productivity of clinical

instruction (Dudding & Justice, 2004). Telesupervision is distinct from online learning and professional webinars in that it often necessitates observing clients/ patients as well as the supervisee. Those engaged in telesupervision should be mindful of the privacy and security regulations imposed by HIPAA and FERPA. Refer to the section on Telepractice Services in this chapter and Chapters 4, 10, and 12 for a further explanation of these regulations. Professional organizations and state licensure boards expanded allowances for e-supervision and e-mentoring during the COVID-19 pandemic. Audiologists seeking certification from the ABA must receive a minimum of 2,000 hours of mentored professional practice as an audiologist following completion of the clinical doctorate in audiology. Professionals seeking ASHA certification in speech-language pathology must complete a clinical fellowship postgraduation from an accredited graduate program. The clinical fellow (CF) must receive ongoing mentoring and formal evaluations from a CF mentor for a minimum of 1,260 hours. The mentor must be able to provide direct observation in real time and must be available to consult with the CF. Beginning in 2023, three of the six required observations of the CF may take place through telesupervision technologies (CFCC, 2018). See Chapter 22 in this book for further discussion of clinical education and mentoring.

Virtual Simulations for Instruction and Learning In 2014, ASHA’s Council for Clinical Certification (CFCC, 2013) changed the implementation language for Speech-Language Pathology Standard V-B to allow up to 20% of the required 375 direct clinical hours to be obtained through simulation. This change, along with the closing of university clinics because of the pandemic, has resulted in an eruption of use of simulations in audiology and speech-language pathology. Simulations, more specifically health care simulations, provide students with a realistic learning environment, allowing them to practice and learn without risk to patients/clients. Simulations allow students to perform a clinical skill, develop critical thinking, and practice communication in a simulated professional health care setting. Programs in CSD are using simulations (e.g., Simucase™) for instruction in the classroom and clinic, for student remediation, and as a method of authentic assessment (Dudding et al., 2018). A key principle to keep in mind is that simulations are more than a type of technology. They are a learning tool for students and professionals. Simulations can take several forms and utilize a range of technologies. They range in the level of fidelity (i.e., realism) and cost. Stan-



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dardized patients, the use of a trained person or persons to portray a patient or family member, have a long history of use in CSD and other health care arenas. The use of manikins (whole body) and task trainers are often found in simulation labs on medical campuses and hospitals. High-tech manikins can simulate a patient experiencing several medical conditions including stroke, cardiorespiratory arrest, and even childbirth. Some advanced human patient simulators can be programmed to cry, breathe, sweat and bleed. Many of us were trained in cardiopulmonary resuscitation (CPR) using RescuciAnne® (Laerdal Medical, n.d.). This is an example of a task trainer. Task trainers are dedicated to training a very specific skill such as cerumen removal. Emerging technologies in VR and AR are being explored to offer immersive and realistic simulation experiences for learning. The possibilities have yet to be imagined. Simulations provide another opportunity for students enrolled in speech-language pathology programs to obtain the required minimum 25 guided clinical observation hours. Accrual of these hours generally precedes direct contact with clients/patients and should reflect varied disorders across work settings. Simulations provide an alternative method for students to gain observation hours for individuals presenting with a variety of disorders across the life span. Reflective debriefing and discussion of clients/patients led by ASHA-certified clinical educators following each simulation experience completes this introductory clinical requirement (CFCC, 2018). Another effective use of simulation is in interprofessional and collaborative practice. Interprofessional education (IPE) and interprofessional practice (IP) have been identified by all health care and medical organizations as key to improving patient safety and outcomes in the medical setting (IPEC, 2016). Simulation-based learning offers students and practitioners from multiple disciplines to gain skills in communication, teamwork, role recognition, and ethics (IPEC, 2016). These experiences allow participants to gain skills in a safe environment that offers opportunity for individual and group reflections.

Ethical Considerations As we continue to integrate existing and emerging technologies into audiology and speech-language pathology, whether it is through collaboration, training, and/or provision of services, it is critical to our professions and to the clients we serve that we maintain the integrity and quality of the services provided. As new technologies continue to emerge, speech-language-hearing practitioners are charged with gaining requisite knowledge for proper and ethical application of these technologies.

ASHA’s Code of Ethics, Principle II, Rule G and Rule H directly address the use of technology by stating, “Individuals shall use technology and instrumentation consistent with accepted professional guidelines in their areas of practice. When such technology is warranted but not available, an appropriate referral should be made” and “Individuals shall ensure that all technology and instrumentation used to provide services or to conduct research and scholarly activities are in proper working order and are properly calibrated” (ASHA, 2023, p. 6). These rules directly address the use of instrumentation and other clinical equipment. Ethical responsibilities are an inherent part of clinical practice and research regardless of the use of technology. While not specifically aimed at technology, other rules of the ASHA Code of Ethics can be applied when it comes to the use of technology: Principle 1, Rule A, states, “Individuals shall provide all clinical services and scientific activities competently,” and Principle 1, Rule B states “Individuals shall use every resource, including referral and/or interprofessional collaboration when appropriate, to ensure that quality service is provided” (ASHA, 2023, p. 3). When employing alternative service delivery models, clients and caregivers should be given a clear and concise explanation of the technologies employed, along with the mention of benefits, limitations, and risks. They should be given an opportunity to ask questions and opt out of services. If the speech-language-hearing professional is dispensing a technology, such as a hearing aid or AT device, the client should be provided with information regarding the full cost, along with a description of the return policy. Although the benefits of technology use for the disciplines of audiology and speech-language pathology are astounding, ASHA’s Healthy Communication and Popular Technology Initiative (ASHA, 2018b) reminds professionals and consumers of the critical need for inclusion of ample face-to-face interaction for young children’s communication development. We know that speech, language, and social skills are fostered by conversation and interaction with varied communication partners versus exposure to screen time alone. Encouraging safe listening practices with technology use and promoting hearing protection are also objectives supported by this initiative. In addition to ASHA’s Code of Ethics, practitioners are bound by the directives of other agencies such as state licensing boards, federal agencies, insurance carriers, and employers. As previously mentioned, HIPAA necessitates that practitioners meet stringent privacy and confidentiality requirements that apply to use of many of the technologies discussed in this chapter, including document-sharing technologies. Additionally, FERPA regulations must be addressed when accessing and

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sharing educational records for students in K–12 and higher education. Reimbursement agencies may also have guidelines for use of technologies. For example, the Centers for Medicare and Medicaid Services provide guidelines for reimbursement for the use of technology in service delivery. Read Chapter 4 for a more in-depth discussion of professional ethics.

American Speech-Language-Hearing Association. (2018). Healthy communication and popular technology initiative. https://communicationandtech.org/

Summary

Assistive Technology Industry Association. (n.d.). What is AT? https://www.atia.org/home/at-resources/ what-is-at/

This chapter offers an introduction to the application of technologies in communication sciences and disorders within the digital age. It includes a description of various technologies including web conferencing, assistive technology, apps, digital games, and virtual simulations. In addition, it offers information about current applications in the areas of online learning, collaboration, e-supervision/e-mentoring, and telepractice. The chapter includes information on service delivery models with consideration of the technologies, security, and ethical considerations. More importantly, this chapter encourages students and professionals in audiology and speech-language pathology to embrace emerging technologies as opportunities to enhance education, collaboration, assessment, and intervention. We want to explore the potential of new and emerging technologies to help better the lives of those that we serve, but to do so with an understanding and appreciation of their strengths and limitations so as not to become enslaved by them.

References American Speech-Language Hearing Association. (n.d.-a). Telepractice. https://www.asha.org/ practice-portal/professional-issues/telepractice/ American Speech-Language Hearing Association. (n.d.-b). Augmentative and alternative commu­ nication. https://www.asha.org/practice-portal/ professional-issues/augmentative-and-alternativecommunication/ American Speech-Language Hearing Association. (n.d.-c). Hearing assistive technology. https:// www​.asha.org/public/hearing/hearing-assistivetechnology/ American Speech-Language Hearing Association. (n.d.-d). Edfind. https://www.asha.org/edfind/. American Speech-Language-Hearing Association. (2023). Code of ethics. https://www.asha.org/policy/ et2016-00342/

American Speech-Language-Hearing Association. (2019). 2018 Audiology survey. Survey summary report: Number and type of responses. https://www​ .asha.org/siteassets/surveys/2018-audiology-surveysummary-report.pdf

Bernard, J. M., & Goodyear, R. K. (1992). Fundamentals of clinical supervision. Allyn & Bacon. Biofeedback Intervention Technology for Speech Lab at NYU Steinhardt. (n.d.). StaRt app for biofeedback. https://wp.nyu.edu/byunlab/projects/start/ Boardmaker. (2014). Boardmaker [Computer software]. https://goboardmaker.com/pages/boardmaker-online/ Boersma, P., & Weenink, D. (2019). Praat: Doing phonetics by computer (Version 6.0.49). [Computer program]. http://www.praat.org/ Bolden, W. (2022). Telehealth across the therapies: Examining the impact of the COVID-19 pandemic on clinical staff working with low socioeconomic status populations. Perspectives of the ASHA Special Interest Groups, 7(4), 1236–1255. https://doi​ .org/10.1044/2022_PERSP-21-00099 Brooks, D. C., & McCormack, M. (2020, June 15). Defining digital transformation. Educause. https:// www.educause.edu/ecar/research-publications/ driving-digital-transformation-in-higher-education/ 2020/defining-digital-transformation Bryant, L., Brunner, M., & Hemsley, B. (2020). A review of virtual reality technologies in the field of communication disability: Implications for practice and research. Disability and Rehabilitation: Assistive Technology, 15(4), 365–372. https://doi​ .org/10.1080/17483107.2018.1549276 CDW Health Care. (2018). Next-generation engagement technology enhances patient outcomes [White paper]. https://healthtechmagazine.net/sites/health​ techmagazine.net/files/document_files/white-paperengagement-technology.pdf Caballero, A., Gallagher, S., Shapiro, H., & Zanville, H. (2022, July 5). Microcredentials: A new category of education is rising. University World News. https://www.universityworldnews.com/post.php​ ?story=20220705223949571



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Carlin, C., Boarman, K., Carlin, E., & Inselmann, K. (2013). The use of e-supervision to support speech-language pathology graduate students during student teaching practica. International Journal of Telerehabilitation, 5, 21–31. https://doi​ .org/10.5195/ijt.2013.6128 Coco, L. (2022). Over-the-counter hearing aids: What the practicing audiologist needs to know. Perspectives of the ASHA Special Interest Groups, 7(6), 1806–1811. https://doi.org/10.1044/2022_PERSP-22-00117 Cooper, A. (2019). Hear me out. Missouri Medicine, 116(6), 469–471. Council for Clinical Certification in Audiology and Speech-Language Pathology of the American Speech-Language-Hearing Association. (2018). 2020 standards for the certificate of clinical competence in speech-language pathology. https://www.asha​ .org/certification/2020-SLP-Certification-Standards Department of Health and Human Services. (2021, May 17). HIPAA for professionals. https://www.hhs​ .gov/hipaa/for-professionals/index.html Douglass, H., Lowman, J. J., & Angadi, V. (2021). Defining roles and responsibilities for school-based tele-facilitators: Intraclass correlation coefficient (ICC) ratings of proposed competencies. International Journal of Telerehabilitation, 13(1), e6351. https://doi.org/10.5195/ijt.2021.6351 Dudding, C. C., Brown, D. K., Estis, J. M., Szymanski, C., & Zraick, R. (2018). Best practices in health care simulations in communication sciences and disorders [E-reader version]. https://growth​ zonesitesprod.azureedge.net/wp-content/uploads/ sites/1023/2020/03/Best-Practices-in-CSD.pdf Dudding, C. C., & Justice, L. (2004). A model for e-supervision: Videoconferencing as a clinical training tool. Communication Disorders Quarterly, 25(3), 145–151. Dudding, C. C., McCready, V., Nunez, L. M., & Procaccini, S. J. (2017). Clinical supervision in speech-language pathology and audiology in the United States: Development of a clinical specialty. The Clinical Supervisor, 36(2), 161–181. https:// www.tandfonline.com/doi/abs/10.1080/07325223​ .2017.1377663?journalCode=wcsu20 Family Educational Rights and Privacy Act of 1974, 20 U.S.C. § 1232g (1974). Food and Drug Administration. (2023, January 12). Hearing aids. https://www.fda.gov/medical-devices/ consumer-products/hearing-aids

Gallaudet University. (2010). What’s a TTY? What’s a TDD? What’s a relay system? https://gallaudet.edu/ museum/history/whats-a-tty-whats-a-tdd-whats-arelay-system/ Goldman, R., & Fristoe, M. (2015). Goldman-Fristoe Test of Articulation–Third Edition (GFTA-3). American Guidance Service, Inc. Google. (2009). Google calendar [Computer software]. https://www.google.com/calendar Google. (2012). Google drive [Computer software]. https://www.google.com/drive/ Health Insurance Portability and Accountability Act of 1996, P.L. 104–91 (1996). https://www.hhs.gov/ hipaa/for-professionals/privacy/laws-regulations/ combined-regulation-text/index.html Huckvale, M. (2012). Waveforms annotations spectrograms and pitch (WASP) (Version 1.54) [Computer program]. https://www.phon.ucl.ac.uk/resource/sfs/ wasp.php Hutchins, S. D. (2021, December 28). Apps you can use in your practice right now. ASHA Leader Live. https://leader.pubs.asha.org/do/10.1044/20211228-apps-for-slps/full/ Interprofessional Education Collaborative. (2016). Core competencies for interprofessional collaborative practice: 2016 update. https://ipec.memberclicks​ .net/assets/2016-Update.pdf Jones, C., Ramanau, R., Cross, S., & Healing, G. (2010). Net generation or digital natives: Is there a distinct new generation entering university? Computers & Education, 54(3), 722–732. Keyworth, C., Hart, J., Armitage, C. J., & Tully, M. P. (2018). What maximizes the effectiveness and implementation of technology-based interventions to support health care professional practice? A systematic literature review. BMC Medical Informatics and Decision Making, 18, 93. https://doi.org/​ 10.1186/s12911-018-0661-3 Laerdal Medical. (n.d.). Simulation and training. https://www.laerdal.com/us/products/simulationtraining/ Lee, S. A. S. (2019). Virtual speech-language therapy for individuals with communication disorders: Current evidence, limitations, and benefits. Current Developmental Disorders Reports, 6(3), 119–125. https://doi.org/10.1007/s40474-019-00169-7 Little Bee Speech. (2018). Articulation station (Version 2.6.2) [Mobile application software].

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Market Research. (2019). Global e-learning market analysis 2019. Syngene Research LLP. https://www​ .marketresearch.com/Syngene-Research-LLPv4190/Global-Learning-12607516/

Seaman, J., Allen, E., & Seaman, J. (2018). Grade increase: Tracking distance education in the United States. Babson Survey Research Group. https:// onlinelearningsurvey.com/reports/gradeincrease.pdf

Martin, F., & Xie, K. (2022, September 27). Digital transformation in higher education: 7 areas for enhancing digital learning. Educause. https:// er.educause.edu/articles/2022/9/digital-transforma​ tion-in-higher-education-7-areas-for-enhancingdigital-learning

Seesaw Learning Inc. (2019). Seesaw: The learning journal (Version 6.2.1) [Mobile application software]. https://itunes.apple.com/us/app/ seesaw-the-learning-journal/id930565184?mt=8

Mashima, P. A. (2010, November 2). Using telehealth to treat combat-related traumatic brain injury. ASHA Leader Live. http://www.asha.org/Publica​ tions/leader/2010/101102/Using-Telehealth-toTreat-Combat-RelatedTraumatic-Brain-Injury.htm McKee, M. M., Choi, H., Wilson, S., DeJonckheere, M. J., Zazove, P., & Levy, H. (2019). Determinants of hearing aid use among older Americans with hearing loss. The Gerontologist, 59(6), 1171–1181. https://doi.org/10.1093/geront/gny051 Morris, A. H., Horvat, C., Stagg, B., Grainger, D. W., Lanspa, M., Orme, J., . . . Berwick, D. M. (2022). Computer clinical decision support that automates personalized clinical care: A challenging but needed health care delivery strategy. Journal of the American Medical Informatics Association: JAMIA, 30(1), 178–194. https://doi.org/10.1093/jamia/ocac143 National Education Association. (n.d.). Microcredentials. https://www.nea.org/professional-excellence/ professional-learning/micro-credentials National Institute on Deafness and Other Communication Disorders. (2022, July 20). United States Society for Augmentative and Alternative Communication (USSAAC). https://www.nidcd.nih.gov/ directory/united-states-society-augmentative-andalternative-communication-ussaac PCG Education. (n.d.). IEP online. https://xeponline​ .wa-k12.net/Account/LogOn?ReturnUrl=/ Pearson Education, Inc. (n.d.). Speech and language. https://www.pearsonclinical.com/language.html Pinterest. (n.d.). Home page. https://www.pinterest. com Prensky, M. (2001). Digital natives, digital immigrants. On the Horizon, 9(5). https://www.marcprensky​ .com/writing/Prensky%20-%20Digital%20

Shah, D. (2018, November 21). By the numbers: MOOCS in 2017. Class Central. https://www .class-central.com/report/mooc-stats-2017/ Shtepura, A. (2018). The impact of digital technology on digital natives’ learning: American outlook. Comparative Professional Pedagogy, 8, 128–133. https://doi.org/10.2478/rpp-2018-0029. Siddiqi, M. (2022, February 21). Leadership for digital transformation. Educause. https://er.educause.edu/ articles/2022/2/leadership-for-digital-transformation Sigfrid, S. D. (2011). Middle-ear implants and osseointegrated implants. The ASHA Leader, 16(3). https://doi.org/10.1044/leader.FTR3sb1.1603​ 2011.16 Simucase. (2017). Simucase [Computer software]. https://www.simucase.com/ SMART Board®. (n.d.). SMART board [Computer technology]. Smith, E. E., Kahlke, R., & Judd, T. (2020). Not just digital natives: Integrating technologies in professional education contexts. Australasian Journal of Educational Technology, 36(3), 1–14. https://doi​ .org/10.14742/ajet.5689 StoryMagic, Inc. (2017). Epic! (Version 3.35) [Mobile application software]. https://itunes.apple.com/us/ app/epic/id719219382?mt=8 Tactus Therapy Solutions Ltd. (2012). Spaced retrieval therapy (Version 1.1) [Mobile application software]. https://play.google.com/store/apps/details?id=com​ .tactustherapy.srt&hl=en_US Unosquare. (2020, May 8). 7 things you need know before starting your digital transformation. https:// www.unosquare.com/blog/7-things-you-needknow-before-starting-your-digital-transformation/ Vayo, E., Ingram, S., Doyle, C., & Ingram, R. (2018, November). Augmented reality for at-home speech



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Wiig, E. H., Semel, E., & Secord, W. A. (2013). Clinical Evaluation of Language Fundamentals —  Fifth Edition (CELF-5). NCS Pearson.

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24 Managing Stress and Conflict in the Workplace Mark DeRuiter and Jennifer P. Taylor

Introduction This chapter is all about stress. Fun! It is important to understand stress, though, because it can produce physical and emotional symptoms that inhibit our ability to accomplish work or personal goals. Stress can also interfere with our overall happiness. Stress is pervasive in everyday life, but it does not need to prevent us from enjoying our jobs and relationships. It also might be difficult to think about stress in your future workplace because right now you are working so hard simply to finish your education. But stress is all around us, in both our professional and personal lives. One misconception is that stress is always a bad thing; in fact, we all need a low level of it to help drive us to accomplish tasks. In this chapter, we will examine what we know about stress, including its signs and symptoms, why it can be prevalent in helping professions, and how it differs from mental health diagnoses such as anxiety or depression. Then, we will discuss workplace conflict, which can be a major source of stress. This chapter offers some basic strategies that may help resolve workplace conflict or eliminate it entirely in less severe situations. Last, we will examine the importance of self-care in combating stress and conflict and how self-care is a fundamental component of ethical behavior.

What Is Stress? Stress is something that all individuals will experience at some point in their lives. A conceptual definition of stress is that it is a person’s subjective reaction and vulnerability to a given situation. Subjective reactions to stressful situations are your opinion of the situation, not fact. What the person is interpreting subjectively results in both emotional reactions like worry or anger and physiological responses such as increased heart rate, headaches, or digestive disturbances. Vulnerability to stress means that we will probably only feel stressed about a situation if we are vulnerable to it in some way, such as being a person who has a challenging time taking critical feedback. If you are sensitive to others critiquing your behavior, receiving critical feedback will cause you stress (Zurich et al., 2015).

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You may have observed yourself or a peer experiencing stress after critical feedback in graduate school, and another peer who received similar feedback who did not exhibit a stress response at all. Neither response is correct or better; it is simply each person’s vulnerability to the stressor (or lack thereof ). Stress can be experienced short or long term, and work-related stress is the leading cause of workplace health problems, even more so than obesity or inactivity (Centers for Disease Control [CDC], 2022). Onefourth to one-third of employees view their jobs as the number one stressor in their lives; at least 40% of individuals describe their jobs as “very stressful,” and 75% of workers believe they have more on-the-job stress than previous generations (CDC, 2014). Work problems have been more strongly related to health complaints than other life stressors such as financial or family problems for many years (CDC, 2017). Since the advent of the COVID-19 pandemic, many health care workers have reported additional stress-related problems. In a study looking at the impact of mental health of health care workers following COVID-19, it was found that younger people and individuals identifying as females noted higher levels of anxiety (Biber et al., 2022.)

A common misconception about stress is that it is always unhelpful. Some stress can be helpful because it can motivate us to accomplish tasks or change our behavior. In many cases, however, prolonged stress can affect one physically in a negative way.

Symptoms of Stress Acute, or short-term, stress can produce a fight-or-flight response, which is a physical change in body functions in response to a perceived threat. During a highly stressful moment, our body interprets this threat much in the same way that cave dwellers saw bears as threats to their safety. These days, most of us do not live where we might be chased by a bear. Instead, experiences that threaten our physical or emotional health can trigger the fight-or-flight response. Ross (2011) described the physiological changes experienced during fight or flight, presented in Table 24–1. It is important to note that these physiological reactions are normal and exactly the way your body is supposed to react when confronted with a perceived threat. The downside to this appropriate and normal body response is that it can make us feel very uneasy and upset. Some people may even have a panic attack, which feels like a heart attack with chest pain, shortness of breath, and dizziness. Fortunately, our evolutionary response to threats has remained much the same as it was in prehistoric

Table 24–1.  Physiological and Physical Responses to Perceived Threats and Possible Impact Physiological Response

Physical Result

Impact

Liver spills adrenaline and sugar into the bloodstream

Spikes in energy

Restlessness, increased feelings of tension can lead to feeling that something really bad is about to happen

Heart rate increases

Increases blood flow to muscles to facilitate quick responses

Feeling your heart racing can contribute to feeling shaky or unstable, which can increase our worry that something is seriously wrong

Respiration increases in frequency but becomes shallower

Provides oxygen to muscles to facilitate quick responses

Feeling like you can’t catch your breath; increases our worry that something is seriously wrong

Impulsive responses

Increases risk taking

Rash judgments; i.e., “Act first, think later”

Experience a range of difficult emotions

Irritability, anger, fear, hostility

Acting short tempered and aggressive towards others, less patience for ourselves and others



CHAPTER 24   Managing Stress and Conflict in the Workplace

times and produces this physiological stress response. It is normal and tells us our bodies are working correctly when we are confronted with a stressful situation. What is different is that the kinds of stressors that cause this acute problem have evolved. Instead of bears, we might be faced with a stressor such as an unhappy patient or colleague expressing their anger at us or being late to work when you have an important appointment scheduled first thing in the morning.

Causes of Stress Many situations can cause a person to feel stressed. Sometimes, we are stressed by our personal factors, such as relationships with partners, family members, or friends. Other life circumstances, such as challenging work environments or unstable living situations, can contribute to stress. Some of these stressors might be temporary and addressable, such as car trouble, a disagreement with a friend, or being assigned a new project at work. Other stressors can be continuous and less easily resolved: being in an unhealthy relationship, death of a family member, unemployment, or overwhelming student debt. Long-term stressors can apply to our work. These include things such as a difficult colleague, a high caseload, unreasonable demands from administration, or problems at home that interfere with work and vice versa. These stressors may not be intense at any given moment yet cause problems because of their continuous nature. These long-term stressors may produce physiological changes like low energy, headaches, stomach upset that can include nausea and changes in bowel habits, sleeplessness, and/or aches and pains. It is not unusual for a person to first attribute these physical and emotional changes to a temporary illness such as the flu, yet the symptoms last longer than those of a common virus.

Stress in Helping Professions People who work in helping professions may encounter stressors within the workplace. High caseloads, demanding employers, difficult clients and families, or unreasonable productivity expectations can all contribute to workplace stress. In a study examining occupational stress among audiologists in New Zealand (Severn et al., 2012), six factors were identified as leading to occupational stress, burnout, and compassion fatigue: time demands, interactions with patients, changing clinical protocols, management of a clinical audiology practice including paperwork, maintaining equipment, and patient accountability. Interestingly, the increasing age of the audiologist was most related to the risk for burnout. In another study of audiologist stress, sales pressure

by employers was perceived as the most stressful aspect of clinical practice and could even result in unethical practice (Simpson et al., 2018). Similar findings to Severn et al. (2012) and Simpson et al. (2018) have been reported for both Swedish and Indian audiologists (Brännström et al., 2016; Ravi et al., 2015). Speechlanguage pathologists (SLPs) are not immune to similar stressors, but the literature examining stress specifically in SLPs is less rich (McLaughlin et al., 2008). Another source of workplace stress comes from witnessing the stress of clients or caregivers. Being diagnosed with a communication disorder disrupts family and work routines to the extent that the client and caregivers will become highly stressed. It is difficult for helping professionals to witness those they care for experience difficult situations and know that as a professional, it is impossible to fix everything a client or family may need. An individual’s response to stress is just that, individual. Some of us have lots of experience dealing with stressful situations because of previous life experiences. As a result, we may have learned a variety of coping skills to combat stress. Coping skills can be more or less helpful, depending on the person and the situation. Regardless of your individualized response to stress, it is important to recognize that we can learn how to deal more effectively with it and increase our repertoire of helpful strategies for combating it. Ignoring stress can lead to negative consequences, such as burnout, which has been demonstrated to be a leading cause of leaving the field (McLaughlin et al., 2008).

Burnout and Compassion Fatigue One consequence of unrelenting stress is burnout, a phenomenon that has been discussed in helping professions since the early 1970s (Cedoline, 1982). It was noticed that helping professionals occasionally presented as being exceptionally tired, uninterested in their work, and having difficulty coping with their work and home lives (Lyndon, 2015). When stress arises from a mismatch in workplace demands with employee capacities, it triggers even greater stress. Ross (2011) wrote that burnout results from prolonged stress over time and should be considered the last stage of stress. What does the ASHA Code of Ethics say about stress? The Code of Ethics addresses stress in this way: Principle I, Rule R:  Individuals shall not allow personal hardships, psychosocial distress, substance use/misuse, or physical or mental health

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conditions to interfere with their duty to provide professional services with reasonable skill and safety. Individuals whose professional practice is adversely affected by any of the above-listed factors should seek professional assistance regarding whether their professional responsibilities should be limited or suspended. (ASHA, 2023)

Dealing appropriately with life and work stressors is part of your ethical responsibility.

professional inefficacy and make it difficult to concentrate or be creative in your approach to work tasks. Brito-Marcelino and colleagues (2020) conducted an integrated literature review of the small number of studies regarding burnout in SLPs and audiologists. These authors examined studies conducted in various international contexts, mainly due to the paucity of research. Although highly specific conclusions are difficult to make due to methodological differences in the 11 studies they reviewed, their work found that clinicians in speech-language pathology and audiology indicate stress in their work environments for a variety of reasons. The authors conclude that the topic of burnout warrants more controlled study within the professions.

What Is Burnout? Generally accepted as a psychological condition, an early and widely accepted definition of burnout identifies three essential parameters: (a) exhaustion, which can be emotional, physical, or both; (b) cynicism, described as indifference about the worker’s own efforts and their colleagues; and (c) professional inefficacy, or a lack of confidence in being able to perform a job well (Maslach, 2007; Maslach & Jackson, 1982). Exhaustion.  If you are experiencing burnout-related exhaustion, you are probably feeling very drained, especially when thinking about going to work or performing work-related tasks. This exhaustion makes it difficult to cope with circumstances at work or with difficult colleagues, and you may have some physical symptoms as well, such as stomach troubles, pain/achiness, or headaches. Cynicism.  When you are feeling cynical about work, you are likely experiencing feelings of bitterness and distrust. These feelings may be due to the agency you work for; perhaps it expects too much of you in caseload, workload, or productivity. You may also feel doubtful or pessimistic about the agency or your colleagues, or that your situation will ever improve. Professional Inefficacy.  The last major category of burnout is professional inefficacy or feeling as though you do not have the skills to stay on top of your work expectations. You may feel too challenged in the environment because it feels impossible to be good at all things, or you might find yourself feeling underchallenged and therefore bored and disinterested. It can be difficult to overcome these feelings in the face of changing work expectations that occur frequently as new laws are passed or as insurance regulations change. An ever-expanding scope of practice can also lead to feelings that you may never master any of the assessments or treatments you are providing. These feelings are often symptomatic of

Is Compassion Fatigue the Same Thing as Burnout? Compassion fatigue is like burnout in that it is work related but is a special type of burnout that results from the stresses involved in caring for others. MerriamWebster’s (n.d.) definition of compassion fatigue is “the physical and mental exhaustion and emotional withdrawal experienced by those who care for sick or traumatized people over an extended period of time.” Note that compassion fatigue focuses specifically on caregiving and the results of being responsible for others, whereas burnout applies more globally to all kinds of work stressors. Burnout and compassion fatigue share similar symptoms; however, we will use burnout as the general term in discussing it as a potential consequence of stress.

What Are the Risks for Experiencing Burnout? The risks for burnout are both individual and environmental. Individual factors that put you at risk for burnout include ability to balance their work and personal life, having a highly demanding or underchallenging workload, and feeling that you have little control over your work or workplace policies and procedures (Cendoline, 1982; Mayo Clinic, 2021. Farber (1990, 2000) discussed three individual subtypes of people who experience burnout. “Frenetic” workers tend to work harder until they reach exhaustion as they seek success and recognition for their efforts. “Underchallenged” workers do not perceive satisfaction from their work because the conditions do not stimulate them. “Worn-out” workers are those who, when faced with a level of stress, will give up easily. These subtype categorizations focus on the worker’s style as contributing significant risk for burnout.



CHAPTER 24   Managing Stress and Conflict in the Workplace

Later theories of burnout, however, also focus on burnout as an environmental disorder (Montero-Marín et al., 2013), because the workplace puts a unique set of demands on each worker. Environmental risk factors for burnout include lack of control over your schedule or work assignments, unclear job expectations, lack of feedback about your performance, unhealthy workplace dynamics and interpersonal relationships, isolation at work, and work over- or underload (Cendoline, 1982; Mayo Clinic, 2018). This interface between worker type and workplace demand will result in individualized responses to stress. That is, some workers will experience burnout more readily than others, and addressing burnout will require individualized interventions that consider both the worker and the environment. As researchers explored the concept of burnout, it was applied across professions, including health care workers, engineers, and others (Brown et al., 2017; Michailidis & Banks, 2016; Montero-Marín et al., 2013; Severn et al., 2012). Despite the realization that burnout is universal to all work environments, Lubinski (2013) attributed causes of burnout for audiologists and SLPs as being related to helping complex clients; not always being able to evaluate success in a meaningful, measurable way; that others may have poor opinions of our help or relationships with them; and the difficulty in contributing to decision making in some helping agencies.

Am I Burnt Out or Is It Something Else? A challenge in identifying burnout is that its symptoms, such as fatigue and apathy, are often the same symptoms we observe in people diagnosed with anxiety disorders or depression. Teasing out whether you may be suffering

from burnout versus a mental health condition can be a bit challenging, but typically involves assessing whether the symptoms you are having are related primarily to work as opposed to life in general. Corey (2016) provided guiding questions to help assess whether you might be experiencing burnout. A few include: n

Does the thought of getting up and going to work make you tired or anxious?

n

Do you experience significant variations in your work productivity?

n

Is it difficult to concentrate on work?

n

Do you notice yourself being more impatient than normal with clients, colleagues, or your boss?

n

Is it difficult to be creative and help identify possible positive outcomes when confronted with a work problem that needs to be solved?

n

When someone compliments you on your work, do you find it difficult to accept their words as truthful or meaningful?

n

Have you noticed changes in sleeping, eating, headaches, stomach problems, or other physical symptoms?

If your answers to these questions relate more to life in general, you may want to consult a counselor to determine whether you are experiencing a mental health condition such as anxiety or depression. Table 24–2 presents a list of general characteristics of stress, anxiety disorder, and depression. Approximately 20% of the U.S. population experiences one or more of these mental health conditions (NAMI, n.d.-a), and a 25% increase in anxiety and

Table 24–2.  General Characteristics of Stress, Anxiety Disorder, and Depression Stress

Anxiety Disorder

Depression

Affects everyone

Does not affect everyone

Does not affect everyone

Can produce changes in physical and mental health

Can produce changes in physical and mental health

Can produce changes in physical and mental health

Can be positive OR negative

Is generally only negative and unhelpful

Is generally only negative and unhelpful

Stressors can be short or long term

Typically lifelong, with some variation in intensity across time

Can be episodic or chronic

Can be managed without professional intervention

May need professional intervention to achieve functional living

Often requires professional intervention

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depression was noted worldwide following COVID-19 (World Health Organization [WHO], 2022), so thinking you are alone in your excessive worry or unhappiness is inaccurate. Many of us have gone through episodes that may have been temporary, while others of us may have a chronic mental health condition. Regardless, help is available, and it works. More information on the kinds of help available will be discussed in the section on self-care.

Workplace Conflict A common source of stress for SLPs and audiologists is workplace conflict. In fact, it is identified as a leading source of stress for any employee regardless of profession and is an inevitable occurrence when people with different professional roles, values, opinions, priorities, and goals interact. Therefore, having awareness of conflict, being able to pinpoint why it occurs, and having strategies for your own participation in deescalation are critical components of your professional knowledge and skills.

Defining Workplace Conflict and Its Sources Saltman et al. (2006) defined workplace conflict as “a disagreement within oneself or between people that causes harm or has the potential to cause harm” (p. 9). The authors also differentiate between disagreements, which they define as differences of opinion, versus conflict, which has the added harm component. It is completely reasonable for us to express differences of opinion without harming the other or the situation in some way. The kinds of harm that can result from conflict at work include negative consequences on a provider’s stress level, decreased workplace morale, increased employee turnover, and compromised client care. Some people even go as far as to leave their professions when conflict is unable to be successfully resolved (Kfouri & Lee, 2019; Morrison et al., 2011). In 2006, Saltman et al. emphasized that many of us may expect that a harmonious workplace is the natural state of things, and that if conflict exists, something must be wrong and that it is most likely attributable to people with personality problems. Instead, they asserted that workplace conflict is normal and there are multiple reasons for it. Saltman et al.’s (2006) description of conflict as a normal situation is a more traditional view. In 2017, Currie et al. stated that in the past, “conflict at work was commonly viewed as something similar to the arrival of bad weather, not particularly welcomed, but inevitable nonetheless” (p. 492). In their comprehensive review

of human resources literature, they found that current theories and practices among human resource managers have shifted to a view that when workplace conflict exists, it represents managerial failure that should and could be avoided. The authors go on to assert that based on their review, there is a lack of even simple consensus on what the best methods are for addressing workplace conflict that result in positive outcomes. Sources of Workplace Conflict.  Sources of conflict at work can be divided into two main categories: interpersonal reasons and organizational reasons. Table 24–3 provides a list of just some of the possible reasons for interpersonal and organizational sources of conflict (Currie et al., 2017; Kfouri & Lee, 2019; Saltman et al., 2006). Although we might assume our personal responsibility in resolving conflicts is only necessary when we have a role in the conflict at hand, that assumption is misleading. First, your responsibilities are not just related to client care but also to being a good citizen and working to increase the success of the organization as an employee. Second, if you are effective at things like being organized, following policies and procedures, and maintaining positive interactions with coworkers and superiors, you may be promoted into a managerial role where you will have direct responsibility for resolving conflicts. Thus, becoming familiar with strategies for resolving both interpersonal and organizational conflicts is highly relevant to your working life.

Strategies for Addressing Workplace Conflict In today’s workplace, many professionals are required to work interprofessionally to serve clients (ASHA, 2021). The increase in interprofessional practice also leads to the possibility for increased conflict. Cain et al. (2019) state that a requirement for successful interprofessional teaming means the employee has developed both a professional identity and a team-based identity. How does my team interact to provide high-quality service delivery to our clients, and how do I fit into the team as the only SLP or audiologist? What am I bringing to the table for my colleagues and our clients? Our perception of our professional role in the team may conflict with other team members’ perceptions of our role and lead to confusion and tension. This is just one way we may experience conflict in the workplace regarding teaming. Examining methods for resolving teaming issues in the health care environment is an increasing area of focus, but it seems less discussed for interprofessional teaming in educational settings (André, 2018; Cain et al., 2019; Cooper-Duffy & Eaker, 2017; Marks, 2018).



CHAPTER 24   Managing Stress and Conflict in the Workplace

Table 24–3.  Possible Reasons for Workplace Conflict Interpersonal Reasons

Organizational Reasons

Personality differences

Human resources managers may not be up to date with more recently identified methods for conflict resolution

Disrespectful or deceptive interactions

A change in conflict resolution policies and procedures may pose an overwhelming burden for the organization

Inability to solve differences of opinion regarding roles, goals, and desired outcomes for a situation

Diffusion of or unclear responsibility for conflict resolution: Is it the job of the human resources office or immediate/intermediate supervisors?

Lack of needed information being shared

Lack of training on workplace conflict for immediate and intermediate supervisors

Competition for resources and/or recognition by superiors

Requirements for interprofessional practice or broader kinds of teamwork

Organizational stress that is inherent to the particular workplace in question

General lack of strategies for improving workplace morale

Saltman et al. (2006) and Kfouri and Lee (2019) identified four typical ways people handle interpersonal conflicts. The first is avoidance: not addressing the problem or developing or denying that a problem even exists. In the immediate situation, this is often our go-to strategy. This can be useful, as time to consider the problem may lead to a satisfactory resolution later. In The Gift of Therapy, Yalom (2002) describes this as “strike while the iron is cold” (p. 121) and describes its benefit as being able to share feedback when emotions are not so high. Trying to resolve a problem when it is in process or escalating often leads to defensiveness. If we are feeling stress at the moment, it also means we have fewer intrapersonal resources to draw from to facilitate deescalation. The second method we resort to is accommodation: giving up on our own needs and letting the other person get what they want. This is another mostly immediate response to conflict. It can be effective in the short term but have negative long-term impact. You might go home at the end of the day and struggle with how you handled the situation and be frustrated that you did not get what you wanted. This increases your overall stress and may contribute to the buildup of a bad attitude about your colleagues or the workplace itself. It may also lead to your colleagues expecting that when you are in conflict, you should and will be the one to capitulate versus their giving in to you. This can result in workplace bullying. The third strategy people may use when in interpersonal conflict is competition. We say “people” because

of course, we would never engage in competition with our coworkers! Other people might do so, but not us! Competition has more of a time delay in implementation because it requires being able to assess the situation, the other person’s areas of vulnerability, and loopholes in the environment that can facilitate competition (e.g., supervisor favoritism toward certain employees). Using competition as a strategy is ineffective at best. If you find yourself feeling like you need to compete with a coworker regarding a conflict, you can ask yourself, “Why is it so important for me to be right?” or “What is driving my need to win?” Carefully considering these needs is a crucial step toward your own successful contributions to problem solving. Another question that can be helpful is “What if the opposite were true?” (See the Box below for an example of this).

A colleague asks me to make a special accommodation for them that will directly affect their management of others. Their request is not outlandish but will result in more work for me. I have a history of negative interactions with this colleague, as do most others in my workplace, so my immediate response is “Meeting your individual need through increased work for me is not going to happen. Besides, I have never known you to do any favors for me or others, so why should I do one for you?”

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After considering the situation overnight (i.e., strike while the iron is cold), I asked myself, “What if the opposite were true?” That is, what if the colleague making such a request was my best work friend instead of this person I genuinely dislike? I know that if my best work friend asked me to do this favor, I would do it in a heartbeat and not complain. My answer to the “opposite” question helped me realize that my initial reaction was a competitive one and would not facilitate any future positive interactions nor lead to a good outcome for our organization. I was only considering my perspective and my feelings about my colleague. I wanted to show them my power instead of considering whether their request might be best for our organization. As a result of shifting my perspective in this way, I emailed them the next day and agreed to their request. I felt good that I was contributing to our organization through this extra work instead of creating more obstacles and tension. The fourth strategy we implement is collaboration (Kfouri & Lee, 2019; Saltman et al., 2006). Collaboration means that when in conflict, we can balance our own interests with others’. This requires objectivity, a belief in your own rationale in the situation, and a willingness to give up a part of your own goal so that others’ goals can be met.

The Importance of Good Communication Skills in Resolving Interpersonal Conflicts When considering the list of possible reasons for interpersonal conflict in Table 24–3, it seems clear that the underlying issues most likely relate to our ability to communicate with our coworkers. It is natural to think that when we say something to others, they understand what we mean and will behave in the way we have expressed. If we perceive that the other person feels slightly uncomfortable about what we are saying, we may feel uncomfortable or lack needed skills for directly and positively addressing a communication breakdown. You are spending time in graduate school learning how to adapt your communication to perform professional tasks with clients, to deliver information to clients and caregivers, and to interact in a professional manner with your colleagues. Some of us receive more emphasis on these skills than others, and it may be unlikely that communication in times of workplace conflict is even addressed.

If you are interested in learning how to develop your communication skills in times of conflict, one of the most widely used resources is the book Crucial Conversations: Tools for Talking When Stakes Are High (Patterson et al., 2011). It is widely available and written in a straightforward manner, and systematically discusses how to implement essential components to stressful interactions. If you read this book and are interested in learning more, the authors have published additional books on workplace topics, and all share the excellent characteristics of the original volume. Organizational Conflict Management Strategies. Despite agreement across many organizations that workplace conflict is unhelpful, examination of the literature in human resources reveals there is no standard method for addressing it at the organizational level (Currie et al., 2017). The authors observed, however, that there is an increasing trend for organizational conflict management to be handled by a direct or intermediate supervisor instead of someone from human resources. They attribute this to organizations’ desires to use mentoring and coaching to help employees develop skills and competencies and the preference for solving problems as close to their origins as possible. Further, Currie et al. (2017) identified several strategies organizations use to decrease workplace conflict from occurring. One is to create alternative dispute resolution (ADR) procedures, such as “workplace mediation, fact-finding, ombudsmen, arbitration, and review panels composed of managers or peer employees” (p. 496). Another is to develop procedures as conflict arises, which leads to inadequate organizational change. Yet another organizational conflict resolution the authors suggested is providing supervisors with training in workplace conflict management. Although this may seem logical and optimal, it does not typically happen in many organizational environments. Additionally, some supervisors may contribute to organizational conflicts because they see conflict management as secondary to their main job responsibilities and feel pressured for their employees’ productivity. In a survey of 303 hospital employees across all departments and levels of responsibility, Kfouri and Lee (2019) reported that 54% of respondents rated the opinion statement “there is a lot of conflict in my workplace” (p. 18) between 5 and 7 on a strength of agreement index, where 7 equaled strong agreement. Regarding training in conflict management, results revealed only 42% of respondents had had previous training, with 49% of these respondents indicating it had taken place in their respective training programs. Despite possible previous education in conflict resolution, only 20% felt adequately trained, and 59%



CHAPTER 24   Managing Stress and Conflict in the Workplace

believed they needed to learn more. Interestingly, only 18% of the 303 participants had plans for enrolling in conflict resolution workshops in the future, despite 74% indicating that workplace conflict increased their stress. Are there factors that can alleviate workplace conflict from occurring at the organizational level in the first place? Yes. Avgar et al. (2014) identified that organizations with strong organizational citizenship among employees and management exhibit fewer instances of organizational conflict. What are the characteristics of good organizational citizenship? In other words, how might you contribute directly to the prevention of conflict in your workplace? Currie et al. (2017) answered in terms of employees who see their own roles and career development being intertwined with the success of an organization. Godard (2014) identified multiple qualities of good organizational citizenship behavior demonstrated by individual employees as including: n

demonstrating willingness to help colleagues and go above and beyond when needed;

n

building tolerance of day-to-day stressors;

n

supporting the mission of the organization;

n

internalizing organizational policies and procedures and being willing to follow them; and

n

trying to build their individual skills and abilities.

These citizenship strategies are part of ethical behavior and require the desire for lifelong learning. Quiet Quitting as a Maladaptive Conflict Resolution Strategy Quiet quitters do the very minimum at their jobs, doing just enough to earn their paychecks and maintain their employment (Klotz & Bolino, 2022). Although quiet quitting became a popular term on social media during the COVID-19 pandemic, these types of employees can be encountered in nearly every environment. Quiet quitters can impact the morale of other employees around them either through their conversations or lack of action. As an audiologist or SLP you will need to consider your ethical responsibilities to the patients, clients, or students you serve. You will be called upon to typically do more than the bare minimum to effectively serve in your role. If you find yourself disenfranchised from your work, take time to

reflect on where the challenges are occurring in your role and what you can do to mitigate this. Actions could range from conversations with your employer or peers all the way to seeking other employment. But do remember that it is your responsibility to remain in conversation with your employer if there are conditions at your workplace that are problematic or dissatisfying.

Workplace Violence Episodes of workplace violence are on the rise. We hear of an episode almost weekly. The U.S. Department of Health’s National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as “the act or threat of violence, ranging from verbal abuse to physical assaults directed toward persons at work or on duty” (NIOSH, n.d.-a). Many reputable online resources, including NIOSH, the U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA), the National Safety Council (NSC), and the Society for Human Resource Management (SHRM), offer excellent resources for how to recognize warning signs of workplace violence, how organizations can develop prevention plans, and how to respond both in immediate situations and in the aftermath of a workplace violence episode. Some of these organizations even offer online training for employees and managers.

When and Where Does Workplace Violence Happen? Although the workplace violence we read about in the news frequently involves a homicide or multiple injured employees (or both), it can also include threatening language or lesser forms of assault. There are four categories of workplace violence: (a) between coworkers; (b) between partners in personal relationships; (c) between service providers and clients/customers; and (d) criminal intent (NIOSH, n.d.-b). According to the National Safety Council (NSC, 2019), health care, service providers, and the education industries are most likely to have episodes of workplace violence, with NIOSH (n.d.-b) reporting that 76% of all workplace violence injury episodes occur in health care and social assistance industries. Episodes can occur as an act of revenge, an expression of one’s ideology, or part of a robbery. Perpetrators may or may not have mental illness. Further, Workplaces Respond (n.d.) tells us that 24% of workplace violence episodes are the outcome of problematic

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personal relationships, and perpetrators are committing crimes targeting their current or previous partners. Warning Signs.  There is no way to predict when an attack may occur, but you may observe behavior that would be characteristic of warning signs. If you observe single or multiple warning signs in a colleague, report them to management. A list of warning signs exhibited by a troubled employee is provided by the NSC (2023): n

Excessive use of alcohol or drugs

n

Unexplained absenteeism, change in behavior, or decline in job performance

n

Depression, withdrawal, or suicidal comments

n

Resistance to changes at work or persistent complaining about unfair treatment

n

Violation of company policies

n

Emotional responses to criticism, mood swings

n Paranoia

protect your own life. Knowing the three options and being able to determine the most reasonable way to protect yourself is critical. n

Run:  Attempt to evacuate the building, leaving your belongings behind and regardless of whether others are going to go with you. Call 911 once you are out and prevent other individuals from entering the building.

n

Hide:  Try to find a spot out of the shooter’s view, and if possible, lock or blockade doors into the area where you are hiding. Make sure any cell phones are on silent and all other noise sources (e.g., radio, televisions, computers) are turned off. Remain as quiet as possible.

n

Fight/take action against the shooter:  Yell, throw things at the shooter that can distract or cause injury, and act as aggressively as possible toward them.

n Termination

For you to notice these warning signs, you must listen well and carefully observe your colleagues’ behaviors and conversations about their personal life, their mental health, and their attitudes toward work. Again, if you see or hear something, say something. It may result in your colleague getting much-needed help before an escalation to violence happens.

Workplace Responsibility for Prevention and Response The NSC (2023) and the SHRM (2022) emphasize that every organization must be concerned about workplace violence. Both organizations describe methods for preventing it, including providing training to all employees, developing an emergency plan, being familiar with both individuals’ warning signs and possible risky situations, encouraging reporting of these instances, and adopting a zero-tolerance policy for workplace violence. Additionally, if an episode occurs, the organization should consider how to respond in the aftermath, such as creating threat assessment teams that can be trained to evaluate the likelihood a person or situation is at increased risk. In an active shooter situation, the Federal Bureau of Investigation (FBI, n.d.) provides recommendations for three different actions you can take to

You should now be aware of the components and causes of stress and your own role and responsibility in addressing workplace conflict at the interpersonal and organizational levels. Another important consideration is recognizing and responding to episodes of workplace violence, and you may refer to Chapter 18 for further discussion on workplace violence. After reading all this stressful information, you are probably wondering how you can effectively cope with it all. Thankfully, there are multiple methods for doing so.

Coping With Stress:  The Importance of Self-Care Learning to cope with stress is a life skill. When we are feeling burnt out or in conflict with others at work, we may be in danger of committing ethical violations. The physical and emotional consequences of stress can lead to diminished decision-making abilities, lead to substance abuse, and interfere with forming harmonious working relationships. These factors put the practitioner at risk for compromised patient care. Therefore, coping with stress is important for your own personal health and critical to your work. Because sources of stress are individualized, so are strategies for successful management. Where one strategy, such as exercise, might work well for your friend, it may not work as effectively for you. It is encouraging,



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however, to know that there is a wide array of strategies available, and it is highly likely that you will find one or more that are helpful to you.

First Steps to Coping Before seeking specific methods for combating stress, it is important to know how it affects you and what kinds of situations are most likely to increase your stress level (NAMI, 2023b). Some people respond to stress with physical symptoms such as those listed in the first part of this chapter. Do you get headaches? Do you feel wiped out after a stressful encounter? Does stress interfere with your ability to sleep or cause stomach/digestive symptoms? Others will experience emotional responses such as memory lapses or less patience with themselves and others. Having an idea of the kinds of situations that will increase your stress level and cause you to feel physically or emotionally uncomfortable is essential in determining how best to cope. Some stressful situations are temporary and can be easily addressed by simply gathering information. For example, if you are traveling to a conference in an unfamiliar city and are unsure about transportation to the venue, you can utilize sources such as the city’s website or convention and visitors’ bureau to learn more about what kinds of transportation are available and how much you can expect to pay. Many stressful situations require approaches, though, that are more consistent in their application and sophisticated in their implementation.

Ensuring Your Basic Needs Are Being Met After you have given some thought to what factors are causing your stress and how you respond to it, it is time to take the first steps toward management. Meeting your basic needs, such as getting enough sleep, eating nutritious food, engaging in simple relaxation exercises, and confiding in a good friend, can make a major impact on your daily stress management. Sleep.  One common effect of stress is insomnia. There are over-the-counter sleep aids that can be helpful for a temporary bout of insomnia, but it is important to monitor your usage of them because it is possible to become dependent. They can also have negative side effects, such as feeling groggy and nauseous when you wake up. Prescription sleep aids are available as well, but these too can have negative side effects and cause dependency. One popular method for dealing with insomnia is practicing good sleep hygiene. Sleep hygiene is a set of practices that individuals engage in to prepare for bed

and increase the likelihood they will be able to fall and stay asleep, resulting in being more alert in the daytime. The options for creating a sleep routine are varied and should be individualized to each person, as the evidence for their effectiveness in the general population is equivocal (Irish et al., 2015). Commonly recommended sleep hygiene strategies are described in Table 24–4. Eating Well.  Our bodies need adequate fuel to accomplish daily tasks and cope with excess demands such as stress. When we are undergoing a period of high stress, it is tempting to skip a meal or grab whatever food is closest or easiest, which is not typically as nutritious as what your body requires. Inconsistent meals can lead to a drop in your blood sugar, which will contribute to feeling shaky and confused. If you are working long hours or taking work home, it can be difficult to plan meals and prepare lunches and dinners that are better for you than fast- or frozen-food options. Meal planning is one way to increase your nutritional intake. Using a meal plan to determine how to grocery shop and implement meal prep time can make a significant difference in how you eat, helping reduce your stress. Fortunately, access to nutritious and convenient food is becoming more available, although usually at an increased financial cost. Many grocery stores now offer convenience foods such as rotisserie chicken or prepared salads, and meal preparation services offer kits that can be delivered to you. Additionally, the COVID-19 pandemic has created a variety of other conveniences such as the option for shopping for groceries online for pickup/ delivery and increased options for healthy foods that can be delivered right to your door. Relaxation Exercises.  Our bodies’ chemical responses to stress can lead to increases in muscle tension. This can result in headaches, stomach/digestive disturbances, or back or neck pain. Recognizing when you have excess muscle tension is not always intuitive, especially if you are enduring a period of prolonged stress. Some simple ways to check in with your body to investigate muscle tension include abdominal breathing; do you notice a change in where your shoulders are as you breathe in and out? Can you easily turn your neck from side to side? Do you feel relief in your lower back when you bend over and try to touch your toes? There are several stretches easily discovered from multiple sources. If you are an SLP student, you may have taken a voice disorders class where you learned specific relaxation exercises that you can apply to yourself, not just your clients! A popular approach was first advocated by Herbert Benson and Miriam Klipper in 1976 in The Relaxation Response. Originally designed for use with cardiac

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Table 24–4.  Commonly Recommended Sleep Hygiene Practices Practice

Description

Exercise

Promotes release of muscle tension, increased oxygenation, and release of endorphins. Be cautious about vigorous exercise right before bed, however; it can interfere with your ability to relax.

Make environmental adjustments

Your mattress/pillows should be comfortable; the ideal room temperature for sleep is between 60 and 67 degrees (National Sleep Foundation, 2019). Limit light, especially from cell phones/computers/tablets. Using white noise machines or apps that provide calming sounds may also be useful.

Establish consistent bedand wake-up times

Having consistent bed- and wake-up times both on weekdays and weekends helps establish a routine so your body begins to expect when to go to sleep and when to wake up.

Limit certain types of foods just before bedtime

Foods that are likely to cause indigestion or reflux, such as fried, spicy, citrusbased foods, and heavy meals can interfere with digestion.

Limit daytime naps

Napping can seem like a great way to rid yourself of tiredness, but it can interfere with your nighttime sleep. The National Sleep Foundation (2019) recommends limiting naps to 20–30 minutes.

Establish a relaxing bedtime routine

Light stretching, taking a warm bath or shower, or reading for a set time (e.g., 20 minutes) also helps your body recognize that it’s bedtime.

Avoid stimulants a few hours before bedtime

Caffeine, nicotine, and some prescription drugs provide enough stimulation to your nervous system that it significantly interferes with your ability to fall and/ or stay asleep.

patients, the techniques outlined in the book have been adopted, modified, and researched, resulting in an evidence-based approach to relaxation. Practicing a relaxation routine can result in stress-reduction benefits such as lowered blood pressure and better sleep. An important advantage to learning relaxation techniques is that they often come at low or no cost and do not require assistance from another professional or coach.

Talking With Others Our stress and worried thoughts can magnify when we keep silent about them. We tell ourselves that if we talk about our stressors, others will think we are overdramatizing what to them may seem a small problem. We discount the significance of our stressors, thinking that others have it worse than we do, so we should not discuss our problems in case the listener has a bigger problem. Here is a secret: It is not a competition. Being the most stressed person you know does not win you a prize, nor does being less stressed than someone else. If what you are going through is the most stressful thing you have ever encountered, then it is the most stressful thing.

You can experience significant relief from your worries just by talking about them to someone else. Friends, colleagues, family members, and religious advisors are all examples of people you might seek out to help you think about a problem that has you stressed. Not every one of the people around you is best suited to listen to you, however. Follette and Pistorello (2007) describe making a list of the people you are close to across all environments. Then, write down the kinds of things you typically confide in them about. Sometimes making an explicit list like this can be helpful in determining who is the best person for you to talk to about a given stressful situation. Once the best person to talk to has been identified, letting them know what kind of help you need is important in addressing your individual needs.

Solutions Versus Support.  We’ve all had stressful things we want to talk about with a friend or loved one. Sometimes it can be frustrating when you are confiding in someone, and they immediately start solving your problem. In these instances, your friend might say, “Oh, that is easy. You just



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need to . . . ” and then they complete the sentence with some simple solution. However, you may feel that your problem is not that clear cut and such a statement makes you feel like they are minimizing the situation. A strategy you can employ with those around you is to set the stage before you start conversations about your stressors. You can agree whether the conversation is for problem solving or supporting through listening. By being clear at the beginning of the discussion, your listener can help meet your expectations and both of you can feel like the objective of the conversation has been met.

Employee Assistance Programs Another more formal option for talking with someone about your stress is seeking out help through an employee assistance program (EAP). EAPs are a benefit offered by many employers; check with your human resources department about whether they have an arrangement with an EAP provider. EAP is designed to be a short series (often fewer than eight sessions) of free, confidential counseling appointments that deal with a focused issue (Office of Personnel Management [OPM], n.d.). These issues can help you figure out how to reduce or cope with workplace conflict, with stress in general, or even with financial issues, relationships, and parenting. The rationale behind EAPs is that happier workers make for more productive working environments. Services are confidential, and if after completing the available number of EAP visits it is determined that you may need additional assistance, EAP counselors can help make referrals to other providers who are better able to support you long term. Additionally, most universities recognize the importance of mental health in students. These universities may offer individual or group counseling services, workshops, or other services focused on mental health. We suggest you check what resources are available to you at your individual institution.

Mindfulness Practices for Stress Reduction One of the hottest topics in mental health and stress reduction today is the implementation of mindfulness practices into everyday life. Enter “mindfulness” into Google and you will find more than 10 pages of listings that include definitions, articles on the benefits of mindfulness, mindfulness mediation practices, different apps for your smartphone, and so on. For our purposes,

we will use a general definition amalgamated from multiple sources and then discuss how some researchers have implemented mindfulness practices to facilitate stress reduction.

Defining Mindfulness There are many definitions available for mindfulness, depending on whether you are accessing them via general sources like dictionary.com, Merriam-Webster’s Dictionary, or Wikipedia. Other sources are more specific depending on the individual offering the definition and their orientation to mindfulness practice (e.g., yoga, meditation). A conceptual definition of mindfulness is being aware and present with your thoughts, feelings, and physical experiences at any given moment. Another component used in some definitions but not others is that your awareness of these thoughts, feelings, and physical experiences is nonjudgmental. Thoughts or feelings are not good or bad; they are just what you are thinking or feeling in the moment. If you are mindful, it means that you take a moment, or more than one, to notice what is around you. Are you feeling hot or cold? Tense or relaxed? What are you thinking about right now? Do you notice any noise in the environment? What about your breathing? When was the last time you took a deep breath and really noticed how great it feels to breathe in and out? When we are stressed, it is not uncommon to hold our breath and not take nice, deep breaths in and out. The oxygenation a deep breath provides can relieve muscle tension almost right away. Kabat-Zinn (2005) describes being nonjudgmental about our thoughts by imagining we are sitting by a stream and watching the leaves float by. Each leaf has one of our ideas on it. Some leaves get caught up against a rock and spin for a bit. This is like when we have a thought that we cannot let go of and we turn it over and over in our heads. This is one kind of stress response. Kabat-Zinn discusses observing that leaf being caught and trying not to do anything about it to urge it down the stream, instead being patient and noticing that the “stuck” aspect will eventually allow the leaf to work itself out. The same can be true of our thoughts. Judging our thoughts as good or bad, immature, helpful, or unhelpful can lead us to try to push them away, resulting in feeling even more stressed.

Strategies for Increasing Mindfulness in Everyday Life There are many ways to begin increasing your mindfulness, whether through formal practice such as yoga or meditation or through informal means such as reading the works of well-known practitioners such as Jon

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Kabat-Zinn, Thich Nhat Hanh, and Pema Chodron and then trying to implement their suggestions. You can also find mindfulness workshops around the country that will help you get started.

in the fifth edition of this book. She embodied all the strategies discussed in this chapter and was an outstanding example of how to thrive during stressful times.

Is There Evidence for Mindfulness in Reducing Stress?

References

Many research centers around the country focus on researching and acquiring evidence for mindfulness practice. Kabat-Zinn’s (2005) book was borne out of his research at a university hospital with cardiac patients, where he found that blood pressure and patient-reported experiences of stress were reduced when they engaged in brief daily mindfulness sessions. Other research centers include the Mindful Awareness Research Center at the University of California‒Los Angeles and the Greater Good Science Center at the University of California‒Berkeley. When examining the use of mindfulness in our own professions, Beck and Verticchio (2014) described a pilot study where six yoga sessions were used with a small group of first-semester graduate students as a method for increasing mindfulness and reducing stress. A control group of students were offered instruction in traditional stress-management techniques. Students who participated in traditional stress-management instruction reported no meaningful reduction in their feelings of stress, whereas students who participated in at least five of the six yoga sessions reported feeling lower levels of perceived stress. Regardless of how you choose to learn about and implement mindfulness into your everyday life, whether through reading more about mindfulness, taking a workshop, or starting regular yoga or meditation classes, it is well worth exploring as a stress management tool.

Summary In this chapter, you learned about stress: what it is, what contributes to personal stress, why workplace conflicts occur and your own role in their resolutions, and a variety of strategies for self-care to increase your coping skills when you feel stressed. As you move forward with your career, remember that stress is inevitable, and some level of stress helps us accomplish our goals. Overwhelming levels of stress can lead to damaged mental and physical health, though, and it is important to ask for help when you need it. Last, learning strategies for reducing workplace stress and your own stress level is an essential component to ethical behavior. Dedication.  We dedicate this chapter to Lisa Scott, PhD. Dr. Scott was the original author of this chapter

American Speech-Language-Hearing Association. (2023). Code of ethics. https://www.asha.org/policy/ et2016-00342/ American Speech-Language-Hearing Association. (2021). Results From ASHA’s April 2021 Interprofessional Practice Survey. https://www.asha.org/ siteassets/surveys/2021-interprofessional-practicesurvey-results.pdf André, S. (2018). Embracing generational diversity: Reducing and managing workplace conflict. Operating Room Nurses Association of Canada (ORNAC), 36(4), 13–35. https://doi.org/10.1310/ hpj4807-537 Avgar, A., Lee, E. K., & Chung, W. (2014). Conflict in context: Perceptions of conflict, employee outcomes and the moderating role of discretion and social capital. International Journal of Conflict Management, 25(3), 276–303. https://doi.org/10.1108/ IJCMA-03-2012-0030 Beck, A. R., & Verticchio, H. (2014). Facilitating speech-language pathology graduate students’ ability to manage stress: A pilot study. Contemporary Issues in Communication Sciences and Disorders, 41, 24–38. https://doi.org/10.1044/cicsd_41_S_24 Benson, H., & Klipper, M. Z. (1976). The relaxation response. Harper Collins Publishing. Biber, J., Ranes, B., Lawrence, S., Malpani, V., Trinh, T. T., Cyders, A., . . . Pop, R. (2022). Mental health impact on health care workers due to the COVID-19 pandemic: A U.S. cross-sectional survey study. Journal of Patient-Reported Outcomes, 6(1), 63. https:// doi.org/10.1186/s41687-022-00467-6 Brännström, K. J., Holm, L., Larsson, J., Lood, S., Notsten, M., & Turunen Taheri, S. (2016). Occupational stress among Swedish audiologists in clinical practice: Reasons for being stressed. International Journal of Audiology, 55(8), 447–453. https:// doi.org/10.3109/14992027.2016.1172119 Brito-Marcelino, A., Olivia-Costa, E. F., Sarmento, S. C. P., & Carvalho, A. A. (2020). Burnout syndrome in speech-language pathologists and audiologists: A review. Revista Brasileira de Medicina do Trabalho, 18(2), 217–222. https://doi.org/​ 10.47626/1679-4435-2020-480



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Brown, C. A., Schell, J., & Pashniak, L. M. (2017). Occupational therapists’ experience of workplace fatigue: Issues and action. Work, 57, 517–527. https://doi.org/10.3233/WOR-172576

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Cain, C. L., Frazer, M., & Kilaberia, T. R. (2019). Identity work within attempts to transform health care: Invisible team processes. Human Relations, 72(2), 370–396. https://doi.org/10.1177/001872​ 6718764277

Fischer, L. S., Lang, J. E., Goetzel, R. Z., Linnan, L. A., & Thorpe, P. G. (2018). CDC grand rounds: New frontiers in workplace health. Morbidity and Mortality Weekly Report, 67(41), 1156–1159. https://www.cdc.gov/mmwr/volumes/67/wr/pdfs/ mm6741a5-H.pdf

Cedoline, A. J. (1982). Job burnout in public education: Symptoms, causes, and survival skills. Teachers College Press. Centers for Disease Control (2014, June 6). STRESS . . . at work. https://www.cdc.gov/niosh/docs/ 99-101/default.html#:~:text=Scope%20of%20 Stress​%20in%20the%20American%20Work​ place&​text=One%2Dfourth%20of%20employees​ %20view,stress%20than%20a%20generation% 20ago Centers for Disease Control (2022, June 9). Workplace health promotion. https://www.cdc.gov/chronicdisease/resources/publications/factsheets/workplacehealth.htm#:~:text=In%20addition%2C%20work​ %20stress%20is,behaviors%20also%20reduce%20 worker%20productivity. Clark, D. A., & Beck, A. T. (2011). The anxiety & worry workbook: The cognitive behavioral solution. Guilford Press. Cooper-Duffy, K., & Eaker, K. (2017). Effective team practices: Interprofessional contributions to communication issues with a parent’s perspective. American Journal of Speech-Language Pathology, 26(2), 181–192. https://doi.org/10.1044/2016_AJSLP15-0069 Corey, G. (2016). Theory and practice of counseling and psychotherapy (10th ed.). Cengage Learning. Currie, D., Gormley, T., Roche, B., & Teague, P. (2016). The management of workplace conflict: Contrasting pathways in the HRM literature. International Journal of Management Reviews, 19(4), 492–509. https://doi.org/10.1111/ijmr.12107 Farber, B. A. (1990). Burnout in psychotherapists: Incidence, types, and trends. Psychotherapy in Private Practice, 8(1), 35–44. https://doi.org/10.13​ 00/J294v08n01_07 Farber, B. A. (2000). Introduction: Understanding and treating burnout in a changing culture. Journal of Clinical Psychology, 56(5), 589–594. https://doi .org/10.1002/(sici)1097-4679(200005)56:53.0.co;2-s

Follette, V. M., & Pistorello, J. (2007). Finding life beyond trauma: Using acceptance and commitment therapy to heal from post-traumatic stress and traumarelated problems. New Harbinger Publications. Godard, J. (2014). The psychologization of employment relations? Human Resources Manage­ment Journal, 24(1), 1–18. https://doi.org/10.1111/17​ 48-8583.12030 Harris, S. F., Prater, M. A., Dyches, T. T., & Heath, M. A. (2009). Job stress of school-based speechlanguage pathologists. Communication Disorders Quarterly, 30(2), 103–111. https://doi.org/10.11​ 77/1525740108323856 Informed Health Online. (2017). Depression: What is burnout? National Library of Medicine. https:// www.ncbi.nlm.nih.gov/books/NBK279286/ Irish, L. A., Kline, C. E., Gunn, H. E., Buysse, D. J., & Hall, M. H. (2015). The role of sleep hygiene in promoting public health: A review of empirical evidence. Sleep Medicine Reviews, 22, 23–36. https:// doi.org/10.1016/j.smrv.2014.10.001 Kabat-Zinn, J. (2005). Wherever you go, there you are: Mindfulness meditation in everyday life. Hachette Book Group. Kfouri, J., & Lee, P. E. (2019). Conflict among colleagues: Health care providers feel undertrained and unprepared to manage inevitable workplace conflict. Journal of Obstetrics and Gynaecology, 41(1), 15–20. https://doi.org/10.1016/j.jogc.2018.03.132 Klotz, A. C., & Bolino, M. C. (2022, September 15). When quiet quitting is worse than the real thing. Harvard Business Review. https://hbr.org/2022/09/ when-quiet-quitting-is-worse-than-the-real-thing Lubinski, R. (2013). Stress, conflict, and coping in the workplace. In M. Hudson & R. Lubinski (Eds.), Professional issues in speech-language pathology and audiology (4th ed.). Delmar. Lyndon, A. (2015). Burnout among health professionals and its effect on patient safety. Patient Safety

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Network. https://psnet.ahrq.gov/perspective/ burnout-among-health-professionals-and-its-effectpatient-safety Marks, A. K. (2018). Interprofessionalism on the augmentative and alternative communication team: Mending the divide. Perspectives of the ASHA Special Interest Groups, 3, 70–79. https://doi.org/​ 10.1044/persp3.SIG12.70 Maslach, C. (2007). Burnout in health professionals. In S. Ayers, A. Baum, C. McManus, S. Newman, K. Wallston, J. Weinman, & R. West (Eds.), Cambridge handbook of psychology, health and medicine (2nd ed., pp. 427–430). Cambridge University Press. https://doi.org/10.1017/CBO9780511543​ 579.094 Maslach, C., & Jackson, S. E. (1982). Burnout in health professions: A social psychological analysis. In G. S. Sanders & J. Suls (Eds.), Social psychology of health and illness. Erlbaum. Mayo Clinic. (2021, June 5). Job burnout: How to spot it and take action. https://www.mayoclinic.org/ healthy-lifestyle/adult-health/in-depth/burnout/ art-20046642 McLaughlin, E., Lincoln, M., & Adamson, B. (2008). Speech-language pathologists’ views on attrition from the profession. International Journal of SpeechLanguage Pathology, 10(3), 156–168. https://doi​ .org/10.1080/17549500801923310 Merriam-Webster. (n.d.). Compassion fatigue. In Merriam-Webster.com dictionary. https://www​ .merriam-webster.com/dictionary/compassion%​ 20fatigue Michailidis, E., & Banks, A. P. (2016). The relationship between burnout and risk-taking in workplace decision-making and decision-making style. Work & Stress, 30(3), 278–292. https://psycnet.apa.org/ record/2016-39611-005 Montero-Marín, J., Prado-Abril, J., Carrasco, J. M., Asensio-Martinez, A., Gascón, S., & GarcíaCampayo, J. (2013). Causes of discomfort in the academic workplace and their associations with the different burnout types: A mixed-methodology study. BMC Public Health, 13, 1‒24. https://doi​ .org/10.1186/1471-2458-13-1240 Morrison, S. C., Lincoln, M. A., & Reed, V. A. (2011). How experienced speech-language pathologists learn to work on teams. International Journal of Speech-Language Pathology, 13, 369–377. https:// doi.org/10.3109/17549507.2011.529941

National Alliance on Mental Illness. (n.d.-a). Mental health by the numbers. https://www.nami.org/ mhstats National Alliance on Mental Illness. (n.d.). Taking care of yourself. https://www.nami.org/Your-Journey/ Family-Members-and-Caregivers/Taking-Care-ofYourself National Institute for Occupational Safety and Health. (n.d.-a). Occupational violence. Centers for Disease Control and Prevention. https://www.cdc.gov/ niosh/topics/violence/default.html National Institute for Occupational Safety and Health. (n.d.). Types of workplace violence [Webcast]. https://wwwn.cdc.gov/WPVHC/Nurses/Course/ Slide/Unit1_5 National Safety Council. (2023). Assault fifth leading cause of workplace deaths. https://www.nsc.org/ workplace/safety-topics/workplace-violence National Sleep Foundation. (2019). Sleep hygiene. https://www.sleepfoundation.org/sleep-hygiene Office of Personnel Management (OPM). (n.d.). What is an employee assistance program (EAP)? https://www.opm.gov/frequently-asked-questions/ work-life-faq/employee-assistance-program-eap/ what-is-an-employee-assistance-program-eap/ Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2011). Crucial conversations: Tools for talking when stakes are high (2nd ed.). McGraw-Hill Education. Patterson, K., Grenny, J., McMillan, R., Switzler, A., & Maxfield, D. (2013). Crucial accountability: Tools for resolving violated expectations, broken commitments, and bad behavior (2nd ed.). McGraw-Hill Education. Ravi, R., Gunjawate, D., & Ayas, M. (2015). Audiology occupational stress experienced by audiologists practicing in India. International Journal of Audiology, 54, 131–135. https://doi.org/10.3109/149920 27.2014.975371 Ross, E. (2011). Burnout and self-care in the practice of speech pathology and audiology. In R. J. Fourie (Ed.), Therapeutic processes for communication disorders: A guide for clinicians and students (pp. 213–228). Psychology Press. Saltman, D. C., O’Dea, N. A., & Kidd, M. R. (2006). Conflict management: A primer for doctors in training. Postgraduate Medical Journal, 82(963), 9–12. https://doi.org/10.1136/pgmj.2005.034 306



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Severn, M. S., Searchfield, G. D., & Huggard, P. (2012). Occupational stress amongst audiologists: Compassion satisfaction, compassion fatigue, and burnout. International Journal of Audiology, 51(1), 3‒9. https://doi.org/10.3109/14992027.2011.60 2366 Simpson, A., Phillips, K., Wong, D., Clarke, S., & Thornton, M. (2018). Factors influencing audiologists’ perception of moral climate in the workplace. International Journal of Audiology, 57(5), 385‒394. https://doi.org/10.1080/14992027.2018.1426892 Society for Human Resource Management. (2022). Understanding workplace violence prevention and response. https://www.shrm.org/resourcesandtools/ tools-and-samples/toolkits/pages/workplaceviolence-prevention-and-response.aspx Workplaces Respond. (n.d.). The facts on gender-based workplace violence. https://www.workplacesrespond​ .org/resource-library/facts-gender-based-workplaceviolence/ World Health Organization. (2022, March 2). COVID-19 pandemic triggers 25% increase in prev­ alence of anxiety and depression worldwide. https:// www.who.int/news/item/02-03-2022-covid19-pandemic-triggers-25-increase-in-prevalenceof-anxiety-and-depression-worldwide Yalom, I. D. (2002). The gift of therapy: An open letter to a new generation of therapists and their patients. HarperCollins. Zurich, E., Altstötter-Gleich, C., Gerstenberg, F. X. R., & Schmitt, M. (2015). Perfectionism in the Transactional Stress Model. Personality and Individual Differences, 83, 18–23. https://doi.org/10.1016/j. paid.2015.03.029

Resources There are many resources available to you on the internet and apps for increasing mindfulness/stress reduction. Given that these sources of information change frequently, we’re going to instead provide you a list of books that address many of the concepts covered in this chapter. Here are just a few. The reference list contains complete indexing information for each. Clark, D. A., & Beck, A. T. (2011). The anxiety & worry workbook: The cognitive behavioral solution. Guilford Press. Cognitive behavioral therapy is an evidence-based approach for treating anxiety. This workbook is just

that: It contains exercises that help you to decrease worry. The exercises are explained in easy-to-understand terms, include example charts or worksheets, and provide a rationale for when a particular exercise is helpful to you. We have used the exercises ourselves, with clients and with family and friends and found them to be helpful to all. Kabat-Zinn, J. (2005). Wherever you go, there you are: Mindfulness meditation in everyday life. Hachette Book Group. Kabat-Zinn helps beginners seeking to develop their mindfulness through practical strategies and essays to guide mindfulness practice. This book can be an invaluable part of your personal and professional life, and you may find the mindfulness essay prompts helpful throughout the year. He also dispels myths about mindfulness, such as that you must have a quiet mind or spend long periods of time in mindfulness practice to experience benefits. A favorite essay prompt addresses how simple it can be to be mindful during daily activities like washing dishes. Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2011). Crucial conversations: Tools for talking when stakes are high (2nd ed.). McGraw-Hill Education. You may feel that because you are studying communication disorders, you will be an expert in areas of communication. However, some discussions and conflicts require something more — and this book might have just what you need, especially if you plan to be an administrator or leader. Patterson, K., Grenny, J., McMillan, R., Switzler, A., & Maxfield, D. (2013). Crucial accountability: Tools for resolving violated expectations, broken commitments, and bad behavior (2nd ed.). McGraw-Hill Education. This book builds on the concepts from Crucial Conversations and is so useful in increasing your ability to navigate and resolve conflicts. Yalom, I. D. (2002). The gift of therapy: An open letter to a new generation of therapists and their patients. HarperCollins. Yalom retired as a faculty psychiatrist from Stanford Medical School and also maintained a private practice. Different from today’s version of psychiatrists who mainly administer and monitor drugs for mental health disorders, Yalom spent time counseling his patients. This book was written as his reflections on his long career and is addressed to psychiatry students, but much of the information is just as applicable to our work. It is written in very short chapters ​

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— there are 85 in just 259 pages. It is possible to read only the chapters that interest you and not the entire text. Lisa Scott, the speech-language pathologist who

originally penned this chapter, found this book was a gift to herself. We hope you will feel the same.

25 Advocacy Tommie L. Robinson, Jr.

Introduction The role of advocacy has been a part of our society from the beginning of time. Clearly, to accomplish a variety of things, one has to advocate to obtain them. Difficulty abounds when attempting to imagine any aspect of our lives where there is no advocacy for self or each other. As we think about childhood, advocacy becomes a part of us very early on in development: “Mrs. Smith, can Johnny come out and play with us? We promise to stay in the yard.” This is an example of an advocacy activity. In this example, Johnny was likely grounded or could not go out. But his friend came over and advocated for him. Let’s think of another example: “Mom and Dad, I have been thinking. My allowance is not enough. I have done my budget and it seems that I will not have enough money to do those things that I am obligated to do. Is it possible that I might have an additional $30 a week?” This is an example of advocating for one’s self. What about Dr. Martin Luther King, Jr.? He worked on behalf of individuals who were treated unfairly and fought to have laws changed. He is a well-known example of an advocate who worked for others and his work impacted change. Finally, the American Civil Liberties Union (ACLU) is an example of an organization that advocates and fights for the rights of all individuals. As we move into the professional arena, advocacy becomes extremely important. We find that advocacy work affects every aspect of our professional lives and every work setting. No one is untouched by the need for advocacy. It is seen from mandating funding for schools to demanding coverage of services for senior citizens. Advocacy is also viewed as a venue for individuals, organizations, and groups to intervene and achieve systemwide change (Gardner & Brindis, 2017). While the results of advocacy can be rewarding, it is also challenging to undertake such tasks. It can be a slow process. Understanding that there are strategies and methodologies involved in advocacy is very important and can often save time and resources. Advocacy may also be a political process by an individual or a large group that normally aims to influence public policy. All members of the speech, language, and hearing community have the right to engage in advocacy activities. Advocacy is important because: n

It empowers and accomplishes goals.  This means any member of the community has the authority to participate in advocacy activities. It allows individuals to be confident and strong, especially in controlling their rights. 509



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n

n

It provides the opportunity to participate in government and local decision making. As speech-language pathologists (SLPs) and audiologists, we each have the opportunity to be a citizen advocate and meet with the legislators who work for us as citizens. Our presence aids in educating legislators on the impact of the public policy for those we serve. It is a part of the ASHA Code of Ethics. While the notion of advocacy is implied throughout the American Speech-Language-Hearing Association (ASHA) Code of Ethics, it is specifically expressed in the Principle of Ethics III, which states, “In their professional role, individuals shall act with honesty and integrity when engaging with the public and shall provide accurate information involving any aspect of the professions” (ASHA, 2023b).

This chapter will focus on the nomenclature used in helping to understand advocacy. It will also address the benefits of being an advocate. The majority of the chapter will be devoted to developing a practical approach to the advocacy process and will include how to develop a plan of action, establish a grassroots advocacy network, work with the legislature, negotiate, and leverage the media. Finally, this chapter will focus on available resources to aid in the advocacy process.

Definitions Table 25–1 is a list of terms that are used in the advocacy process.

Recognizing the Benefits of Being an Advocate Advocates are in a unique position to make changes to or lend support for issues that impact the well-being of communities. There are many benefits associated with being an advocate as well as the individuals for whom the action was directed. The advocate receives self-satisfaction and a sense of purpose, while the individuals for whom the advocate acts receive the benefits of the advocacy efforts. There are other benefits that are more global and impactful. Policymakers or decision makers carry a lot of weight and power; thus, the role of the advocate is to ensure the decisions being made are in the best interest of those whose lives are impacted by the decisions. Roles of the advocate to effect global changes will be described next.

Educate Decision Makers About Issues of Concern We cannot be so naïve as to think decision makers have all the answers. It is helpful if we assume there is always an opportunity for educating the policymakers on the issues relative to communication sciences and disorders. This opens the door to opportunities to educate decision makers about the concern regarding the policies being considered. Oftentimes, decisions are made by relying on the advice of trusted aides. If these aides have not had experiences with a communication or related disorder, the decision will likely reflect that perspective and may not serve in the best interest of the individuals being affected. Our role as advocates is to teach decision mak-

Table 30–1.  Advocacy Nomenclature Terms

Definitions

Advocate

A person who works effectively to bring about positive change by influencing public policy.

Self-advocacy

An act in which people speak out for themselves to express their own needs and interests. This type of advocacy is often seen with people with disabilities.

Group advocacy

A group coming together to support a cause or an issue to work in a concerted manner to call for change.

Citizen advocacy

When actively involved and engaged citizens provide long-term advocacy to individuals with a disability.

Professional advocacy

When professionals advocate to provide their services for the benefit of their patients/ clients/students. In this case the SLP or audiologists are advocating for prevention, assessment, and treatment that would benefit those receiving the services.

Grassroots advocacy

An organized way to achieve change that benefits a group (professionals and consumers).



ers as much information as we can about every aspect of the issue. Share Knowledge on an Issue’s Impact in the Local Area.  The impact of a decision can be negative or positive. Our role as advocates is to emphasize a positive outcome based on the decision of the policy under consideration. It is crucial that the advocate points out all aspects of the policy and the effect it might have on the local area. Moreover, the importance of understanding policy changes at the bigger level might have an exorbitant adverse effect at the local level. For example, let’s say there is a change to the clinical or academic standards at the national level. This does not mean the requirements for licensure at the state level will change, thereby posing a conflict. It is important to educate policymakers about this potential conflict and what it means to constituents. Help Legislators, Regulators, and Other Decision Makers Understand How Audiology and SpeechLanguage Pathology Services Improve the Quality of Life for Their Constituents.  Our highest calling in the advocacy process is to make legislators, regulators, and other decision makers understand how audiology and speech-language pathology services work. As advocates, we need to educate them about the services we offer and the impact they have on the lives of their constituents. A rule of thumb is to help them connect the dots. Often, if they have had a personal experience along these lines, they understand things better. Sometimes we have to share the process and help them become cognizant of the fact that there are adverse communication results if preventative measures are not in place. The advocate’s role is to make the decision makers fully aware of who we are and what our roles and responsibilities are, particularly along the lines of assessment, prevention, and treatment. As speech-language pathology and audiology advocates we need to help those in power understand the impact their actions have on the patients/students/clients and families we serve. There are many benefits to both patients and communication sciences disorders (CSD) professionals as a result of advocacy activities. Additionally, lawmakers can now make decisions based on factual and pragmatic information.

Advocacy Case Examples Advocacy for Patients/Students/Clients Case:  Robert is a middle school student who does excellent work in the classroom. He is a straight-A student in all of his classes. However, he stutters. The school system indicates that he is not eligible for speech therapy for

CHAPTER 25   Advocacy

his stuttering because there is no academic impact. The SLP works with the school’s administration and other team members to make a case for the adverse educational impact the stuttering has on Robert’s everyday communicative and social–pragmatic interactions as well as on his general performance. Robert typically does not participate in classroom discussions, raise his hand to answer questions, and/or partner with others on projects in or outside the classroom despite his ability to earn all A’s. He gets the services he needs because the SLP advocates for him.

Advocacy for Professions Case:  The District of Columbia Speech-LanguageHearing Association (DCSHA) discovered that a bill was being considered by the city council to require licensure for all SLPs and audiologists practicing in Washington, D.C. The association leaders were totally unaware of this initiative at a time when licensure did not exist for SLPs or audiologists. The SLPs and audiologists in the area requested a meeting with city council leaders to obtain a better understanding of how and why this bill was created. The DCSHA leaders communicated with ASHA for assistance. A meeting was then held with DCSHA, ASHA representatives, city council leaders, and the Department of Health Administration to shape the bill in accordance with the ASHA-recommended scope of practice requirements. It was determined that the bill had originated from the otolaryngologists (ENT) association, the American Academy of Otolaryngology–Head and Neck Surgery (AAOHNS). The ENTs had included themselves in the bill so they could have two seats on the Speech-Language Pathology and Audiology Licensure Board to assert greater power on decision making. This was unusual as most boards are small (six to eight members) and consist of a majority of practitioners within the discipline and members of the public. One physician or fewer, who may or may not be an ENT, a consumer, and practitioners is a typical composition for a licensure board. DCSHA leaders met individually and collectively with the city council members to help them understand the roles and responsibilities of SLPs and audiologists in communication processes. It was determined that a few of the aides and members had experiences with SLPs and audiologists through family members and personal accounts. This helped in the process. Through their lobbying efforts, the DCSHA leaders advocated with the city council and received council approval to reduce the number of ENTs on the board to one and increase public participation. Additionally, as noted previously, the bill was shaped according to the ASHA scope of practice requirements versus the AAOHNS perspectives. This is an example of how professionals can advocate

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with the advocate or the advocacy administrator identifying the constituency groups. The groups must be surveyed to assess and identify issues. This can be done via traditional survey methods or with a series of focus groups. After completing the survey, advocacy goals are established. These goals are prioritized by the group. The final step in this process is to develop a time frame for implementing and achieving the goals.

together to have a public policy changed. It took dedication, time, and grassroots efforts, but the mission was accomplished.

Advocacy for Changes to Public Policy at the National Level Case:  There was once a $1,500 Medicare cap on outpatient rehabilitation therapy services originally instituted under the Balanced Budget Act of 1997 (BBA-97; Congress.Gov, n.d.). The original bill required speechlanguage pathology and physical therapy (PT) combined services to be capped at $1,500. Occupational therapy services had their own separate cap. For years, ASHA members representing every U.S. state lobbied on Capitol Hill, after receiving training from the association’s advocacy administrators, to have the cap repealed. It was always met with temporary relief. This process continued for 21 years and was finally permanently repealed in 2018. This was due to the efforts of the national ASHA headquarters aiding members in grassroots and organized lobbying efforts (Regan, 2018; Jones-McNamara, 2001). When each of these situations ended, the necessary individuals were educated, the local impact was minimized, and the legislators, regulators, and policymakers had a new-found appreciation for SLPs and audiologists.

n

Developing a Game Plan for Advocacy The aforementioned cases, though few, reveal how service providers are implementing advocacy efforts daily and are getting results. To achieve success, one has to develop a game plan. For example, ASHA has a public policy agenda (ASHA, 2023a). This agenda guides the advocacy activities of the association and specifically focuses on areas that are of urgency to members and the patients/ students/clients who are served. The current agenda addresses priorities relative to (a) health care; (b) schools; (c) clients, patients, and students; and (d) diversity, equity, and inclusion. Below are elements used in creating a successful game plan for approaching advocacy activities. The process includes developing an action plan, establishing a grassroots advocacy network, working with the legislature, negotiating, and leveraging the media. The first act of advocacy is to develop an action plan. There are three steps in the action plan development process: (a) identify issues and set priorities, (b) identify the factors necessary for change, and (c) identify the key decision makers. Each step is detailed below. n

Identifying issues and setting priorities is the first action item as it creates the road map. It starts

n

Step two is to identify the factors necessary for change. The advocacy group determines what the realistic factors are to begin developing the action plan. To achieve this, there are several questions that may be asked. n

Question 1.  Is your issue a priority for the leadership? This is important because there must be leadership buy-in to implement or push forward the action plan. This positions the leaders to champion the cause and to serve as advocates for the plan.

n

Question 2.  Are there sufficient financial resources available to achieve the plan? This, too, goes back to leadership. To move the plan forward, there must be adequate financial support, and that rests in the hands of leadership.

n

Question 3.  Is there significant opposition to the plan? The creators of the plan can use a straw poll to determine support for the plan. If there is significant opposition, the plan will likely not move forward and will adversely affect funding or financial resources.

The final step of developing the action plan is to identify the key decision makers. Decision makers come in a number of different forms. They may be legislators on committees of the jurisdiction, state or local Department of Health and Education officials, regulators or insurers, school officials, superintendents, special education directors, employee unions, and so forth. Sometimes it is important to rely on connections. This can be done by determining who in the group knows or has a connection to one of the key decision makers. It is imperative that advocates determine the level of support or opposition of these different key decision makers. It is also important that the political climate be evaluated, as there are times when the situation may not be conducive for certain policy decisions. Finally, determine what actions to take to garner support from the key decision makers.



Example A group of SLPs in a school district have met and agree that their caseloads are too high, there is too much paperwork and no time for planning, and their salaries are not commensurate with other local school districts. In accordance with the game plan, the group meets to prioritize the issues and agrees to address caseload/ paperwork issues. They rule out salary negotiations, as the district has already indicated there will be some layoffs and no additional pay raises in the coming year. They understand that reducing caseload size will necessitate additional hires but learn about a service delivery model (3:1) that will help lessen the impact of the large case­loads and help reduce the paperwork burden. They identify the decision makers and determine who will support and oppose this effort. They develop advocacy tools such as fact sheets, survey results from similar districts, examples of districts where the 3:1 model is used successfully, and a PowerPoint presentation, and appoint a spokesperson for the group. They identify a decisionmaking timeline to ensure their best chance for success and begin the process of advocating for the new model. Successful advocacy takes patience and persistence, and they recognize that they may need to compromise to eventually achieve their goal. The result of their negotiation is an agreement to pilot a 3:1 model for 1 year and reevaluate. This example reflects a successful negotiated outcome. Note:  In the 3:1 model, the SLP provides direct services to children on the caseload for 3 consecutive weeks each month, followed by a week of paperwork, testing, and meetings with parents, teachers and staff, including individualized educational plan (IEP) and eligibility meetings. This model helps the SLP achieve a more productive balance between caseload and workload requirements.

CHAPTER 25   Advocacy

Working with the legislature can be intimidating, but it is important to remember that the legislators work for us, their constituents. It is their job and responsibility to meet with advocates and listen to concerns. Having said this, there are a few things to consider when working with the legislature: n

Understand your audience. Prior to meeting with legislators, it is important to know their political views and policy interests. Learn about their constituent base and who these individuals are and what might appeal to them. Identify the committee to which the legislator is assigned. Read their biographies and identify personal interests. It is also advantageous to know the legislators’ own political agenda. The bottom line is, do the necessary homework.

n

Learn the best way to influence decision makers. Find out what works best for them. Do they enjoy face-to-face conversations? Would letters be appropriate? If so, letters need to be original. Will they respond to telephone calls? If so, find the best time to call and who to call. Also, learn email addresses because email is effective. Follow their social media sites (e.g., Facebook, Twitter, Instagram, or blogs).

n

Plan a visit to the legislators’ offices and attend a legislative session. Prepare a fact sheet with talking points that provide background information, data, and facts to support your position. Invite a consumer or plan to share a personal story during the visit. Finally, create a handout or other “leave behind” information sheet with contact information to share with them.

n

Deliver the message. Make an appointment and be on time. When delivering the message, please be sure to do the following:

Legislative Advocacy

n

Be accurate and concise, and do not get off message.

Legislative advocacy and establishing a grassroots advocacy network are among the most important parts of the advocacy process. To establish the network, one must recruit like-minded individuals who will become key contacts in the legislative districts. It is important that the key leaders establish a database to keep track of those contacts and develop a system to connect and communicate within the network of members. Remember, there is power in grassroots advocacy networks! These are the individuals who will walk the halls and meet with the key decision makers or write letters and make telephone calls. They are often described as the ones on the ground or the ones who have their fingers on the pulse of the issues.

n

Use facts and data to support your position.

n

Eliminate jargon.

n

Ask for support and wait for a reply.

n

Share a personal story.

n

Be courteous and polite even if your positions differ.

n

Promise to follow up with answers to questions you do not know.

n

Do not overstay your welcome.

n

After the meeting, write a personal thank-you note. Then, inform your group of the results.

513



514

SECTION IV   Working Productively

Please remember to get back to the legislator with answers to questions you did not know. Negotiation is the lifeblood of politics (Shell & Moussa, 2007). If the advocate does not understand this, the outcome is likely not going to be successful. Negotiating is nothing more than the ability to win others over; it is also about compromising, or meeting in the middle. If an advocate thinks 100% of a request is going to be granted, the loss is going to be particularly disappointing. Negotiating involves trust and understanding in addition to an element of education that aids in the process. Each of the heretofore ideas and strategies turns on negotiation. The passion the advocate brings to the process helps in selling the idea. It is therefore imperative to speak from the heart. Tell a story, personalize it, and make the listeners a part of it. Bring it to life by making it vivid and forcing the audience to think and start questioning the obvious. This could result in a reversal from the legislators’ initial perspective. When this happens, the advocate has found the correct formula and process. Leveraging the media to your advantage is also an excellent way to implement advocacy work. The easiest way to begin this process is to locate a reporter who covers issues focusing on health care, education, or whatever area meets your advocacy needs. Determine what the reporter wants and is looking for and create a spin on the issues based on your need. It is important to develop a tip sheet with the issues at hand. Develop a reciprocal, long-term relationship with the reporter that is based on trust, where you become the most valuable go-to resource for information. The media is your biggest friend in the advocacy process. Building exposure tells the story that needs to be told. Contacting the media to gain or maintain visibility is crucial to this process. It is important to develop a media plan that includes a calendar of events, a list of potential sources and contacts, as well as a newsworthy story. Some key factors to consider when developing the story are the angle, the timing, the uniqueness, and the broad audience appeal.

Resources Advocates do not need to feel as if they do not know where to start. Utilize ASHA resources (ASHA, 2019a). ASHA has a team of government affairs and public policy professionals who can assist with advocacy planning and advocacy needs. In addition, examine ASHA’s e-advocacy tool (ASHA, 2019b), which helps with developing advocacy messages and sending an email blast as well as getting assistance from ASHA state liaisons to create legislative and regulatory messages to member advocates.

Summary Politics, policy, and advocacy shape our daily lives and future in fundamental ways. Without them, our professions would not be positioned where they are today. This chapter addressed the nomenclature used in helping to understand advocacy and the benefits of being an advocate. It presented a practical approach to the advocacy process including how to develop a plan of action, establish a grassroots advocacy network, work with the legislature, negotiate, and leverage the media, and offered some available resources to aid in the advocacy process. There are many advocacy opportunities. It takes work, but the knowledge that your efforts may contribute to positive changes for the patients/clients/students and families you serve can be extremely rewarding. The number of members in the speech-language pathology and audiology professions along with those entering our fields can make a difference when their collective voices are heard. Examples noted in the chapter prove there is power in numbers and thereby power in advocacy.

References American Speech Language-Hearing Association. (n.d.). ASHA state-by-state. http://www.asha.org/ Advocacy/state/ American Speech-Language-Hearing Association. (2019a). Advocacy. https://www.asha.org/advocacy/ American Speech-Language-Hearing Association. (2019b). ASHA take action. https://www.asha.org/ advocacy/takeaction/ American Speech-Language-Hearing Association. (2023a). ASHA public policy agenda. https://www​ .asha.org/siteassets/advocacy/2023-asha-publicpolicy-agenda.pdf American Speech-Language-Hearing Association. (2023b). Code of ethics. https://www.asha.org/ policy/et2016-00342/ Gardner, A., & Brindis, C. (2017). Advocacy and policy change evaluation: Theory and practice. Stanford Business Books. H. R. 2015, 105th Cong., Balanced Budget Act of 1997 (1997). https://www.congress.gov/bill/105thcongress/house-bill/2015 Jones-McNamara. (2001). Legislation to create SLP Medicare independent practitioner status introduced in Senate. Perspectives in Administration and Supervision, 11(3), 25.



Regan, J. (2018, February 9). Congress repeals Medicare therapy caps and lifts limits on speechgenerating devices. ASHA Leader Live. https:// leader.pubs.asha.org/do/10.1044/congress-repealsmedicare-therapy-caps-and-lifts-limits-on-speechgenerating-devices/full/

CHAPTER 25   Advocacy

Shell, R., & Moussa, M. (2007). The art of woo: Using strategic persuasion to sell your ideas. Penguin Books.

515

Index

Note:  Page numbers in bold reference non-text material.

A AAA. See American Academy of Audiology AAC. See Augmentative and alternative communication AAO-HNS. See American Academy of Otolaryngology-Head and Neck Surgery AAPMs. See Advanced Alternative Payment Models AAS. See American Auditory Society ABA. See American Board of Audiology Abandonment of child, 387 of elderly, 397, 402 ABAs. See Applied behavioral analysts ABRs. See Auditory brain stem responses Abuse. See Child abuse and neglect; Elder abuse; specific form of abuse ACA. See Affordable Care Act Academia ethical issues in, 53 salaries in, 126 Academy for Doctors of Audiology, 10 Academy Founders, 11 Academy of Dispensing Audiologists, 12, 20–21, 52 Academy of Doctors of Audiology Board of Directors, 54 bylaws of, 49 Code of Ethics, 48–49, 52 unethical complaint process, 54

Academy of Neurologic Communication Disorders and Sciences, 21, 39, 311 ACAE. See Accreditation Commission for Audiology Education Accommodation, of interpersonal conflict, 497 Accountability learning health systems and, 58–59 overview of, 57 risk management and, 57–58 value equation, 58 Accountable care, 57 Accountable care organizations, 58, 208 Accreditation Council on Academic Accreditation, 18 definition of, 34 health care agencies for, 360 of institutions of higher education, 40–41 quality assurance through, 73–74 standards of, 18–19 Accreditation Commission for Audiology Education, 18–19, 41 Accreditation Council for Graduate Medical Examination, 65 ACGME. See Accreditation Council for Graduate Medical Examination ACOM. See Aphasia Communication Outcome Measure ACOs. See Accountable care organizations 517

Acoustical Society of America, 21 Acronyms, 364 Action verbs, 129 Active learning, 450 Active listening, 264, 345, 452 Active shooters, 361, 500 Acute care hospitals, 214, 215 ADA. See Academy of Dispensing Audiologists; Academy of Doctors of Audiology; Americans with Disabilities Act ADR. See Alternative dispute resolution Adult Protective Services, 405 Advanced Alternative Payment Models, 208 Advanced certification, 39 Advanced practice nursing, 230 Advancement, career, 163 Advocacy action plan for, 512–513 affiliation benefits, 10 for audiology services, 511–512 career building uses of, 162 case examples of, 511–512 in consumers and their significant others, 315–316 for culturally and linguistically diverse populations, 434–435 E-advocacy, 514 in educators, 316–317 importance of, 509–510 legislative, 317, 511, 513–514 local, 162 media leveraging for, 514 nomenclature associated with, 510



518

INDEX

Advocacy  (continued) for patients, 511 for professions, 511–512 for public policy changes at national level, 512 resources for, 514 in schools, 248–249 for speech-language pathology services, 313–317, 511–512 for students, 511 in students, 316–317 Advocate benefits of being, 510–511 decision makers educated by, 510–511 definition of, 510 negotiation by, 514 Affordable Care Act, 206–208, 228–229 A.G. Bell Academy for Listening and Spoken Language, 39 Agency for Healthcare Research and Quality, 104 Aggressive communication, 154 Aging population, 6–7, 127, 309, 396 AI. See Artificial intelligence Aides, 200 AIHC. See American Interprofessional Health Collaborative ALA. See Assessment of Living With Aphasia Alternate forms reliability, 105 Alternative dispute resolution, 498 Alternative Payment Models, 208 American Academy of Audiology advanced certifications from, 39 affiliate members of, 18 audiology assistants membership of, 18 position statement, 175 Board of Directors, 20 bylaws of, 17 Code of Ethics appeals for violation of, 56 confidentiality in, 51 delegating service provision to trainees, 52 description of, 18, 48–49 documentation, 330 familiarization with, 152 informed consent in, 51

sanctions for violations of, 55–56 support personnel supervision, 174 continuing education requirement of, 27 COVID-19 resources from, 24 credentialing program of, 37 Ethical Practices Committee of, 54 fellows of, 18 governance structure of, 20 HearCareers, 127 history of, 11–12 maintenance of membership in, 18 membership in, 18 national office of, 20 student membership in, 18 Taskforce on Supervision, 447 unethical practice complaint process of, 54 vision of, 16–17 American Academy of Otolaryngology-Head and Neck Surgery, 175 American Academy of Speech Correction, 11 American Audiology Board of Intraoperative Monitoring, 39 American Auditory Society, 21 American Board of Audiology certification from, 19 Pediatric Audiology Specialty Certification, 19 preceptor requirements, 461 American Board of Child Language and Language Disorders, 39 American Board of Fluency and Fluency Disorders, 39 American Board of Swallowing and Swallowing Disorders, 39 American Council on Education Center for Internationalization and Global Engagement, 72 American Interprofessional Health Collaborative, 381 American Speech-LanguageHearing Association Ad Hoc Committee on Professional Education, 12

Ad Hoc Committee on Supervision, 446, 461 advocacy resources of, 435, 514 ASHA’s Envisioned Future: 2025, 64, 69 assistants training guidance, 184 training guidelines, 180–181 Board of Directors, 20, 47 Board of Ethics, 47–48, 53–54 Career Portal of, 127, 145 certification from accreditation of, 36 for audiologists, 446–447 external accreditation of, 36 history of, 36 maintenance standards, 152 source of standards for, 461 state licensure and, 37 updating of, 446 certified membership in, 17 Code of Ethics advocacy in, 510 appeals for violations of, 56 certification requirements, 457–458 confidentiality, 51, 368 conflict of interest, 47 cultural diversity, 293 documentation, 51, 330, 331 evidence-based judgment, 118 familiarization with, 152 history of, 48 impaired practitioners, 51 informed consent, 51 practice settings, 238 principles of ethics, 48 professional self-disclosure, 55 purpose of, 47, 292 referrals, 51 revisions to, 48 sanctions for violations of, 55 stress, 493–494 technology, 485 vendor relationships, 50 Continuing Education Board of, 39 continuing education requirement of, 27, 39 Council for Clinical Certification in Audiology and Speech-Language Pathology, 19, 183, 447, 520



INDEX

COVID-19 resources, 24 definition of, 123 demographic profile of, 424–426, 425 Educational Testing Service partnership with, 19 employment membership and affiliation data regarding, 124–126 salaries, 125–126 settings for, 285 statistics regarding, 285 ethics education resources, 56 Evidence Maps, 103, 116 governance structure of, 20 graduate school membership in, 17 Healthy Communication and Popular Technology Initiative, 485 history of, 12 infection control resources, 365, 365 international alliances 2017 Agreement of Mutual Recognition of Professional Association Credentials, 71 Pan American Health Organization, 22–23, 69, 71 scopes of practice, 67–68 international alliances through, 70–71 International Issues Board, 23, 69 interprofessional education, 379–380 Interprofessional Educational Collaborative, 68 life membership in, 17 members/membership demographic profile of, 424–426, 425 description of, 17–18, 124, 238, 380 Minority Student Leadership Program, 10 multicultural constituency groups of, 434, 436 multilingual service providers, 424 national office of, 20 Office of Multicultural Affairs, 13

over-the-counter hearing aid resources, 25–26 Pan American Health Organization and, 22–23, 69, 71 Practice Portal of, 160, 471 Professional Assessment of Contributions and Effectiveness of SpeechLanguage Pathologists, 249 publications of, 145 Quality of Communication Life Scale, 222 research funding, 85 scope of practice, 67–68, 181, 422, 456 Special Interest Groups of, 16, 71, 161–162, 354 Strategic Pathway to Excellence, 16, 22, 64, 69, 127 supervision guidance from, 226, 446 support personnel, 170 Take Action Advocacy webpage of, 162 telehealth resources, 24 unethical practice complaint process of, 53–54 vision statement of, 42 website of, 145 Americans with Disabilities Act description of, 313 highlights of, 240 history of, 13 American Telemedicine Association, 471 Amplification and augmentative communication, 4 ANCDS. See Academy of Neurologic Communication Disorders and Sciences Anderson’s Continuum of Supervision, 448–449, 449 ANSD. See Auditory neuropathy spectrum disorder Anxiety disorder, 495 Aphasia Communication Outcome Measure, 222 APMs. See Alternative Payment Models Apple II, 15 Apple Watch, 15 Applied behavioral analysts, 25

Apps, digital, 475, 478–479 APS. See Adult Protective Services AR. See Augmented reality ARC. See Association for Retarded Citizens ARPAnet, 14 Artificial intelligence, 4, 59 ASA. See Acoustical Society of America ASD. See Autism spectrum disorder ASHA. See American SpeechLanguage-Hearing Association ASHA-PAHO alliance, 71 ASHA’s Envisioned Future: 2025, 64, 69 ASLP-IC. See Audiology and Speech-Language Pathology Interstate Compact Assertive communication, 154–155 Assessment diagnostic accuracy of, 106–109, 107–109 purposes of, 104 reliability of, 104–106 technology used in, 473, 475–479 validity of, 106 Assessment-based certificate program, 35 Assessment evidence applications of, 109–111 diagnostic accuracy of, 106–109, 107–109 evaluation of, 104–109 reliability of, 104–106 standardized test evaluated using, 110–111 technology evaluations using, 111 validity of, 106 Assessment of Living With Aphasia, 222 Assistants, 167–200. See also Support personnel American Speech-LanguageHearing Association affiliation category for, 170 in audiology. See Audiology assistants certification of, 183, 248 challenges associated with, 170 classroom team use of, 169 credentialing of, 167, 183

519



520

INDEX

Assistants  (continued) definition of, 200 educational requirements for, 178–179 effectiveness of, 188–190 employment of settings for, 175 trends in, 179–180 ethical practice policies associated with, 171–173, 173–174 interpreters, 169, 200, 433 multilingual, 170 national standard for, 170 overview of, 167–168 payment of services provided by, 185–186 professional policies and practices chronology of, 171–173 evolution of, 171–172 rationale for using, 168 roles and responsibilities of, 168–170 in schools, 170, 248 in speech-language pathology. See Speech-language pathology assistants supervision of, 179, 183–185 in telepractice, 168–169 training for, 180–183 translators, 169, 200, 433 Assistive Technologies Act, 14 Assistive technology cochlear implants. See Cochlear implants definition of, 479 hearing aids. See Hearing aids hearing assistive technology systems, 480 Association for Retarded Citizens, 13 Associations. See also specific association professional. See Professional associations state, 21–22, 161 Asynchronous telepractice, 200, 470 AT. See Assistive technology ATA. See American Telemedicine Association At-risk practitioners, 51–52 Attire, for job interview, 132 Atypical development, 268

AuD. See Doctor of Audiology Audiological diagnostic testing, 339, 339–340 Audiologists American Academy of Audiology credentialing of, 37 assistants and, studies comparing treatment outcomes between, 187 certifications for, 455 in early intervention, 257–258, 260 employment outlook for, 6 externship for, 455–456 goal of, 7 salaries of, 6, 125 in schools. See School(s), audiologists in supervising, 184–185 Audiology disability rights movement influences on, 13 entry-level education requirements in, 230–231 recent changes in, 25–26 social reform influences on, 13–14 technological influences on, 14–15 trends in, 16 World War II influences on, 12–13 Audiology and Speech-Language Pathology Interstate Compact, 25, 27, 38, 210 Audiology assistants American Academy of Audiology membership of, 18 certification of, 248 credentialing of, 167, 183 delegated tasks, 185 effectiveness of, 188–190, 190 employment of, 179–180 ethical practice policies for, 171–173, 173–174 job responsibilities of, 185 professional practice policies for, 171–173, 173–178 in schools, 248 studies involving, 186–190 supervision of, 184 training of, 180–181 Audiology Foundation of America, 12

Audit, 289 Auditory brain stem responses, 473 Auditory neuropathy spectrum disorder, 26 Augmentative and alternative communication, 160, 205, 247, 475, 478 Augmented reality, 475 Autism definition of, 244 intervention evidence application example, 115–117 Autism spectrum disorder, 25 Autonomy, 227

B Background checks, 361–362 Bacterial meningitis, 26 Bad energy, 157 Behavioral management, 363 Bell Telephone Labs, 14 Benefits, employment business partnerships, 141 continuing education reimbursement, 141 description of, 138–139 educational assistance programs, 141 employee assistance programs, 141 health care insurance, 139 licensure reimbursement, 141 paid time off, 140 parking, 141 professional fees, 141 retirement, 140 time off, 140 Best practices international alliances that promote exchange of, 82 in remote service delivery, 278 Bilingual Education Act, 433 Bilingual populations. See also Culturally and linguistically diverse populations COVID-19 pandemic effects on, 434 culturally and linguistically responsiveness assessment strategy for, 430 data regarding, 430



description of, 7 education for, 433–434 growth of, 309 interpreters/translators for, 169, 200, 433 language attrition in, 428–429 language characteristics of, 427–429 language environments of, 431 language proficiency of, 430 Billing, 297 Bitsboard, 479 Blinding, 113–114 Blogs, 475, 478 Board-certified specialist, 19 Boardmaker, 475 Board of Directors, 12, 17, 20 Bonuses, 125, 140 BOSS. See Burden of Stroke Scale Boundary setting, 276 Bring your own device, 483 Burden of Stroke Scale, 222 Bureau of Labor Statistics, 6, 127 Burnout definition of, 156, 494 risks for experiencing, 494–496 signs and symptoms of, 495–496 strategies for, 157–158 stress and, 156 symptoms of, 156 Business licenses, 292 Business partnerships, 141 Business plan, 289–291, 290 Bylaws, 17

C CAA. See Council on Academic Accreditation Campbell Collaboration, 104 Cancer hospitals, 214 CAOHC. See Council for Accreditation in Occupational Hearing Conservation CAPCSD. See Council of Academic Programs in Communication Sciences and Disorders CAPTA. See Child Abuse Prevention and Treatment Act Career advancement, 163

INDEX

Career building advocacy for, 162 burnout, 156–158 code of ethics, 152 continuing education for, 162–163 curiosity, 159–160 emotional intelligence, 153, 155–156 employment changes, 163–164 financial considerations, 164 imposter syndrome, 158–160 mentoring, 153–154 networking for, 161–162 organization skills, 150–152 procrastination effects on, 151 professional associations for, 160–161 professional engagement and responsibilities, 160–163 promotion, 163 roles and responsibilities, 149–150 routines, 151 teamwork for, 158–159 Career map, 158 Career path, 152–153 Career readiness competencies, 65 Care extenders caregivers as, 318 definition of, 317 family members, 318 graduate students, 317–318 support personnel. See Support personnel trained volunteers, 318 Caregivers, 318 CARF. See Commission on Accreditation of Rehabilitation Facilities Carryover, 479 Case-control studies, 113 Caseloads ethical dilemmas regarding, 53 paperwork burdens associated with, 5–6 CCC. See Certificate of Clinical Competence CCC-A. See Certificate of Clinical Competence in Audiology CCC-SLP. See Certificate of Clinical Competence in SLP CCSC. See Committee on Clinical Specialty Certification

CCSPA. See Council of University Supervisors in SpeechLanguage Pathology and Audiology CDC. See Centers for Disease Control and Prevention CEC. See Council for Exceptional Children CEFL-5. See Clinical Evaluation of Language Fundamentals — ​ Fifth Edition Centers for Disease Control and Prevention, 23–24, 220, 365, 399 Certificate of Clinical Competence academic preparation requirement of, 36 clinical fellowship requirement of, 36 description of, 123 education requirement, 36 elements necessary for, 36 history of, 35 maintenance of, 152 mentoring requirement, 36 requirements for, 36 revocation of, 368 supervision after earning, 456 suspension of, 368 Certificate of Clinical Competence in Audiology, 19, 68 Certificate of Clinical Competence in SLP, 17, 67, 238 Certification. See also specific certification advanced, 39 American Board of Audiology, 19 American Speech-LanguageHearing Association. See American SpeechLanguage-Hearing Association, certification from assessment-based program for, 35 board-certified specialist, 19 characteristics of, 34 continuing education requirements for, 162 definition of, 34 maintenance of, 38–39, 152 national requirements, 42–43 for private practice, 292

521



522

INDEX

Certification  (continued) purpose of, 34–35 on resumé, 129 specialty, 19–20 speech-language pathology assistant, 182 standards of, 19 CEUs. See Continuing education units CF. See Clinical Fellowship CFCC. See Council for Clinical Certification in Audiology and Speech-Language Pathology CHEA. See Council for Higher Education Accreditation; Council of Higher Education Accreditation Child abuse and neglect abuser characteristics, 391 case studies of, 416–417 causes of, 389–391, 390 of children with disabilities, 389–390 continuum of, 388–389 definition of, 385, 392 effects of, 393–394 emotional abuse, 386, 391–392 extent of, 393 fatalities caused by, 390–391 financial costs of, 393 indicators of, 388 mandated reporter of, 394–395 Munchausen by proxy as risk factor for, 391 parental age and, 389 parental substance abuse as, 386 physical abuse, 386, 392 reporting of, 276–277, 394–396 resources for, 395, 413–414 risks for, 389–391, 390 sexual abuse, 388, 392 signs and signals of, 392–393, 394 societal consequences of, 393–394 suspicions about, 394 victims of, 393 website resources for, 414–415 Child Abuse Prevention and Treatment Act, 385 Child maltreatment and neglect, 387, 388 Child Protective Services, 277, 386

Children’s Bureau, 393 Children’s Health Insurance Program, 206, 313 Childwelfare.Gov, 386 CHIP. See Children’s Health Insurance Program Chronological resumé, 128 CHWs. See Community health workers CI. See Cochlear implants CISA. See Cybersecurity and Infrastructure Security Agency Citizen advocacy, 510 Classical test theory approach, 106 Classroom teams, 169 Clean Slate law, 361 Client information authorization to release, 367 confidentiality of, 366–369, 367 privacy of, 366 Clinical documentation. See Documentation, clinical Clinical educator, 446 Clinical Evaluation of Language Fundamentals — Fifth Edition, 473 Clinical expertise, in evidencebased practice, 102 Clinical fellowship, 36, 445–446, 454–455, 484 Clinical perspectives, in evidencebased practice, 102 Clinical practice. See also Professional practice ethical issues in management of, 49–52 evidence-based approach to, 101 Clinical record, 333 Clinical research, 315 Clinical service provider, 125 Clinical simulation, 229–230 Cloud computing, 482 COA. See Council on Accreditation Coaching models, for early intervention, 274–275, 275 Coalition for Global Hearing Health, 23 Cochlear implants candidacy for, 26 description of, 14, 479–480 in infants with hearing loss from bacterial meningitis, 26

off-label use of, 26 Cochrane Library, 103 Code of Ethics Academy of Doctors of Audiology, 48–49, 52 American Academy of Audiology appeals for violation of, 56 confidentiality in, 51 delegating service provision to trainees, 52 description of, 18, 48–49 documentation, 330 familiarization with, 152 informed consent, 51 informed consent in, 51 sanctions for violations of, 55–56 support personnel supervision, 174 American Speech-LanguageHearing Association advocacy in, 510 appeals for violations of, 56 certification requirements, 457–458 confidentiality, 51, 368 conflict of interest, 47 cultural diversity, 293 documentation, 51, 330, 331 evidence-based judgment, 118 familiarization with, 152 history of, 48 impaired practitioners, 51 informed consent, 51 practice settings, 238 principles of ethics, 48 professional self-disclosure, 55 purpose of, 47, 292 referrals, 51 revisions to, 48 sanctions for violations of, 55 stress, 493–494 support personnel supervision, 174 technology, 485 vendor relationships, 50 in career building, 152 definition of, 152, 292 purpose of, 457 Code switching, 428 Coding systems, 205–206, 297, 310, 333, 338 Cognitive aging, 397 Cohort studies, 113



COIL. See Collaborative online international learning Collaborations with Community Constituents, 435 Collaborative online international learning, 74, 76 Colleges employment resources, 145 faculty salaries in, 126 international alliances and attributes of high-quality programs offered through, 72–81 programs, 11 Combat-related hearing loss, 12–13 Commission on Accreditation of Rehabilitation Facilities, 360 Committee on Clinical Specialty Certification, 40 Communication aggressive, 154 assertive, 154–155 errors in, 378–379 interpersonal conflict resolved through, 498–499 passive, 154–155 passive-aggressive, 155 professional, 154–155 supervision affected by, 451–452 Communication sciences and disorders assessment of, 430 continuing education in, 225, 316 early identification of, 430 faculty shortage in, 126–127, 163 focus of interventions, 58 health literacy affected by, 228 interprofessional education in, 381 intervention for, 431–432 PhD shortages in, 126–127, 163 in prison populations, 309 research. See Research social consequences of, 310 virtual simulations in, 473, 475 Communicative Participation Item Bank, 222 Community health workers, 168–169, 186, 188 Community hospital, 214

INDEX

Compassion fatigue, 494 Competencies career readiness, 65 cultural, 262–263, 293 global engagement, 96–97 international alliance, 64–65 transferable professional, 65, 91 Competencies Proficiency Scale, 34–35, 35 Competition, in interpersonal conflict, 497 Comprehensive Addiction and Recovery Act of 2016, 385 Computers, 14, 369 Conceptual frameworks, 15–16 Confidentiality in ASHA Code of Ethics, 51 of client information, 366–369, 367 of clinical documentation, 330–331 Family Educational Rights and Privacy Act protections, 330–331, 332 Health Insurance Portability and Accountability Act protections, 330–331, 332 Conflict in leadership, 349–351 problem-solving model for, 350–351 in workplace defining of, 496 management strategies for, 498–499 reasons for, 497 sources of, 496, 497 strategies for addressing, 496–498 stress caused by, 496 Conflicts of interest, 45–47 Connecticut Asylum for the Education and Instruction of Deaf and Dumb Persons, 13 Consolidated Appropriations Act of 2023, 210 Constant Therapy, 478, 479 Constructive feedback, 159 Consumer groups, 317 Consumers advocacy among, 315–316 clinical documentation purposes for, 323–324

Continuing education advocacy through, 314 American Speech-LanguageHearing Association requirement for, 39 in career building, 162–163 for certification, 162 description of, 314 employer coverage of costs for, 141 in health care settings, 224–225 importance of, 43 for licensure, 27, 162 requirements for, 27, 162–163 on resumé, 129 in supervision, 461 Continuing education units, 38–39 Continuing professional development, 224–225 Convergent criterion-related validity, 106 Convergent-related validity, 106 Coping with stress, 493, 500–504 Core Competencies for Interprofessional Collaborative Practice, 462 CORE Model of Supervision and Mentoring, 451 Coronavirus Aid, Relief, and Economic Security Act, 210 Corporation, 288, 289 Correlation, 105 Council for Accreditation in Occupational Hearing Conservation, 175, 181 Council for Clinical Certification, 36, 484 standards of, 17 Council for Clinical Certification in Audiology and SpeechLanguage Pathology, 19, 170, 183, 447, 461 Council for Exceptional Children, 21, 171 Council for Higher Education Accreditation, 73 Council of Academic Programs in Communication Sciences and Disorders, 21, 126, 229, 460 Council of Higher Education Accreditation, 40–41

523



524

INDEX

Council of University Supervisors in Speech-Language Pathology and Audiology, 446 Council on Academic Accreditation accreditation from, 18 description of, 18, 36, 41 perceived conflicts of interest, 46 standards of, 454 Council on Accreditation, 360 Cover letter, 130 COVID-19 pandemic American Academy of Audiology resources on, 24 American Speech-LanguageHearing Association resources on, 24 Audiology and Speech-Language Pathology Interstate Compact, 25, 27, 38, 210 bilingual population affected by, 434 Centers for Disease Control and Prevention, 23–24 description of, 3 early intervention programs affected by, 277 e-mentoring during, 484 e-supervision during, 484 Guidelines for Conducting Education Abroad during COVID-19, 74 health care delivery affected by, 220–221 health care workers affected by, 492 inflation after, 6 international alliances and, 66 origins of, 23 personal protective equipment during, 220 professions affected by, 23–24 quiet quitting during, 499 remote technology and, 56 state shutdowns secondary to, 24 stress caused by, 492 telehealth in, 24–25, 210, 231 telepractice during, 37, 168, 247, 319, 470–473 U.S. population affected by, 7 CPIB. See Communicative Participation Item Bank CPS. See Child Protective Services

CPT. See Current Procedural Terminology Creative thinking, 347 Creative writing, 325 Credentials/credentialing accreditation of, 36 from American Academy of Audiology, 37 of audiology assistants, 167, 183 certification, 35–36 definition of, 34 examination for, 37 familiarizing yourself with, 150 initials indicating, 33 maintenance of, 42–43 for private practice, 292–293 programs for, 35–36 public education, 38 requirements for, 33–34 specialized areas of practice, 39–40 of speech-language pathology assistants, 183 terms associated with, 34 Criminal background checks, 361–362 Crisis response procedures, 74 Criterion-related validity, 106, 110 Cronbach’s alpha, 105 Cross-language interference and transfer, 429 CSDs. See Communication sciences and disorders Cultural and linguistic responsiveness, 262 Cultural broker, 200 Cultural competence, 256, 262–263, 293, 429 Cultural competencies, 75–76 Cultural Connections in Senegal program, 79 Cultural differences, 264, 426–427 Cultural diversity, 92, 293 Cultural humility, 429 Culturally and linguistically diverse populations. See also Bilingual populations advocacy for, 434–435 Collaborations with Community Constituents, 435 cultural differences, 426–427 decision-making involvement by, 434–435 definition of, 426

description of, 421–422 graduate programs for, 435–436 language, 427–429. See also Language leadership roles in, 434–435 learnability, 431 LGBTQIA+ community, 426–427 mentoring for, 435 nonverbal processing skills, 431 overview of, 421–422 service delivery for assessment and diagnosis, 430–431 barriers to, 432–434 functional skills in both languages, 430–431 general knowledge, 430–431 intervention, 431–432 systems-level inequities, 432–434 verbal processing skills, 431 Culturally and linguistically responsiveness services, 262–265 Cultural responsiveness definition of, 263, 429 in early intervention, 263 in global engagement, 69 in global practices, 67–68, 81 for global workforce, 69–70 in graduate education curriculum, 435–436 promotion of, 64–67 by speech-language pathology assistants, 177–178 standards of practice and, 69 Culture, 262–263, 426 Curiosity, 159–160 Current Procedural Terminology, 206, 297, 333, 338 Curriculum vitae, 128 Cybersecurity and Infrastructure Security Agency, 359 Cynicism, 494 Cytomegalovirus, 26

D Data mining, 114 Deaf-blindness, 244 Deaf community, 427 Deafness, 244 Decision makers, advocacy for, 510–511



Decision-making capacity, in elderly, 397–398 Dedicated education units, 229 Deescalation, 363 Defined contribution pension plans, 140 DEI. See Diversity, equity, inclusion Dementia, 190, 404 Demographic trends, 6–7 Denial, of interpersonal conflict, 497 Department of Homeland Security, 359, 424 Department of Labor statistics, 3 Dependability, 346 Depression, 495 DEUs. See Dedicated education units Developmental delay, 244, 268 Developmental Disabilities Assistance and Bill of Rights Act, 13 Developmental language disorder, 248–249 DHS. See Department of Homeland Security Diagnosis in culturally and linguistically diverse populations, 430–431 decisions involved in, 104 Digital apps, 475, 478–479 Digital games, 480, 486 Digital immigrants, 469 Digital natives, 469 Digital revolution, 4–5, 469–470 Digital transformation, 482, 483 Digital Transformation in Higher Education, 482 Digital Twin, 4 Direct supervision, 200 Disability rights movement, 13–14 Discharge note, 339 Discharge summary, 328–329 Dismissal of patients, 50 Distance supervision, 460 Divergent criterion-related validity, 106 Diversity, equity, inclusion, 56, 152, 206 Diversity, population, 7 Division for Early Childhood, 278 DLD. See Developmental language disorder

INDEX

Doctorate education, 42, 127, 230–231 Doctor of Audiology, 12, 127 Documentation, clinical active voice in, 326 audience of, 324–325 audiological diagnostic testing, 339, 339–340 Code of Ethics requirements, 51 confidentiality of, 330–331 discharge note, 339 discharge summary, 328–329 electronic health records, 5, 325, 330, 369, 481 electronic medical records, 224, 294, 369, 479, 481 ethical considerations, 330, 331 evaluation note, 338 evaluation reports, 326–327 failure in, 379 in health care settings, 223, 223–224 health care settings influence on, 333, 339–340 influences on, 330 informing purpose of, 324–325 jargon in, 326 Medicare, 323, 333, 338–339 overview of, 323–324 passive voice in, 326 persuading purpose of, 324–325 planning of, 324–325 plan of care notes, 338 preemployment health screening, 365 principles of, 324–326 progress notes, 328, 339 purposes of, 323–325, 340 SOAP notes, 223–224, 224, 328, 329 technical writing style for, 325–326 treatment encounter note, 339 treatment plans, 327–328 types of, 326–330 writing of, 325–326 Dominance behaviors, 264 Dreyfus Model of Skill Acquisition, 445, 447–448 Dual degree program, 76, 79–80 Due process, 242 Duty of care, 348 Duty of fidelity to purpose, 349 Duty of loyalty, 348–349

Dysphagia acute care settings, 214, 215 culturally responsive practices, 81 definition of, 249 documentation of, 243 eating affected by, 432 instrumentation technology for diagnosing, 473 management of, 81 in postacute settings, 218 quality of life affected by, 432 self-assessment tools for, 222 telehealth for, 231

E E-advocacy, 514 EAPs. See Employee assistance programs Early Childhood Technical Assistance Center, 278 Early intervention for at-risk children, 269 for atypical development, 268 audiologists in, 257–258, 260 benefits of, 257 coaching models for, 274–275, 275 COVID-19 pandemic effects on, 277 cultural competence in, 262–263 definition of, 255 for developmental delay, 268 for diagnosed physical or mental condition, 268–269 eligibility determination for, 267–269 evidence supporting, 257 goal of, 257 guiding principles of, 258–275 comprehensive, coordinated, and team-based services, 266–273 culturally and linguistically responsive services, 262–265 developmentally supportive services in natural environment, 265–266, 270, 275–277, 276 family-centered services, 259–262, 261, 274

525



526

INDEX

Early intervention  (continued) highest quality of evidence for services, 274–275 in home visits, 265–266 Individualized Family Service Plan content, 334–335 interdisciplinary teams for, 273 multidisciplinary teams for, 273 in natural environment, 265–266, 270, 275–277, 276 overview of, 255–256 purpose of, 265 range of services, 257, 258 referral for, 266–267 remote service delivery in, 277–278 routines-based intervention, 274 sequence of, 267 service coordination for, 271, 272 speech-language pathologists in, 257–258, 259 summary of, 278 supports and services pathway of assessment, 269 definition of, 266 diagram of, 267 eligibility determination, 267–269 individualized family service plan, 269–270 intake, 267 referral, 266–267 transition, 270–271 team-based approach to, 271–273 telehealth in, 277–278 transdisciplinary teams for, 273 in unclean environment, 277, 277 “Eat the frog” technique, 151 EBP. See Evidence-based practice Economic trends, 6 Education. See also Continuing education bilingual, 433–434 Certificate of Clinical Competence requirement, 36 entry-level degree requirements, 230–231 failure to educate as child neglect, 387 inclusive practices in, 6

interprofessional, 316, 373, 379–381, 462 public, 38 of support personnel, 178–179 technology in, 6 trends in, 5–6 Educational assistance programs, 141 Educational Testing Service, 19, 37 Education for All Handicapped Children Act, 13, 240, 255–256 Educators, advocacy among, 316–317 Effectiveness studies, 113 Efficacy studies, 113 Efficiency, 345 EHRs. See Electronic health records EI. See Early intervention EIN. See Employer identification number Elder abuse abuser characteristics, 403 Adult Protective Services for, 405 case study of, 418 causes of, 403–404 decision-making ability and, 397–398 definition of, 396, 399 dementia as risk factor for, 404 financial, 397, 401, 402 five-step approach for, 405 forms of, 396–397 indicators of, 401–402 intervention for, 405–406, 406 in long-term care facilities, 399, 404 in nursing homes, 399 physical, 397, 401, 402 prevalence of, 398 prevention of, 404–405 psychological, 397, 401, 402 reporting of, 406–407 resources for, 413–414 risk factors for, 398–399, 400, 404 sexual, 401, 403 signs of, 399, 402–403 victim characteristics, 399 website resources for, 414–415 World Health Organization and definition, 399 strategy and action plan, 407

Elderly abuse of. See Elder abuse decision-making capacity of, 397–398 mistreatment/maltreatment of, 399, 403 neglect of, 397, 402, 402–403 self-neglect by, 397, 402 Electronic health records, 5, 325, 330, 369, 481 Electronic medical records, 224, 294, 369, 479, 481 Elementary and Secondary Education Act, 240, 249, 433 ELL. See English-Language Learners Email cover letter sent using, 130 phishing scams, 369 e-mentoring, 484 Emergency preparedness, 361 Emergency protocols, 74 Emergency response plan, 360 Emotional abuse of child, 386, 391–392 of elderly, 397, 401 Emotional disturbance, 244 Emotional intelligence, 153, 155–156 Emotional neglect, 386–387 Empathy, 155–156 Employee assistance programs, 141, 503 Employer continuing education opportunities from, 162 educating of, 316 information gathering on, 150 Employer identification number, 288 Employer offer decision-making considerations, 142–143 first contact regarding, 141–142 getting started after acceptance of, 143–144 negotiation of, 142 Employment aging population effects on, 127 American Speech-LanguageHearing Association data regarding, 124–125 of audiology assistants, 179–180



changing of, 163–164 characteristics of, 124–125 as clinical service provider, 125 cover letter, 130 factors that affect, 127 full-time, 124 interview for. See Interview job search for, 127–128 population factors, 127 relocation for, 164 resigning from, 164 resumé. See Resumé salaries, 125–126 settings for American Speech-LanguageHearing Association data regarding, 124 health care. See Health care settings private practice. See Private practice schools. See School(s); School settings of speech-language pathology assistants, 180 Employment benefits business partnerships, 141 continuing education reimbursement, 141 description of, 138–139 educational assistance programs, 141 employee assistance programs, 141 health care insurance, 139 licensure reimbursement, 141 paid time off, 140 parking, 141 professional fees, 141 retirement, 140 time off, 140 EMR. See Electronic medical records Endrew v. Douglas County School District, 240, 241 Energy, 157 English for Children Initiative, 433 English-language learners, 169, 239, 269 Entry-level education, 230–231 Environmental Protection Agency, 358–359 EPA. See Environmental Protection Agency

INDEX

EPO. See Exclusive provider organizations EQ. See Emotional intelligence Equity, 65 Ergonomic hazards, 362–363 Errors, 378–379 ESEA. See Elementary and Secondary Education Act ESLA. See European Speech and Language Therapy Association ESSA. See Every Student Succeeds Act e-supervision, 484. See also Telesupervision Ethics, professional in academia, 53 for assistants, 173–174 in clinical documentation, 330, 331 conflicts of interest, 45–47 delegating service provision to trainees, 52 dilemmas in, 10, 53 in documentation, 330 education on, 56 in private practice, 292–293 professional associations in, 47–49 professional communications, 49–52 standards of professional conduct, 45 in supervision, 52–53, 173–174 in technology, 485–486 unethical practice complaints Academy of Doctors of Audiology process, 54 American Academy of Audiology process for, 54 American Speech-LanguageHearing Association process for, 53–54 appeals for, 56 description of, 293 disclosure, 55 sanctions, 55–56 types of, 54–56 vendor relationships, 49–50 ETS. See Educational Testing Service Europe, international alliances in, 71–72 European Speech and Language Therapy Association, 23

Evaluation note, 338 Evaluation reports, 326–327 Every Student Succeeds Act, 240, 249 Evidence assessment. See Assessment evidence levels of, 111–113, 112 quality of, 113–115 Evidence-based medicine, 102 Evidence-based practice American Speech-LanguageHearing Association guiding principles for, 255 clinical expertise in, 102 clinical perspectives in, 102 components of, 102 definition of, 7 description of, 5 external scientific evidence in, 102 goal of, 102 history of, 16 process for guiding, 103 remote service delivery, 277–278 speech-language pathology services affected by, 311–312 EVP. See Evidence-based practice Exchange programs, 77–79 Exclusive provider organizations, 295–296 Exercise, 502 Expectations, 52–53, 346 External scientific evidence, in evidence-based practice, 102 Externship, audiologist, 455–456 Eye contact, 264

F Facial expressions, 264 Faculty engagement, 75 Faculty exchange programs, 82–83 Faculty-led study abroad programs, 76–77 Family. See also Parents culture effects on, 263 early intervention services focusing on, 259–262, 261, 274 elder abuse by, 403 rapport with, 262, 263 telepractice guidelines, 472–473

527



528

INDEX

Family Educational Rights and Privacy Act confidentiality protections under, 330–331, 332 description of, 366, 368, 481 educational record rights under, 243 permitted disclosures, 332 purpose of, 332 student school record access requirements under, 485–486 summary of, 332 Family members, as care extenders, 318 Family-systems model, 260 FAPE. See Free and appropriate public education FDA. See Food and Drug Administration Federal Bureau of Investigation, 500 Federal Communications Act, 14 Feedback constructive, 159 supervisory, 52–53, 452 Feedback behaviors, 264 Fee-for-service model, 58 FEES. See Flexible endoscopic evaluation of swallowing FERPA. See Family Educational Rights and Privacy Act Fidelity to purpose, 349 Fiduciary duty, 348–349 FIM. See Functional independence measure Financial aid, for graduate education programs, 41, 42 Financial exploitation, of elderly, 397, 401, 402 Financial recordkeeping, 289 “Fishbowl effect,” 363 Flexible endoscopic evaluation of swallowing, 14, 473 FM systems. See Frequency modulation systems Fogarty International Center, 85 Food and Drug Administration, 14, 25, 359 “Forbidden” interview questions, 137–138 Forum on Education Abroad, 74 401(k) plan, 140

“Fourfold planning,” 449 Framework for Global Engagement Competencies, 65–66 Fraternal organizations and sororities, 312 Free and appropriate public education, 240, 256 “Frenetic” workers, 494 Frequency modulation systems, 480 Fulbright program, 83–84 Functional Communication Measures, 222 Functional Independence Measure, 222 Functional resumé, 128 Fundraising, 312

G Gallaudet, Thomas H., 13 GDP. See Gross domestic product Generalization of skills, 479 Genomic medicine, 4 Gesturing, 264 GFTA-3. See Goldman-Fristoe Test of Articulation — Third Edition GHE. See Global health experience Global ambassador’s program, 69 Global competencies, 66, 75–76 Global engagement, competencies for, 96–97 Global health experience, 65 Global learning definition of, 92 online, 74 VALUE rubric for, 92–95 Global mentor network, 69 Global population, 6 Global practices, culturally responsive, 67–68, 81 Global research, 82–85 Global self-awareness, 92 Global supervisor’s network, 69 Global systems, 93 Goldman-Fristoe Test of Articulation — Third Edition, 473 Good energy, 157 Gore, Al, 429 Governance, of professional associations, 20 GRADE, 113

Grading of Recommendation, Assessment, Development, and Evaluation. See GRADE Graduate programs accreditation of, 40–41 for culturally and linguistically diverse populations, 435–436 financial aid for, 41, 42 scholarships for, 41, 42 for students from underrepresented backgrounds, 435–436 Graduate students, 317–318 Grassroots advocacy, 510 Grief, 409, 414, 419–420 Gross domestic product, 6 Group advocacy, 510 Guidelines for Conducting Education Abroad during COVID-19, 74

H Habilitation, 207 Habilitative services, 207 HATS. See Hearing assistive technology systems Hazards, workplace, 357, 362–364 HCA. See Hearing Conservation Amendment HCPCS. See Healthcare Common Procedures Coding System Head and neck cancer, 222 Health care accrediting agencies in, 360 artificial intelligence in, 4 costs associated with, 5, 228–229 COVID-19 pandemic effects on delivery of, 220–221 disparities in, 227–228 language access and, 433 legislation affecting Affordable Care Act, 206–208, 228–229 Medicare Access and CHIP Reauthorization Act, 208 patient-driven payment model, 208–209 reform in, 228–229 risks facing, 58 trends in, 5



Healthcare Common Procedures Coding System, 205–206, 333, 338 Health care insurance, 139 Healthcare Providers Service Organization, 292 Health care reimbursement coding systems, 205–206, 297, 310, 333, 338 description of, 5 Medicaid, 205 Medicare, 203–204 private health insurance, 205 Health care settings acute care hospitals, 214, 215 cancer hospitals, 214 characteristics of, 214 clinical documentation based on, 333, 339–340 clinical simulation application to, 229–230 community hospital, 214 continuing professional development, 224–225 dedicated education units, 229 documentation in, 223, 223–224, 333, 339–340 education for, trends in, 229–230 employment in, 124 errors in, 378–379 health disparities, 227–228 health status of patient considerations, 219 home care, 216, 218 hospice care, 217, 218 infection control in, 220 inpatient rehabilitation, 215 interprofessional responsibilities and competencies, 226–227 long-term acute care hospital, 214 measuring of change, progress, and outcomes in, 221–223 multicultural issues, 227–228 outpatient rehabilitation, 216, 218–219 overview of, 213–214 palliative care, 217 patient reported outcomes used in, 221, 222 pediatric specialty hospitals, 214 performance-based measurement tools, 221–223

INDEX

postacute, 214, 218 regulatory processes in, quality and compliance with, 226 rehabilitation hospitals, 214 rural hospital, 214 safety concerns, 219–220 salaries in, 125 skilled nursing facilities, 214, 216 standardized patients, 230 supervision in, 225–226 telehealth, 231 tertiary care hospitals, 214 Health disparities, 227–228, 432 Health information technologies, 5, 481 Health insurance audiology services offered by, 205 barriers to obtaining, 432–433 employment provision of, 139 health maintenance organizations, 295–296 lack of, 432–433 policy coverage inconsistencies in, 316 providers of, 294–296 speech-language pathology services offered by, 205 types of, 294–296 Health Insurance Portability and Accountability Act confidentiality protections, 330–331, 332 description of, 310 permitted disclosures, 332 privacy protections, 366, 368, 471, 485 Privacy Rule, 331 protected health information under, 331, 332, 471 purpose of, 332 summary of, 332 telepractice and, 471 Health literacy, 228, 379 Health maintenance organizations, 139, 295–296 Health status of patient, 219 HearCareers, 127 Hearing aids dispensing of, license for, 22 history of, 14, 479 over-the-counter, 25–26, 479 Hearing assistive technology systems, 480

Hearing Conservation Amendment, 184 Hearing Handicap Inventory for Adults, 222 Hearing impairment, 244 Hearing Industries Association, 26 Hearing Loss Association of America, 26 HEO. See Higher education organization HEPs. See Home exercise programs HHIE. See Hearing Handicap Inventory for Adults HIA. See Hearing Industries Association High-deductible insurance plans, 139 Higher education organization, 77 Higher Learning Commission, 40 High-Value Practice Initiative, 58 HIPAA. See Health Insurance Portability and Accountability Act HITs. See Health information technologies HLAA. See Hearing Loss Association of America HLC. See Higher Learning Commission HMOs. See Health maintenance organizations Home exercise programs, 479 Home health care growth of, 5 speech-language pathologists in, 126, 216, 218 telepractice, 318 Honig v. Doe, 241 Hospice care, 214, 217, 407–409 Hourly wages, 125 HPSO. See Healthcare Providers Service Organization Hudson v. Rowley, 241 Humility, 429 Hybrid cochlear implants, 26

I ICC. See Interagency Coordinating Council ICD-10. See International Classification of Disease, 10th Revision, Clinical Modification

529



530

INDEX

ICE. See Institute for Credentialing Excellence IDDSI. See International Dysphagia Diet Standardization Initiative IDEA. See Individuals with Disabilities Education Act IDEIA. See Individuals with Disabilities Education Improvement Act of 2004 IEP. See Individualized Education Program IEP Online, 481 IERASG. See International Evoked Response Audiometry Study Group IFSP. See Individualized Family Service Plan IHEs. See Institutions of higher education IHS. See International Hearing Society IIB. See International Issues Board Immigrants, 424 Impaired practitioners, 51–52 Implementation studies, 113 Imposter syndrome, 158–160 Imprecision, 115 Inclusion, 65 Inclusive practices, 6 Inconsistency, 114 Indirectness, 115 Indirect supervision, 200 Individualized Education Program components of, 337 description of, 241–242 local education agency viewing of, 243 technologies for, 481 Individualized Family Service Plan, 256, 269–270, 333, 334–336 Individuals with Disabilities Education Act definition of, 255, 331 disability categories, 244 early intervention services under, 331, 333 evaluation under, 243 highlights of, 240 Individualized Family Service Plan components, 333, 334–336

Part C of, 256–257, 333 Part H of, 256 passage of, 256 standardized testing, 243 terminology associated with, 245 Individuals with Disabilities Education Improvement Act of 2004 description of, 239–240, 255 disability determinations under, 249 early intervention services under. See Early intervention evaluation report, 324 free and appropriate public education provision of, 240, 249 highlights of, 240 least restrictive environment provision, 240–241 natural environments as defined by, 265, 270 Part C, 256–257, 258, 261–262, 265–273 Infection control, 220, 364–366, 365 Inflation, 6 Information processing conceptual framework, 15 Information technology, 309, 319 Informed consent, 51 Innovation, 347 Inpatient rehabilitation, 215 Insomnia, 501 Institute for Credentialing Excellence, 35 Institute for Health Care Improvement description of, 57 Triple Aim Measures, 57 Institute of Education Science, 103 Institutions of higher education, 40–41 Instrumentation technology, 473 Insurance, health care, 139 Intellectual disability, 244 Interagency Coordinating Council, 256 Interdisciplinary teams, for early intervention, 273 Interjudge reliability, 105 Internal Revenue Service, 288–289

International alliances American Speech-LanguageHearing Association 2017 Agreement of Mutual Recognition of Professional Association Credentials, 71 description of, 70–71 Pan American Health Organization, 22–23, 69, 71 scopes of practice, 67–68 best practices and, 82 colleges and universities, 72–81 competencies associated with, 64–65 definition of, 64 dual degree program, 79–80 engagement, 75 in Europe, 71–72 exchange programs, 77–79 faculty-led study abroad programs, 76–77 Fogarty International Center, 85 Fulbright program, 83–84 global competencies promoted by description of, 64–65 in scopes of practice, 67–68 global research for scholars promoted by, 82–85 health/medical organizations, 85 joint degree program, 79–80 macro international experiences promoted by, 81–82 Memorandum of Understanding checklist for, 99–100 on-site, 69–70 purpose of, 63–64 quality assurance, 73–75 research partnerships, 85 service learning, 80 strategic planning, 75 sustainable practices promoted by, 82 transparency of, 75–76 virtual, 70 International Association of Communication Sciences and Disorders, 23 International Classification of Disease, 10th Revision, Clinical Modification, 205–206, 333, 338



International Classification of Functioning, Disability, and Health, 68, 221–222, 430 International Dysphagia Diet Standardization Initiative, 81 International Evoked Response Audiometry Study Group, 23 International Hearing Society, 26 International Institute of Education, 74 International Issues Board, 23, 69 Internationalization in Action: International Partnerships, 64 International professional associations, 22–23 International Society of Audiology, 23 Internet electronic presence on, 127 job search using, 127 safety on, 369 Interpersonal conflict, 497–498 Interpreters, 169, 200, 433 Interprofessional collaborative practice, 25, 373–374, 381 Interprofessional education, 25, 316, 373, 379–381, 462, 485 Interprofessional Education Collaborative, 68, 381, 462 Interprofessionalism, 380 Interprofessional practice, 25, 373–379, 485 Interprofessional responsibilities and competencies, 226–227 Interprofessional teaming, 496 Intervention evidence application example of, 115–117 levels of, 111–113, 112, 114 quality of, 113–115, 114 Interview arriving at, 133 attire for, 132 beginning of, 133–134 end of, 135–136 flexibility in, 131, 134 follow-up after, 138 “forbidden” questions in, 137–138

INDEX

general appearance guidelines for, 132–133 greetings at, 133 items to bring to, 132–133 meal, 137 middle of, 134–135 questions in, 135–136, 137–138 red flags during, 143 resources for, 146 salary discussions, 138–139 second, 137 smartphone at, 132–133 STAR format used in, 134–135 telephone, 136–137 thank-you letter after, 138 virtual, 136 Intrajudge reliability, 105, 111 iPad, 15, 475 IPCP. See Interprofessional collaborative practice IPEC. See Interprofessional Education Collaborative iPhone, 15 IPP. See Interprofessional practice IQ, 155 IRS. See Internal Revenue Service ISA. See International Society of Audiology Item reliability, 105 Item response theory, 106

J JASA Express Letters, 21 Jerger, James, 11 Job interview. See Interview Job search for changing employment, 163–164 cover letter for, 130 description of, 127–128 financial considerations during, 164 letters of recommendation used in, 131 resumé for. See Resumé verbal references used in, 131 web-based applications used in, 130–131 Joint degree program, 76, 79–80 Journal of the Acoustical Society of America, 21

Justice for Victims of Trafficking Act, 385

K Knowledge application, 93 Kubler-Ross, Elizabeth, 407

L LAMP Words for Life language system, 478 Lancet, The, 72 Lancet commission, 72 Landro Play Analyzer, 460 Language attrition of, 428–429 in bilingual individuals, 427–429 code switching, 428 cross-language interference and transfer, 429 dialectal differences in, 433 differences in, 427 health care affected by access to, 433 second, communication strategies at beginning stage of learning, 428 translanguaging, 428 in United States, 422–424, 423 Language-based processing tasks, 431 Lau vs. Nichols, 433 LEA. See Local education agency Leader duty of care, 348 duty of fidelity to purpose, 349 duty of loyalty, 348–349 fiduciary responsibilities of, 348–349 goal of, 343 influencer role of, 344 mediator role of, 344 motivator role of, 344 organizer role of, 344 spokesperson role of, 344–345 Leadership characteristics of, 347–348 conflict in, 349–351 definition of, 343 pathways to, 351–354, 353 summary of, 354–355

531



532

INDEX

Leadership skills active listening, 345 dependability, 346 efficiency, 345 expectations, 346 hierarchy of, 346–347 innovation, 347 overview of, 345 prioritizing, 347 resource access, 345–346 sharing ideas, 346 timing, 346 Learnability, 431 Learn From Every Patient program, 59 Learning collaborative online international, 74 global. See Global learning online, 74, 483–484 virtual simulations for, 484–485 Learning health systems, 58–59 Learning management platforms, 482 Learning management systems, 75 Learning outcomes, quality assurance through, 74 Least restrictive environment, 6, 240–241 Legal liability, 287 Legislation. See also specific legislation health care Affordable Care Act, 206–208, 228–229 Medicare Access and CHIP Reauthorization Act, 208 patient-driven payment model, 208–209 special education services in schools affected by, 239–242, 240–241 Legislative advocacy, 317, 511, 513–514 Letters of recommendation, 131 LFEP program. See Learn From Every Patient program LGBTQIA+ community, 426–427 LHS. See Learning health systems Liability insurance, 292 License business, 292 definition of, 34 effects of, 27

Licensure for audiology, 22 continuing education requirements, 27, 162 definition of, 34 employer coverage of costs for, 141 for hearing aid dispensing, 22 on resumé, 129 state, 21–22, 37–38 Likelihood ratio, 109, 109 Limited liability company, 288 Limited liability partnership, 287–288, 289 Limited partnership, 287, 289 Listening, active, 264, 345, 452 Literacy, 314 LLC. See Limited liability company LLP. See Limited liability partnership LMS. See Learning management systems Local education agency, 243, 359 Long-term acute care hospital, 214 Long-term care facilities, 399, 404 Long-term stressors, 493 Lovaas, Ivar, 15 Loyalty, 348–349 LRE. See Least restrictive environment LTACH. See Long-term acute care hospital

M MACRA. See Medicare Access and CHIP Reauthorization Act MACs. See Medicare Administrative Contractors Maltreatment child, 387, 388 elder, 399, 403 Managed care organizations, 295 Mandated reporters, of child abuse and neglect, 394–395 MARC. See Mentoring Academic Research Careers Marginal students, 459 Marketing in private practice, 291 of speech-language pathology services, 314 Masks, 220 Massive open online courses, 483

Material exploitation, of elderly, 397, 401 MBSS. See Modified barium swallow studies MCO. See Managed care organizations M.D. Anderson Dysphagia Inventory, 222 MDADI. See M.D. Anderson Dysphagia Inventory Meal interviews, 137 Meal planning, 501 Medicaid assistant services, regulations for payment of, 186 clinical documentation requirements, 323 description of, 205, 294–295 hospice benefits, 408 reimbursement rates, 297 in schools, 243, 246 service coverage under, 205 telehealth services from, 24, 278 Medical liability insurance, 292 Medicare clinical notes, 333 codes, 333 description of, 203–204, 295 documentation requirements, 323, 333, 338–339 hospice benefits, 407 Part A, 333, 204 Part B, 204, 333 telehealth services, 24, 209–210 Medicare Access and CHIP Reauthorization Act, 208 Medicare administrative contractors, 204, 310 Medicare Audiologist Access and Services Act, 209 Memorandum of Agreement, 77, 99–100 Memorandum of Understanding, 76–78, 99–100 Mentor for clinical fellowship program, 455 supervisor transition to, 453–454 Mentoring career building through, 153–154 for Certificate of Clinical Competence, 36 for culturally and linguistically diverse populations, 435



e-mentoring, 484 future needs in, 462 history of, 445–447 shared responsibility as part of, 453–454 telesupervision for, 484 Mentoring Academic Research Careers, 70 Merit-based Incentive Payment System, 208 Meta-analyses, 112 Middle States Commission on Higher Education, 40 Mills v. B.O.E. (Board of Education), 241 Mindfulness, 503–504 Minority Student Leadership Program, 10 MIPS. See Merit-based Incentive Payment System Mission statement, 12, 16 MOA. See Memorandum of Agreement Modified barium swallow studies, 473 MOOCS. See Massive open online courses MOU. See Memorandum of Understanding MRA. See Mutual Recognition Agreement MSCHE. See Middle States Commission on Higher Education MSLP. See Minority Student Leadership Program MTSS. See Multitiered systems of support Multicultural constituency groups, 434, 436 Multicultural practice, 81 Multidisciplinary teams, for early intervention, 273 Multiple disabilities, 244 Multitiered systems of support, 246 Munchausen by proxy, 391 Mutual Recognition Agreement, 70

N N-95 respiratory masks, 220 NACE. See National Association of Colleges and Employers Napping, 502

INDEX

National Association of Colleges and Employers, 65 National Association of Teachers of Speech, 11 National Black Association for Speech-Language and Hearing, 21 National Center for Interprofessional Practice and Education, 381 National Center on Elder Abuse, 403 National Child Abuse and Neglect Data System, 386, 393 National Coalition on Personal Shortages in Special Education and Related Services, 27 National Commission for Credentialing Agencies, 36 National Commission for Quality Assurance, 360 National Council of State Board of Examiners, 37–38 National Council on Disability, 13 National Education Association, 11 National Federation of Independent Business v. Sebelius, 207 National Institute of Occupational Safety and Health, 369, 499 National Institute on Deafness and Other Communication Disorders, 85 National Institutes of Health Competencies Proficiency Scale, 34–35, 35 description of, 85 National Joint Committee on Learning Disabilities, 171 National Mental Health Foundation, 13 National office, 20 National Safety Council, 499–500 National Society for the Study and Correction of Speech Disorders, 11 National Student Speech Language Hearing Association, 22, 238, 352, 434 National Survey of Student Engagement, 78 Native language, 265 NATS. See National Association of Teachers of Speech

Natural environments, early intervention services in, 265–266, 270, 275–277, 276 NBASLH. See National Black Association for SpeechLanguage and Hearing NCANDS. See National Child Abuse and Neglect Data System NCCA. See National Commission for Credentialing Agencies NCPSSERS. See National Coalition on Personal Shortages in Special Education and Related Services NCQA. See National Commission for Quality Assurance NEA. See National Education Association NECHE. See New England Commission of Higher Education Negative likelihood ratio, 109, 109 Negative predictive power, 108, 108–109 Neglect causes of, 390 child, 392. See also Child abuse and neglect definition of, 387 elder, 397, 402, 402–403 emotional, 386–387 failure to educate as, 387 indicators of, 388 Negotiation, 514 Networking career building uses of, 161–162 in private practice, 298 social, 161 Neurodiversity, 426 Newborn hearing screening, 26, 473 New England Commission of Higher Education, 40 Newsom, Gavin, 24 NEXUS. See National Center for Interprofessional Practice and Education NIDCD. See National Institute on Deafness and Other Communication Disorders NIH. See National Institutes of Health

533



534

INDEX

NIOSH. See National Institute of Occupational Safety and Health NMHF. See National Mental Health Foundation No Child Left Behind Act, 239, 240 Noncompete clause, 286 Nonrandomized controlled trials, 112 Nonword repetition processing tasks, 431 NSC. See National Safety Council NSSE. See National Survey of Student Engagement NSSLHA. See National Student Speech Language Hearing Association Nursing homes, 399

O OAA. See Older Americans Act OAEs. See Otoacoustic emissions Observational studies, 113 Occupational Safety and Health Administration, 220, 358, 358, 369 Occupational stress, 493 OECD. See Organisation for Economic Co-operation and Development Office of Multicultural Affairs, 13 Older adults. See Elder abuse; Elderly Older Americans Act, 396 OMA. See Office of Multicultural Affairs On Death and Dying, 407 One-way exchange programs, 77–78 Online learning, 74, 483–484 On-site alliances, 69–70 Organisation for Economic Co-operation and Development, 75 Organization skills, 150–152 Orthopedic impairment, 244 OSHA. See Occupational Safety and Health Administration Other health impairment, 244 Otoacoustic emissions, 473 Otologic technicians, 170, 175, 184 Outcome events, 114

Outcome inconsistencies, 115 Outpatient rehabilitation, 216, 218–219 Outreach, 249–250 Over-the-counter hearing aids, 25–26, 479 Oxford Centre for Evidence-based Medicine, 111

P P2P collaborations. See Peer-topeer collaborations PACE. See Professional Assessment of Contributions and Effectiveness of SpeechLanguage Pathologists PAHO. See Pan American Health Organization Paid time off, 140 Palliative care, 217, 407–408 Pan American Health Organization, 22–23, 69, 71 Paralyzed Veterans of America, 13 PARC v. Pennsylvania, 241 Parents. See also Family as child abuser, 394 Munchausen by proxy, 391 substance abuse by, 386 Parking, 141 Parkinson’s disease, 222 Partnership, 287–288, 289 PASC. See Pediatric Audiology Specialty Certification Passive-aggressive communication style, 155 Passive communication, 154–155 Patient-centered medical homes, 208 Patient-driven payment model, 208–209 Patient Protection and Affordable Care Act. See Affordable Care Act Patient reported outcomes, 221, 222 Patient Self-Determination Act of 1990, 407 Payment model, 58 PCMHs. See Patient-centered medical homes Pediatric Audiology Specialty Certification, 19

Pediatric specialty hospitals, 214 Peer-to-peer collaborations, 482 Perceived conflicts of interest, 46 Perfectionism, 157–158 Performance appraisal, of supervisor, 461 Performance-based measurement tools, 221–223 Personal and social responsibility, 92 Personal computers, 14–15 Personality type, 150 Personalized health care, 481 Personal protective equipment, 220 Personal sound amplification products, 25 Personal space, 264 Perspective taking, 92 PhD degree description of, 230–231 shortage of, in communication sciences and disorders, 126–127 PHI. See Protected health information Phishing scams, 369 Physical abuse of child, 386, 392 of elderly, 397, 401 PICO question, 102–104, 110, 117 PL 111-148, 207 Plan of care notes, 338 Polyvictimization, 404 Population aging of, 6–7, 127, 309, 396 diversity of, 7 global, 6 in 19th century, 10 older adult. See Elderly in United States, 422 Positive likelihood ratio, 109, 109 Positive predictive power, 108, 108–109 PPE. See Personal protective equipment PPOs. See Preferred provider organizations PRAAT, 473 Praxis, 19 Preceptor, 19, 153–154, 453–454 Preemployment health screening documentation, 365



Preferred provider organizations, 139, 296 Prioritizing, 151, 347 Privacy of client information, 366, 368, 471 in telepractice, 471 in telesupervision, 484 Private health insurance, 205 Private practice advantages of, 286 billing by, 297 business licenses for, 292 business plan for, 289–291, 290 business structure of, 287–288 certifications for, 292 challenges associated with, 298, 298–299 corporation structure of, 288, 289 credentials for, 292–293 cultural competence in, 293 definition of, 285 direct services offered by, 287 disadvantages of, 286, 298 electronic medical records in, 294 ethics considerations, 292–293 financial considerations for, 286–287 financial recordkeeping in, 289 goals for, 286–287 insurance billing by exclusive provider organizations, 295–296 health maintenance organizations, 295–296 Medicaid, 294–295 Medicare, 295 preferred provider organizations, 296 private, 295 learning curve for, 298 liability insurance for, 292 limited liability company structure of, 288, 289 limited liability partnership structure of, 287–288, 289 limited partnership structure of, 287, 289 location of, 291 marketing strategy for, 291 motivations to start, 299 networking in, 298

INDEX

operating expenses of, 291 outcomes data for, 297–298 partnership structure of, 287–288, 289 payment for services in, 294–296 practice management software used in, 294 rates for services in, 296–297 resources needed for, 293–294 revenue fluctuations in, 286 revenue-to-cost ratio, 291 sole proprietorship structure of, 287, 289 speech-language pathologist’s role in, 287 staffing of, 293–294 start-up funds for, 293 state licensure for, 292 taxes in, 288–289 telepractice in, 291 unemployment insurance for, 292 Privileged communications, 395 Problem-solving model, for conflict, 350–351 Procrastination, 151–152, 346 Professional advocacy, 510 Professional Assessment of Contributions and Effectiveness of SpeechLanguage Pathologists, 249 Professional associations. See also specific association accreditation standards of, 18–19 advantages of membership in, 160–161 affiliation with, reasons for, 9–10 birth of, 11–12 Board of Directors, 12, 20 bylaws of, 17 characteristics of, 12 continuing education requirements, 27 costs associated with, 12 governance of, 20 history of, 11–12 international, 22–23 lobbying by, 22 membership, 17–18, 160–161 mission statement of, 12, 16 national office of, 20 professional connections from, 10

role of, 47–49 standards of, 18–20 statement of purpose, 12, 16 vision statement of, 12, 16 Professional communication(s) description of, 154–155 dismissal of patients, 50 ethical issues in, 49–52 second opinions, 50 types of, 330 Professional connections, 10 Professional development continuing, 224–225 requirement for, 38–39 Professional doctorates, 42, 127, 230–231 Professional ethics. See Ethics, professional Professional fatigue, 156. See also Burnout Professional fees, 141 Professional liability, 59 Professional organizations. See also specific organization affiliations with, listed on resumé, 129 American Academy of Audiology. See American Academy of Audiology American Speech-LanguageHearing Association. See American SpeechLanguage-Hearing Association Professional practice in other countries, 38 settings for health care. See Health care settings private practice. See Private practice school. See School settings technology considerations, 480–482, 481 specialized areas of, 19–20, 39–40 Professional relationships, 161 Professional writing, 325 Professions COVID-19 effects on, 23–24 evolution of, 27–28 organization of, 10–12 specialized area of practice, 19–20, 39–40

535



536

INDEX

Professions  (continued) technological influences on, 14–15 telehealth effects on, 24–25 in twenty-first century, 3–7 Profit sharing plans, 140 Program for Infants and Toddlers with Disabilities, 255–256 Progressivism, 11 Progress notes, 328, 339 Proliability, 292 Promotion, 163 Protected health information, 331, 332, 471 PSAPs. See Personal sound amplification products PSLF. See Public Service Loan Forgiveness Psycholinguistics, 15 Psychological abuse of child, 391 of elderly, 397, 401, 402 PTO. See Paid time off Publication bias, 115 Public education, 38, 240, 256. See also School(s); School settings Public Law 94-142, 256 Public Service Loan Forgiveness, 228 Purpose statement, 12, 16–17 PVA. See Paralyzed Veterans of America

Q Quality assurance, 73–75 Quality improvement, 315 Quality Payment Program, 208 Quasi-experiments, 112 Quiet quitting, 499

R RAISE Family Caregiver Act, 396 Randomized controlled trials, 112 Rapport, 262, 263 RBI. See Routines-based intervention RCTs. See Randomized controlled trials Recession, 6 Reciprocating exchanges, 78 Recordkeeping, 289

References, 131 Refugees, 424 Regional accrediting organizations, 40 Rehabilitation definition of, 207 telerehabilitation, 318 Rehabilitation 2030 initiative, 23 Rehabilitation hospitals, 214 Rehabilitative services, 207 Reimbursement assistant-performed services, 185–186 health care coding systems, 205–206, 297 description of, 5 Medicaid, 205 Medicare, 203–204 private health insurance, 205 Medicaid, 297 Relationship management, 156 Relative Value Scale Update Committee, 206 Relaxation exercises, 501–502 Relentless reimagining, 59 Reliability, of assessment evidence, 104–106 Relocation for employment, 164 Remote service delivery, 277–278 Remote technology, 56 Reporting, of child abuse and neglect, 276–277, 394–396 Research clinical, 315 funding for, 85, 313 global, 82–85 partnerships for, 85 in school settings, 250 Response to Instruction/ Intervention, 5, 246–247 Restraints, 363 Resumé action verbs used in, 129 certifications on, 129 chronological, 128 content of, 128–130 continuing education on, 129 definition of, 128 functional, 128 licensures on, 129 professional affiliations on, 129 resources for, 146 sample, 147–148 style suggestions for, 129

Retirement, 140 Retrospective studies, 113 Revenue-to-cost ratio, 291 Risk intelligence, 58 Risk management, 57–58, 74 Risk of bias, 113 Road to Freedom bus tour, 14 Roosevelt, Franklin D., 13 Routines, 151 Routines-based intervention, 274 RTI. See Response to Instruction/ Intervention RUC. See Relative Value Scale Update Committee Rural hospital, 214

S SAA. See Student Academy of Audiology SACSCOC. See Southern Association of Colleges and Schools Commission on Colleges Safety computer, 369 in health care settings, 219–220 Internet, 369 workplace. See Workplace safety Salaries in academia, 126 of audiologists, 6, 125 considerations for, 138–139 in health care settings, 125 hourly rate breakdown for, 139 in school settings, 125–126 of speech-language pathologists, 6, 125–126 SALT. See Systematic Analysis of Language Transcripts SCBs. See Specialty Certification Boards Scheduling nontraditional, 319–320 of speech-language pathology services, 319–320 Scholar-in-Residence program, 83 Scholars, 82–85 Scholarships, for graduate education programs, 41, 42 School(s). See also Public education audiologists in administration role of, 250 advocacy by, 248



leadership role of, 250 outreach by, 249–250 research used by, 250 roles and responsibilities for, 238 supervision of, 250 dysphagia in, 249 Individualized Education Programs in, 241–242 legislation and court cases that affect, 239–242, 240–241 Medicaid in, 243, 246 multitiered systems of support in, 246 population in, 238–239 Response to Instruction/ Intervention in, 246–247 safety in, issues regarding, 6 special education services in due process for, 242 identification, assessment, and intervention of, 242–247 least restrictive environment for, 240–241 legislation and laws that govern, 239–242 standardized testing for, 243 speech-language pathologists in administration role of, 250 advocacy by, 248 direct services by, 247 education by, 248 indirect services by, 247 leadership role of, 250 outreach by, 249–250 research used by, 250 roles and responsibilities of, 238, 246 scheduling of, 248 service delivery by, 247 specialty area of, 250 statistics regarding, 250 supervision of, 250 support personnel for, 248 3:1 model, 247 viewing of records by, 243 student demographics in, 238–239 teacher shortage in, 27 technology in, 482–483 School settings errors in, 378–379 overview of, 237–238

INDEX

salaries in, 125–126 speech-language pathology assistants in, 170 technologies in, 481 Scope of practice. See also Employment, settings for; Professional practice, settings for American Speech-LanguageHearing Association, 67–68, 181, 422, 456 description of, 67–68 development of, 11 historical perspective on, 12–16 speech-language pathology assistants, 456 World War II influences on, 12–13 Seashore, Carl, 14 Second interviews, 137 Second opinions, 50 Section 504, 240 Seesaw, 479 Selective outcome reporting, 114 Self-advocacy, 510 Self-assessment, 34, 222 Self-awareness, 155 Self-doubt, 158 Self-management, 155 Self-neglect, 397, 402 Self-reflection, 349 Self-supervision, 450, 452 Sensitivity, 108, 108–109 Service coordination, for early intervention services, 271, 272 Service coordinator, 266–270 Service delivery for culturally and linguistically diverse populations. See Culturally and linguistically diverse populations, service delivery for technology for, 470–482, 471 telepractice for, 470–473 Service learning, 80 Service-learning alliances, 64 Sexual abuse of child, 388 of elderly, 401, 403 SGDs. See Speech-generating devices Short-term limited duration plans, 207–208

SHRM. See Society for Human Resource Management Signage, for workplace safety, 364, 364 Silence, 264 Simulations clinical, 229–230 virtual, 229–230, 473, 475, 484–485 Sister 2 Sister exchange program, 79 Skilled nursing facilities, 214, 216 Sleep, 501, 502 Sleep hygiene, 501, 502 SLPAs. See Speech-language pathology assistants SLPs. See Speech-language pathologists Small Business Administration, 290 SMART method, 153 SNFs. See Skilled nursing facilities SOAP approach/notes, 223–224, 224, 328, 329 Social awareness, 155–156 Social networking, 161 Social reform, 13–14 Social Security Act, 13, 313 Society for Human Resource Management, 499–500 Sole proprietorship, 287, 289 Southern Association of Colleges and Schools Commission on Colleges, 40 SPAI. See Supervisee Performance Assessment Instrument Spanish-English Language Proficiency Scale, 431 Special education services, in schools due process for, 242 identification, assessment, and intervention of, 242–247 least restrictive environment for, 240–241 legislation and laws that govern, 239–242 standardized testing for, 243 Special Interest Groups, 16, 71, 161–162 Specialty area/specialized areas of practice certification in, 19–20 credentials for, 39–40 Specialty Certification Boards, 19

537



538

INDEX

Specificity, 108, 108–109 Specific learning disability, 244 SpeechBite, 311 Speech-generating devices, 475 Speech-language pathologists assistants use by, 180 certification of. See Certification Department of Labor statistics regarding, 3 in early intervention, 257–258, 259 employment outlook for, 6. See also Employment factors affecting, 3 goal of, 7 practical dilemmas for, 9–10 requirements for practice, 27 salaries of, 6, 125–126 in schools. See School(s), speechlanguage pathologists in speech-language pathology assistants and, studies comparing treatment outcomes between, 186–187 supervising, 185 workload of, 9–10 Speech-language pathology access to barriers to, 307–309 educating the public about, 319 legislation to improve, 313 technology for expanding of, 318–319 advocacy for, 313–317 awareness of, tips for expanding, 319 barriers to access, 307–309 conceptual frameworks in, 15–16 denials for appealing of, 315 description of, 310–311 “medical necessity,” 311 evidence-based practice in, 311–312 factors affecting the demand for, 168 funding challenges for, 308, 312–313 infrastructure challenges, 308 interprofessional education, 316 marketing of, 314

need for, 309–310 reimbursement for, 310–313 scheduling considerations, 319–320 settings for. See Employment, settings for; specific setting sociocultural barriers to, 308–309 technological influences on, 14–15 trends in, 16 World War II influences on, 13 Speech-language pathology assistants, 185, 317, 456. See also Assistants; Care extenders; Support personnel adults and, 190 ASHA Scope of Practice for, 181 certification requirements, 182, 248 clinical hours requirement for, 182–183 credentialing of, 183 culturally responsive practices by, 177–178 direct clinical contact hours requirement for, 182 educational pathways for, 182 effectiveness of, 188–190 employment of, 180 ethical practice policies for, 171–173, 173–174 in foreign countries, 190 indirect clinical contact hours requirement for, 183 job responsibilities of, 185 professional practice policies for, 171–173, 176–178 in schools, 248 scope of practice for, 181, 456 service delivery by, 176–177 speech and language screening programs, 188 speech-language pathologists and, studies comparing treatment outcomes between, 186–187 state regulation of, 178–179 studies involving, 186–190 supervision of, 184–185 swallowing screening and education by, 187 training of, 180–181

Speech-Language Pathology Clinical Fellowship, 454–456 SPLCF. See Speech-Language Pathology Clinical Fellowship Split-half reliability, 105 Staffing, of private practice, 293–294 Standard(s) accreditation, 18–19 certification, 19 professional conduct, 45 Standardized patients, 230 STAR format, 134–135 StaRt apps, 478 Start-up funds, for private practice, 293 State(s) associations, 21–22, 161 speech-language pathology assistant regulation by, 178–179 State licensure description of, 37–38 for private practice, 292 Statement of purpose, 12, 16–17 STLD plans. See Short-term limited duration plans Strategic Pathway to Excellence, 16, 22, 64, 69, 127 Strategic thinking, 344 Stress American Speech-LanguageHearing Association Code of Ethics on, 493–494 benefits of, 492 burnout and, 156 characteristics of, 495 coping with, 493, 500–504 definition of, 491 eating well and, 501 insomnia caused by, 501 mindfulness practices for, 503–504 occupational, 493 relaxation exercises for, 501–502 sleep affected by, 501 strategies for managing, 157–158 talking with others about, 502–503 vulnerability to, 491 workplace, 492, 496



Stressors, long-term, 493 Strings attached, 47 Student(s). See also School(s) advocacy, 316–317, 511 demographics of, 238–239 English-language learners, 239 marginal, 459 with specific learning disabilities, 239 supervision of, 456–457 training of, affiliation benefits for, 10 from underrepresented backgrounds, 435–436. See also Culturally and linguistically diverse populations Student Academy of Audiology, 18, 22, 434 Student organizations, 22 Study abroad programs, faculty-led, 76–77 Supervisee Performance Assessment Instrument, 451 Supervision analysis in, 450 Anderson’s Continuum of, 448–449, 449 assistants, 183–185 of assistants, 179, 184–185 of audiology assistants, 184 of challenging supervisees, 459 communication effects on, 451–452 continuing education in, 461 CORE Model of Supervision and Mentoring, 451 cultural issues, 458–459 data collection in, 449–450 definition of, 451 direct, 200 Dreyfus Model of Skill Acquisition, 445, 447–448 e-supervision, 484 ethical issues in, 52–53, 457–458 evaluation in, 450–451 feedback in, 52–53, 452 future needs in, 462 generational issues, 458–459 in health care settings, 225–226 history of, 445–447 indirect, 200

INDEX

knowledge and skills for, 460–461 linguistic issues, 458–459 of marginal students, 459 objective data in, 450 observation in, 449–450 planning of, 449 postcertification, 456 process of, 447–451 regulations, standards, and guidelines in, 454 self-supervision, 450, 452 of speech-language pathology assistants, 184–185 of students, 456–457 style of, 451–453 of support personnel, 456–457 technology in, 459–460 telesupervision, 459–460, 484 training in, 460 Supervisor accountability of, 461–462 ethical misconduct by, 458 feedback from, 452 knowledge and skills for, 460–461 mentor/preceptor transition for, 453–454 self-supervision promoted by, 452 supervisory style used by, 451–452 vicarious liability of, 458 Supervisory Process in SpeechLanguage Pathology and Audiology, The, 448 Supporting Grandparents Raising Grandchildren Act, 396 Supporting Older Americans Act of 2020, 396 Support personnel. See also Assistants; Audiology assistants; Speech-language pathology assistants advantages of, 317 definition of, 200 delegable tasks for, 52, 317 in dementia treatment, 190 ethical policies and practices for, 171–173, 173–174 interpreters, 169, 200, 433 opposition to, 317 professional policies and practices for, 171–173, 174–178

speech-language pathologists and, studies comparing treatment outcomes between, 186–187 state regulations for, 178–179 supervision of, 179, 456–457 training of, 317 translators, 169, 200, 433 Sustainable practices, 82 Swallowing, 14, 473. See also Dysphagia Swallowing Quality of Life, 222 SWAL-QOL. See Swallowing Quality of Life Synchronous telepractice, 200, 470 Systematic Analysis of Language Transcripts, 473 Systematic reviews databases that contain, 103–104 definition of, 112

T Taxes, 288–289 TCP/IP. See Transfer Control Protocol/Internetwork Protocol TDD. See Telecommunications Device for the Deaf Teacher shortage, 27 Teachers Pay Teachers, 475 Teamwork, 158–159 Technology. See also specific technology in assessment, 473, 475–479 augmentative and alternative communication, 160, 205, 247, 475, 478 digital apps, 475, 478–479 in education, 6 ethical considerations in, 485–486 funding for, 319 instrumentation, 473 professional practice settings, 480–482, 481 quality assurance through, 74–75 remote service delivery using, 277–278 in schools, 482–483 for service delivery, 470–482, 471

539



540

INDEX

Technology  (continued) speech-language pathology service access expanded using, 318–319 in supervision, 459–460 trends in, 4–5 websites, 475, 478–479 Telecommunications Device for the Deaf, 480 Telefacilitators, 473, 474 Telehealth in COVID-19 pandemic, 24–25, 210, 231 description of, 24–25, 231, 318, 470 evidence-based practices for, 277–278 international, 70 Medicare coverage for audiology and speech-language pathology services provided via, 209–210, 278 Telemedicine, 318 Telephone interview, 136–137 Telepractice asynchronous, 200, 470 barriers to care alleviated by, 318 client guidelines for, 472–473 clinician guidelines for, 470–472 during COVID-19 pandemic, 37, 168, 247, 319 definition of, 318 delivery methods, 470 evidence-based practices for, 277–278 example of, 472 family guidelines for, 472–473 home health care, 318 platforms for, 471–472 privacy standards in, 471 in private practice, 291 in schools, 247 service delivery uses of, 470–473 state licensure for, 37–38 synchronous, 200, 470 telefacilitators in, 473, 474 Telerehabilitation, 318 Telesupervision, 70, 459–460, 484 Teletherapy, 470 TeleTYpe, 480 Tertiary care hospitals, 214 Test-retest reliability, 105, 110 Text Telephone, 480 Thank-you letter, 138

The Joint Commission, 220, 359 Third Industrial Revolution, 4 3:1 model, 247, 513 Three-dimensional printing, 4 Time off, 140 Tinnitus, 19 Touching, 264 Trained volunteers, 318 Trainees, delegating service provision to, 52 Training of audiology assistants, 180–181 of speech-language pathology assistants, 181 of students, affiliation benefits for, 10 in supervision, 460 in workplace safety, 360–361 Transdisciplinary teams, for early intervention, 273 Transferable professional competencies, 65, 91 Transfer Control Protocol/ Internetwork Protocol, 15 Translanguaging, 428 Translators, 169, 200, 433 Transparency, 75–76 Trauma, 27 Trauma-informed care, 27 Traumatic brain injury, 244, 478 Travis, Lee Edward, 14 Treatment encounter note, 339 Treatment plans, 327–328 Trends demographic, 6–7 economic, 6 in education, 5–6 in health care, 5 in technology, 4–5 Triple Aim Measures, 57 TT. See Text Telephone TTY. See TeleTYpe Turn-taking behaviors, 264 2017 Agreement of Mutual Recognition of Professional Association Credentials, 71 Two-way exchange programs, 77

U “Underchallenged” workers, 494 Underrepresented backgrounds, students from, 435–436 Unemployment, 6

Unemployment insurance, 292 Unethical practice complaints Academy of Doctors of Audiology process, 54 American Academy of Audiology process, 54 American Speech-LanguageHearing Association process for, 53–54 appeals for, 56 description of, 293 disclosure, 55 sanctions, 55–56 types of, 54–56 United Nations Declaration on the Rights of Disabled Persons, 13 World Day for Cultural Diversity for Dialogue and Development, 426 United States demographics in, 422–424 Department of Defense, 145 gross domestic product in, 6 health disparities in, 432 immigrant population in, 424 language use in, 422–424, 423 population in, 6–7, 10, 422 racial diversity of, 422 refugee population in, 424 Small Business Administration, 290 spoken language in, 7 United States Society of Augmentative and Alternative Communication, 475 “Universal licensure,” 38 Universal newborn hearing screening, 26, 473 Universities exchange programs, 77–79 faculty-led study abroad programs, 76–77 faculty salaries in, 126–127 international alliances and attributes of high-quality programs offered through, 72–81 programs, 11 Unz, Ron, 433 URAC. See Utilization Review Accreditation Commission U.S. Census Bureau, 422



U.S. Department of Education, 359 U.S. Department of Health and Human Services Policy for Protection of Human Research Subjects, 368 USDE. See U.S. Department of Education USSAAC. See United States Society of Augmentative and Alternative Communication Utilization Review Accreditation Commission, 360

V Validity, 106, 110 Value-based health care, 57 Value-Based Insurance Design, 58 Value equation, 58 VAMC. See Veterans Health Administration VBHC. See Value-based health care VBID. See Value-Based Insurance Design Vendor relationships, conflict of interest issues in, 50 Verbal references, 131 Veterans Health Administration, 13, 217, 218 VFSS. See Videofluoroscopic swallowing study VHI. See Voice Handicap Index Vicarious liability, 458 Victims of Child Abuse Act Reauthorization Act of 2018, 385 Videoconferencing, 277, 460 Videofluoroscopic swallowing study, 14 Video relay services, 480 Violence, workplace, 58, 361, 363–364, 499–501 Virtual alliances, 70 Virtual interview, 136 Virtual programs, 74 Virtual reality, 229–230, 473, 475, 476–477

INDEX

Virtual simulations, 229–230, 473, 475, 484–485 Visionary thinking, 347 Vision statement, 12, 16, 421 Visual impairment, 244 Vocational Rehabilitation Act, 240 Voice Handicap Index, 222 Volume, speaking, 264 Volunteers, trained, 318 VR. See Virtual reality VRS. See Video relay services

W WASC Senior College and University Commission, 40 WASP. See Waveform Annotations Spectrograms and Pitch Waveform Annotations Spectrograms and Pitch, 473 WaveSurfer, 473 Web-based applications, 130–131 Web conferencing software programs, 481–482 Webinars, 460 WebMD, 139 Websites, 475, 478–479 What Works Clearinghouse, 103 WHO. See World Health Organization Workforce cultural responsiveness in, 64–67 current, 123 generational differences in, 459 transferrable competencies valued in, 91 Workplace behavioral management in, 363 causes of, 493 emergency response plan for, 360 ergonomic hazards in, 362–363 hazards in, 357, 362–364 networking in, 161 physical hazards in, 362 physiological responses to, 492 restraints used in, 363 standard operating procedures for, 360

stress in, 492, 496 symptoms of, 492, 492–493 violence in, 58, 361, 363–364, 499–501 Workplace conflict defining of, 496 management strategies for, 498–499 reasons for, 497 sources of, 496, 497 strategies for addressing, 496–498 stress caused by, 496 Workplace safety accrediting agencies for, 359–360 acronyms for, 364 active shooter, 361, 500 background checks for, 361–362 confidentiality of client information, 366–369, 367 infection control, 364–366, 365 overview of, 357–358 plans and policies for, 360–362 preemployment health screening documentation, 365 regulatory agencies for, 358–359 signage for, 364, 364 training in, 360 websites for, 361, 361 World Health Organization description of, 381 elder abuse, 398–399, 399, 407 International Classification of Functioning, Disability, and Health, 68, 221–222 Rehabilitation 2030 initiative, 23 World War II, 12–13 “Worn-out” workers, 494 Writing, of clinical documentation, 325–326 WSCUC. See WASC Senior College and University Commission

Y Yoga, 504

541