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Research Report

Ethical perspective on quality of care: the nature of ethical dilemmas identified by new graduate and experienced speech pathologists

Belinda J. Kenny † , Michelle Lincoln

† , Katrina Blyth

‡ and

Susan Balandin §

†Speech Pathology, Faculty of Health Sciences, University of Sydney, Lidcombe, Australia ‡Medway Maritime Hospital, Gillingham, UK §Avdeling for helse-og sosialfag, Hogskolen i Molde, Molde, Norway

(Received 27 September 2007; accepted 2 March 2008)

Abstract

Background: Speech pathologists are confronted by ethical issues when they need to make decisions about client care, address team conflict, and fulfil the range of duties and responsibilities required of health professionals. However, there has been little research into the specific nature of ethical dilemmas experienced by speech pathologists and whether the nature of ethical conflict changes as they acquire experience in the professional workforce. Speech pathologists’ perceptions of ethical issues provide insight into factors impacting upon quality of care in contemporary healthcare settings. Aims: To describe, compare, and contrast the nature of ethical dilemmas identified by new graduate and experienced speech pathologists. Methods & Procedures: A narrative methodology was used to explore the ethical dilemmasthatparticipantsexperiencedintheprofessionalworkplace.Primarydata were collected through in-depth interviews with ten new graduate and ten experienced speechpathologists in theirwork settings.During these interviews, participantswereaskedto‘tell thestory’ofethicaldilemmasthey identifiedatwork. Outcomes & Results: An ethical story was constructed for each participant based upon keywords and concepts from interview transcripts. These keywords and conceptswerecodedintogroupthemesthatreflectedthenatureofethicaldilemmas experienced by new graduate versus experienced speech pathologists. Comparing the results of thematic analysis for both groups of participant revealed similarities and differences in ethical dilemmas identified by new graduate and experienced health professionals.

International Journal of Language & Communication Disorders ISSN 1368-2822 print/ISSN 1460-6984 online q 2009 Royal College of Speech & Language Therapists

http://www.informahealthcare.com DOI: 10.1080/13682820902928711

Address correspondence to: Belinda J. Kenny, Speech Pathology, Faculty of Health Sciences, The University of Sydney, PO Box 170, Lidcombe 1825, Australia; e-mail: [email protected]

INT. J. LANG. COMM. DIS., JULY-AUGUST 2009,

VOL. 44, NO. 4, 421–439

Conclusions & Implications: Participants identified ethical dilemmas in the professional practice areas of client management, professional relationships, service delivery, and personal/professional identity. Themes from new graduates’ ethical dilemmas included: making safe choices; avoiding conflict, following service delivery rules, and building professional identity. Experienced speech pathologists’ themes included: lifechoices,adaptingpolicies, andprofessional status.Supporting client autonomy, managing risk taking, adopting fair service delivery policies, and supporting health professionals’ ethical practice are part of ethical quality care. The results support the need for an increased focus on ethical practice in the workplace andfurther support for speechpathologistsexperiencingethicalconflict inresponse to service delivery policies.

Keywords: ethics, allied health professions (AHPs), qualitative, quality care.

What this paper adds Speech pathologists experience a range of ethical dilemmas in their professional practice. This study used qualitative methodology to describe and interpret the nature of these ethical dilemmas and to draw implications for quality client care. The findings were that speech pathologists shared similar experiences of ethical dilemmas involving client care, professional relationships, service delivery, and personal/professional identity. However, there were some important differences in the nature of ethical dilemmas identified and described by new graduate versus experienced speech pathologists. The results may inform preparation of new graduates and continuing professional development programmes for speech pathologists in ethical practice.

Introduction

Healthcare practice is evolving, resulting in changes and challenges for the health professions (Mullavey-O’Byrne and West 2001). Changes include: increased focus upon competency standards; guidelines for Best Practice, consumer-focused service delivery; continuing education; and evaluation of health outcomes. These measures were developed to improve the quality, efficiency and accountability of healthcare services. However, these policy and practice changes are implemented against a backdrop of rising healthcare costs and budgetary limitations. Health professionals are challenged to maintain quality services in a climate of rationalization. To adapt to the changes and challenges of contemporary healthcare, health professionals must meet a number of demands (Sim and Richardson 2004). These demands include: (1) professional demands to manage clients competently, (2) external demands to manage clients within medico-legal guidelines, (3) institutional demands to conform to policies and professional codes of conduct, and (4) ethical demands to address moral requirements for healthcare practice.

Speechpathologistshaverespondedtothedemandsofethicalpracticebydeveloping Codes of Ethics, based upon bioethical principles of beneficence, non-maleficence, justice and autonomy (Beauchamp and Childress 1994, Bergland 1998). Speech Pathology Australia (SPAA) has adopted the ethical principles of beneficence and non- maleficence, fairness (justice), autonomy and additional principles of truth and professional integrityaskeys toethicalpractice(SPAA2000,2002).Theseprinciplesare

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consistent with values and standards espoused by international professional organizations (New Zealand Speech–Language Therapists’ Association (NZSTA) 2000,HealthProfessionsCouncil (HPC)2001,AmericanSpeech–Language–Hearing Association(ASHA)2003,RoyalCollegeofSpeechandLanguageTherapists (RCSLT) 2006). Hence, professional Codes of Ethics present and interpret ethical principles to guide ethical decision-making by members of health professions.

Beneficence/non-maleficence describes professionals’ obligations to do good, facilitate health, and prevent harm to clients (SPAA 2000). These ethical principles recognize health professionals’ duty to hold paramount the welfare of people who use their services (HPC 2001, NZSTA 2000). Upholding the principle of fairness or justice facilitates equality in the service provided to clients (SPAA 2000). Furthermore, speech pathologists must commit to the development and provision of quality services consistent with evidence based practice for all clients who require intervention (RCSLT 2006). Autonomy incorporates respect for clients’ healthcare choices (SPAA 2000). The ethical principle of autonomy is also expressed in acknowledgement of the individuality of clients and need for speech pathologists to be sensitive towards factors such as clients’ race, age, religion, culture, sexual orientation and gender (NZSTA 2000). The principle of truth requires professionals to provide true and accurate information to others (SPAA 2000). The principle addresses speech pathologists’ responsibility to promote public understanding of communication disorders by education and unbiased dissemination of research findings (ASHA 2003). Professional integrity underlies professionals’ responsibility to honour commitments to clients, colleagues and employers (SPAA 2000, 2002) and informs healthcare consumers and providers of the standards that they should expect from speech pathology services (RCSLT 2006). Additionally, the principle of professional integrity guides speech pathologists to behave in a manner that protects the dignity and reputation of their profession (HPC 2001).

Ethical codes provide an important framework for professional practice by presenting the values and standards expected from members of the profession. Nevertheless, knowledge of ethical codes does not remove the necessity for moral choices in healthcare (Higgs and Jones 1995). Moral issues arise when healthcare choices involve equally desirable or undesirable options or when the decision-maker is required to prioritize one ethical principle over another (Kornblau and Starling 2000).

Previous research indicates that health professionals are confronted by a range of ethical dilemmas in the workplace (Barnitt 1998, Swisher 2002). These dilemmas included managing unethical behaviour by colleagues, clients disagreeing with intervention approaches, difficulties assigning treatment priorities, inadequate supervision and training, and external constraints on clinical decision-making (Buie 1997). Additionally health professionals may experience ethical dilemmas when they work with incompetent staff, resources are limited, or colleagues and clients refute their professional recommendations (Barnitt 1998, Buie 1997, Kenny et al. 2007). The potential impacts of ethical dilemmas on quality of client care, professional accountability and continuing professional education warrant further investigation of ethical conflict experienced by speech pathologists in contemporary healthcare settings.

To date there has been no investigation of whether speech pathologists experience similar or different ethical dilemmas as they develop clinical expertise and adopt a range of professional roles. The aims of this study were: (1) to describe the nature

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of ethical dilemmas identified by new graduate and experienced speech pathologists and (2) to compare and contrast the ethical dilemmas they experienced at work.

Methods

Participants

Ten new graduate speech pathologists with less than 18 months postgraduate experience and ten experienced speech pathologists with a minimum of five years professional experience were recruited from seven healthcare workplaces in New South Wales, Australia, using purposive sampling techniques. Population demographics for recent migrants, unemployed adults and families dependent on welfare were higher than the state average in the sampled Area Health Service (Health Services Planning 2005). A summary of participants’ professional experience is presented in Table 1. All participants were female; new graduates were 21–25 years of age, and experienced professionals were 27–50 years of age. The participants reflected the nature of the professional workforce in this setting where 98% of speech pathologists were female, 75% of whom were aged 35 years or under, and only 2% of whom were aged over 55 years (Health Services Planning 2005).

Table 1. Participants’ professional experience

New gradu- ate

professional a Experience (months)

b Role and setting

Experienced professional

a Role and setting

Experience (years)

c

Jane 12 –18 Clinician, community health

Gemma Senior clinician, manager, community health

10–15

Karen 12 –18 Clinician, hospital Eliza Senior clinician, manager, hospital

5–10

Louise 12 –18 Clinician, disability service, hospital

Alicia Senior clinician, manager, hospital

5–10

Erin 12 –18 Clinician, private practice, hospital

Anne Senior clinician, manager, community health

5–10

Felicity 6 –12 Clinician, community health

Kelly Senior clinician, manager, disability services

10–15

Marion 0 –6 Clinician, community health

Therese Senior clinician, community health

5–10

Sophia 0 –6 Clinician, community health

Rebecca Senior clinician, manager, hospital

Over 15

Alexis 12 –18 Clinician, community health hospital

Danielle Senior clinician, manager, hospital

5–10

Hayley 6 –12 Clinician, community health

Lisa Senior clinician, hospital

5–10

Morgan 6 –12 Clinician, community health

Megan Senior clinician, hospital

5–10

Notes: a Pseudonyms.

b New graduate participants’ experience was coded 0–6, 6–12, or 12–18 months.

c Experienced participants’ experience was coded as 5–10, 10–15, or over 15 years to protect the identity of professionals.

424 Belinda J. Kenny et al.

Data collection

The first author conducted and audiotaped an in-depth interview with each participant. Before the interview, participants provided a verbal description of their professional roles. A narrative approach (Goodfellow 1998) was used to elicit participants’ descriptions of ethical dilemmas they experienced at work. They were asked to explain the nature of the ethical conflict and tell the story of how the dilemma unfolded in the workplace. Participants’ narratives were about cases or specific events they identified as ethically conflicting. The narrative concluded when participants indicated there were no further ethical dilemmas they wished to discuss. Following the interview, the investigator reviewed each ethical dilemma and asked the participant to identify any bioethical principles at stake in the conflict. Participants were provided an Australian Code of Ethics (SPAA 2000) during this task. Their responses were recorded in interview fieldnotes.

Data analysis

Each interview was transcribed verbatim and all identifying material removed. Individual,groupandcomparativeanalyseswereconductedontheinterviewtranscripts.

Individual analysis

A narrative approach (Goodfellow 1998) was used to synthesize participants’ transcripts into ethical stories. The first author used the participant’s own words to develop a story that described and interpreted the participant’s response to ethical issues. Each story described the nature of the participant’s ethical dilemmas, ethical reasoning strategies and outcomes. This paper presents the results of the analysis of the nature of participants’ ethical dilemmas. Ethical stories were shared with participants to determine whether they were authentic reflections of their experience (Chase 2000). This process resulted in minor changes to the content of four participants’ transcripts and did not impact upon their stories.

Group analysis

Analysis of ethical stories identified key areas of professional practice that consistently featured in participants’ ethical dilemmas. Each ethical dilemma was coded according to professional practice areas and the bioethical principle(s) the participant indicated were at stake in the dilemma. This analysis revealed the broad types of ethical dilemmas experienced by participants. The nature of these ethical dilemmas was analysed by coding for themes occurring in new graduate and experienced participants’ ethical stories using Braun and Clarke’s (2006) guidelines for thematic analysis. Group themes were reviewed against individual stories and transcripts to confirm that they reflected participants’ experiences.

Comparative analysis

Thenatureofethicaldilemmas identifiedbynewgraduateandexperiencedparticipants was compared and contrasted by comparative analysis of group themes (Barnitt 1998). Analysis resulted in shared, new graduate and experienced participant themes.

Ethical dilemmas in speech pathology 425

Results and discussion

To reduce replication across the paper the results are discussed as they are presented (Patton 2005). The professional practice areas impacted by ethical conflict are followed by the nature of ethical dilemmas represented by shared, new graduate and experienced themes.

Ethical dilemmas identified by new graduate and experienced speech pathologists

Four areas of professional practice featured in participants’ ethical stories: client management, professional relationships, service delivery and personal and professional identity. Table 2 presents the number of participants who discussed a dilemma in each clinical practice area.

Client management

All participants identified ethical dilemmas where conflict emerged during client management. Conflict emerged during planning intervention goals, negotiating treatment, and discharge decisions. Speech pathologists working in community settings reported that discharging children who failed to consistently attend treatment sessions was a difficult client management issue.

The mother was aware that if she hadn’t contacted the file would have been closed. But . . . I felt that she’d come to the assessment and had a few sessions but she really didn’t go away with anything and didn’t really gain any benefit out of it. And she really needed that help! (Hayley)

Participants perceived all ethical principles (beneficence/non-maleficence, autonomy, professional integrity, truth, fairness) were at stake in ethical dilemmas surrounding client management.

Table 2. Types of ethical dilemmas

Professional practice area Type of dilemma New graduate (n ¼ 10)

Experience (n ¼ 10)

Client management Planning 10 10 Treatment Discharge

Professional relationships Client 10 8 Carer Colleague Team Supervisory relationships External services

Service delivery Models of service delivery 7 10 Resource limitations Policies

Personal and professional identity Professional experience 10 9 Personal attributes

426 Belinda J. Kenny et al.

How much you tell patients and how much control you give them has been quite interesting because his medical condition and prognosis and plans have changed during the course of his management. (Alicia)

Professional relationships

All new graduate and eight experienced participants raised ethical dilemmas in professional relationships. Ethical dilemmas occurred during professional inter- actions with clients and their carers, colleagues, interdisciplinary teams, supervisory relationships and external services. Ethical dilemmas resulted from conflict between duties towards employers and clients and in maintaining professional relationships with clients, carers and colleagues.

Mum called to book a session and she specifically requested not to have an interpreter for the reason that she will have to wait a longer time. (Sophia)

The ethical principles of professional integrity, truth, beneficence, non-maleficence and autonomy were at stake when conflict occurred within professional relationships.

The dietician was very distressed that there wasn’t a more aggressive role taken in providing tube feeding. The doctor’s perspective was that there was no medical reason to support tube feeding when the client was electing not to eat. (Rebecca)

Service delivery

Seven new graduate and all experienced participants identified ethical dilemmas in service delivery. Service delivery issues addressed quantity and quality of speech pathology services and the impact of health policies on service delivery.

Other Area Health (Services) have got more clinicians and they can provide a better service. It doesn’t seem fair that people in this area are more disadvantaged and they have to wait longer for services. (Felicity)

Conflict arose between principles of fairness, beneficence and non-maleficence and professional integrity when participants needed to distribute speech pathology resources across large caseloads.

I think about it in terms of ethics because you’re always trying to balance off everybody’s benefit. And trying to balance the individual good against the group good. Who’s going to benefit the most? (Megan)

Personal and professional identity

All new graduate and nine experienced participants reported personal and professional identity influenced perceptions of ethical dilemmas. In this study, professional identity included participants’ interpretation of a speech pathologist’s roles and responsibilities.

Our job should always be to improve the quality of life of a patient. (Erin)

Our participants experienced ethical dilemmas when their professional identity was undermined by others or opportunities to fulfil professional roles were thwarted by economic factors. Personal identity referred to participants’ character

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traits, life experiences, attitudes and values. When participants explained their role in ethical dilemmas, they identified professional integrity as the ethical principle at stake.

One of the client’s mothers commented that it was a really nice ring I was wearing and I commented that one of the speechies here sells them and she wanted me to put her in touch with the speechie and I went and told (the speech pathologist) and I just went . . . ‘This is a bit too close to the edge!’ (Jane)

When asked to explain the nature of this ethical dilemma, Jane responded:

You’re not supposed to make money on the side off your clients!

The results indicate that participants were challenged by ethical issues in a range of practice areas consistent with Buie’s (1997) and Barnitt’s (1998) studies. However, in our study the ethical dilemmas involved complex interactions between clients’ healthcare needs, professional relationships, resource limitations and participants’ perceptions of professional roles. Similar to findings by Braunack-Mayer (2001) and Hurst et al. (2005), the ethics domain covered by our participants included dilemmas over publicity, avoiding conflict and threats to reputation.

It was very confronting ethically because I had to take all this on board while maintaining some professional stature, without collapsing in a heap, thinking I was going to be the next case on A Current Affair. (Karen)

1

Furthermore participants’ ethical stories addressed conflict between personal values (attitudes and beliefs of the speech pathologist), professional values (presented in codes of ethics and based upon bioethical principles), organizational values (interpreted as cost effective and outcome driven care) and community values (focused upon clients’ rights and choices).

Shared themes

Although participants identified dilemmas within similar professional practice areas, thematic analysis revealed differences between the two groups. Table 3 presents themes shared across participants and themes reflecting new graduates’ and experienced professionals’ ethical dilemmas.

Table 3. Participant themes

Shared themes New graduate Experienced speech pathologist

The complex client at the heart of the dilemma

Safe choices Life choices

Avoiding conflict Adapting policies Defining boundaries in professional relationships Following rules Professional status

Fair access to quality services Building professional identity

Incorporating self into professional role

428 Belinda J. Kenny et al.

The complex client at the heart of the dilemma

Participants reported that ethical dilemmas occurred during the management of complex clients. Severe medical diagnosis, poor prognosis, psychosocial and cultural issues increased the complexity of client management.

This child’s history is that he has a mother with a mental illness. He has a father that goes in and out of jail and he has a severe impairment impacting his academic performance. (Gemma)

Ethical conflict occurred when professionals analysed relative benefits and harm associated with management options.

It’s been particularly complex because at one stage he was for total laryngectomy, so we needed to keep him well and then once it was decided he was inoperable then the whole picture changed. (Alicia)

Participants cited time restraints as a barrier to addressing ethical concerns during case conferences for complex clients.

There’s like seventy beds to get through in an hour. So it’s very fast and if you want to say something you’ve gotta be really ready to say it! (Rebecca)

Hence, complex clients may represent a particularly vulnerable subset of the healthcare community (Titchen and Ersser 2001). Participants identified complex clients whose voices and needs remained unheard and unmet.

She’s got major language difficulties and she’s just going about her daily life not communicating with anyone. (Sophia)

A relationship between client complexity and ethical dilemmas was reported by our participants. This finding suggests a need for increased focus on ethics during supervisory, case and team meetings to support quality of care for these clients.

Defining boundaries in professional relationships

Professional relationships were central to many participants’ ethical conflicts. Ethical issues will arise whenever health professionals must intervene on another’s behalf (Horner-Catt 2000). Our participants intervened when carers experienced difficulty making appropriate healthcare choices for clients.

Mum couldn’t see the extent of the difficulties, didn’t really have that insight that her daughter was having these problems. (Anne)

New graduate participants questioned professional boundaries in response to needy or aggressive carers.

A dilemma that I experienced, working in paediatrics, was when to ‘back off’ from parents. (Erin)

Their motivation to build rapport with carers conflicted with professional roles, including child protection responsibilities.

The parent is there trusting you and maybe being just that little more open with you and then you’re meant to use a system to judge them. (Morgan)

Participants debated whether speech pathologists should filter information to meet the perceived skills and resilience of the carer. New graduates struggled with the

Ethical dilemmas in speech pathology 429

nature of truth in healthcare relationships. Ethical dilemmas resulted when accurate information was perceived as harmful.

I’ve explained, even if I’ve had to make it up, why they were doing what they were doing. So these parents don’t feel like the last two years have been a total waste of time. (Marion)

Experienced participants adopted advocacy roles for clients that reflected a wider perspective of healthcare relationships than new graduates.

We quite often take on a supportive role for our clients and our families and so whilst we are meeting the speech pathology need we need to do a lot of casework slash advocacy at times for them and I suppose an ethical dilemma arises in terms of the extent to which you fulfil that role. (Kelly)

Advocacy roles resulted in conflict between professional boundaries between health services. As experienced professionals gained expertise, limits to professional responsibilities became an issue.

At what point are we overstepping the mark of what is speech pathology territory? (Alicia)

Experienced participants needed to examine responsibilities towards clients and colleagues in the wider healthcare community.

A few of the grade ones were ringing me up. It had been ongoing for a long time. It’s probably not a direct dilemma with me but they were having a problem with their senior and it was a very big problem. (Danielle)

Professional boundaries raise questions over ethical and legal responsibilities of speech pathologists who frequently fulfil multiple roles including educators, therapists, counsellors and advocates for vulnerable healthcare consumers. Our new graduate participants struggled to develop professional boundaries with clients and their carers. Experienced participants readily accepted advocacy roles for clients and were confident in managing client/carer relationships. However, client and carer autonomy may be undermined whenever professionals direct healthcare decisions. Furthermore, experienced professionals may need to traverse traditional administrative boundaries to protect the wellbeing of colleagues or the community. Speech pathologists are advised to report suspected breaches of ethical practice (SPAA 2000, ASHA 2003). Our findings suggest that both new graduates and experienced speech pathologists require education in the management of incompetent or unprofessional practices by their colleagues. Speech pathologists’ failure to accept professional responsibility for reporting ethical concerns may perpetuate incompetent practice (Pannbacker 1998). This is a rarely acknowledged but significant issue impacting on workplace culture and ultimately quality of client care.

Fair access to quality services

Limitations in healthcare resources generated a host of ethical and quality care issues. Sim and Richardson (2004) argued that healthcare practitioners must reconcile needs of individual clients with requirements to work within a broader context of efficient healthcare delivery. Yet, participants perceived that healthcare policies did not ensure equal quality of intervention or similar health benefits. Participants employed

430 Belinda J. Kenny et al.

in hospital settings were concerned when clients who were frail aged received limited access to rehabilitation.

Oh, this patient’s got a poor prognosis. We won’t do anything. (Erin)

Participants employed in community settings argued that clients from culturally and linguistically diverse backgrounds experienced difficulties accessing healthcare services.

We have to book interpreters a month ahead and that means that services clients from a non-English speaking background get is not as good as the services for people who don’t need an interpreter. (Felicity)

Experienced participants discussed the conflicting responsibilities of healthcare professionals to discharge clients who demonstrated limited treatment response and to prevent harm to disadvantaged communities.

We don’t have the capacity to give him what he needs so it’s easier to make him go away. (Gemma)

In this study, tension between upholding standards of professional competence and the need to distribute existing resources across large caseloads featured consistently in participants’ ethical dilemmas. An ethical issue concerned the widening gap between evidence-based practice and clinical reality.

I do go to professional development events and reading and know that hey! People get better because we do therapy with them. So, how can that happen if, the lady I was with today, we haven’t seen her for three weeks? (Lisa)

Speech Pathologists must determine when quality of client care drops to a level of unethical practice. Our findings suggest that achieving a balance between quality service and efficiency is difficult in the current healthcare climate. Hence, Professional Associations and healthcare organizations have an important role in supporting ethical practice by incorporating the language of ethics in healthcare policies and outcome measures.

Incorporating self into professional role

Participants experienced ethical conflict when their values were challenged in professional practice. New graduates were confronted by diverse community attitudes towards parenting, relationships and health issues.

It was extremely hard and very morally confronting to think that this could be occurring in families because I’m not from that background. (Karen)

Experienced participants’ concerns for clients’ autonomy were in keeping with their own beliefs about individual rights to dignity and independence.

I don’t feel it’s my place to aggressively make a decision one way or another. I wouldn’t like it if someone did it for me! (Megan)

Participants reported that contributions to clients’ health impacted on professional identity and career satisfaction. Our participants’ stories were consistent with Mullavey-O’Byrne and West’s (2001) assertions that professionals have expectations of applying their knowledge and skills to achieve positive outcomes.

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The reason I went into the job in the first place was because it was a caring profession and the idea was that you help people achieve some sort of improvement in their life. (Megan)

Participants reported professional fatigue when expectations for workload and quality of care were unmet.

It’s very hard for us to be productive when we come together to talk about it because it’s just ebbed away at us. (Lisa)

This finding has implications for retention of experienced speech pathologists in the healthcare system and the preparation of new graduates to manage workplace expectations.

New graduates’ themes

Safe choices

New graduates identified conflict between quality of life and prevention of harm during client management. They focused upon potential harmful, immediate consequences of clients’ choices.

Wanting to try and give this the lady the most quality of life considering she was in late stage of her life but not wanting to make her any sicker. (Karen)

Issues of risk and harm emerged when new graduates discussed accountability for clinical decisions. Our new graduates were concerned about harmful professional or medico-legal consequences.

As a new grad that’s quite confronting . . . to think that, potentially you could be scrutinized about the decisions you made. (Karen)

New graduates experienced difficulties identifying the long-term implications of health issues and complex factors affecting benefit and harm in client management.

There were issues that, while I knew they needed to be addressed for the client, but just under the rush and pressure to get through clients I didn’t make a referral to the psychologist; something I really regret now. (Alexis)

Professional craft knowledge is required for understanding the importance of illness within the contexts of people’s lives and identifying ethical issues around principles of autonomy and beneficence (Titchen and Ersser 2001). Our findings suggested that new graduates needed support to manage concerns about personal and professional repercussions of clients’ healthcare choices. They experienced difficulties prioritizing ethical principles to facilitate clients achieving their desired health outcomes.

Avoiding conflict

New graduates experienced conflict in managing healthcare relationships. They were anxious about clients’, carers’ and colleagues’ perceptions of their competence and avoided conflict in the workplace.

I certainly wouldn’t want to get on her bad side or look like I’m siding with anyone else on the team. (Sophia)

432 Belinda J. Kenny et al.

Furthermore, new graduates found it difficult to manage interdisciplinary conflict when clients’ health was at stake.

Nursing staff come to you and say ‘Well, the doctor said this. You said that. What do we do?’ (Karen)

New graduates were unsure of how to demonstrate empathy for clients in a professionally acceptable manner.

How much should I try and counsel this mother? (Erin)

Additionally, new graduates experienced divided loyalties towards their clients and employers.

The hardest thing I’ve had to come to terms with personally is how to almost protect the face of the service while at the same time going ‘I can understand what you mean’ (Felicity)

White (2001) proposed that an effective care orientation requires sensitivity, empathy and receptivity towards people and relationships. Graves (2007) identified the need for speech pathologists to develop expertise in collaborative and relational skills. Our findings suggest that new graduates need support to manage professional relationships with carers and colleagues as they develop competence in their professional roles. Preparation programmes and employers may need to place further emphasis on developing new graduates’ skills in managing the complex professional interactions integral to healthcare relationships.

Following rules

New graduates perceived their role as working within existing service delivery policies. Following the rules enabled new graduates to deliver clinical services without addressing complex issues of priority in healthcare.

I want to stick to the system, not just because I trust the system but because if you rang everyone on that waiting list they would all have some heart wrenching story about why their child needs the service. (Morgan)

At the same time, new graduates identified ethical conflict between the need to rationalize service limitations and achieve positive health outcomes.

It’s still something that I struggle with every time I’m discharging a client with severe language difficulties. (Hayley)

They experienced conflict in determining how to provide quality services without breaking service delivery policies.

I’ve got really high need clients who need intensive therapy over a period of years. And I can only offer them a period of six to eight sessions. It’s an ethical dilemma figuring what sort of services to provide, how to best provide them. (Felicity)

Although new graduates were motivated to facilitate healthcare improvements, they did not feel empowered to change existing practices.

I’m on the bottom of the rank. I can’t say anything yet. (Alexis)

New graduates’ unwillingness to challenge service delivery policies may result in complex clients receiving limited opportunities for improving their health status.

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Building Professional Identity

A complex interaction was observed between new graduates’ self-perception, professional identity and ethical conflict.

Being a new graduate and also being quite young and therefore struggling to have the knowledge and experience to back up decisions you were making. (Louise)

New graduates struggled to establish a professional identity on interdisciplinary teams.

Well . . . what is my role? And how valued am I, in terms of being part of a team? (Karen)

Difficulty establishing professional identity resulted in ethical dilemmas when healthcare teams challenged new graduates’ professional recommendations. These dilemmas impacted on client care by undermining new graduates’ confidence in advocating for clients.

Not knowing nurses and where they’re coming from and also not having the confidence and the experience to say, ‘No, straight down the line ‘No!’ (Louise)

Clearlyournewgraduatesrequiredsupporttodevelopaprofessionalidentityintheirnew workplaces.Ourfindings support theneed for seniorcolleagues to takeanactive role in facilitatingnewgraduates’understandingoftheirrightsandresponsibilitiesashealthcare practitionersandprovidestrategiestoenablethemtofunctionaseffectiveteammembers. Additionally,therelationshipbetweenhealthcarepractitioners’personalandprofessional identity warrants further investigation. The speech pathology profession, generally, is under-represented by members from diverse cultural and linguistic backgrounds (Greenwood et al. 2006) and this may be a factor impacting on professionals’ awareness of underlying assumptions in fulfilling the roles of healthcare providers.

Experienced speech pathologists’ themes

Life choices

Experienced participants focused upon clients’ rights to autonomous healthcare decisions.

It’s more about life choices and quality of life rather than medical safety. (Megan)

However, it was not always easy to determine whether clients were making informed healthcare choices.

She’d never really voiced what she wanted and so we just had to rely on what the family had said. (Rebecca)

Furthermore, ethical dilemmas resulted when experienced professionals balanced rights to autonomy with responsibilities for providing sound healthcare advice.

Weneedtoworkwithhimtoensurethat it’sareasonabledecisionhemakesandkeep supporting him in that decision given the overall prognosis. (Alicia)

Supporting client autonomy did not absolve professionals’ responsibility for clients’ health and safety. Health professionals were confronted with further ethical issues when clients pursued health choices contraindicated by medical advice.

434 Belinda J. Kenny et al.

It was going to be life threatening but he made the decision that he would eat and drink. Between the doctors they made a decision that if he got another chest infection they wouldn’t treat it; which I found really difficult. How can you not treat? (Eliza)

Our participants challenged the penalties resulting from life choices; an ‘all’ or ‘nothing’ approach whereby healthcare services were withdrawn unless clients demonstrated strict compliance. They questioned whether health professionals should adopt more flexible responses towards client autonomy.

Adapting policies

Experienced participants perceived their role as adapting service delivery to meet clients’ needs. They observed long-term impacts of intervention programmes on clients’ social, educational and vocational outcomes.

Ethically I felt we were bound to this child. We know he is one of the severest of the severe and we know that he’s got very long-term implications with his impairment if we don’t manage him. (Gemma)

According to Sim and Richardson (2004) health professionals must use morally relevant criteria of health needs or perceived benefits to determine exceptional cases. Herein lay an ethical dilemma for experienced participants; to judge whether to adapt policies for one case when there were many needy clients awaiting intervention.

The hardest thing is knowing where to draw the line, knowing how far to let it go. Because, while I am bending the rules, I still do maintain the philosophy ‘equal services for all’ (Therese)

Professionals’ differing perceptions of priority versus fairness resulted in team conflict.

I could understand some of those parents being quite upset and angry if they found out there were children who were seeing a different therapist and receiving quite a different service. (Anne)

Inconsistent application of service delivery policies may result in subgroups of clients receiving superior or inferior intervention. Furthermore, this was an area of disharmony between colleagues. Such findings indicated that speech pathologists may benefit from openly sharing decision-making strategies and feedback about impacts of service delivery policies on quality of client care.

Professional status

Experienced professionals have a pivotal role in determining the ethical culture of a workplace because they model and advise new graduates on ethical practice (Handelsman et al. 2005).

I’m the person that people come to when they don’t know what to do regarding something about a client or something they’ve seen or heard. (Gemma)

Our findings indicate that experienced professionals accept their responsibilities as ethical role models but experience anxiety about the consequences of tackling ethical issues.

Ethical dilemmas in speech pathology 435

I don’t want to be the ‘young upstart’ that’s just taken over for a few months and trying to change everything, challenging the system. (Anne)

A workplace culture that acknowledges and addresses ethical issues is necessary to maintain and evaluate quality of care.

According to Lubinski and Frattali (2001) there are three major professional issues impacting upon future speech pathology practice. Firstly, client demographics are changing so that speech pathologists must manage increasingly ageing, culturally diverse and clinically complex caseloads. Secondly, healthcare organizations are moving towards resource driven and consumer oriented models of service delivery. Thirdly, speech pathologists are challenged by expanding scopes of practice characterized by technological advances, case management, interdisciplinary teamwork and emerging specialty areas.

Our participants’ ethical stories reflected these three professional issues and raised underlying ethical concerns accompanying changes in healthcare practices. Our findings identify four key ethical issues that may influence future directions in speech pathology intervention.

Quality of life, benefit and harm in healthcare decision-making

Reorganization of care from hospital to community settings and organizational philosophies that focus upon social rather than medical models of disability require speech pathologists to consider health within the context of clients’ rights, choices and independence (Graves 2007). Speech pathologists’ understanding of issues of quality of life, benefit and harm may influence the nature of their assessments, recommendations and client advocacy. Additionally, the speech pathology profession must weigh consumer and corporate demands with professional duty of care, which presumes their management should be in the best interests of their clients (Best et al. 2001). Further research is required to inform healthcare professionals’ understanding of the complex factors affecting client autonomy and to facilitate inter-professional teams to work towards beneficial outcomes for current and future patients.

The nature of truth in professional relationships

Healthcarepracticetodaythreatensthetraditionalpractitioner–clientrelationship(Best et al. 2001). Health professionals mustunderstand thegoals of all of the stakeholders in the practitioner-client relationship including families, team members and adminis- trators. Our speech pathologists’ concerns over personal and professional consequences ofraisingdifficult issueswithfamiliesandcolleaguesmaylimitcollaborativeapproaches to healthcare management. Addressing such issues may require health professionals to demonstrate courage and perseverance. Furthermore, the profession has a role in developing closer relationships with policy-makers and health-funding bodies so that speech pathologists retain some control over resource distribution and quality of care provided for clients with communication and swallowing disorders.

The relationship between fairness and quality of care

Limitations in healthcare resources generated a host of ethical issues relevant to quality of care. Clearly, there is a need for continued research to support ecologically

436 Belinda J. Kenny et al.

valid models of practice that are based on mutual respect of differential expertise of healthcare providers so that services are complementary, integrated and cost effective (Dockrell et al. 2006). Such research should also address our speech pathologists’ concerns about the long-term economic and health outcomes from current service delivery policies. Additionally the profession is charged with the responsibility to ensure that evidence based practice translates to improved quality of services for all clients, including those individuals with complex needs and culturally and linguistically diverse backgrounds.

Heath professionals’ interpretation of ethical practice

Adherence to a Code of Ethics must be instilled into the daily working lives of professionals so that they identify and manage ethical issues that arise from changing healthcare practices (Shinn 2004). Our findings supported the need for educational institutions to prepare new graduates for ethical practice and for the speech pathology professiontoengageit’smembersinanongoingdialogueofcontemporaryethical issues. Additionally, our findings endorse attempts by professional organizations to review codes of ethics in responses tochanging national and internationalhealthcaredemands.

Conclusions

Ethical practice is one lens through which we may evaluate quality of care. Speech pathologists’ ethical dilemmas reflect quandaries in healthcare practice at the interface between clients and professionals, policies and practice, employers and interdisciplinary teams. Ethical stories reveal a need for education and support to balance the competing needs of client care, organizational philosophy, professional and community values.

Quality of life, benefit and harm in healthcare decision-making, the challenges of truth in professional relationships, and conflict between fairness and quality of care when resources are scarce, will influence health service delivery. Speech pathologists’ interpretation of ethical practice in the workplace will also determine how effectively healthcare providers meet the economic, evidence based and moral components of quality care. The ethical dilemmas identified by our participants are not unique to the speech pathology profession. Allied health, medical and nursing professions are confronted by the challenges of an evolving healthcare system (Barnitt 1998, Purtilo 2000, Shinn 2004, Swisher 2002). Hence, these ethical challenges present healthcare professionals with new opportunities for collaboration, education and research in applying,maintainingandrefiningcodesofethics relevant forcontemporarypractice.

Acknowledgements

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Note 1. A Current Affair is an Australian television programme that uses investigative journalism to present

contemporary and frequently controversial human interest stories.

Ethical dilemmas in speech pathology 437

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