boundary issues (5)

(Over)extended roles
Linda Armstrong considers the following scenario:
peech and language therapy has never been static. An examination of preCollege of Speech Therapists journals showed our earliest evidence-base focused on dysfluency and cleft lip and palate (Armstrong & Stansfield, 1996). The proportion of these disorders in our overall caseload has faded, and they have become specialities. Since 1984 when I graduated, different disorders and client groups have come into vogue according to medical and social priorities, such as people with learning disability, or geriatrics. The two main tidal waves of new areas of practice have been adult acquired dysphagia (with instrumental methods of assessment) and autistic spectrum disorders. These have been accompanied by the professional requirement for us to deliver evidence-based practice, an increase in the number of speech and language therapists, increased public awareness through the internet, and more challenge from clients and families when services fall short. Demand continues to outstrip supply as we aim to meet standards and follow guidelines, and this pattern is likely to mushroom in current economic and political conditions. Practice innovations and role evolution will likely increasingly have to happen without any new money. This will have a knock-on negative impact on current clients for whom less clinical time will be available. Arguably, the Health Professions Councils first and overarching - registrants duty will be contravened: You must act in the best interests of service users (HPC, 2008, p.3). Another relevant duty to this discussion is You must keep within your scope of practice (HPC, 2008, p.11). However, the Council also requires that therapists be able to change their practice as needed to take account of new developments (HPC, 2007, p.10). Though we are autonomous, the decisions we make about planning and delivering new services should sit within our scope of practice, and service and employer priorities. In this scenario, we have what Roulstone (2009, p.156) labels Reductions in one service to develop another: robbing Peter to pay Paul. We have tried hard over the years not to spread the jam thinner but to argue that we need to spend more rather than less time with individual clients to effect a change in their communication and/or swallowing. Frameworks such as Malcolmesss care aims (www.careaims.com) have provided tools to measure the input required to reduce the impact of a clients communication

You are one of 3.5 whole time equivalents working with adults with acquired neurological, voice and fluency disorders. A full-time member of the team has been evolving a new role. There is no new money, and no benefit to the teams usual clients. Where before you had the flexibility to adapt and innovate, you are now struggling to provide them with an evidence based service.
BOUNDARY ISSUES EXPLAINED The Health Professions Council Standards of Conduct, Performance and Ethics (2008) require us to behave with honesty and integrity at all times (p.14). We are reminded that poor conduct outside of your professional life may still affect someones confidence in you and your profession (p.9). Arguably, our clinical conversations and research literature do not focus sufficiently on moral principles, but they at least touch on the ethics around issues such as prioritisation and evidence-based practice. In this series we think through everyday events which receive much less attention but also need to be on our ethical radar. and/or swallowing disorder. Squeezing a new role into a service probably already under-resourced cannot facilitate a clinically effective service for our existing clients or those covered by the new role. Our professional body was concerned enough about new and evolving roles to produce a policy statement (RCSLT, 2008). Its examples are mainly for medical, hospitalbased (invasive) procedures, which seem to predominate in current evolving roles. Other new roles for an adult service might involve advocacy for clients, or work in conjunction with job centres to support people back to work. We are cautioned that a new role should not be developed because it saves someone else from doing a job for which they are trained but consider the activity to be a low priority (p.5). So we should ask ourselves whether a speech and language therapist is necessary to fulfil the proposed new role. The policy statement provides a flow chart to support us in decision-making (p.7) and so focuses on the processes and safeguards necessary to establish new practices (p.3). Funding and resources are considered to be local management issues (p.3). Thus, in this scenario, it is the managers responsibility to agree a new role before it is assumed, and to assess how it fits within current service provision and financial limitations. This might be achieved by measuring increased waiting times for current client groups, or reduced frequency of sessions with current clients. Alternatively, part of the existing service may have to be withdrawn, or devolved to our support workers, other professionals or lay carers. Speech and language therapy is a constantly evolving profession for which

Linda Armstrong (pictured on holiday with her husband) is a speech and language therapist with NHS Tayside in Perth & Kinross (email linda.armstrong2@nhs.net).

new roles are developed to fit with changing needs and emerging evidence (RCSLT, 2008, p.3). Ilsley (2011) and Haines (2011) discuss new roles related to people with chronic obstructive pulmonary disease and other respiratory conditions. The professions early members would hardly recognise much of our work now. In this scenario, perhaps the new role will eventually complement and improve the service already provided. It may on the other hand continue to have a negative impact on core practice. It may even, over time, be instrumental in changing core practice and adding to our evidence-base. My concern remains that new roles without new resources inevitably have a detrimental effect on the service we provide to clients for whom we have an existing evidence base that suggests speech and language therapy can SLTP be effective and beneficial.
References Armstrong, L. & Stansfield, J. (1996) A Content Analysis of Speech, the Professional Journal of the British Society of Speech Therapists - the First Ten Years. Spotlight on Speech, 1935-1945, European Journal of Disorders of Communication 31, pp.91-105. Haines, J. (2011) Respiratory Speech and Language Therapy, RCSLT Bulletin 706, pp.15-16. Health Professions Council (2007) Standards of Proficiency. Available at: http://www.hpc-uk.org/assets/ documents/10000529Standards_of_Proficiency_SLTs. pdf (Accessed 4 April 2011). Health Professions Council (2008) Standards of Conduct, Performance and Ethics. Available at: http://www.hpcuk.org/assets/documents/10002367FINALcopyofSCPEJ uly2008.pdf (Accessed 4 April 2011). Ilsley, E. (2011) Dysphagia and Chronic Obstructive Pulmonary Disease, RCSLT Bulletin 706, pp.13-14. Roulstone, S. (2009) Commentary on Scenario 8.2 in Body, R. & McAllister, L. (2009) Ethics in Speech and Language Therapy. Chichester: Wiley-Blackwell. Royal College of Speech & Language Therapists (2008) Policy Statement: Evolving Roles in Speech and Language Therapy. Available at: http://www.rcslt.org/members/ publications/RCSLT_Evolving_roles_Policy_Statement_ October_2008_a.pdf (Accessed 4 April 2011).

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2011

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